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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 59-63

Role of proximal femoral nailing in fracture neck of femur


1 Department of Orthopedics, S.N. Medical College, Agra, India
2 Department of Orthopedics , Safdarjung Hospital, New Delhi, India
3 Department of Orthopedics , U.P R.I.M.S. and Saifai, Utter Pradesh, India

Date of Web Publication6-Jun-2014

Correspondence Address:
Chandra Prakash Pal
Department of Orthopedics, S.N. Medical College, Agra - 282 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.134020

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  Abstract 

Background: The present study was done (a) to assess the role of proximal femoral nailing in the femoral neck fractures. (b) To assess the effect of early weight bearing after stabilization with proximal femoral nail. (c) To assess the incidence of complications in femoral neck fractures treated by proximal femoral nail. Materials and Methods: The present prospective study was conducted in the department of Orthopedics, of this institute from September 2007 to August 2009, which is a tertiary care center. A total of 22 patients of fracture neck of femur were included in the study. Only patients with basal and transcervical type of fractures with viable femoral head were included in the study. Patients with subcapital type of fracture were excluded from the study. All the patients were followed regularly for a period of two years. These fractures were fixed with proximal femoral nail. The final outcome measurement was done according to Harris hip scoring (HHS) method of functional assessment. Results: Sixty three percent of cases of our study presented with non union and 37% showed osseous union of which three were of basal type and five were of transcervical type. Out of the 22 patients assessed according to Harris hip score only 27.24% cases showed good result whereas 63.56% cases showed poor results. Results based on the anatomical type of fracture showed basal type of fractures with good results of union while 73.68% of the transcervical type of fractures showed poor results. Fair results were seen in 10.25% while only 15.26% of the patients showed good results in transcervical type of fractures. Good results obtained in transcervical type of fracture were the ones associated with subtrochanteric fracture femur. The purely transcervical type of fracture showed fair results in only two patients while the rest showed non union. Conclusions: After conduction of this study on results of the treatment of intracapsular fracture neck of femur by proximal femoral nailing we conclude that (A) proximal femoral nail is useful in basal type of fracture and in those types of transcervical fractures which are associated with ipsilateral subtrochanteric fracture. (B) Proximal femoral nail should be avoided in pure transcervical fracture neck of femur. (C) As it is a small study a further study for transcervical fractures is required.

Keywords: Basal, complications, fracture neck of femur, proximal femoral nail, transcervical


How to cite this article:
Pal CP, Kumar H, Singh P, Pruthi KK. Role of proximal femoral nailing in fracture neck of femur. J Orthop Traumatol Rehabil 2014;7:59-63

How to cite this URL:
Pal CP, Kumar H, Singh P, Pruthi KK. Role of proximal femoral nailing in fracture neck of femur. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 27];7:59-63. Available from: http://www.jotr.in/text.asp?2014/7/1/59/134020


  Introduction Top


Fractures of the neck of femur have always presented great challenges to the orthopedic surgeon and remains in many ways today as the unsolved fracture as far as the treatment and results are concerned. With life expectancy increasing with each decade, our society is becoming more and more a geriatric society, with significant numbers of hospitalized and nursing home patients suffering from femoral neck fractures and their sequela. [1] Femoral neck fractures in young patients are usually caused by high energy trauma and often are associated with multiple injuries and high rates of avascular necrosis and non union. [1],[2] It differs in many ways from the same fracture in the elderly patients as it occurs through relatively normal bone. [3] Incidence of non union has been significantly reduced by early anatomical reduction, impaction of fractures and rigid internal fixation. [3] The treatment protocol of the femoral neck fractures depends on the age of the patient, duration of the injury, activity level of the patient, degree of displacement and degree of osteoporosis. [4] The principles to get success in the management of these fractures are

  1. Anatomical reduction.
  2. Stable internal fixation.
  3. Preservation of the blood supply to the bone fragments and soft tissue by means of atraumatic surgical technique.
  4. Early active pain free mobilization of the joints, which prevents the development of stiffness. [4],[5]


The struggle to find the best treatment in the relatively younger patients continues as relentlessly as it did half a century ago. [2] The prognosis is all the more gloomy, if as often happens in developing countries, the patient is presents several weeks after the injury, often with resorption of the neck and sometimes with radiological signs of the avascular necrosis of the femoral head. [3],[4] A fracture rigidly fixed by means of interfragmentary compression (lag effect) demonstrates absolutely no movement between the fracture fragments. [6] In sharp contrast to this is a fracture which has only been splinted which will always demonstrate the movement between the fragments even if of only microscopic dimensions. [7],[8],[9] In proximal femoral nailing interfragmentary compression is achieved by head screws and splinting is achieved by intramedullary nail in femoral shaft. [4],[8] The present study was done

  1. To study the role of proximal femoral nailing in femoral neck fractures.
  2. To assess the effect of early weight bearing after stabilization with proximal femoral nail.
  3. To assess the incidence of complications in femoral neck fractures treated by proximal femoral nail.



  Materials and methods Top


The cases of this study were selected from the patients attending the outpatient department of orthopedics and from those arriving at the emergency department of this institute from September 2007 to August 2009. A total of 22 cases were selected. Each patient was subjected to detailed clinical and radiological examination along with the routine pathological investigations.

Inclusion criteria

  • Fracture neck femur mainly basal and transcervical type.
  • Fracture neck femur with ipsilateral fracture shaft femur.
  • Fracture neck femur with ipsilateral intertrochanteric and subtrochanteric fractures.
  • Viable femoral head.
  • Patients who can tolerate major operation.
  • No other associated hip anomaly like polio, coxa-vara.


Exclusion criteria

  • Subcapital type of fracture neck of femur.
  • Those with inability to walk.
  • Compound fractures.
  • Very poor anesthetic and general risk patients.
  • Those unable to cooperate in the post operative program.


The patients were thoroughly examined clinically and all the routine blood investigations were done. Along with plain skiagrams, CT scans and MRI of the pelvis was done to find out the site of fracture, type of fracture, quality of the bone, amount of the neck absorption, amount of posterior comminution and signs of avascular necrosis. This also showed viability of the head, measurement of the proximal fragment, gap between the two fragments and condition of the fractured surfaces.

The patients were treated using the proximal femoral nail which is available in two types:

  1. Short PFN: Available in steel or titanium consists of a 250 mm short nail with a shaft diameter of 10, 11, 12 mm, neck shaft angle of 125°, 130° and 135°.
  2. Long PFN: Available in steel or titanium consists from 340 to 420 mm long nail with a shaft diameter of 9, 10, 11 mm, neck shaft angle of 130° and 135°.


Procedure

The intramedullary nail was inserted using a closed technique under image intensifier control. Closed reduction of the fracture was achieved by gentle traction in 45° of flexion and in slight abduction; the hip was then extended and internally rotated to 30°-45° and brought parallel to the trunk. A Garden's alignment index of 160° to 180° on the anteroposterior view and 0° to 20° on the lateral view were considered as acceptable for reduction and fixation. Open reduction was done in cases where closed reduction was not achieved. It was done by Watson Jones anterolateral approach. Care was taken to incise the middle of the anterior capsule from the acetabular margin to 1 cm proximal of the intertrochanteric line to avoid major arterial circle around the base of the neck. The entry was made through the tip of the greater trochanter and guide wire was introduced into the shaft. Appropriate size nail was introduced after reaming. Guide wires for the load bearing and anti-rotation screws were passed and their position checked under image intensifier. Finally the screws were tightened and distal locking was done [Figure 1] and [Figure 2].
Figure 1: Preoperative, postoperative and follow-up radiographs of a case showing fracture neck of femur with ipsilateral shaft femur fracture treated by proximal femoral nail

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Figure 2: Follow-up radiographs of the same patient

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Postoperative management

Antibiotics were given for 12 days and analgesics SOS. The limb was kept in 15° of flexion and 20° abduction. Quadriceps drill was encouraged as soon as the patient was in a position to tolerate. Stitches were removed on the 12 th postoperative day.

Follow-up study

The patients were called for follow-up at monthly interval for three months and then after an interval of two months. Clinical and radiological assessment was done during the follow-up. All the patients were followed regularly for a period of two years.

Clinical assessment

Clinical evaluation was done for presence or absence of pain, status of union, movement at the hip and knee joint, limb length discrepancy, muscle power around hip and knee joint, stability of the hip joint. The assessment of results was done according to Harris hip score (HHS) [Figure 3]. [9]
Figure 3: Preoperative, postoperative and follow-up radiographs of another case showing fracture neck of femur treated by proximal femoral nail

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Radiological assessment

Plain skiagrams of the pelvis with both the hip antero posterior (AP) view in internal rotation was taken and assessed. Obliteration of the fracture site with trabecular bridging was taken as an evidence of the union. Position of the screws in the head, any loosening of the screws, advancement of the screw in the joint space, any change in the Pauwel's angle and secondary varus was noted.

After one month of follow-up the patients were encouraged to do flexion and extension exercises. Partial weight bearing with help of walker and then stick was allowed at 8 to 12 weeks. Full weight bearing was allowed after 12 weeks depending upon the clinical and radiological evidence of union.


  Results Top


A total of 22 patients of the fracture neck of femur were operated and fixed with proximal femoral nail. The age of the patients varied from 20 years to 65 years in which 14 patients were male and 8 were female.

Transcervical femoral neck fracture was present in 19 (86.38%) cases while the rest 3 (13.62%) had basal type femoral neck fracture. In this series of 22 patients, 9.9% had Pauwel's type I fracture, 59.02% Pauwel's type II and the rest 31.78% had type III fracture. According to Garden's classification, 68.22% of the cases were grade III and rest 31.78% cases were grade IV. In this study most (54.6%) of the patients were operated within 2 weeks of the injury. In isolated fracture neck femur we used short proximal femoral nail (PFN) while we used long PFN in associated ipsilateral trochanteric fracture. The duration of the surgery in 91% of the patients was within 90 minutes.

Postoperatively knee mobilization exercises were started on the second postoperative day in 91% of the patients while in the rest 9% it was started between 5-7 days. In our study, partial weight bearing walking with the help of walker was started in the first week in >80% of the patients after the surgery. Out of the 22 patients assessed, full weight bearing was started within 6 weeks in 81% cases. In two cases weight bearing was encouraged late due to posterior comminution.

Sixty-three percent of cases of our study presented with non union and 37% showed osseous union of which 3 were of basal type 5 were of transcervical type. Out of the 22 patients assessed in our study according to Harris hip score (HHS); only 27.24% cases showed good result whereas 63.56% cases showed poor results. Results based on the anatomical type of the fracture showed basal type of fractures with good results of union while 73.68% of the transcervical type of fractures showed poor results. Fair results were seen in 10.25% while only 15.26% of the patients showed good results in transcervical type of fractures. Good results obtained in transcervical type of fracture were the ones associated with subtrochanteric fracture femur. The purely transcervical type of fracture showed fair results in only two patients while the rest showed non union.

Fifty percent of the Pauwel's type I fractures, 30.77% of the Pauwel's type II fractures and 14.28% of type III fractures showed good results. Results according to Garden' classification showed good results in 33.33% of the grade III fractures while only 14.29% of the grade IV fractures showed good results. Eighty five point seventy one percent of the grade IV fractures showed poor results. There were no patients of grade I and grade II fractures. In our study two cases had posterior comminution which showed poor results. Preoperative absorption of femoral neck was present in four cases due to late arrival of the cases. All the cases failed to unite.

Out of the various complications noted the most important was non union which was seen in 14 cases followed by avascular necrosis which was seen in 10 patients. Cut through of the screw into the hip joint was seen in 4 cases.


  Discussion Top


The femoral neck fracture is probably the fracture for which there exists the largest number of methods of osteosynthesis (Tronzo 1974). [10] The main reason for this is the high frequency of complications i.e. non union, avascular necrosis, which requires secondary surgical procedures. [11] Controversy regarding the prosthetic replacement versus internal fixation warrants special attention. [4],[12] Nicoll in 1963 criticized the routine use of prosthesis in fresh fracture neck femur as even this treatment had high rate of complications. [13] Boyd and Salvatora (1964) made a comparison between the results of femoral neck fracture treated by endoprostheses or internal fixation and concluded that no prosthesis is better than patients own head. [13] Thus, routine use of prosthesis in fresh femoral neck fractures is not justified except in a small group of older patients with short life span. [11],[12],[13]

There are not many studies on the use of proximal femoral nail in the fracture neck of femur. The only study that can be found is the one published by P. Vishna, E. Beitl, Z. Smidl, J. Kalvach and J. Pilny in 2007. [14] Aim of this study was to evaluate the outcomes of surgical therapy using different type of implant (PFN) for intracapsular fracture neck of femur. In 33.3% of the patients the operative stabilization was performed early, within six hours of the injury. In 51.8% the operation was carried out within 24 hrs and 14.3% of the patients underwent surgery later than 24 hours after injury. At one year of follow-up fracture union without complications was recorded in 45 patients (80%). Complications included avascular necrosis of the femoral head in seven patients (12.5%), pseudoarthrosis in two patients (3.6%) and other serious complication in two patients (3.6%). Reoperations were indicated in five patients and these underwent total hip replacement. No refracture occurred in the vicinity of the implant.

In our study majority of the patients belonged to young age group i.e. 20-50 years of age. Most of our patients were males because they are the outgoing ones and risk of sustaining injury is also greater in them. The lower average age in our series as compared to western series may be attributed to greater age expectancy in the west. In a series of 146 cases of femoral neck fractures the average age was 58.2 years (Sharma 1993). [8] In most of the western studies the female show a higher incidence of femoral neck fractures as compared to males (Frangkis 1966, Colbert and Muirvheartaigh 1976, Baker 1980, Olerude and Rheberg 1990 and Asnis and Sgaglion 1994). [4],[5],[6],[7],[8],[9],[10],[11] Key and Conwell (1961) mentioned that it is usually because of the fact that neck shaft angle is lesser in females than males and the neck is smaller in females. [15] Frangkis (1966) attributed the higher incidence of femoral neck fracture in female to the relatively higher incidence of senile osteoporosis and higher proportion of women in aged population. [11] Ratio of males have always exceeded to females in most of the Indian studies (Kulkarni 1987, Babulkar 1987). [16] In our study also 63.56% of the patients were males and the rest 36.44% were females.

Posterior comminution was seen in two of the cases in our series. Frangkis (1966) showed that comminution in posterior cortex is an important factor. [8],[11] In comminuted fracture reduction if achieved at all is difficult to maintain. [11],[13] In severely comminuted fractures the proximal fragment angulates posteriorly as the cortex collapses the implant loses its grip and fixation is lost. [3],[12] Time required for operation is relatively more in this technique which is a drawback of the procedure. An attempt was made to operate the cases as early as possible following the injury. Barne et al. (1976) in a study of 1,066 cases found that delaying surgery for up to six days had no effect on the incidence of non union, but after that incidence of non union increased dramatically. [11],[15] Holmberg et al. (1989) in a study of 2,151 cases found that incidence of non union increased from 24% to 59% if surgery was performed after seven days of the injury. [5],[7],[11],[17]


  Conclusion Top


After conduction of this study on results of treatment of intracapsular fracture neck of femur by proximal femoral nailing we conclude that:

  1. Proximal femoral nail is useful in basal type of fracture and in those types of transcervical fractures which are associated with ipsilateral subtrochanteric fracture when-

    • Young adult patient
    • Acute presentation
    • Fracture minimally displaced (Garden Grade - I, II, III)
    • Viable femoral head
    • No posterior comminution at fracture site


    Because:

    • It is a closed technique
    • Minimal chances of infection
    • Preservation of femoral head
    • It eliminates the risk of lateral protrusion of implant
    • It allows for even distribution on weight bearing thus reduces the risk of pseudo arthrosis development.


  2. Proximal femoral nail should be avoided in pure transcervical fracture neck of femur.


  3. As it is a small study a further study for transcervical fracture is required with keeping in mind the following facts:

    • Earliest operation
    • Late weight bearing particularly in osteoporotic bone


 
  References Top

1.Calandruccio RA, Anderson WE 3rd. Post fracture avascular necrosis of femoral head: Correlation of experimental studies and clinical studies. Clin Orthop Relat Res 1980;49-84.  Back to cited text no. 1
    
2.Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck, results of cannulated screw fixation. J Bone Joint Surg Am 1994;76:1793-803.  Back to cited text no. 2
    
3.Baksi DP. Internal fixation of non united femoral neck fractures combined with muscle pedicle bone grafting. J Bone Joint Surg Br 1986;68:239-45.  Back to cited text no. 3
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4.Huang CH. Treatment of neglected femoral neck fractures in young adults. Clin Orthop Relat Res 1986;206:117-26.  Back to cited text no. 4
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5.Gary AJ, Parker MJ. Intracapsular fractures of the femoral neck in young patients. Injury 1994;25:667-9.  Back to cited text no. 5
    
6.Johnson KD, Brock G. A review of reduction and internal fixation of adult femoral neck fractures in a country hospital. J Orthop Trauma 1989;3:83-96.  Back to cited text no. 6
    
7.Kyle RF. Operative techniques of fixation for femoral neck fractures in young adults. Techniques in Orthopaedics. 1986;1:33-38.  Back to cited text no. 7
    
8.Nagi ON, Dhillon MS, Gill SS. Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children. J Orthop Trauma 1992;6:306-13.  Back to cited text no. 8
    
9.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737-55.  Back to cited text no. 9
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10.Nagi ON, Dhilion MS, Sharma S, Gill SS. Donor site morbidity and regeneration after harvesting of fibula as free graft. Contemp Orthop 1992;24:535-40.  Back to cited text no. 10
    
11.Nilsson LT, Johansson A, Strongquist B. Factors predicting healing complications in femoral neck fractures. 138 patients followed for two years. Acta Orthop Scand 1993;64:175-7.  Back to cited text no. 11
    
12.Nagi ON, Gautam VK, Marya SK. Treatment of femoral neck fractures with a cancellous screw and a fibular graft. J Bone Joint Surg 1986;68B:387-91.  Back to cited text no. 12
    
13.Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fractures of femoral neck. J Bone Joint Surg Br 1998;80:798-804.  Back to cited text no. 13
    
14.Visna P, Beitl E, Smídl Z, Kalvach J, Pilný J. Treatment of Intracapsular femoral neck fractures with the use of a proximal femoral nail. Acta Chir Orthop Traumatol Cech. 2007;74:37-46.  Back to cited text no. 14
    
15.Steinberg ME, Hoyken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br 1995;77:34-41.  Back to cited text no. 15
    
16.Babhulkar SS, Nagpur: Osteonecrosis of femoral head in young individuals. Indian J Orthop 2003;37:2.  Back to cited text no. 16
    
17.Wang KZ, Tong ZQ, Wang CS. Treatment of osteonecrosis of femoral head with free vascularized fibular grafting. Chin J Microsurg 2000;23:254-6.  Back to cited text no. 17
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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