Sharma Anirudh, Mahajan Anupam, John Bobby
Senior Resident, Department of Orthopaedics, Christian Medical College and Hospital, Ludhiana, Punjab, India.
Associate Professor, Department of Orthopaedics, Christian Medical College and Hospital, Ludhiana, Punjab, India.
J Clin Diagn Res. 2017 Jul;11(7):RC05-RC09. doi: 10.7860/JCDR/2017/28492.10181. Epub 2017 Jul 1.
Management of unstable intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes. There is a paucity of clinical data comparing the commonly used Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) implants, especially in relation to osteoporosis.
To assess comparative performance of PFN and PFNA in the setting of osteoporosis.
Patients presenting with unstable intertrochanteric fractures (AO 31.A2 and 31.A3) were included and treated with either PFN or PFNA. Preoperative radiographs of normal side were used to grade osteoporosis by Singh's index. Grade 3 or less was considered significant. Postoperative radiographs were assessed for tip-apex distance, Cleveland index and quality of reduction. Patients were followed up for a minimum of nine months and any complications noted. Comparison of functional outcomes was done using the Harris Hip Score and Parker-Palmer mobility score at final follow up. Statistical analysis was done using the unpaired t-test/Mann-Whitney U test and Chi-square test/Fisher's-exact test. A p-value of < 0.05 was considered significant.
The study included 48 patients with unstable intertrochanteric fractures, of which 23 were treated with PFN and 25 with PFNA. Average age of PFN group was 60.78 years and of PFNA group was 74.12 years. In PFN group 8 patients (38.09%) and in PFNA group 13 patients (54.1%) had Singh's osteoporotic index of ≤ 3. The average Harris Hip Score was 75.37 and 78.85 in PFN and PFNA groups (p=0.54) respectively. From PFN and PFNA groups, 35% and 32% patients respectively were able to return to pre-injury mobility status as assessed by the Parker-Palmer mobility score (p=0.83). Out of eight implant related complications; seven were in patients treated with PFN (p=0.02). Among patients with Singh's grade ≤ 3, 3 (37.5%) in PFN group suffered from implant failure whereas all 13 patients in PFNA group had successful outcome (p=0.04).
Although functional outcomes achieved with both implants are similar (p=0.83), number of implant related complications were fewer with PFNA (p=0.02), even in osteoporotic group (p=0.04). We recommend use of the PFNA in unstable fractures, especially in the elderly osteoporotic population.
不稳定型股骨粗隆间骨折的治疗在获得稳定固定及良好术后效果方面存在挑战。比较常用的股骨近端髓内钉（PFN）和股骨近端抗旋髓内钉（PFNA）植入物的临床数据较少，尤其是在骨质疏松方面。
评估PFN和PFNA在骨质疏松情况下的对比性能。
纳入不稳定型股骨粗隆间骨折（AO 31.A2和31.A3）患者，用PFN或PFNA治疗。用健侧术前X线片按辛格指数对骨质疏松进行分级。3级及以下被认为是严重的。术后X线片评估尖顶距、克利夫兰指数及复位质量。患者至少随访9个月并记录任何并发症。末次随访时用Harris髋关节评分和帕克 - 帕尔默活动度评分比较功能结果。采用非配对t检验/曼 - 惠特尼U检验及卡方检验/费舍尔精确检验进行统计分析。p值<0.05被认为具有统计学意义。
该研究纳入48例不稳定型股骨粗隆间骨折患者，其中23例用PFN治疗，25例用PFNA治疗。PFN组平均年龄60.78岁，PFNA组平均年龄74.12岁。PFN组8例（38.09%）和PFNA组13例（54.1%）辛格骨质疏松指数≤3。PFN组和PFNA组平均Harris髋关节评分分别为75.37和78.85（p = 0.54）。根据帕克 - 帕尔默活动度评分，PFN组和PFNA组分别有35%和32%的患者能够恢复到受伤前的活动状态（p = 0.83）。在8例与植入物相关的并发症中，7例发生在接受PFN治疗的患者中（p = 0.02）。在辛格分级≤3的患者中，PFN组3例（37.5%）发生植入物失败，而PFNA组所有13例患者均获得成功结果（p = 0.04）。
尽管两种植入物获得的功能结果相似（p = 0.83），但PFNA的植入物相关并发症较少（p = 0.02），即使在骨质疏松组也是如此（p = 0.04）。我们建议在不稳定骨折中使用PFNA，尤其是在老年骨质疏松人群中。
