Mallya Sharan, Kamath Surendra U, Annappa Rajendra, Nazareth Nithin Elliot, Kamath Krithika, Tyagi Pragya
Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India.
Department of Orthopaedics, Father Muller Medical College Hospital, Mangalore, India.
Adv Orthop. 2020 Mar 28;2020:2834816. doi: 10.1155/2020/2834816. eCollection 2020.
Proximal femoral nail antirotation-2 (PFNA-2) has been widely used to treat intertrochanteric fractures with varied outcomes in the previous studies. The entry point of the nail plays an important role in achieving acceptable reduction, stable fixation, and avoiding implant related complications. This study was proposed to determine the optimal greater trochanteric entry point for PFNA-2 in unstable intertrochanteric femur fractures.
We conducted an observational study on 40 patients with unstable intertrochanteric fracture treated with PFNA-2 implant in a tertiary care hospital. The patients were grouped into two based on the entry point: group L for lateral and group M for medial entry. Randomization was carried out by assigning the patients to the group by alternate allocation. The quality of reduction, tip apex distance, Cleveland index, and all the complications were noted. The final follow-up was conducted at six months. The functional outcome was evaluated using modified Harris hip score. The data analysis was performed using Student's -test, chi square test, and Mann-Whitney test. A value below 0.05 was considered significant.
Forty patients with 20 patients treated with medial entry point were included in group M and 20 patients in group L with lateral entry point. The group L had an average tip apex distance of 20.53 and group M had 20.02 (=0.8). The complication of screw back out was seen in 3 out of 4 patients with poor reduction in group L. As per the Cleveland index, 6 patients in each group had suboptimal position and 4 out of 6 patients in group L with suboptimal position had screw back out. The lateral cortex impingement was seen in 14 patients of group L and 6 patients in group M with significant comparison (=0.01). Three patients in group L had varus collapse with screw back out. Also, none in group M (0.05). The average modified Harris hip score in group L at six months follow-up was 71.94 and 76.8 in group M (=0.84).
Overall, to achieve good quality of fixation and reducing damage to gluteus medius entry point for PFNA-2 should be 5 mm medial to the greater trochanter tip.
股骨近端抗旋髓内钉-2（PFNA-2）已被广泛用于治疗股骨转子间骨折，但以往研究中其疗效各异。髓内钉的进针点对于实现满意的复位、稳定的固定以及避免植入物相关并发症起着重要作用。本研究旨在确定PFNA-2治疗不稳定型股骨转子间骨折时大转子的最佳进针点。
我们在一家三级医院对40例接受PFNA-2植入治疗的不稳定型股骨转子间骨折患者进行了一项观察性研究。根据进针点将患者分为两组：外侧进针的L组和内侧进针的M组。通过交替分配将患者随机分组。记录复位质量、尖顶距、克利夫兰指数以及所有并发症。最终随访在6个月时进行。使用改良Harris髋关节评分评估功能结局。采用学生t检验、卡方检验和曼-惠特尼检验进行数据分析。P值低于0.05被认为具有统计学意义。
40例患者中，M组20例采用内侧进针点治疗，L组20例采用外侧进针点。L组平均尖顶距为20.53，M组为20.02（P = 0.8）。L组4例复位不佳的患者中有3例出现螺钉退出并发症。根据克利夫兰指数，每组各有6例位置欠佳，L组位置欠佳的6例患者中有4例出现螺钉退出。L组14例患者出现外侧皮质撞击，M组6例，差异有统计学意义（P = 0.01）。L组3例患者出现内翻塌陷伴螺钉退出。M组无此情况（P = 0.05）。L组6个月随访时改良Harris髋关节评分平均为71.94，M组为76.8（P = 0.84）。
总体而言，为实现良好的固定质量并减少对臀中肌的损伤，PFNA-2的进针点应位于大转子尖内侧5毫米处。
