Skip to main content
SpringerLink
Log in

Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?

  • Symposium: Papers Presented at the 2011 Meeting of the International Hip Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Proximal femoral nail antirotation devices (PFNAs) are considered biomechanically superior to dynamic hip screws for treating unstable peritrochanteric fractures and reportedly have a lower complication rate. The PFNA II was introduced to eliminate lateral cortex impingement encountered with the PFNA. However, it is unclear whether the new design in fact avoids lateral cortex impingement without compromising stability of fixation and fracture healing.

Questions/Purposes

We therefore asked whether the PFNA II: (1) eliminates the lateral cortex impingement and fracture displacement experienced with PFNA; and (2) provides stable fracture fixation with a low major complication rate for unstable fractures in European patients.

Methods

We retrospectively reviewed 108 patients with an unstable peritrochanteric fracture, 58 treated with PFNA and 50 with PFNA II. We compared nail positioning, major and minor complication rates, operative and fluoroscopy time, blood transfused, time to mobilization, hospital stay, fracture union, and Harris hip score. The minimum followup was 12 months (mean, 13 months; range, 12–18 months).

Results

In the PFNA II group we encountered no impingement on the lateral cortex and no patients with lateral fragment or loss of reduction at insertion, whereas with the PFNA group, we had 10 and five cases, respectively. Fracture union occurred in all patients treated with PFNA II without mechanical failures. PFNA II cases were associated with a slightly shorter surgical time than PFNA cases (23 minutes versus 27 minutes, respectively).

Conclusion

PFNA II avoided lateral cortex impingement experienced with PFNA, providing fast and stable fixation of the unstable peritrochanteric fractures.

Level of Evidence

Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4A–C

Similar content being viewed by others

References

  1. Al-Yassari G, Langstaff RJ, Jones JWM, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002;33:395–399.

    Article  PubMed  CAS  Google Scholar 

  2. Anglen JO, Weinstein JN; American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am. 2008;90:700–707.

    Article  PubMed  Google Scholar 

  3. AO Foundation. Proximal Femur Nail Antirotation, PFNA®. Available at: www.aofoundation.org. Accessed June 2008.

  4. Aros B, Tosteson AN, Gottlieb DJ, Koval KJ, Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res. 2008;466:2827–2832.

    Article  PubMed  Google Scholar 

  5. Banan H, Al-Sabti A, Jimulia T, Hart AJ. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN): our first 60 cases. Injury. 2002;33:401–405.

    Article  PubMed  CAS  Google Scholar 

  6. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77:1058–1064.

    PubMed  CAS  Google Scholar 

  7. Butler M, Forte ML, Joglekar SB, Swiontkowski MF, Kane RL. Evidence summary: systematic review of surgical treatments for geriatric hip fractures. J Bone Joint Surg Am. 2011;93:1104–1115.

    Article  PubMed  Google Scholar 

  8. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury. 1994;25:99–104.

    Article  PubMed  CAS  Google Scholar 

  9. David A, von der HD, Pommer A. Therapeutic possibilities in trochanteric fractures. Safe–fast–stable. Orthopade. 2000;29:294–301.

    PubMed  CAS  Google Scholar 

  10. Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with a proximal femoral nail. Int Orthop. 2001;25:298–301.

    Article  PubMed  CAS  Google Scholar 

  11. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Mini-invasive nail versus DHS to fix pertrochanteric fractures: a case-control study. Injury. 2011;42:204–208.

    Article  Google Scholar 

  12. Friedl W, Clausen J. [Experimental examination for optimized stabilisation of trochanteric femur fractures, intra- or extramedullary implant localisation and influence of femur neck component profile on cut-out risk] [in German]. Chirurg. 2001;72:1344–1352.

    Article  PubMed  CAS  Google Scholar 

  13. Gardenbroek TJ, Segers MJ, Simmermacher RK, Hammacher ER. The proximal femur nail antirotation: an identifiable improvement in the treatment of unstable pertrochanteric fractures? J Trauma. 2011;71:169–174.

    Article  PubMed  Google Scholar 

  14. Garg B, Marimuthu K, Kumar V, Malhotra R, Kotwal PP. Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial. Hip Int. 2011;21:531–536.

    Article  PubMed  Google Scholar 

  15. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83:643–650.

    PubMed  Google Scholar 

  16. 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;51:737–755.

    PubMed  CAS  Google Scholar 

  17. Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Järvinen M. Epidemiology of hip fracture. Bone. 1996;18(Suppl):57S–63S.

    Article  PubMed  CAS  Google Scholar 

  18. Kokoroghiannis C, Aktselis I, Deligeorgis A, Fragkomichalos E, Papadimas D, Pappadas I. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures—a review. Injury. 2012;43:686–693.

    Article  PubMed  Google Scholar 

  19. Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures J Orthop Trauma. 2009;23:465–470.

    Article  PubMed  Google Scholar 

  20. Laros GS. The role of osteoporosis in intertrochanteric fractures. Orthop Clin North Am. 1980;11:525–537.

    PubMed  CAS  Google Scholar 

  21. Little NJ, Verma V, Fernando C, Elliott DS, Khaleel A. A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2008;90:1073–1078.

    Article  PubMed  CAS  Google Scholar 

  22. Liu M, Yang Z, Pei F, Huang F, Chen S, Xiang Z. A meta-analysis of the Gamma nail and dynamic hip screw in treating peritrochanteric fractures. Int Orthop. 2010;34:323–328.

    Article  PubMed  Google Scholar 

  23. Lv C, Fang Y, Liu L, Wang G, Yang T, Zhang H, Song Y. The new proximal femoral nail antirotation—Asia: early results. Orthopedics. 2011;34:351.

    PubMed  Google Scholar 

  24. Madsen J, Næss L, Aune A, Alho A, Ekeland A, Strømsøe K. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma. 1998;12:241–248.

    Article  PubMed  CAS  Google Scholar 

  25. Muller ME, Nazarian S, Koch P, Schatzker J (1990) The Comprehensive Classification of Fractures of Long Bones. 1st ed. Berlin, Heidelberg, Germany, New York, NY, USA: Springer-Verlag;

    Book  Google Scholar 

  26. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma. 1996;10(Suppl 1):v–ix, 1–154.

    Google Scholar 

  27. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005;87:76–81.

    Article  PubMed  CAS  Google Scholar 

  28. Panjabi MM, Lindsey RW, Walter SD, White AA 3rd. The clinician’s ability to evaluate the strength of healing fractures from plain radiographs. J Orthop Trauma. 1989;3:29–32.

    Article  PubMed  CAS  Google Scholar 

  29. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2005;4:CD000093.

    Google Scholar 

  30. Parker MJ, Handoll HH. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2006;3:CD004961.

    Google Scholar 

  31. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;9:CD000093.

    Google Scholar 

  32. Radford PJ, Needoff M, Webb JK. A prospective randomized comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993;75:789–793.

    PubMed  CAS  Google Scholar 

  33. Sabin S, Ertürer E, Oztürk I, Toker S, Seçkin F, Akman S, Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44:127–134.

    Article  Google Scholar 

  34. Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury. 2004;35:142–151.

    Article  PubMed  CAS  Google Scholar 

  35. Sommers MB, Roth C, Hall H, Kam BC, Ehmke LW, Krieg JC, Madey SM, Bottlang M. A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. J Orthop Trauma. 2004;18:361–368.

    Article  PubMed  Google Scholar 

  36. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures. A biomechanical evaluation. Injury. 2006;37:984–989.

    Article  PubMed  Google Scholar 

  37. Streubel PN, Wong AH, Ricci WM, Gardner MJ. Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? J Orthop Trauma. 2011;25:202–207.

    Article  PubMed  Google Scholar 

  38. Synthes. Proximal Femur Nail Antirotation, PFNA®. Available at: www.synthes.com. Accessed June 2008.

  39. Tyagi V, Yang JH, Oh KJ. A computed tomography-based analysis of proximal femoral geometry for lateral impingement with two types of proximal femoral nail anterotation in subtrochanteric fractures. Injury. 2010;41:857–861.

    Article  PubMed  Google Scholar 

  40. Verettas DA, Ifantidis P, Chatzipapas CN, Drosos GI, Xarchas KC, Chloropoulou P, Kazakos KI, Trypsianis G, Ververidis A. Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. Injury. 2010;41:279–284.

    Article  PubMed  Google Scholar 

  41. Windolf M, Braunstein V, Dutoit C, Schwieger K. Is a helical shaped implant a superior alternative to the dynamic hip screw for unstable femoral neck fractures? A biomechanical investigation. Clin Biomech (Bristol, Avon). 2009;24:59–64.

    Google Scholar 

  42. Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture. J Int Med Res. 2010;38:1266–1275.

    PubMed  CAS  Google Scholar 

  43. Yoshimine F, Latta LL, Milne EL. Sliding characteristics of compression hip screws in the intertrochanteric fracture: a clinical study. J Orthop Trauma. 1993;7:348–353.

    Article  PubMed  CAS  Google Scholar 

  44. Ziran BH, Heckman DS, Olarte CM, Chou K, Baranick J. Intramedullary hip screw versus standard compression hip screw: early postoperative rehabilitation comparisons. Orthopedics. 2009;32:83.

    PubMed  Google Scholar 

  45. Zou J, Xu Y, Yang H. A comparison of proximal femoral nail antirotation and dynamic hip screw devices in trochanteric fractures. J Int Med Res. 2009;37:1057–1064.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. 4th Department of Orthopaedics and Traumatology, KAT Hospital, 2 Nikis Street, 145 61, Athens, Greece

    George A. Macheras MD, PhD, Stefanos D. Koutsostathis MD, PhD, Spyridon Galanakos MD, Konstantinos Kateros MD, PhD & Stamatios A. Papadakis MD, PhD

Authors
  1. George A. Macheras MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefanos D. Koutsostathis MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Spyridon Galanakos MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Konstantinos Kateros MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stamatios A. Papadakis MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to George A. Macheras MD, PhD.

Additional information

Each author certifies that he or she, or a member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Macheras, G.A., Koutsostathis, S.D., Galanakos, S. et al. Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?. Clin Orthop Relat Res 470, 3067–3076 (2012). https://doi.org/10.1007/s11999-012-2445-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2445-x

Keywords

Search

Navigation