Session X - Pelvis/Geriatrics

Pertrochanteric Fractures: Is There an Advantage to an Intramedullary Nail?

Richard E. Stern, MD; Christophe Sadowski, MD; Anne Lübbeke, MD; Marc Saudan, MD; Nicolas Riand, MD; Pierre Hoffmeyer, MD, University Hospital of Geneva, Geneva, Switzerland

Purpose: The objective of our study was to compare the results between a sliding compression hip screw and an intramedullary nail in the treatment of pertrochanteric fractures.

Methods: We prospectively studied 206 patients with pertrochanteric fractures classified as AO/OTA 31-A1 and A2 for a minimum follow-up of at least 1 year. Our inclusion criteria included all fractures of the trochanteric region in persons over the age of 55 caused by a low-energy injury. Fractures classified as AO/OTA 31-A3 (intertrochanteric) were excluded. The patients were strictly randomly assigned into two treatment groups. Patients of Group I (n = 106) were treated with a Dynamic Hip Screw (DHS), and patients of Group II (n = 100) were treated with a Proximal Femoral Nail (PFN). (DHS and PFN, Synthes-Stratec, Oberdorf, Switzerland). Both groups were strictly comparable with regards to age, sex, place of residence, co-morbid diseases, and state of health prior to fracture. Each patient was evaluated with a "mobility score" (Parker and Palmer), and a score for "social function" (Jensen). Operative and fluoroscopic times, the necessity for an open reduction of the fracture prior to fixation, intraoperative complications, the number of patients requiring transfusion, and the number of units transfused were recorded. Fracture healing and failure of fixation was assessed from radiographs. Pain, mobility score, and social functioning score were also recorded.

Results: There were 168 patients available for final review (DHS = 89, PFN = 79), with a minimum follow-up of 1 year. Results revealed no statistical difference between any of the intraoperative variables. Postoperative complications, length of hospital stay, and place of discharge after hospitalization were also the same. There was one case of hip screw cut-out in the DHS group. There were two cases of hip screw cut-out and one case of hip-pin migration across the joint in the PFN group. There were two early infections (less than 6 weeks), one each in the DHS and PFN groups. In the PFN group there were two late infections, at 11 and 15 months, respectively. The frequency and amount of persistent pain was comparable in both groups. Functional outcome (mobility and social function scores) was not statistically different between the two groups.

Discussion: Intramedullary devices for pertrochanteric fractures are appealing because they appear to combine the advantages of intramedullary fixation with those of a sliding hip screw and can be inserted in a limited open fashion. However, most carefully documented studies do not reveal any advantage to an intramedullary nail. Our study did not reveal any statistically significant difference between the two groups regarding intraoperative or postoperative variables, complications, or functional outcome.

Conclusion: There is no advantage to the PFN as compared with the DHS for pertrochanteric fractures classified as AO/OTA 31-A1 and A2. Its cost is greater, and there is no evidence of a decreased rate of complications or improved patient outcome.