PFN versus PFNA: functional and radiological outcome in intertrochanteric fractures of femur

Introduction: Intertrochanteric fractures pose a major problem in elderly osteoporotic age group of patients and its incidence has been on the rise. There are several treatment options available for the fixation of such type of fractures. Newer implant designs such as PFN and PFN-A have shown promising results in the treatment of intertrochanteric fractures. Despite the availability of various implants for the treatment of these fractures, there is no common consensus as to which implant would be ideal in the scenario of intertrochanteric fractures. Therefore, there is a need for further clinical trials to establish the biomechanical and functional outcome superiority of implants such as PFN and PFN-A. Aims and Objectives: The primary objective of this study is to compare the functional outcome using Harris Hip Score (HHS) and evaluation of complications with the use of PFN and PFN-A in treatment of intertrochanteric fractures. The secondary objectives are the assessment of comparative performance of PFN and PFN-A in the setting of osteoporosis and to compare the radiological outcome of the implants based on TAD, Cleveland’s index, neck shaft angle and type of reduction. The operative time for the two procedures is also compared. Methodology: Intertrochanteric fracture patients, after meeting the inclusion criteria, were assigned into 2 groups based on the type of implant used, being PFN and PFN-A. A total of 152 patients were included in this study, 94 in PFN group and 58 in PFN-A group. Postoperatively radiological outcome was assessed and compared using parameters such as TAD, Cleveland index, neck shaft angle and type of reduction. Operative time for the procedure, pre and post-operative hemoglobin levels were recorded and compared. Fracture union rates were compared at follow up period of 6 weeks and 6 months. Functional outcome was compared between the two groups at follow up period of 6 months using parameters such as Harris hip Score and pre and post-operative Parker Palmer mobility Score. Complication rates were compared between the two groups even in osteoporotic patients. Also, the patients were graded based on Singh’s index for osteoporosis and the radiological and functional outcome parameters were compared in this group based on the type of implant used. Results: The radiological parameters were similar in both the groups. There was a shorter operative time and better postoperative hemoglobin levels in the PFN-A group. The complication rate in PFN group was 7.4% when compared to PFN-A group which was just 1.7%. The functional outcome based on HHS and PPS was found to be similar in both the groups. In osteoporotic patients which were graded based on Singh’s index, similar results were observed with a higher complication rate seen in PFN group. Conclusion: Intramedullary nailing with the PFN A has distinct advantages over conventional PFN like shorter operating time and lesser blood loss. The complication rates are significantly less in intertrochanteric fracture patients operated with PFN-A when compared to PFN even in the osteoporotic age group. The importance of adequate radiological parameters especially postoperative neck shaft angle, type of reduction, Tip Apex Distance (TAD) and Cleveland index for the success of the implant has been clearly demonstrated in this study. Thereby, concluding that PFN-A is a better option for the treatment of all types of intertrochanteric fractures in skeletally mature age group of patients