Choice of implant in stable intertrochanteric fracture femur: PFNA vs DHS

Abstract

Introduction:The best treatment for trochanteric fracture remains controversial Many methods have been recommended. Stable fixation that allows early mobilization is the treatment of choice. In this study, we aimed to compare the results of osteosynthesis using the PFNA and DHS system, in the treatment of stable intertrochanteric fractures including operative and postoperative complications, general complications and final outcome measurements. Method: We randomised 60 patients with low-energy extracapsular pertrochanteric stable femoral fractures (AO category 31-A1.1-31A.2.1)7 to be treated with the dynamic hip screw or the proximal femoral nail A2. All fractures were categorised according to the AO/ASIF classification. Follow-up reviews were undertaken at four weeks, three and six months post-operatively using Harris hip score. Results: From the first to the 6 th month, there was a significant improvement in Harris hip score (p<0.05), when each time point was compared with the previous one in both groups. On 3 -month followup, PFNA2 group had significantly better daily functioning than DHS group, as defined by Harris hip score. At 6 months, the PFNA2 group approached but did not normalise to its pre-operative Harris hip screw values (p =0.043). In contrast, DHS group values at 6 months lagged significantly to pre-operative values (p<0.001) PFNA group has fewer complications compared to DHS group. Conclusion: PFNA can benefit peritrochaneric fractures with less blood loss, earlier mobilization, better functional outcome and fewer complication compared to DHS.

High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study

“…This could imply that the high observed failure rate compared to these previous studies has resulted from a discrepancy in what was classified as an implant failure. The definitions of the other studies, compared to the one of this study, seems either too vague to be sure [1,4,20], or seems to match reasonably [5,31]. Other potential reasons for the significant discrepancy in the failure rates, such as differences in the patient populations, cannot be ruled out.…”

“…Only Yu et al presented failure rates in the order of magnitude observed in our cohort [1,4,5,20,31]. While Adams et al (2001) reported only failures which were reoperated, some studies stated less clearly whether non-reoperated failures were also included as implant failures [4,20]. Only Cho et al (2016) and clearly included these non-reoperated failures also [5,31].…”

“…Most previous studies reported failure rates for sliding hip screw devices lower than those observed in our study, ranging from 0 to 6%. Only Yu et al presented failure rates in the order of magnitude observed in our cohort [1,4,5,20,31]. While Adams et al (2001) reported only failures which were reoperated, some studies stated less clearly whether non-reoperated failures were also included as implant failures [4,20].…”

“…Many studies comparing intramedullary nails and extramedullary implants in trochanteric fractures find only minor differences in implant failure rates. These range between 0 and 6% for the DHS and between 0 and 3% for the PFNA [1,4,5,20,30]. A systematic review by Parker et al (2008) comparing intramedullary nails and extramedullary implants for extracapsular hip fractures demonstrated higher rates of surgical complications for intramedullary nails, but included only one study involving the PFNA [17,18].…”

“…A systematic review by Parker et al (2008) comparing intramedullary nails and extramedullary implants for extracapsular hip fractures demonstrated higher rates of surgical complications for intramedullary nails, but included only one study involving the PFNA [17,18]. Few studies focus specifically on treatment of stable trochanteric fractures, and most of these observed no differences in implant failure and reoperation rates between the PFNA and DHS [5,20,30,31]. Nevertheless, some studies indicated that the PFNA might be favourable in stable trochanteric fractures due to a shorter operation time [5], less blood loss [5,20], less postoperative pain, faster weight bearing [20] and a better functional recovery in the often frail older hip fracture patient [5,20,31].…”