InterTan Nail Versus Proximal Femoral Nail Antirotation-Asia in the Treatment of Unstable Trochanteric Fractures

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1 n Feture Article InterTn Nil Versus roximl Femorl Nil Antirottion-Asi in the Tretment of Unstle Trochnteric Frctures Sheng Zhng, MD; Kirui Zhng, MD; Ynfei Ji, MD; Bin Yu, MD; Wei Feng, MD strct Full rticle ville online t Helio.com/Orthopedics. Serch: The gol of this study ws to compre the outcomes of unstle trochnteric frctures treted with the InterTn nil (Smith & Nephew, Memphis, Tennessee) nd the roximl Femorl Nil Antirottion (FNA-II) (Synthes, Solothurn, Switzerlnd). A totl of 132 consecutive ptients with unstle trochnteric frctures of the femur were enrolled in the study. The only intervention ws InterTn nil or FNA-II fixtion of the unstle trochnteric frctures. Follow-up occurred t 1, 3, 6, nd 12 months postopertively nd yerly therefter. Rdiogrphs were otined t ech follow-up, nd ll implnt position chnges, complictions, nd fixtion filures were recorded. A totl of 113 ptients meeting the criteri were evluted t men lst follow-up of months (rnge, months). Intropertive complictions nd length of hospitl sty were comprle etween the groups. tients treted with the FNA-II experienced shorter fluoroscopy nd opertive times, less intropertive lood loss, nd less femorl neck shortening. The incidence of thigh pin ws significntly higher in the FNA-II group (30.4%) thn in the InterTn group (10.3%) (5.001). No sttisticlly significnt differences existed in generl complictions, locl complictions, wlking ility, Hrris Hip Scores, or hip rnge of motion t finl follow-up. The uthors re from the Deprtment of Orthopedics nd Trumtology (SZ, KZ, BY), Nnfng Hospitl, Southern Medicl University, Gungzhou; nd the Deprtment of Orthopedics (YJ, WF), The Second Affilited Hospitl of Inner Mongoli Medicl University, Hohhot, Chin. The uthors hve no relevnt finncil reltionships to disclose. Drs Zhng (Sheng) nd Zhng (Kirui) contriuted eqully to this work. The uthors thnk Ling ing for his help in revising the rticle. Correspondence should e ddressed to: Bin Yu, MD, Deprtment of Orthopedic Trum, Nnfng Hospitl, Southern Medicl University, No Gungzhou Avenue N, Gungzhou, Chin, (zhngrmc@hotmil.com) or Wei Feng, MD, Deprtment of Orthopedics, The Second Affilited Hospitl of Inner Mongoli Medicl University, Hohhot, Chin, ( @qq.com). doi: / ORTHOEDICS Helio.com/Orthopedics

2 InterTn Nil Vs FNA-II Zhng et l Becuse most ptients with trochnteric frctures re older dults, opertive tretment must e rpid nd permit immedite postopertive weight ering. 1 Intrmedullry fixtion devices hve ecome incresingly populr due to iomechnicl dvntges in the tretment of unstle trochnteric frctures compred with extrmedullry fixtion. 2,3 However, previous intrmedullry fixtion devices, such s the Gmm nil 4 (Howmedic, London, United Kingdom) nd roximl Femorl Nil, 5,6 (Synthes, Solothurn, Switzerlnd) resulted in persistent prolems including femorl shft frcture, 7 fixtion filure, 8 the Z effect, 9 nd distl locking complictions 10 requiring reopertion with susequent moridity nd even mortlity. Therefore, other intrmedullry fixtion devices hve een introduced. The roximl Femorl Nil Antirottion (FNA), 11 modifiction of the roximl Femorl Nil, uses helicl neck lde fixtion to otin high stility to prevent rottion nd collpse. The helicl lde voids one loss tht occurs during the drilling nd insertion of the stndrd sliding hip screw. This device llows for improved purchse in the femorl hed y rdil compction of the cncellous one round the lde during insertion. The helicl neck lde hs the dvntges of fixtion stility, ntirottion, nd ntivrus collpse. 12 However, ecuse its proximl dimeter of 17 mm is too lrge for the Asin proximl femur, intr- nd postopertive complictions, such s difficulty inserting it, pin in the hip nd thigh, femorl shft frcture, lterl lde migrtion, nd lterl cortex splitting intropertively, hve een reported since it egn eing used in Asin ptients. 13,14 In response to these concerns, AO/ASIF developed the roximl Femorl Nil Antirottion-Asi (FNA-II) specificlly for Asin ptients. revious studies hve demonstrted tht the flt lterl shpe of the FNA-II is etter suited for the femurs of Asin ptients y reducing the chnces of impingement with the lterl proximl femorl cortex during intropertive reduction of sutrochnteric frctures. 15 Similrly, new device, the InterTn nil (Smith & Nephew, Memphis, Tennessee), uses 2 cephlocervicl screws in n integrted mechnism llowing liner intropertive compression nd rottionl stility of the hed-neck frgments. 16 A iomechnicl study showed tht the InterTn nil possesses some iomechnicl enefits for internl fixtion of unstle femorl neck frctures compred with dynmic hip screw nd cnnulted screw. 17 Menwhile, clinicl outcomes show tht the InterTn nil ppers to e relile implnt for the tretment of intertrochnteric femorl frctures. 18 Its design provides for stility ginst rottion nd minimizes neck mlunions (shortening) through liner intropertive compression of the hed-neck segment to the shft. 16 Although oth nils hve een reported to hve good clinicl outcomes, no rndomized, controlled tril hs compred the outcomes of the FNA-II nd InterTn nil. Therefore, the gol of the current prospective, rndomized clinicl tril ws to compre the FNA-II nd InterTn nil in terms of intropertive use nd outcomes. Mterils nd Methods Between July 2009 nd Septemer 2010, totl of 132 consecutive ptients with unstle trochnteric frctures of the femur (AO/ASIF clssifictions, 31-A2.1-3 nd 31-A3.1-3) were included in this study. The study ws pproved y the ethics committees of the uthors institutions. Informed consent ws otined from the ptients or from fmily memers if the ptients were unle to consent. tients with unstle trochnteric frcture cused y low-energy trum were considered eligile for the study. Exclusion criteri included highenergy trum, pthologic frctures, open frctures, multiple frctures, Americn Society of Anesthesiologists (ASA) score of V, inility to work efore injury, nd presence of degenertive osteorthritis/ rthritis in the injured hip. A totl of 113 ptients met the inclusion criteri. They were rndomized to FNA-II group (n556) nd n InterTn group (n557), which ws ccomplished with the use of consecutive numered nd seled envelopes sed on computergenerted list. Seled envelopes were opened y the surgeon (K.Z., Y.J.) preopertively. Generl dt were collected from the ptients regrding ge, sex, frcture type ccording to OTA clssifiction, nd ASA score with regrd to preopertive comoridities (Tle 1). Both tretment groups were comprle in terms of generl dt preopertively. The surgicl procedures were comprle etween the 2 groups, other thn the type of nil used. All surgeries were performed y surgeons (B.Y., W.F.) who hd performed t lest 5 procedures independently with either the FNA-II or InterTn nil. Generl nesthesi nd spinl nesthesi were used in oth groups. tients underwent prophylxis for thromosis periopertively nd received prophylctic ntiiotics 30 minutes preopertively. tients were operted on while in supine position trction tle, nd, if possile, closed reduction ws performed with the help of the C rm. Surgery ws performed ccording to the stndrd protocols for the FNA-II nd InterTn nils, which re recommended y the mnufcturer nd hve een descried in erlier studies. 15,16 The FNA-II nil used in the current study is solid titnium nil tht is mm long nd 9, 10, or 11 mm in dimeter. The InterTn nil hs trpezoidl proximl end 180 mm long nd dimeter decresing from mm t the proximl end to 11 mm t the distl end. The proximl end of the nil will ccept 2 cephlocervicl screws: lrger superior 11-mm lg screw nd smller 7-mm compression screw. The smller screw is integrted into the lrger nd hs the effect of creting n ovl screw with composite dimeter of 15.5 mm. MARCH 2013 Volume 36 Numer 3 183

3 n Feture Article Both nils were inserted using percutneous technique. ostopertively, nlgesic cre nd diet were relted to locl stndrds nd equl for oth groups. The 2 groups were compred regrding intropertive time, fluoroscopy time, intropertive lood loss, length of hospitl sty, nd complictions. ostopertively, ll ptients hd suction drins plced for 48 hours nd were given prophylctic ntiiotics for 24 hours. Continuous pssive motion ws used twice dily fter the dringe tues were removed. lin nteroposterior nd lterl rdiogrphs were otined on postopertive dy 1 nd nlyzed for frcture reduction nd implnt position. All ptients were encourged to wlk with full weight ering, while ssisted y physiotherpist, s soon s possile postopertively. Follow-up occurred t 1, 3, 6, nd 12 months postopertively nd yerly therefter. lin nteroposterior nd lterl rdiogrphs were otined t ech visit (Figures 1, 2). All implnt position chnges, complictions, nd fixtion filures were recorded. At ech follow-up, hip rnge of motion; pin in the hip nd thigh; wlking ility score; postopertive complictions, including wound infection nd pulmonry, crdiovsculr, thromoemolic, renl, nd gstrointestinl disorders; frcture complictions, including cutout, implnt rekge, nd revision surgery; length of hospitl sty; nd Hrris Hip Score were recorded. Sttisticl nlyses were performed using SSS version 13.0 softwre (SSS, Inc, Chicgo, Ilinois). All continuous dt were expressed s men6sd. The Mnn- Whitney U test (evluted y the Monte Crlo method) ws used to test hypotheses out men opertive time, intropertive lood loss, length of hospitl sty, nd Hrris Hip Score ecuse the dt from the 2 groups were not normlly distriuted. For ll tests, vlue less thn.05 ws considered significnt. Ctegoricl vriles were nlyzed with the chi-squre test or Fisher s exct test where pproprite. Tle 1 reopertive Dt Dt FNA-II InterTn No. of ptients Sex, No. M/F 19/37 23/34 Men6SD ge, y Side, No. left/right 26/30 19/38 Injury mechnism, No. Fll t home Fll outside AO frcture type, No. A A A A A A ASA score, No Men6SD HHS Arevitions: ASA, Americn Society of Anesthesiologists; HHS, Hrris Hip Score; FNA-II, roximl Femorl Nil Antirottion-Asi. Synthes, Solothurn, Switzerlnd. Figure 1: Anteroposterior rdiogrph showing n unstle proximl femorl frcture of the left hip in mn who fell from his ed nd ws treted with n InterTn nil (Smith & Nephew, Memphis, Tennessee). 1 Figure 2: Anteroposterior rdiogrph showing n unstle proximl femorl frcture of the right hip in mn who fell outside nd ws treted with FNA-II nil (Synthes, Solothurn, Switzerlnd). 2A 2B e288 ORTHOEDICS Helio.com/Orthopedics

4 InterTn Nil Vs FNA-II Zhng et l Tle 2 eriopertive Vriles Tle 3 Intropertive Complictions Vrile Anesthesi, No. FNA-II (n556) Results eriopertive dt re shown in Tle 2. Open reduction ws performed in 12 ptients, 4 in the FNA-II group nd 8 in the InterTn group (5.087). Men opertive time ws significntly longer in the InterTn group ( minutes) thn in the FNA-II group ( minutes) (5.012). Intropertive lood loss ws significntly higher in the InterTn group ( ml) thn in the FNA- II group ( ml) (5.007). Fluoroscopy time ws significntly longer in the InterTn group ( minutes) thn in the FNA-II group ( minutes) (5.026). On postopertive rdiogrphs, frcture reduction ws considered ntomicl in 85 ptients (44 in the FNA-II group nd 41 in the InterTn group), nd im- InterTn (n557) Generl Spinl Men opertive time, min Men lood loss, ml Men fluoroscopy time, min Men hospitl sty, d Open reduction, No Reduction results, No..562 Antomicl Acceptle 9 11 oor 3 5 Implnt position, No..285 Optiml Suoptiml 9 13 Tip-pex distnce, mm 26.6 (2.9) 23.7 (2.1).718 Arevition: FNA-II, roximl Femorl Nil Antirottion-Asi. Synthes, Solothurn, Switzerlnd. Compliction FNA-II (n556) No. InterTn (n557) Totl Itrogenic femorl shft frcture Lterl greter trochnter frcture plnt position ws considered optiml in 92 ptients (47 in the FNA-II group nd 45 in the InterTn group). No significnt differences existed in the qulity of reduction etween the implnts nd frcture types (31-A2 nd -A3). The tippex distnces were comprle etween the 2 groups. Men hospitl sty did not differ significntly etween the 2 groups (5.391). Nineteen locl intropertive complictions occurred, 9 in the FNA-II group nd 10 in the InterTn group (5.973). Itrogenic femorl shft frctures were noted in 3 ptients (2 in the FNA- II group nd 1 in the InterTn group; 5.735), ll of whom were short, older dult Chinese women treted with 200- mm FNA-II or InterTn nil. The new injury ws treted successfully with long FNA-II or InterTn nil insted. Seven lterl greter trochnter frctures cused y insertion of the nil were oserved intropertively (1 in the FNA- II group nd 6 in the InterTn group; 5.008). They were minor splits in the lterl cortex of the proximl femur in more unstle frcture ptterns (31-A2.3 nd 31-A3.3) with just cceptle reduction nd were successfully treted with conservtive mngement nd delyed full weight ering. Distl interlocking difficulty ws oserved in 2 ptients (1 in ech group). The proximl end of the nil penetrted the top of the trochnter in 4 ptients in the FNA-II group nd 1 in the InterTn group (5.018) (Tle 3). Of the 113 ptients treted during the study period, 20% were not ville for follow-up. Five (4.4%) were lost to followup t 12 months (3 in the FNA-II group nd 2 in the InterTn group) ecuse they were too ill, nd nother 15 (13.3%) died within 12 months postopertively (7 in the FNA-II group nd 8 in the InterTn group; 5.42). This left 93 ptients for clinicl study (46 in the FNA-II group nd 47 in the InterTn group). Men follow-up ws months (rnge, months). Men time to one heling ws weeks (rnge, weeks) Distl interlocking prolem roximl end of nil penetrting top of trochnter Arevition: FNA-II, roximl Femorl Nil Antirottion-Asi. Synthes, Solothurn, Switzerlnd. MARCH 2013 Volume 36 Numer 3 e289

5 n Feture Article in the FNA-II group nd weeks (rnge, weeks) in the InterTn group. Six min postopertive complictions occurred in the study, including femorl shft frcture, cutout, lterl lde migrtion, hemtom, deep infection, nd superficil wound infection. Two cutouts occurred through the femorl hed nd neck in the FNA-II group (including 1 helicl lde penetrting into the pelvis), ut none occurred in the InterTn group. One ptient in the FNA-II group sustined fll 2 months postopertively, resulting in femorl shft frcture, which ws treted with plting. Four ptients experienced lterl lde migrtion in the FNA-II group, ut none did in the InterTn group. No significnt differences existed etween the 2 groups regrding other complictions (Tle 4). Generl complictions were comprle etween the 2 groups. Men femorl neck shortening cused y frcture compression ws 1.1 mm (rnge, 0-13 mm) in the FNA-II group nd 3.2 mm (rnge, 1-24 mm) in the InterTn group, which ws significnt difference (5.021). No significnt etween-group differences existed with regrd to wlking ility nd hip rnge of motion t finl followup. Hrris Hip Scores showed no differences in function etween the 2 groups t finl follow-ups (Tle 5). Severl ptients reported hip nd thigh pin during the follow-up period: 14 (30.4%) ptients in the FNA-II group nd 5 (10.6%) in the InterTn group) (5.001). The incidence of muscle wekness ws higher in the InterTn group (n58; 17.0%) thn in the FNA-II group (n54; 8.7%), ut it ws not significntly different (5.092). Other symptoms were comprle etween the groups. Discussion The current study hd men opertive time of minutes in the InterTn group, longer thn tht reported y Ruecker et l 16 t minutes. This my e ssocited with frcture type. All Compliction Outcome Tle 4 ostopertive Complictions t Finl Follow-up FNA-II (n546) Tle 5 Functionl Outcomes t Finl Follow-up FNA-II (n546) Men6SD InterTn (n547) Wlking ility score Hip rnge of motion, deg Hrris Hip Score Arevitions: deg, degrees; FNA-II, roximl Femorl Nil Antirottion-Asi. Synthes, Solothurn, Switzerlnd. No. InterTn (n547) Locl complictions Superficil wound infection Deep infection Hemtom Cutout Lterl migrtion hip screw Femorl shft frcture Femorl neck shortening, mm Hip pin Thigh pin Delyed union Reopertion Generl complictions Deep venous thromosis ulmonry emolism Crdiovsculr disorder ressure sore Urinry trct infection Arevition: FNA-II, roximl Femorl Nil Antirottion-Asi. Synthes, Solothurn, Switzerlnd. of the frctures in the current study were unstle nd therefore more difficult to reduce. It my lso e relted to the design of the nil. The InterTn nil hs trpezoidl proximl end tht is not esy to insert into poorly reduced mrrow cvity, nd insertion of the interlocking nil my led to loss of reduction. Repeted e290 ORTHOEDICS Helio.com/Orthopedics

6 InterTn Nil Vs FNA-II Zhng et l reduction nd mnipultion will increse opertive nd fluoroscopy time nd intropertive lood loss, especilly in more unstle frcture types (AO/ASIF 31-A2.3 nd 31-A3.3). This prolem is frequently seen in short, older dult Chinese women, especilly those with osteoporosis. When reming is not enough for inserting the nil, the lterl cortex of the proximl femur my split s the nil is hmmered into the mrrow cvity. In the current study, this compliction occurred in 6 ptients, ll older dult women. In ddition, perfect implnt position cnnot lwys e chieved ecuse it is difficult to insert the nil completely into the cvity even when the lterl wll ecomes thin fter repeted reming. The uthors suggest tht the FNA-II nil should e the first choice in the tretment of older dult women with osteoporosis or ptients with more unstle frcture ptterns, nd, if possile, open reduction should e performed. The decrese in the dimeter of the InterTn nil my lso e helpful, ut more ntomic mesurements re needed. Hip nd thigh pin is common compliction in previous reports nd occurred in up to 90.1% of ptients during follow-up. 14,19 One explntion my e the inevitle dmge to the gluteus medius tendon during pproprite plcement of the intrmedullry nil, s reported in previous studies. 20 Another explntion my e the chronic muscle injury cused y the over-long proximl end of the nil protruding into the gret trochnter, ut this hs een significntly improved in with FNA-II compred with the FNA. The rte of hip nd thigh pin in this study ws significntly lower thn tht in previous reports, 14,19 nd higher in the FNA-II group thn in the InterTn group. Similr results were reported y Lv et l 15 nd Ruecker et l, 16 who reported no hip nd thigh pin with the use of the FNA-II or InterTn nil. This my e relted to the overll instility of the one-implnt constructed uneven stress distriution etween the implnts nd inner one cortex. The FNA-II nil, the dimeter of which is uniform from the ending point to the distl tip, cnnot lwys otin good contct with the one from the lesser trochnter to the isthmus. Moreover, the 200-mm-long distl tip of the intrmedullry FNA-II nil is ised to the nterior side of the inner cortex so tht stress concentrtion cn more esily occur round, mking the femorl shft more vulnerle to frcture compred with the InterTn nil or leding to long-term middle thigh pin. In contrst, the dimeter of the InterTn nil tpers from 13.5 mm in the middle to 11 mm t the tip, which is in line with the vrition of the proximl femorl modulrly cvity nd more closely integrted with the inner cortex. Such design hs stress dispersion effect on the InterTn nil nd inner cortex nd voids stress overconcentrtion round the nil tip. In ddition, the clothes-pin distl tip of the 22-mm nil contriutes to lleviting this prolem, reducing the overll cross-sectionl stiffness of the implnt distlly. 16 Vrus collpse of the hed nd neck cused y lg screw cutout or lterl protrusion is one of the most common postopertive complictions tht led to surgicl filure in intertrochnteric frctures. Cutout rtes, including the Z effect, hve een reported to rnge from 3% to 10% 7,9,21-24 with the Gmm nil, roximl Femorl Nil, nd dynmic hip screw ut re lower with the FNA (1%- 3%) 14 nd with the InterTn (0%) nil. 16 Becuse the screw is rottionlly unstle within the one when using single lg screw, flexion-extension of the lim results in loosening of the one-screw interfce, with the screw secondrily cutting out. Biomechnicl studies nd clinicl reports hve demonstrted tht the InterTn nd FNA nils hve good ntirottion performnce. 14,17,19 Although other devices, such s the roximl Femorl Nil, feture 2 seprte screws plced into the hed nd neck frgments in reconstruction mode nd tend to resist rottion of the hed nd neck segment during hip motion, these devices re ssocited with the Z effect, 9,25 where the superior screw ers disproportionte mount of lod during weight ering. 26 Neck shortening is concerning to surgeons Although controlled frcture collpse on weight ering is the key principle in dynmic devices feturing sliding screw, uncontrolled collpse cn result in uncceptle shortening of the hed nd neck segment (neck mlunion), resulting in excessive shortening of the neck nd, secondrily, the lim. A previous study suggested tht excessive shortening of the neck (more thn 5 mm) my cuse wekness in the gluteus medius nd thus limit hip joint movement. 28 The InterTn nil uses hyrid worm-ger mechnism to convert rottionl forces into liner compression. This chrcteristic cn void shortening during heling. Most ptients treted with the InterTn nil in the current study experienced pproximtely 3 mm of shortening of the neck segment, ut fewer cses of shortening were oserved in the FNA-II group. By contrst, heling time ws significntly shorter in the InterTn group thn in the FNA-II group. However, no significnt differences existed in finl functionl outcomes etween the 2 groups. The InterTn nil cn reduce heling time nd is good choice for elderly ptients who need to wlk ering full weight in the erly postopertive period. Conclusion This study compred the clinicl outcomes of the FNA-II nd InterTn nils. The results suggest tht men opertive nd fluoroscopy time nd intropertive lood loss were greter in the InterTn group thn in the FNA-II group. Although intropertive complictions were comprle etween the groups, the InterTn nil ws more likely to cuse proximl lterl femorl frcture during insertion, wheres the FNA-II nil ws more likely to penetrte the proximl end of the femur. Hrris Hip Scores nd cutout MARCH 2013 Volume 36 Numer 3 e291

7 n Feture Article rtes were comprle etween the groups, ut the rte of thigh pin ws lower in the InterTn group. The InterTn nil my result in more enefits for ptients with unstle trochnteric frctures ut needs some improvement to reduce the intropertive complictions. References 1. Clyer MT, Buze RJ. Moridity nd mortlity following frctures of the femorl neck nd trochnteric region: nlysis of risk fctors. J Trum. 1989; 29(12): Kuik EN, Bong M, rk SS, Kummer F, Egol K, Kovl KJ. Intrmedullry fixtion of unstle intertrochnteric hip frctures: one or two lg screws. J Orthop Trum. 2004; 18(1): Louignc F, Chs JF. A newly designed locked intrmedullry nil for trochnteric hip frctures fixtion: results of the first 100 trochnteric implnttions. Orthop Trumtol Surg Res. 2009; 95(2): Butt MS, Krikler SJ, Nfie S, Ali MS. Comprison of dynmic hip screw nd gmm nil: prospective, rndomized, controlled tril. Injury. 1995; 26(9): Bnn H, Al-Sti A, Jimuli T, Hrt AJ. The tretment of unstle, extrcpsulr hip frctures with the AO/ASIF proximl femorl nil (FN) our first 60 cses. Injury. 2002; 33(5): Al-yssri G, Lngstff RJ, Jones JW, Al- Lmi M. The AO/ASIF proximl femorl nil (FN) for the tretment of unstle trochnteric femorl frcture. Injury. 2002; 33(5): Alred J, Lderig A, lnc D, nigu L, Serl F. Complictions nd technicl prolems with the gmm nil. Int Orthop. 1996; 20(1): Miedel R, onzer S, Tornkvist H, Soderqvist A, Tidermrk J. The stndrd Gmm nil or the Medoff sliding plte for unstle trochnteric nd sutrochnteric frctures. A rndomised, controlled tril. J Bone Joint Surg Br. 2005; 87(1): Tyllinkis M, ngopoulos A, pdopoulos A, psimos S, Mousfiris K. Tretment of extrcpsulr hip frctures with the proximl femorl nil (FN): long term results in 45 ptients. Act Orthop Belg. 2004; 70(5): Windolf J, Hollnder DA, Hkimi M, Linhrt W. itflls nd complictions in the use of the proximl femorl nil. 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