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1 A-PDF Merger DEMO : Purchase from to remove the watermark ABSTRACT BACKGROUND AND OBJECTIVES: Incidence of intertrochanteric fractures has increased significantly during recent decades and this tendency will probably continue in near future due to rising age of population. Closed methods of treatment for intertrochanteric fractures have shown higher mortality rates & have largely been abandoned. Rigid internal fixation and early mobilization has been standard method of treatment. This study is intended to compare the results of OR and IF of IT fractures by DHS and PFN. METHODOLOGY: This is a prospective study of 30 cases of IT fracture admitted to Bowring and Lady Curzon and Victoria Hospitals between October 2006 and July 2008 treated with PFN and DHS. Cases were taken according to inclusion and exclusion criteria i.e., fresh IT fracture in adults. Pathologic fractures, multiple fractures, fractures in children, old neglected fractures were excluded from the study. RESULTS: In our series of 30 patients, there were 19 female and 11 male. Minimum age was 16years, maximum 85 years with mean age of 48.6years. Most of the people were between years. Fall from height accounted for 40% of cases. Right side was more common, accounted for 70% of cases. Boyd and Griffin type II fracture accounted for

2 53.3% of cases. Mean duration of hospital stay was 26 days in both PFN and DHS groups. Mean time of full weight bearing was 10.6 weeks for PFN group and 14.8 weeks for DHS group. Out of 30 cases, 5 cases were lost in follow up and 2 cases died. Good to excellent results were seen in 81.8% of cases in PFN group and 63.33% in DHS group. CONCLUSION: From the study, we consider PFN as better alternative to DHS in the treatment of intertrochanteric fractures but is technically difficult procedure and requires more expertise compared to DHS. With experience gained from each case operative time, radiation exposure, blood loss and intraoperative complications can be reduced in case of PFN

3 THESIS Submitted to the University of Seychelles, American Institute of Medicine, in partial fulfillment of the requirements for the degree of USAIM s M.Ch. ( Orth ) TITLE A COMPARATIVE PROSPECTIVE STUDY OF DYNAMIC HIP SCREW & PROXIMAL FEMORAL NAIL IN THE TREATMENTOF INTERTROCHANTERIC FRACTURES By Dr. RAMESH KRISHNA. K M S ( Ortho ) DEPARTMENT OF ORTHOPAEDICS BANGALORE MEDICAL COLLEGE & RESEARCH INSTITUTE BANGALORE. March to August 2009

4 2 TABLES OF CONTENTS No. CONTENT PAGE 1 COPYRIGHT TRANSFER AND AUTHOR AGREEMENT 3 2 INTRODUCTION 4 3 OBJECTIVES 5 4 MATERIALS & METHODS 5 5 OUTCOMES 12 6 ANALYSIS 13 7 DISCUSSION 24 8 CONCLUSIONS & RECOMMENDATIONS 26 9 REFERENCES 28

5 COPYRIGHT OWNERSHIP / TRANSFER & AUTHOR AGREEMENT CERTIFICATE 3 This is to certify that the Dissertation / Thesis submitted to the University of Seychelles, American Institute of Medicine, in partial fulfillment of the requirements for the degree of USAIM s M.Ch. ( Orth ), which is titled A COMPARATIVE PROSPECTIVE STUDY OF DYNAMIC HIP SCREW & PROXIMAL FEMORAL NAIL IN THE TREATMENT OF INTERTROCHANTERIC FRACTURES is the bonafide original work done by me. It has not been published in any of the national or international journals & I declare sole ownership of the contents & copyrights of the same. Place : Bangalore Date : 06 / 06 / 2009 sd/- ( Dr. Ramesh Krishna. K ) M.B.B.S., M.S ( Ortho)., Fellowship in Trauma & Ortho ( U.K )., Fellowship in Arthroscopic Surgery ( Hyd ) Professor, Dept. of Orthopaedics, Bangalore Medical College & Research Institute, Bangalore & Orthopaedic Surgeon, Victoria Hospital, Bangalore. ( Tel : Ext-272 ) Residence : # 483 / 36, 19th Main, 34th Cross, 4th T Block, Jayanagar, Bangalore Tel : Mobile :

6 INTRODUCTION 4 INCIDENCE : Intertrochanteric fractures are commonly seen in patients over 70yrs of age, mostly due to trivial trauma. Incidence has increased primarily due to increasing life span & more sedentary life style brought by urbanization. In younger population, IT fracture occurs due to high velocity trauma. SEX INCIDENCE & MORTALITY : These fractures is more in females compared to males due to osteoporosis. Mortality ranges between 15% - 20 %. TREATMENT : IT fractures can be managed by conservative or operative methods. Conservative methods were the treatment of choice until 1960 before the introduction of new fixation devices. As conservative methods resulted in higher mortality rates and complications like decubitus ulcer, urinary tract infections, pneumonia, thromboembolic complications. these methods have been abandoned. Conservative methods are now indicated under 2 conditions, (i) Elderly person with high medical risk for anesthesia and surgery. (ii) Non ambulatory patient with minimal discomfort following injury. Rigid Internal fixation and early mobilization has been the standard method of treatment. FACTORS determininig the Strength of fracture implant assembly depends on Bone quality, Fragment geometry, Reduction, Implant type & Implant placement. Surgeon can control only the quality of reduction, choice of implant and its placement. IMPLANTS for the fixation of intertrochanteric fractures can broadly be divided into 1. Extramedullary devices, ex:-.dhs 2. Intramedullary devices ex:- PFN DHS with side plate assembly is most commonly used device for fixation of intertrochanteric fractures.it is a non collapsible fixation device, which permits the proximal fragment to collapse or settle on the fixation device seeking its own position of stability.

7 5 The latest implant for management of intertrochanteric fracture is PFN. This implant is a cephalomedullary device and has many potential advantages like 1. Being intramedullary, load transfer is more efficient. 2. Shorter lever arm results in less transfer of the stress & less implant failures. 3. Advantage of controlled impaction is maintained. 4. Sliding is limited by intramedullary location, so less shortening & deformity. 5. Shorter operative time, less soft tissue dissection and less blood loss. In view of these conditions, this study is taken up to compare the results of DHS and PFN in the treatment of intertrochanteric fractures. OBJECTIVES To determine the rate of union, complications, operative risks and functional outcomes in intertrochanteric fractures treated with DHS and PFN. To compare the results obtained. To determine the effectiveness of PFN in comparison to DHS in treatment of intertrochanteric fractures. MATERIALS & METHODS The present study consists of 30 adult patients with intertrochanteric fractures of femur who were treated with DHS and PFN at Victoria Hospital & Bowring and Lady Curzon Hospital, attached to Bangalore Medical College & Research Institute. This study was carried out to study the results of intertrochanteric fractures treated with DHS and PFN. All the 30 patients were followed up at regular interval. DATA COLLECTION : After the patient with intertrochanteric fracture was admitted to hospital all the necessary clinical details were recorded in proforma prepared for this study. After the completion of the hospital treatment, patients were discharged and called for follow up at out patient level, at regular intervals for serial clinical and radiological evaluation.

8 6 MANAGEMENT OF PATIENT : As soon as the patient with suspected IT fracture was seen, necessary clinical and radiological evaluation was done and admitted to ward after necessary resuscitation and splintage with skeletal traction. The following Investigations were done routinely on all these patients preoperatively. Blood Hb%, Bleeding time, Clotting time, Blood grouping and Cross matching, Fasting and Post prandial blood sugar, Blood urea and Serum Creatinine Urine Albumin, Sugar, Microscopic examination. X-ray Pelvis with both hips (AP view), Chest X ray PA view in necessary patients All the patients were evaluated for associated medical problems and were referred to respective department and treated accordingly. Associated injuries were evaluated and treated simultaneously. The patients were operated on elective basis after overcoming the avoidable anaesthetic risks. PRE - OPERATIVE PLANNING DYNAMIC HIP SCREW. 1 Length of Richard s Length of Richard s screw is measured from tip of the head to screw the base of greater tronchanter on AP view X ray subtracting magnification 2 Neck - Shaft angle Neck shaft angle is determined using goniometer on X ray AP view on unaffected side 3 Length of side plate Length of the side plate is determined to allow purchase of atleast 8 cortices to the shaft distal to the fracture PROXIMAL FEMORAL NAIL. 1 Determination of Nail diameter was determined by measuring diameter of the Nail diameter femur at the level of isthmus on an AP X ray 2 Determination of Neck shaft angle was measured in unaffected side in AP X ray Neck - Shaft angle using goniometer 3 Length of the nail A standard length PFN (250mm) was used in all our cases

9 IMPLANT DETAILS : DYNAMIC HIP SCREW 7 The implant consists of lag screw, a compression screw & barrel attached to side plate. Lag Screw Compression Screw Barrel side plate is available in length from mm. of 19mm allows a compression of 5mm in angles of 125,130, 135, 140 degrees & from 2-12 holes The key and slot mechanism of the implant prevents rotational movements of the proximal fragments. 4.5mm cortical screws used to fix the side plate with shaft..most proximal hole in the side plate allows insertion of 6.5 mm cancellous screw which can be used for fixation of lesser tronchanter or a larger posteriomedial fragment. In our study we used lag screw of mm and a side plate that allowed a purchase of atleast 8 cortices with shaft of femur and degrees angled plate depending upon the neck shaft angle determined preoperatively. A minimum of 4 cortical screws were used to fix the side plate with the shaft. DHS INSTRUMENTATION

10 8 Screw Drivers Guide Wires Drill Bits Cannulated Screws Cortical Screws DHS BARELL PLATES RICHARD SCREWS OF DIFFERENT LENGTHS

11 IMPLANT DETAILS : PROXIMAL FEMORAL NAIL 9 The implant consists of proximal femoral nail, self tapping 6.5mm pin, self tapping 8mm femoral neck screw, 4.9mm distal locking screw and an end cap.pfn is made up of either 316L stainless steel or titanium alloy. PFN comes in following sizes Length Diameter Neck shaft angle range Standard PFN : 250 mm. Long PFN : 340, 380, 420 mm. 9, 10, 11, 12 mm 125,130, 135 degrees. The nail is having 14mm proximal diameter. This increases the stability of the implant. There is 6 degrees mediolateral valgus angle which prevents varus collapse of fracture, even when there is medial communition. The distal diameter is tapered to 9-12 mm, which also has groove to prevent stress concentration at the end of the nail and avoids fracture of the shaft distal to the nail. Proximally it has two holes, the distal one for insertion of 8mm neck screw which acts as a sliding screw and the proximal one is for 6.5mm hip pin which helps to prevent the rotation. Distally pin has two holes for insertion of 4.9mm locking screws of which one is static and the other one is dynamic which allows dynamization of 5mm. In our study we used the standard length PFN of 250mm with distal diameter of 9,10, 11. The proximal diameter of the nail is 14mm. Proximal derotation screw of 6.5mm and distal lag screw of 8mm. Distal locking is done with self tapping 4.9mm cortical screws, one in static mode and the other in dynamic mode allowing 5mm dynamization. The nail is universal with 6 degrees of mediolateral valgus angulation and with neck shaft angle of 135 degrees. End cap was not used.

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14 OUTCOMES 12 ANATOMICAL RESULTS ANATOMICAL GOOD FAIR RESULTS Shortening <1cm >1cm Varus deformity Absent Present Hip movements Full range Restricted Knee movements Full range Restricted FUNCTIONAL RESULTS - Assessed based following hip scoring system adopted. Hip pain No pain 2 points Occasional pain 1 point Constant pain 0 point Ambulatory status Waking without aid Walking with aid Not able to walk 2 points 1 point 0 point Ability to squat Able to squat Unable to squat 1 point 0 point Sitting crossed legged Able to sit Unable to sit 1 point 0 point Interpretation Excellent Good Fair Poor 6 points 4-6 points 2-4 points <2 points

15 ANALYSIS 13 The following observations were made from the data collected during the study of 30 cases of intertrochanteric fractures treated by proximal femoral nail and DHS in the Department of Orthopaedics in Bowring and Lady Curzon Hospital and Victoria Hospital, attached to Bangalore Medical College between October 2006-July AGE DISTRIBUTION : In our study maximum age was 85 years and minimum age was 16 years. Most of the patients were between 20-60years. Mean age was 48.6years. TABLE 1: AGE DISTRIBUTION Age group Number of cases Percentage PFN DHS PFN DHS % 3.33% % 9.99% % 16.65% % 19.99% % 0 Total % 50% GRAPH 1 : Age distribution Age distribution Number of cases Total Age group PFN DHS

16 SEX DISTRIBUTION 14 Male : 11 Female : 19 TABLE 2 : Sex distribution Sex Number of cases Percentage PFN DHS PFN DHS Male % 31.11% Female % 19.99% Total % 50% GRAPH 3 : Sex distribution Sex Number of cases Male Female Total Number of cases PFN Number of cases DHS

17 NATURE OF VOILENCE 15 Slip and fall -9 Fall from height 12 RTA-9 TABLE 3: Nature of violence Nature of violence Number of cases Percentage PFN DHS PFN DHS Slip and fall % 13.33% Fall from height % 26.64% Road traffic accident % 9.99% Total % 50% GRAPH 3 : Nature of violence Nature of violence Number of cases Number of cases PFN 4 Number of cases DHS 2 0 Slip and fall Fall from height Road traffic accident Total Nature of violence

18 SIDE AFFECTED 16 Right : 21 Left :9 TABLE 4:Side affected Side affected Number of cases Percentage PFN DHS PFN DHS Right % 29.99% Left % 19.99% Total % 50% GRAPH 4: Side affected Side affected Number of cases Right Left Total Side affected Number of cases PFN Number of cases DHS ASSOCIATED INJURIES One patient had ipsilateral pelvic fracture which was managed by external fixation, during fixation of intertrochanteric fracture. No other patient had any other associated injuries.

19 TYPE OF FRACTURE: 17 Trochanteric fractures are classified according to BOYD AND GRIFFIN CLASSIFICATION TABLE 5 : Type of fractures Type of fracture Number of cases Percentage PFN DHS PFN DHS Type I % 13.33% Type II % 29.99% Type III % 6.66% Type IV 0 0 0% 0% Total % 50% GRAPH 5 : Type of fracture Type of Fracture Total Type of fracture Type IV Type III Type II Number of cases DHS Number of cases PFN Type I 4 5 Number of cases

20 TIME OF SURGERY 18 All the cases included in our study group were fresh fractures who underwent surgery at the earliest possible in our set up. The delay was due to associated injuries and medical condition of the patient. All the patients were operated at an average interval of 10.9 days from the day of trauma. INTRAOPERATIVE DETAILS In our study we considered various intra operative parameters like radiographic exposures, duration of surgery and amount of blood loss. Radiographic exposure was more for PFN where closed reduction was done and for comminuted fractures with difficult reduction. Exposure was more for initial few cases, as we got experienced radiation exposure was less. Duration of surgery was more for PFN compared to DHS and for initially operated cases. Blood loss was measured by mop count and collection in suction. Blood was more for DHS compared to PFN and in PFN there was more blood loss where open reduction was performed. TABLE 6: INTRAOPERATIVE DETAILS INTRAOPERATIVE DETAILS PFN DHS Mean radiographic exposure (no of times) Mean duration of operation (in minutes) Mean blood loss(in milli litres)

21 INTRAOPERATIVE COMPLICATIONS: DHS TABLE 7 : INTRAOPERATIVE COMPLICATION DHS. Complications Number of cases Percentage Improper positioning of Richard screw % Varus angulation % Drill bit breakage % 19 There were comparatively minimal intraopertive complications encountered during DHS fixation. Reduction was comparatively easier as open reduction was performed in all the cases. However difficulties in reduction were encountered in cases that were delayed and in case of comminuted fractures. In 5 of 15 cases there was improper placement of Richard s screw. The screw was placed superiorly. Drill bit breakage was encountered in one case as the entry point was made posteriorly and there was difficulty in drilling through posteriorly placed plate. Difficulties were encountered in reverse oblique fractures as the fracture site extended to entry point. Screw had to be inserted more proximally which resulted in varus angulation. Comparatively DHS fixation was technically easier and had lesser intraoperative complications. TABLE 8 : INTRAOPERATIVE COMPLICATIONS OF PFN. Complications Number of cases Percentage Failure to achieve closed % reduction Fracture of lateral cortex % Fracture displacement by % nail insertion Failure to put derotation % screw Failure to lock distally 0 0% Jamming of nail 0 0% Drill bit breakage 0 0% Guide wire breakage 0 0%

22 20 In our study we encountered certain complications intraoperatively. Most of these occurred in the first few cases. There was difficulty in achieving closed reduction particularly in case of comminuted displaced and reverse oblique fractures, where the surgery was delayed. Open reduction had to be performed in 7 of 15 cases of PFN. There was iatrogenic fractures of the lateral cortex of proximal fragment in 3 of 15 of PFN. This occured in initial cases probably due to wrong entry point and osteoporotic bone. 2 of 15 cases, we failed to put antirotation screw, it could not be accommodated in the neck after putting neck screw. 2 of the cases antirotation screw had to be removed after inserting as it was penetrating superior cortex of the neck. In 3 of the cases anatomic reduction could not be achieved as fracture extended to the entry point of the nail, nail opened up fracture and prevented anatomic reduction. We had no difficulties in distal locking. All the cases were locked distally with atleast one locking bolt. There were no instances of drill bit breakage or jamming of nail. POST OPERATIVE COMPLICATIONS There was 1 case of post operative infection where open reduction was performed and fracture was fixed with PFN. There was no infection among the DHS patients. DELAYED COMPLICATIONS TABLE 9 : DELAYED COMPLICATION - DHS Complications Number of cases Percentage Hip stiffness 0 0% Knee stiffness 0 0% Non union 0 0% Shortening of >1cm % Varus malunion % Screw cut out was seen in 2 cases, where the implant had to be removed. Varus malunion was seen with 1 case. Shortening of more than 1cm was seen in 1 case. There were no cases of non union.

23 21 TABLE 10 : DELAYED COMPLICATIONS - PFN Complications Number of cases Percentage Hip stiffness % Knee stiffness % Non union 0 0% Shortening of >1cm % Varus malunion % Implant failure 0 0% There were 2 cases of malunion in patient where the fracture was severely communited. There were 2 cases with shortening more than 1cm. There were no cases of screw cutout & nail breakage.there was no case of femoral shaft fracture or non union. ANALYSIS TABLE 11 : ASSESMENT OF RESULTS PFN DHS Mean duration of Hospital stay (in days) Mean time for full weight bearing (in weeks) Mobility after surgery(6 weeks post operatively) Independent 9 7 Aided 3 5 Non-ambulatory 1 0 Mean range of movements(6weeks post operatively) Hip-joint(0-110 degrees) 12/13 12/12 Knee joint(0-120 degrees) 12/13 12/12 In our study the average duration of hospital stay was 26.13days for DHS patients and 26.8 days for PFN patients. The mean time of full weight bearing was 10.6weeks for

24 22 PFN and 14.8 weeks for DHS. All patients enjoyed good, hip and knee range of motion except for 1 patient of PFN who had extensive lateral cortex communition during surgery and had to be immobilized for prolonged period. All the patients except 1 case of PFN was ambulatory with or without walking aid at 6 weeks follow up. FOLLOW-UP All patients were followed up at 2 weeks interval till fracture union, at 12 weeks & at 6 months post operatively. 5 patients failed to attend the first follow up & were lost for further follow up (3 cases of DHS and 2 PFN). At each follow up radiographs of upper femur and hip were taken to assess the fracture union, implant failure & screw cut out. ANATOMICAL RESULTS Anatomical results were assessed by shortening, hip and knee range of movements and varus deformity. TABLE 12 : ANATOMICAL RESULTS Anatomical Result Number of cases PFN DHS Shortening more than 1cm 2 1 Varus deformity 2 1 Restriction of Hip movement 2 4 Restriction of Knee movement 1 0 FUNCTIONAL RESULTS In our series of 30 patients 5 cases were lost for follow up and 2 cases expired due to associated medical problems. Functional and Anatomical results were assessed by taking the remaining 23 cases into consideration. PFN-11 DHS-12

25 23 Interpretation of functional results of DHS Functional Results Number of cases Percentage Excellent 6 50% Good % Fair % Poor % Interpretation of functional results of PFN Functional Results Number of cases Percentage Excellent % Good 1 9.1% Fair 1 9.1% Poor 1 9.1% GRAPH 6: FUNCTIONAL RESULTS OF PFN AND DHS FUNTIONAL RESULTS PERCENTAGE OF CASES 80% 70% 60% 50% 40% 30% 20% 10% 0% Excellent Good Fair Poor RESULT DHS PFN

26 DISCUSSION 24 The treatment of intertrochanteric fracture is still associated with some failures. High stress concentration that is subject to multiple deforming forces, high incidence of complications reported after surgical treatment, compels the surgeon to give a second thought regarding selection of proper implant. DHS : The most commonly used method of fixation is sliding screw system. PFN : The AO ASIF in 1996, therefore developed the Proximal Femoral Nail with an antirotation hip pin together with a smaller distal shaft diameter which reduces stress concentration to avoid failures. From mechanical point of view an intramedullary device inserted by means of minimally invasive procedure seems to be better in elderly patients. Closed reduction preserves the fracture heamatoma, an essential element in consolidation process. Intramedullary fixation allows the surgeon to minimize soft tissue dissection, there by reducing surgical trauma, blood loss, infection and wound complications. Other Studies Our Study Menez and Daneil conducted a study on However no such complications was 155 cases of intertrochanteric fractures reported in our study. treated with PFN, and found 2% failure of fixation A study of 20 patients of unstable This correlated with our study where the intertrochanteric fractures treated with PFN duration of hospital stay was 26 days in and DHS by Barathi and Arshad, was both cases, average blood loss was 240 conducted in They found duration of and 320 ml, persistent hip pain was seen in stay for PFN and DHS were 14 and 22 1/11 and 2/12 cases of PFN and DHS days, blood loss was 275 and 475ml, respectively. persistent hip pain was seen in 3% and 9% respectively. In a study, by Pajarein and Lindal, of 108 In our study mean time for full patients of pertrochanteric fractures treated weight bearing for DHS was 14.8 weeks with DHS and PFN, found PFN allowed while that for PFN was 10.6 weeks. 9 of 13 faster restoration of post operative walking patients treated with PFN had indepent ability when compared with DHS. mobility while 7 of 12 patients of DHS had independent mobility.

27 25 In our study, intertrochanteric fracture was common due to fall from height, age ranged between years, mean age of 48.6 years. Females were common contributing to 64%. Right sided fractures were common accounting for 70%. Type II Boyd and Griffin fractures were common, consisted of 53.3%. Type I and Type III were 30% and 16.6% respectively. Mean frequency of radiaton exposure were 70 and 40 times mean duration of duration of operation 100 and 80 minutes, mean blood loss was 240ml and 320 ml for PFN and DHS respectively. INTRAOPERATIVELY : Among DHS, intraopertively had fewer complications which included improper placement of the screw in 5 cases, varus angulation in 3 cases, drill bit breakage in 1 case. Among PFN, 7 cases had to undergo open reduction, iatrogenic fracture of lateral cortex was seen in 3 cases, 3 cases fracture got displaced by nail insertion, 4 cases antirotaton screw could not be put in. POST OPERATIVELY 1 case of PFN had wound infection and none of the DHS cases got infected. HOSPITAL STAY was 26 days in both cases, mean time of full weight were 10.6 and 14.8 in PFN and DHS. All patients were mobile at the end of 6 weeks with or without walking aid except for one case of PFN. 9/13 and 7/12 cases of PFN and DHS had independent mobility FOLLOW UP : In our 30 cases, 5 patients were lost for follow up and 2 cases died due to associated medical problems. Excellent results were seen in 50% and 72.73%, good in and 9.1% cases of DHS and PFN respectively.

28 26 CONCLUSIONS & RECOMMENDATIONS In the present study of 30 patients of intertrochanteric fractures, 15 cases were treated with PFN and 15 cases with DHS. The data was assessed, analyzed, evaluated and following conclusions were made. 1. Age : Intertrochanteric fractures common between years and years. 2. Etiology : In young patients it was due to high velocity trauma. Fall from height being the common mechanism of injury. slip and fall was common mechanism in elderly. 4. Sex : It was more common in females due to post menopausal osteoporosis. 5. Associated injuries : were more common in high velocity trauma. 6. Treatment : Early reduction and internal fixation increases patients comfort, facilitates nursing care, helps in early mobilization of patients and decreases hospital stay. 7. Reduction in fracture can be achieved by open or closed means and fixed by Extramedullary or Intramedullary devices. 8. PFN has the following advantages - controlled collapse at fracture site and is biomechanically sound - can be done by closed means - prevents excess collapse at fracture site, thus maintaining neck length - Two screws placed in neck provides rotational stability 9. In PFN entry point determination is crucial particularly in elderly with osteoporotic bones as wrong entry point may result in iatrogenic comminution of lateral cortex. 11. Post operatively : Early mobilization can be begun in case of PFN as it is a load sharing device and because of its design. 13. Results : Fracture union and functional results (ability to sit crossed leg, squat, absence of hip pain, independent mobility) was better with PFN. 14. Complications : in both PFN and DHS can be avoided with proper patient selection and good preoperative planning. With experience gained from each case operative time, radiation exposure, blood loss and intraoperative complications can be reduced in case of PFN. Thus I conclude PFN is a better alternative to DHS in management of intertrochanteric fractures but is technically difficult procedure and requires more expertise compared to DHS.

29 27 SUMMARY Intertrochanteric fracture is a leading cause of hospital admissions in elderly people. The number of such admissions is on a raise because of increasing life span, sedentary habits and increased road traffic accidents. Conservative methods of treatment results in malunion with shortening and limitation of hip movement as well as complications of prolonged immobilization like bed sores, deep vein thrombosis and respiratory infections. This study is done to compare the results of surgical management of intertrochanteric fractures with Proximal Femoral Nail and Dynamic Hip Screw. In our series of 30 patients, there were 19 female and 11 male. Minimum age was 16years, maximum 85 years with mean age of 48.6years. Most of the people were between years. Fall from height accounted for 40% of cases. Right side was more common, accounted for 70% of cases. Boyd and Griffin type II fracture accounted for 53.3% of cases. Mean duration of hospital stay was 26 days in both PFN and DHS groups. Mean time of full weight bearing was 10.6 weeks for PFN group and 14.8 weeks for DHS group. Out of 30 cases, 5 cases were lost in follow up and 2 cases died. Good to excellent results were seen in 81.8% of cases in PFN group and 63.33% in DHS group. From the study, we consider PFN as better alternative to DHS in the treatment of intertrochanteric fractures but is technically difficult procedure and requires more expertise compared to DHS. With experience gained from each case operative time, radiation exposure, blood loss and intraoperative complications can be reduced in case of PFN

30 28 REFERENCES 1. S.Terry Canale s "CAMPBELL S OPERATIVE ORTHOPEDICS" Volume 3,Tenth Edition ;Pages Micheal. W. Chapman s "CHAPMAN S ORTHOPAEDIC SURGERY", third edition, volume 1,Lipincott Williams and wilkins company, pages Boyd HB Griffin CLASSIFICATION AND TREATMENT OF TROCHANTERIC FRACTURES". Arch surgery.1949; 58; Habernek H,Wallnce T, Aschaner E, Schmid L, COMPARISION OF ENDER S NAILS,DYNAMIC HIP SCREW AND GAMMA NAILS IN TREATMENT OF PERITRONTERIC FEMORAL FRACTURES Orthopaedic 2000;23(2);127(7). 5. THE GAMMA NAIL AS RESILENT ALTERNATIVE TO DHS IN UNSTABLE PROXIMAL FEMORAL FRACTURES IN ELDERLY.Helv-Chir-Acta 1992 mar;5 and (5); PRELIMINARY EXPERIENCE WITH GAMMA NAILS. Magy-traumatol-orthop-kezsebplasztikai Sept l994; 37(4): Ruland W D. PERTROCHANTERIC FEMORAL FRACTURES IN ELDERLY PATIENTS-INJURY PATTERN AND MANAGEMENT WITH GAMMA NAILING". Langenbecks-Arch-Chir-suppl- Kongresshd, 1996; 113: Menes, Daniel,Gamulin Noesberg, IS PROXIMAL FEMORAL NAIL A SUITABLE IMPLANT FOR TREATMENT OF ALL TROCHANTERIC FRACTURES Lipincott,Williams and wilkins Inc, volume 439 October 2005 pp McConnell, Alison MSc(Eng)*; Zdero, Rad PhD*; Syed, Khalid MD, THE BIOMECHANICS OF IPSILATERAL INTERTROCHANTERIC AND FEMORAL SHAFT FRACTURES: A COMPARISON OF 5 FRACTURE FIXATION TECHNIQUES Volume 22(8), September 2008, pp Saudan, Marc; Lübbeke, Anne; Sadowski, Christophe; Riand, Nicolas; Stern, Richard; Hoffmeyer, Pierre IS PERTROCHANTERIC FRACTURES: THERE AN ADVANTAGE TO AN INTRAMEDULLARY NAIL?: A RANDOMIZED, PROSPECTIVE STUDY OF 206 PATIENTS COMPARING THE DYNAMIC HIP SCREW AND PROXIMAL FEMORAL NAIL Volume 16(6), July 2002, pp

31 Bhatti, Arshad; Power, Dominic; Qureshi, Sohail; Khan, Ishrat; Tan, Simon A PROSPECTIVE TRIAL OF PROXIMAL FEMORAL NAIL VERSUS DYNAMIC HIP SCREW FOR UNSTABLE AND COMPLEX INTERTROCHANTERIC FRACTURES OF THE FEMUR Volume 86-B Supplement III, 2004, p 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 Volume 87-B(1), January 2005, pp Simmermacher RKJ, Bosch A M, Van der Werken C. THE AO ASIF-PROXIMAL FEMORAL NAIL (PFN): A NEW DEVICE FOR THE TREATMENT OF UNSTABLE PROXIMAL FEMORAL FRACTURES Injury 1999; 30: Michael R. Baumgaertner and Thamos F.Higgins.chapter 38 in ROCKWOOD AND GREEN'S FRACTURES IN ADULTS.5TH edition;vol and Jesse C Delee. ROCKWOOD AND GREEN S FRACTURES IN ADULTS Chapter 18, 3 rd edition 1991, Charles A. Rockwood, David P. Green and Robert W. Bucholz JB(eds), Lippincott Company, Vol. 2, Kaufer H., Matthews L.S. and Sonstegard D. STABLE FIXATION OF INTERTROCHANTERIC FRACTURES JOURNAL OF BONE AND JOINT SURGERY 1974, 56A: Kenneth J. Koval and Joseph D. Zuckerman: ROCKWOOD AND GREEN S FRACTURE IN ADULTS Chapter 39, 5th edition, 2001-edited by Robert W. Bucholz and James D.Heckman, J.B. Lippincott Company, Vol. 2, Christian Boldin, Franz J Seibert, Florian Fankhauser, Geroif Peicha, WolfgangGrechenig and Rudolf Szyszkowitz. THE PROXIMAL FEMORAL NAIL (PFN) -AMINIMAL INVASIVE TREATMENT OF UNSTABLE PROXIMAL FEMORAL FRACTURES A PROSPECTIVE STUDY OF 55 PATIENTS WITH A FOLLOW-UP OF 15 MONTHS Acta Orthop Scand 2003; 74(1): Radford P J. Needoff M, Webb J K. A PROSPECTIVE RANDOMISED COMPARISON OF THE DYNAMIC HIP SCREW AND THE GAMMA LOCKING NAIL. J Bone Joint Surg (Br) 1993; 75: Bridle S H, Patel A D, Bircher M, Calvert PT. FIXATION OF INTERTROCHANTERIC FRACTURES OF THE FEMUR..1 Bone Joint Surg (Br) 1991;73:330-4.

32 INTRAOPERIVE PHOTOGRAPHS OF PFN 55

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37 C- ARM IMAGES OF PFN 60

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45 INTRA OPERATIVE PHOTOS OF DHS 68

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48 C-ARM IMAGES OF DHS 71

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51 FOLLOW UP PHOTOGRAPHS OF A CASE OF PFN 90

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53 FOLLOW UP X RAYS OF A CASE OF PFN 92

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58 FOLLOW UP PHOTOGRAPHS OF A CASE OF DHS 97

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60 FOLLOW UP X RAYS OF A CASE OF DHS 99

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62 COMPLICATIONS 101

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