Comparing the supine and lateral positions for proximal femoral nail use in the treatment of intertrochanteric femoral fractures: Comparing supine and lateral positions for proximal femoral nail

İsmail Güzel; Tarık Altunkılıç; Bünyamin Arı; Halil Saraç

doi:10.28982/josam.7444

Authors

İsmail Güzel Department of Orthopedics and Traumatology, Turgut Özal University Malatya Training and Research Hospital, Malatya, Turkey https://orcid.org/0000-0003-2740-4139
Tarık Altunkılıç Department of Orthopedics and Traumatology, Turgut Özal University Malatya Training and Research Hospital, Malatya, Turkey https://orcid.org/0000-0002-1640-4275
Bünyamin Arı Department of Orthopedics and Traumatology, Turgut Özal University Malatya Training and Research Hospital, Malatya, Turkey https://orcid.org/0000-0001-9720-1869
Halil Saraç Department of Orthopedics and Traumatology, Malatya Training and Research Hospital, Malatya, Turkey https://orcid.org/0000-0003-1358-946X

DOI:

https://doi.org/10.28982/josam.7444

Keywords:

anti-rotation proximal femoral nail, intertrochanteric fractures, supine, lateral decubitus

Abstract

Background/Aim: The management of unstable intertrochanteric fractures (ITF), which are becoming more common, is still a significant issue for public healthcare systems. As a result, successful fracture therapy is becoming a more crucial aspect of orthopedic practice. To treat older patients who have an ITF, this study compared the therapeutic outcomes and side effects of proximal femoral nail anti-rotation (PFNA) conducted in lateral decubitus and supine postures.

Methods: One-hundred twenty patients between the ages of 65 and 90 who underwent PFNA surgery as a result of an unstable femoral ITF brought on by low-energy trauma were included in the study, which was conducted as a retrospective cohort study. Two groups of patients were established: (1) Group L, consisting of patients who underwent surgery in the lateral decubitus position and (2) Group S, consisting of patients who underwent surgery in the supine position. Several patient characteristics were compared: (1) demographic information, (2) length of hospital stay, (3) length of surgery, (4) intra-operative blood loss, (5) incision length, (6) number of intra-operative fluoroscopies, (7) duration of activity outside of bed, (8) duration of clinical recovery of fracture, (9) surgical complications, (10) patient outcomes, and (11) Harris hip scores (HHS).

Results: Group L (60 patients) consisted of patients who underwent surgery in the lateral decubitus position, while Group S (60 patients) underwent surgery in the supine position (60 patients). The average hospital stay for patients receiving PFNA was 8.2 days for those in the supine position compared to 8.0 days for those in the lateral decubitus position. The difference between the operative times was significant (P<0.001) with 48.6 and 59.7 min in Groups L and S, respectively. Intra-operative blood losses in Groups L and S were 129.2 and 151.5 mL, respectively. Compared to Group S, Group L's mean incision length was much lower at 6 cm (as compared to 8 cm in Group S). The difference between the mean intra-operative radiation exposure times for Groups L and S was considerable at 9.38 versus 12.5 min. The mean times for fracture union and the HHS were not statistically different between the two groups after 12 weeks of treatment.

Conclusion: ITFs in elderly patients can be successfully treated with PFNA in either the lateral decubitus or supine position. Surgical duration, blood loss, intra-operative X-ray exposure, and incision lengths were all reduced with PFNA performed in the lateral decubitus position. As a result, treatment of ITFs in older individuals may involve PFNA fixation in the lateral decubitus position. Particularly for people with a muscular gluteal region or obese patients, the lateral decubitus position is advised.

Downloads

Download data is not yet available.

References

Shukla S, Johnston P, Ahmad MA, Wynn-Jones H, Patel AD, Walton NP. Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails. Injury. 2007;38(11):1286-93. doi: 10.1016/j.injury.2007.05.013. DOI: https://doi.org/10.1016/j.injury.2007.05.013

Benz D, Tarrant SM, Balogh ZJ. Proximal femur fracture non-union with or without implant failure: A revision technique with clinical outcomes. Injury. 2020;51(8):1925-30. doi: 10.1016/j.injury.2020.05.030. DOI: https://doi.org/10.1016/j.injury.2020.05.030

Gül D, Akpancar S. Fractures in Geriatric Cases. Geriatrik Bilimler Dergisi. 2019;2:14-9.

Hutchings L, Fox R, Chesser T. Proximal femoral fractures in the elderly: how are we measuring outcome? Injury. 2011;42(11):1205-13. doi: 10.1016/j.injury.2010.12.016. DOI: https://doi.org/10.1016/j.injury.2010.12.016

Kokoroghiannis C, Aktselis I, Deligeorgis A, Fragkomichalos E, Papadimas D, Pappadas I. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures--a review. Injury. 2012;43(6):686-93. doi: 10.1016/j.injury.2011.05.031. DOI: https://doi.org/10.1016/j.injury.2011.05.031

Zeng C, Wang YR, Wei J, Gao SG, Zhang FJ, Sun ZQ, et al. Treatment of trochanteric fractures with proximal femoral nail antirotation or dynamic hip screw systems: a meta-analysis. J Int Med Res. 2012;40(3):839-51. doi: 10.1177/147323001204000302. DOI: https://doi.org/10.1177/147323001204000302

Kesmezacar H, Oğüt T, Bilgili MG, Gökay S, Tenekecioğlu Y. Yaşlilarda intertrokanterik femur kiriklarinin tedavisi: Internal tespit mi, hemiartroplasti mi? [Treatment of intertrochanteric femur fractures in elderly patients: internal fixation or hemiarthroplasty]. Acta Orthop Traumatol Turc. 2005;39(4):287-94. Turkish. PMID: 16269874.

Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br. 2004;86(1):86-94. PMID: 14765872. DOI: https://doi.org/10.1302/0301-620X.86B1.14455

Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury. 2009;40(4):428-32. doi: 10.1016/j.injury.2008.10.014. DOI: https://doi.org/10.1016/j.injury.2008.10.014

Sahin S, Ertürer E, Oztürk I, Toker S, Seçkin F, Akman S. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44(2):127-34. doi: 10.3944/AOTT.2010.2237. DOI: https://doi.org/10.3944/AOTT.2010.2237

Gardenbroek TJ, Segers MJ, Simmermacher RK, Hammacher ER. The proximal femur nail antirotation: an identifiable improvement in the treatment of unstable pertrochanteric fractures? J Trauma. 2011;71(1):169-74. doi: 10.1097/TA.0b013e3182213c6e. DOI: https://doi.org/10.1097/TA.0b013e3182213c6e

Faul F, Erdfelder E, Lang AG, Buchner A. Faul F. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2007 May;39(2):175-91. doi: 10.3758/bf03193146. DOI: https://doi.org/10.3758/BF03193146

Takigami I, Matsumoto K, Ohara A, Yamanaka K, Naganawa T, et al. Treatment of trochanteric fractures with the PFNA (proximal femoral nail antirotation) nail system - report of early results. Bull NYU Hosp Jt Dis. 2008;66(4):276-9. PMID: 19093903.

Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture. J Int Med Res. 2010;38(4):1266-75. doi: 10.1177/147323001003800408. DOI: https://doi.org/10.1177/147323001003800408

Tang P, Hu F, Shen J, Zhang L, Zhang L. Proximal femoral nail antirotation versus hemiarthroplasty: a study for the treatment of intertrochanteric fractures. Injury. 2012;43(6):876-81. doi: 10.1016/j.injury.2011.11.008. DOI: https://doi.org/10.1016/j.injury.2011.11.008

Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U; AO - PFNA study group. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury. 2008;39(8):932-9. doi: 10.1016/j.injury.2008.02.005. DOI: https://doi.org/10.1016/j.injury.2008.02.005

Lu JF. [Comparison of PFNA and DHS for the treatment of elderly unstable intertrochanteric fractures of femur]. Zhongguo Gu Shang. 2019;32(9):824-9. Chinese. doi: 10.3969/j.issn.1003-0034.2019.09.010.

Huang C, Wu X. Surgical Selection of Unstable Intertrochanteric Fractures: PFNA Combined with or without Cerclage Cable. Biomed Res Int. 2021;2021:8875370. doi: 10.1155/2021/8875370. DOI: https://doi.org/10.1155/2021/8875370

Kristek D, Lovrić I, Kristek J, Biljan M, Kristek G, Sakić K. The proximal femoral nail antirotation (PFNA) in the treatment of proximal femoral fractures. Coll Antropol. 2010;34(3):937-40. PMID: 20977086.

Liu HT, Wang IC, Yu CM, Huang JW, Wang KC, Chen CH, et al. Closed femoral nailing in lateral decubitus position without a fracture table: a preliminary report of fifteen patients. Chang Gung Med J. 2005;28(9):629-35. PMID: 16323554.

Bishop JA, Rodriguez EK. Closed intramedullary nailing of the femur in the lateral decubitus position. J Trauma. 2010;68(1):231-5. doi: 10.1097/TA.0b013e3181c488d8. DOI: https://doi.org/10.1097/TA.0b013e3181c488d8

Wolinsky PR, McCarty EC, Shyr Y, Johnson KD. Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table. J Orthop Trauma. 1998;12(7):485-95. doi: 10.1097/00005131-199809000-00010. DOI: https://doi.org/10.1097/00005131-199809000-00010

Aiyer S, Jagiasi J, Argekar H, Sharan S, Dasgupta B. Closed antegrade interlocked nailing of femoral shaft fractures operated up to 2 weeks postinjury in the absence of a fracture table or C-arm. J Trauma. 2006;61(2):457-60. doi: 10.1097/01.ta.0000210269.05305.75. DOI: https://doi.org/10.1097/01.ta.0000210269.05305.75

Boz M, Şahin A. Lateral imaging technique of the femoral neck in a supine-semilithotomy position without a fracture table. Medicine Science. 2020;9(4):1061-4. doi: 10.5455/medscience.2020.07.123 DOI: https://doi.org/10.5455/medscience.2020.07.123

Ding Q, Wang CL, Wang PF, Zuo CH, Xie W, Sun LY. Treatment of intertrochanteric fracture of femur with closed reduction of proximal femoral anti rotation intramedullary nail in supine position. Zhongguo Gu Shang. 2020;33(4):327-31. Chinese. doi: 10.12200/j.issn.1003-0034.2020.04.008.

Li M, Chen J, Ma Y, Li Z, Qin J. Comparison of proximal femoral nail anti-rotation operation in traction bed supine position and non-traction bed lateral position in treatment of intertrochanteric fracture of femur. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2020;34(1):32-6. Chinese. doi: 10.7507/1002-1892.201905076.

Haddad FS, Cobiella CE, Wilson L. Inferior epigastric artery avulsion: a fracture table complication. J Orthop Trauma. 1998;12(8):587-8. doi: 10.1097/00005131-199811000-00010. PMID: 9840794. DOI: https://doi.org/10.1097/00005131-199811000-00010

Xue L, Zha L, Chen Q, Liang YJ, Li KR, Zhou Z, et al. Randomized controlled trials of proximal femoral nail antirotation in lateral decubitus and supine position on treatment of intertrochanteric fractures. ScientificWorldJournal. 2013;2013:276015. doi: 10.1155/2013/276015. PMID: 23606811; PMCID: PMC3628658. DOI: https://doi.org/10.1155/2013/276015