An unusual case of femoral head perforation following fixation with proximal femoral nail antirotation (PFNA-II) for an unstable intertrochanteric fracture: Case report and literature review

A Prospective, Randomised Controlled Trial Comparing the use of the Proximal Femoral Nail - Antirotation and Dynamic Hip Screw for Stable Intertrochanteric Femur Fractures-Stable Trochanteric Fractures Intramedullary versus Extramedullary (STRIVE) Study

Introduction

Intramedullary nailing in the management of hip fractures is gaining in popularity. Our study aims to determine if there are any clinical and radiological differences between the Proximal Femoral Nail Antirotation II (PFNA II) and the Dynamic Hip Screw (DHS) in the management of stable intertrochanteric (IT) femur fractures. Materials and methods: This is a single blinded prospective randomised controlled trial of 33 patients, aged above 60, comparing the use of the PFNA II and the DHS for the treatment of stable IT femur fractures in a single tertiary centre with an established ortho-geriatric co-managed hip fracture care pathway.

Results

Of the 33 patients enrolled, 18 patients were treated with the DHS and the rest with the PFNA II. The two groups had similar demographic profiles and pre-operative radiological parameters. There was no statistical difference between the two groups in terms of intra-operative bleeding, post-operative pain score and total surgical time. The median Harris Hip and Parker Mobility Scores for the DHS group were non-inferior compared to the PFNA II group. Surgical time, blood loss, post-op radiological parameters and functional outcomes including time to ambulation were similar in both groups.

Conclusion

We recommend the use of the DHS for stable IT fracture patterns in view of its cost savings and equivalent functional and radiological outcomes.

A rare complication of pelvic perforation by an excessive medial slide of the helical blade after treatment of an intertrochanteric fracture with proximal femoral nail anti-rotation: A case report and literature review

Intertrochanteric fractures have become a severe public health problem in elderly patients. Proximal femoral nail anti-rotation (PFNA) is a commonly used intramedullary fixation device for unstable intertrochanteric fractures. Pelvic perforation by cephalic screw is a rare complication. We reported an 84-year-old female who fell at home and sustained an intertrochanteric fracture. The patient underwent surgery with PFNA as the intramedullary fixation device. Routine postoperative examination revealed medial migration of the helical blade that eventually caused pelvic perforation. We performed a cemented total hip arthroplasty as the savage procedure. At the latest follow-up of 12 months after total hip arthroplasty, the patient had no pain or loosening of the prosthesis in the left hip. Pelvic perforation should be considered when choosing PFNA as the intramedullary fixation device, especially in patients with severe osteoporosis wherein the helical blade can be easily inserted during the operation. The lack of devices to avoid oversliding of the helical blade in PFNA is an unreported cause of this complication and should be considered in such cases.