ABSTRACTJournal of Orthopaedic Surgery 2007;15(3):273-7

Purpose. To report outcomes of 87 consecutive

patients treated with a proximal femoral nail (PFN)
for trochanteric femoral fractures.
Methods. 17 men and 70 women aged 58 to 95
(mean, 85) years with trochanteric femoral fractures
underwent PFN fixation using an intramedullary nail,
a lag screw, and a hip pin. Fractures were classified
according to the AO system; the most common
fracture type was A2 (n=45), followed by A1 (n=36)
and A3 (n=6). The position of the lag screw within the
femoral head was measured. The lateral slide of the
lag screw after fracture consolidation was measured
by comparing the immediate postoperative and final
anteroposterior radiographs.
Results. 90% of lag screws were placed in an optimal
position. The length of lateral slide of the lag screw
in stable A1 fractures was significantly less than that
in unstable A2 fractures; it was over 10 mm in 7 of 45
patients with A2 fractures. Cut-out of lag screw did

Proximal femoral nail for treatment of

trochanteric femoral fractures
T Morihara
Department of Orthopaedic Surgery, Kyoto Prefectural Yosanoumi Hospital, Kyoto, Japan
Y Arai, S Tokugawa, S Fujita, K Chatani, T Kubo
Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of
Medicine, Kyoto,
Japan
Address correspondence and reprint requests to: Dr Toru Morihara, Department of Orthopaedics,
Graduate School of
Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto
602-8566, Japan.
E-mail: toru4271@koto.kpu-m.ac.jp
Journal of Orthopaedic Surgery 2007;15(3):273-7
not occur, suggesting that free sliding of the lag screw
facilitates direct impaction between fragments.
Conclusion. A PFN is useful for the treatment of
trochanteric femoral fractures.
Key words: bone nails; femoral fractures; hip fractures
INTRODUCTION
Compression hip screws and Ender nails are commonly
used implants for fixation of intertrochanteric
fractures. For unstable pertrochanteric fractures,
further intervention is needed because of the risks
of postoperative deformities and cut-out of the lag
screw.1,2 Biomechanically, compared to a laterally
fixed side-plate, an intramedullary device (the gamma
nail) decreases the bending force of the hip joint on
implants by 25 to 30%. This has advantages especially
in elderly patients, in whom the primary treatment
goal is immediate full–weight-bearing mobilisation.3
The gamma nail fixation is recommended for
pertrochanteric fractures, but serious complications
274 T Morihara et al. Journal of Orthopaedic Surgery
such as cut-out of lag screws have been reported in
8 to 15% of cases.4–6 The proximal femoral nail (PFN)
has an additional anti-rotational screw (hip pin)
placed in the femoral neck to avoid rotation of the
cervicocephalic fragments during weight bearing.7,8
We report outcomes of 87 consecutive patients treated
with a PFN for trochanteric femoral fractures.
MATERIALS AND METHODS
Between August 1999 and March 2002, 17 men and 70
women aged 58 to 95 (mean, 85) years with trochanteric
femoral fractures underwent PFN fixation and were
followed up for >12 months. Fractures were classified
according to the AO system; the most common
fracture type was A2 (n=45), followed by A1 (n=36)
and A3 (n=6).
Reduction was achieved by closed manipulation
and traction under anaesthesia. The fracture site was
exposed only if reduction by closed means was not
successful. The fixation used an intramedullary nail
(10–11 mm in diameter), a lag screw (90–105 mm
in length), and a hip pin (10–15 mm shorter than
the lag screw). The lag screw was inserted near the
subchondral femoral head. The intramedullary nail was
interlocked distally with one or 2 screws. Prophylactic
intravenous antibiotics were administered.
Patients were allowed to mobilise on postoperative
day 2, and weight-bearing walking was initiated on
day 3 or 4 as tolerated. To measure the influence of
lag screw placement on migration, the femoral head
was divided into 9 sectors by drawing 2 parallel lines
on the anteroposterior (AP) radiograph to divide
superior and inferior parts and 2 parallel lines on the
lateral radiograph to divide anterior and posterior
parts (Figs. 1a and 1b). The position of the lag screw
tip within the femoral head was then measured.9,10
The lateral slide of the lag screw after fracture
consolidation was measured by comparing the
immediate postoperative and final AP radiographs
(Fig. 2). At postoperative 2 years, 45 patients (16 A1,
24 A2, and 5 A3) had their mobility scores for walking
and social functioning scores evaluated.11,12 The Mann-
Whitney U test was used for statistical analysis.
RESULTS
The mean operating time was 77 (range, 31–218)
Figure 1 The femoral head is divided into 9 sectors by
drawing 2 parallel lines on the (a) anteroposterior radiograph
to divide superior and inferior parts and 2 parallel lines on
the (b) lateral radiograph to divide anterior and posterior
parts. (c) All of the lag screws are inserted in the inferior part
of the femoral head.
(a) (b)
(c)
Anterior Posterior
Superior
Inferior
0
0
78
00
00
72
Superior
Anterior
Inferior Posterior
(a) (b)
Figure 2 Measurement of lateral slide of the lag screw
by comparing (a) immediate postoperative and (b) final
anteroposterior radiographs.
Vol. 15 No. 3, December 2007 Proximal femoral nailing for trochanteric femoral fractures 275
minutes and mean blood loss was 72 (range, 10–390)
g. In AP radiographs, 100% of lag screws appeared
to be placed in the inferior part of the femoral head.
In lateral radiographs, 90% of lag screws appeared to
be placed centrally, 8% anteriorly, and 2% posteriorly
(Fig. 1c). The optimal position—inferior on AP
view and central on lateral view—was achieved
in 78/87 (90%) patients. The overall mean lateral
slide of the lag screw was 3.7 (range, 0–22) mm; it
was 2.7 (range, 0–10) mm in A1, 4.4 (range, 0–22)
mm in A2, 4.8 (range, 0–8) mm in A3 fractures. The
mean lateral slide in A1 fractures was significantly
less than that in A2 fractures (p=0.012, Fig. 3). The
lateral slide in 7 of the 45 patients with A2 fractures
was over 10 mm. An 82-year-old woman with an
A2 fracture had a 22-mm lateral slide of the lag
screw at postoperative week 3 (Fig. 4). She changed
to partial weight bearing and had bone united at
month 4 without any cut-out of the lag screw and
could walk with a stick.
The mean duration of hospitalisation was 25
(range, 7–60) days for A1 fractures, 29 (range, 8–103)
days for A2 fractures, and 25 (range, 22–30) days for
A3 fractures; the corresponding differences were not
significant (p=0.182, 0.494, and 0.933, respectively).
All patients were followed up until clinical and
radiological consolidation.
There was no cut-out of lag screws, not even
a knife or Z-effect. Lateral slide of hip pin or lag
screw occurred in 5 patients, femoral head necrosis
in one, and non-union in one. One patient exhibited
partial bipolar cemented arthroplasty and another
underwent removal of the lag and hip screws because
of fracture-site fusion. One patient endured a non-fatal
pulmonary embolus, 4 had heart dysfunctions, and
one developed pneumonia during the immediate/
early postoperative period.
Two years postoperatively, the mean mobility
scores of all fracture types decreased (A1: 5.6 to 4.2;
A2: 6.5 to 4.4; A3: 9.0 to 7.5) but not significantly
(p=0.811, 0.894, and 0.786, respectively). The mean
social functioning scores of all fracture types
increased (A1: 2.3 to 2.7; A2: 1.8 to 2.3, A3: 1.0 to
2.3) but not significantly also (p=0.73, 0.52, and 0.44,
respectively).
DISCUSSION
Operating time and blood loss are both less in
Figure 3 The number and length of lateral slide of lag
screw at final follow-up.
A1
0
Length of lateral slide (mm)
Fracture
p=0.012, 2.7 vs 4.4 mm
5
10
15
20
25
A2 A3
(a) (b) (c) (d) (e)
Figure 4 Radiographs of an 82-year-old woman with an A2 fracture showing a 22-mm lateral slide of
the lag screw: (a)
preoperation, (b) immediate, (c) 3-week, (d) one-year, and (e) 2-year postoperation.
276 T Morihara et al. Journal of Orthopaedic Surgery
patients undergoing PFN as opposed to gamma nail
procedures, because reaming is not necessary.13,14 The
PFN is fixed with 2 screws; the larger (lag) screw is
designed to carry most of the load, and the smaller
screw (the hip pin) is to provide rotational stability. If
the hip pin is longer than the lag screw, vertical forces
would increase on the hip pin and start to induce cutout,
a knife effect or Z-effect. This might force the hip
pin to migrate into the joint and the lag screw to slide
laterally. The cut-out rate with a PFN is reportedly
0.6 to 8%.15–17 Although complication rates remain
low, cut-out of either screw is a serious complication,
which can lead to revision surgery and related
morbidity. When the hip pin was 10 mm shorter than
the lag screw, the percentage of the total load carried
by the hip pin ranged from 8 to 39% (mean, 21%)18;
no cut-out of the femoral head and no unacceptable
implant or fracture displacement were observed.8 In
our study, the hip pin was 10 to 15 mm shorter than the
lag screw, and this may have prevented overloading
the hip pin and cut-out in all cases.
Unstable A2 fractures should be initially reduced
to a slightly valgus position during PFN surgery,
because the neck-shaft angle would decrease during
the first 6 postoperative weeks.19 The lag screw
should be inserted into the femoral head as deeply
as noted in the AP view, and centrally in the lateral
view.13 The tip of the lag screw should always be
inferior to the centre of the femoral head.7,8,20,21
Anatomic and biomechanical studies have shown
that the superomedial quadrant of the femoral head
is the weakest part for the implant, and therefore
proper positioning of the screw is emphasised.21 Cutout
is usually resulted from poor positioning of the
proximal screw in the femoral head, particularly in
the osteoporotic bone.14,18,21
In our study, the lag screw was inserted close to
the subchondral bone, and the hip pin superior to the
femoral head. This resulted in 90% of the lag screws
being inserted at the optimal site (inferior to the centre
of the femoral head) and to an optimal depth, thereby
achieving rigid fixation. Good reduction of the
fracture, and optimal positioning and length of the hip
pin and lag screws are crucial for the PFN procedure
and reported to yield excellent outcomes.14,18,21
Lateral slide may occur more often in patients
with a PFN than a gamma nail, because of impaction
of the fracture, rather than migration of the screws,
assuming that anchorage of the lag screws in the
femoral head for PFN and that of the gamma nail
are similar.14,18 Restriction of the sliding mechanism
of the gamma nail caused by the more rigid femoral
neck screw-nail assembly may initiate cut-out or
penetration of the joint.
In our study, although the lateral slide in 7 of
the 45 patients with A2 fractures was over 10 mm,
cut-out of lag screws did not occur regardless of the
extent of slide. Therefore, free sliding of a PFN may
provide better impaction for unstable A2 fractures.
The presence of an additional anti-rotational screw,
and the free sliding mechanism of the lag screw
may increase rotational stability of cervico-cephalic
fragments and decrease overload on the femoral
head. Our results therefore suggest that a PFN is
useful for the treatment of all types of trochanteric
femoral fractures.
REFERENCES
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(PFN)—a minimal
invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a
follow-up of 15 months.
Acta Orthop Scand 2003;74:53–8.
8. Schipper IB, Bresina S, Wahl D, Linke B, Van Vugt AB, Schneider E. Biomechanical evaluation of the
proximal femoral nail.
Clin Orthop Relat Res 2002;405:277–86.
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short AO-ASIF proximal
femoral nail. Arch Orthop Trauma Surg 2004;124:31–7.
10. Galanakis IA, Steriopoulos KA, Dretakis EK. Correct placement of the screw or nail in trochanteric
fractures. Effect of the
initial placement in the migration. Clin Orthop Relat Res 1995;313:206–13.
11. Jensen JS. Determining factors for the mortality following hip fractures. Injury 1984;15:411–4.
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13. Kawaguchi S, Sawada K, Nabeta Y. Cutting-out of the lag screw after internal fixation with the
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femoral nail (PFN)—our first 60 cases. Injury 2002;33:401–5.
17. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new
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Orthop Scand 1980;51:429–37. ed exercises following total hip replacement: a randomised
controlled trial

Toby O. Smitha, ,
, Charles J.V. Mannb, Allan Clarkc and Simon T. Donelld
a
Orthopaedic Physiotherapy Research Unit, Physiotherapy Department, Norfolk and Norwich
University Hospital, Colney Lane, Norwich NR4 7UY, UK
b
Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich,
UK
c
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
d
Faculty of Health, University of East Anglia, Norwich, UK
Available online 20 March 2008.

Abstract

Objectives

To determine whether the addition of bed exercises after primary total hip replacement (THR)
improves functional outcomes and quality of life, in adult patients, during the first six
postoperative weeks.

Design

Single-blind randomised controlled trial.

Setting

Inpatient and outpatient orthopaedic departments at a National Health Service hospital.

Participants

Sixty primary elective THR patients.

Intervention

Patients were assigned at random to receive either a standard gait re-education programme and
bed exercises, or the standard gait re-education programme without bed exercises after THR. The
bed exercises consisted of active ankle dorsiflexion/plantarflexion, active knee flexion, and static
quadriceps and gluteal exercises.

Main outcome measures

Iowa Level of Assistance Scale (ILOA), the Short Form-12 Health Survey (SF-12), duration of
hospital admission and postoperative complications were assessed at baseline, and 3 days and 6
weeks postoperatively.

Results

There was no statistically significant difference in ILOA scores between the two groups on the
third postoperative day [gait re-education and bed exercise group median 40.5, interquartile
range (IQR) 17.5 to 44.5; gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70].
Although there was a small difference between the median ILOA scores at Week 6 between the
two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to 12.5; P = 0.05), this difference was not
statistically or clinically significant. There was no difference between the groups in duration of
hospital admission, SF-12 scores or postoperative complications at Week 6.
Conclusion

This study suggests that during the first six postoperative weeks, the addition of bed exercises to
a standard gait re-education programme following THR does not significantly improve patient
function or quality of life.

Keywords: Hip; Replacement; Exercise;Clinical Trial; Rehabilitation

Treadmill training with partial body-weight support after total hip arthroplasty: a randomized
controlled trial.
• Hesse S,
• Werner C,
• Seibel H,
• von Frankenberg S,
• Kappel EM,
• Kirker S,
• Kading M.
Department of Neurological Rehabilitation, Klinik Berlin, Kladower Damm 223, D-14089 Berlin,
Germany. bhesse@zedat.fu-berlin.de
OBJECTIVE: To compare treadmill training with partial body-weight support (TT-BWS) and
conventional physical therapy (PT) in ambulatory patients with hip arthroplasty. DESIGN:
Randomized controlled trial. SETTING: Rehabilitation center. PARTICIPANTS: Eighty patients
with a fully loadable implant who could walk independently with crutches after unilateral total
hip arthroplasty were randomized to receive either TT-BWS (treatment group) or conventional
PT (controls), for 10 working days. INTERVENTIONS: Each patient received 45 minutes of
individualized PT, either treadmill training plus PT in the experimental or PT alone in the control
group. MAIN OUTCOME MEASURES: The Harris score, recorded by blind assessors, served as
the primary outcome measure. Secondary outcome measures were the hip extension deficit, gait
velocity, gait symmetry, affected hip abductor power; hip abductor amplitude of
electromyographic activation; and the interval from surgery to abandoning crutches. RESULTS:
At the end of training, the treatment group's Harris score was 13.6 points higher (P<.0001) than
the control group's score. Further, hip extension deficit was 6.8 degrees less (P<.0001), gait
symmetry was 10% greater (P=.001), affected hip abductor was stronger (Medical Research
Council grades 4.24 vs 3.73; P<.0001), and the amplitude of gluteus medius activity was 41.5%
greater (P=.001) than those measures for controls. Gait velocity did not differ in the 2 groups.
These significant differences in favor of the treatment group persisted at 3 and 12 months. The
treatment group abandoned crutches sooner than the control group (3 vs 8wk). In the treatment
group, 39 patients finished treatment, 35 appeared at 3, and 26 at 12 months for follow-up. In the
control group, the corresponding numbers were 40, 35, and 24 patients, respectively.
CONCLUSION: TT-BWS is more effective than conventional PT at restoring symmetrical
independent walking after hip replacement.
PMID: 14669181 [PubMed - indexed for MEDLINE]