Effectiveness of the Valgus Reduction Technique in Treatment of Intertrochanteric Fractures Using Proximal Femoral Nail Antirotation

Ji-Kang Park; Hyun-Chul Shon; Yong-Min Kim; Eui-Sung Choi; Dong-Soo Kim; Kyoung-Jin Park; Byung-Ki Cho; Jung-Kwon Cha; Sang-Woo Kang

doi:10.4055/jkoa.2013.48.6.441

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Park, Shon, Kim, Choi, Kim, Park, Cho, Cha, and Kang: Effectiveness of the Valgus Reduction Technique in Treatment of Intertrochanteric Fractures Using Proximal Femoral Nail Antirotation

Original Article

Journal of the Korean Orthopaedic Association 2013; 48(6): 441-448.

Published online: 26 December 2013

DOI: https://doi.org/10.4055/jkoa.2013.48.6.441

Effectiveness of the Valgus Reduction Technique in Treatment of Intertrochanteric Fractures Using Proximal Femoral Nail Antirotation

Ji-Kang Park, M.D., Hyun-Chul Shon, M.D., Yong-Min Kim, M.D., Eui-Sung Choi, M.D., Dong-Soo Kim, M.D., Kyoung-Jin Park, M.D., Byung-Ki Cho, M.D., Jung-Kwon Cha, M.D., Sang-Woo Kang, M.D.

Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.

Correspondence to: Hyun-Chul Shon, M.D. Department of Orthopaedic Surgery, Chungbuk National University Hospital, 776 1 Sunhawn-ro, Heungdeok-gu, Cheongju 361-711, Korea. TEL: +82-43-269-6077, FAX: +82-43-274-8719, hcshon@hanmail.net

Received 3 February 2013 Revised 14 April 2013 Accepted 7 October 2013

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The purpose of this study is to investigate the functional and radiologic results of treatment of the old with intertrochanteric fractures by implementation of the proximal femoral nail antirotation (PFNA) with Valgus reduction.

Materials and Methods

A retrospective review of patients (over 65 years old) with intertrochanteric fractures undergoing PFNA, during the period March 2008 to August 2012 at Chungbuk National University Hospital, with follow-up for at least 12 months, was conducted. Fifty-one patients were identified. The mean observation period was 15.6 months and the mean age of patients was 78.6 years old. In this study, AO foundation and Orthopaedic Trauma Association (AO/OTA) classification of initial fractures, post operative neck shaft angle, location of the blade tip (Cleveland index), tip-apex distance (TAD), incidence of complication, Wayne-County reduction, and Koval walking ability were analyzed.

Results

Satisfactory reduced status was achieved by significant (p<0.05) valgus reduction in 49 out of 51 cases and the mean period for radiologic bony union was 15.3 weeks. The mean blade sliding distance was 3.5 mm and the mean TAD was 18.7 mm; however, the blade location did not affect the results. No complications, including surgical site infection, delayed union, nonunion, rotational angulation, and cutting out of the blade tip were found. Thirty-one patients out of 42 who maintained their pre-fracture ambulatory ability, 11 patients (out of 42) remained ambulatory but became more dependent on assistive devices.

Conclusion

It is expected that the Wayne-County reduction followed by internal fixation with PFNA is a useful treatment option for intertrochanteric fractures in elderly patients because it shows few complications with good functional and radiologic results.

Keywords: femur, intertrochanteric fracture, proximal femoral nail antirotation, Wayne-County reduction

Figures and Tables

Figure 1

(A) First, the leg must be pulled on a fracture table until the gap between proximal and distal fragment can be identified. (B) Illustration shows that the fracture line is involved to the greater trochanter tip, which will be the nail entry point. (C) Illustration shows the varus angulated neck-shaft angle which results from insertion of the nail without sufficient reaming of the medial entry point. (D) Illustration shows reaming of the medial cortex of the entry point with medial direction force on the reamer. (E) Intraoperative image shows reaming of the medial entry point by towel clip assistance applying medial direction force. (F) Illustration shows hitting the blade several times when adequate tip-apex distance is attained for compression of the fracture line, as indicated by arrows. (G) Illustration shows the compressed fracture site after blade locking with valgus neck-shaft angle.

Figure 2

(A) Preoperative radiograph shows an unstable intertrochanteric fracture (AO type A2.3) of the femur and varus angulated states in a 78-year-old female. Pre-injury neck shaft angle in this patient was 129 degrees. The contralateral side shows mal-united states of the previous intertrochanteric fracture. (B) Preoperative 3-dimensional reconstructive computed tomography shows a posteromedial comminuted unstable intertrochanteric fracture of the femur. (C) Immediate postoperative radiograph shows a valgus reduced state compared to the pre-injury neck-shaft angle of the femur. (D) Radiograph 16 months after the operation shows complete union of the femur fracture with a 6 mm screw sliding and maintained valgus state.

Figure 3

Cleveland index shows satisfactory results for blade tip position.

Table 1

Radiological Change

Values are presented as median (range).

N/A: not applicable. ^*p<0.05.

Table 2

Comparative Results of Pre-Injury and Postoperative Koval Walking Ability (n=51)

Notes

This study was supported by a clinical research grant from 2011 Chungbuk University.

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