International Journal of Orthopaedics Sciences 2021; 7(3): 269-273

E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2021; 7(3): 269-273 Evaluation of functional outcome of subtrochanteric
© 2021 IJOS
www.orthopaper.com fracture of femur treated surgically with long proximal
Received: 28-05-2021
Accepted: 30-06-2021 femoral nail
Dr. Paramesha KC
Associate Professor, Dr. Paramesha KC, Dr. Anand SR and Dr. Chandrahas A
Department of Orthopaedics,
MMCRI, Mysore, Karnataka,
India DOI: https://doi.org/10.22271/ortho.2021.v7.i3d.2759

Dr. Anand SR Abstract

Assistant Professor, Background: Subtrochanteric area is described as the region from the lesser trochanter to 5cm distal of
Department of Orthopaedics, proximal femur. It is one of the most challenging fractures for the orthopaedic surgeons. The cause of
MMCRI Mysore, Karnataka, frequent commination is that these fractures occur at the junction of trabecular bone and cortical bone
India where the mechanical stress is highest. Non-Operative management of subtrochanteric femur fractures
poses difficulties in obtaining and maintaining a reduction, making operative management the preferred
Dr. Chandrahas A treatment. This study is aimed to prospectively evaluate the clinical and functional outcomes of
Post Graduate, Department of
subtrochanteric fractures treated with Long PFN.
Orthopaedics, MMCRI Mysore,
Karnataka, India
Material and Methods: 24 patients above the age of 18 years with subtrochanteric fractures were
included in the study. Patients were assessed clinically and radio logically at 6, 12, 18 and 24 weeks and
at 9months and final follow-up was done at 1year. At each follow-up, functional evaluation of the patient
was done.
Results: A total of 24 patients(16 males and 8 females) were evaluated with age ranging from 18 years to
75 years with most patients in between 40-60 years; 58% of the cases were road traffic accidents, 33%
due to fall from height and 9% due to trivial fall with right side being more common side affected. In our
study most of the cases belong to Sensheimer type III B (25%) Mean duration of hospital stay was 12
days. Out of 24 cases, excellent results were seen in 70% of cases in our study.
Conclusion: Long PFN is an effective, efficient and biomechanically stable device for the treatment of
subtrochanteric fractures with a high rate of bony union and good functional outcome.

Keywords: subtrochanteric fracture, seinsheimer classification, long PFN, harris hip score

Introduction
Subtrochanteric fractures are femoral fractures occurs below the lesser trochanter to 5 cm
distally in the shaft of femur [1]. These fractures account for 10% to 34% of all hip fractures [2].
These fractures have a bimodal distribution [3] and are seen in two main populations, older
osteopenic patients following low energy falls and younger patients with high energy trauma.
The cause of frequent comminution is that these fractures occur at the junction of trabecular
bone and cortical bone where the mechanical stress is highest. The biomechanical
characteristics of the area, poor vascularity caused by the predominance of cortical bone and
inadequacy of reduction and internal fixation are responsible for malunion, delayed union and
mechanical failure of implants used in the treatment [4-11].
Subtrochanteric region is exposed to higher stresses during daily living activities. Hence,
subtrochanteric fracture is difficult to manage and associated with many complications [12].
Due to the insertions of muscles in this region, it is put through many distorting forces like
flexion by the iliopsoas muscle, abduction by the gluteus medius muscle, and external rotation
by the external rotators of the proximal femur fragment. The adductors are inserted in the
distal region of the femur which causes the varus deformity [3, 13].
Corresponding Author: The non-surgical treatment causes delay in return to their functional activities, which will
Dr. Paramesha KC increase the morbidity and mortality caused by the extended periods of immobilization.
Associate Professor,
Conservative treatment of subtrochanteric fractures of the femur is only indicated in patients
Department of Orthopaedics,
MMCRI, Mysore, Karnataka, associated with serious comorbidities that is contraindicated for anesthesia or surgical
India procedures [14].
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As compared to conservative treatment, operative treatment is wire was inserted at the tip of the greater trochanter and was
better tolerated by elderly because of greater comfort, early crossed the fracture site under C-arm control. The guide wire
mobilization of patient, lower morbidity and mortality of was advanced such a way that it is located in the middle of the
patient [15]. shaft in both AP and Lateral views. We manually reamed the
In 1996, the Arbeitsgemein-schaft für Osteosynthesefragen proximal and distal femur. After satisfactory fracture
AO/ASIF developed the proximal femoral nail (PFN) as an reduction under C-arm guidance, an appropriate size nail as
intramedullary device for the treatment of such fractures. determined preoperatively was assembled to insertion handle
With all advantages of an intramedullary nail, it has several and inserted manually. Stab incision for drill sleeve was made
other favourable characteristics: it can be dynamically locked, and 2.8guide wire was inserted. A second 2.8 mm guide wire
allows early mobilization, has high rotation stability and is was inserted through the drill sleeve above the first one for
done with minimal soft tissue damage [16]. Our study is a hip pin. Both confirmed under C arm [Fig 2 and 3]. Drilling
prospective study carried out at our institute on 24 patients was done over 2.8 mm guide wire until the drill is 8 mm short
who had suffered a subtrochanteric fracture between of tip of the guide wire. Neck screw was inserted using
November 2018 and November 2019 and were treated with a cannulated screw driver. Similarly, appropriate length hip pin
Long PFN. was inserted. Length and position of the screw was confirmed
under C-arm guidance distal locking was performed with 2
Material and Methods cortical screws with free hand technique. Locking screw was
All the patients with subtrochanteric fractures who presented inserted and position was confirmed under C-arm guidance.
to the Department of Orthopaedics, in our institute between Thorough wash was given, then wound closed in layers and
Nov 2018 and Nov 2019 were considered for the study. sterile dressing applied.
Ethical clearance was granted from institutional ethical
committee, Mysore Medical College and Research Institute
and associated hospitals. A total of 30 patients were presented
in this period. They were subjected to the inclusion and
exclusion criteria of the study and a total of 24 patients
qualified to be included in the study.

Inclusion criteria
• All patients with Subtrochanteric fracture
• All skeletal mature patient (>18yrs)
• Pathological fractures.

Exclusion criteria
• Patients not willing for surgery.
Fig 1: Entry Point at Greater trochanter
• Patients medically unfit for surgery.
• Open fractures
• Segmental fractures
• Patients with neurovascular deficit
• Pre-existing deformity in the same hip

All the cases with subtrochanteric fractures who require

surgical intervention were admitted, after taking consent,
analysed clinically and radiologically. All the patients
selected for the study examined according to protocol,
associated injuries noted, clinical and laboratory
investigations carried out. After complete work up, all
patients were operated with Long PFN which is third
generation cephalomedullary nail. [Nebula Company, Cat
No.:-180.L/R / T180.L/R]. The functional outcome assessed Fig 2: Guide wire position in AP view
using Harris Hip Score (HHS).

Surgical Technique
The patient was placed in supine position on the fracture table
under spinal or general anesthesia. The opposite extremity
measurements of rotation and length was determined before
shifting on to the operating table. The fracture was reduced by
longitudinal traction and the operating limb was placed in
neutral or slight adduction for easy nail insertion through the
greater trochanter. Straight lateral incision taken from the tip
of greater trochanter, extending 4-6 cm proximally. Gluteus
maximus muscle dissected in line with its fibers. If open
reduction required we extended the incision distally, incising
the iliotibial band in line with the skin incision. The entry
point for the PFN was at the tip of the greater trochanter, Fig 3: Guide wire position in lateral view
halfway between its anterior and posterior extent[Fig 1].Guide
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Post-operative protocol Results

Quadriceps static exercise and knee mobilization was started In our study most of the patients were in between the age
in the immediate postoperative period. Patients were allowed group of 40-60 years [Table 1]. Male patients were greater in
for touch down weight bearing with the help of a walker for number compared to female patients with ratio 2:1 [Table 2].
the first 6 weeks and advanced based on healing as shown on In most of the cases the mechanism of injury was due to road
follow-up radiograph. All patients were followed up at 6 traffic accident (58%) [Table 3]. In our study most of the
weeks, 12 weeks and every 6 weeks thereafter till fracture cases belong to Sensheimer type III B (25%) [Table 4]. The
union is noted; [Fig 4,5 and 6] then at 6 months, 9 months and average time for fracture union was 14-16 weeks [Table 5].
final follow-up at 1 year. At each visit, patient was assessed All cases were operated within one week of trauma.80% of
clinically according to Harris Hip Score questionnaire. X-ray cases underwent closed reduction [Fig 7] and open reduction
of the pelvis with both hip, hip with thigh Antero-posterior was required in five cases (20%) in which two cases cerclage
and Lateral full length of operated side taken. Fracture union wiring was done. Mean operating time was 1.30-2 hrs.
was assessed by radiographic cortical bridging and lack of By 12 weeks, 7 fractures (30%) were considered healed, and
fracture line. by 18 weeks, 19 fractures had healed (80%) and by 24 weeks
all fractures (100%) were healed (Table 4). Functional
outcome evaluated using HHS (Harris Hip Score) which
showed 17 patients (71%) had Excellent, 3patients (13%) had
good, 2 patients(8%) had fair outcome [Fig 8]. In our series,
we had 2 cases of superficial wound infection controlled by
intravenous antibiotics for one week. We didn’t come across
any case with delayed union or non-union and implant failure.

Fig 4: Pre-operative xray AP view

Fig 7: Type of Reduction

Fig 5: Immediate post-operative xray

Fig 8: Harris Hip Scoring

Table 1: Age distribution

Age group No. of Cases Percentage%
18-30 3 12.5%
31-40 6 25%
41-60 13 54.16%
>60 2 8.3%

Fig 6: At 18 weeks follow-up

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Table 2: Sex in diameter and distal part available in 9, 10, 11 and 12. Due
Sex Number of cases Percentage % to increased cases of stress fractures at the distal tip of short
Male 16 66.66% PFN in recent past [18], we preferred long PFN in all our cases.
female 8 33.33% The long PFN comes in lengths of 340, 380,400 and 420 mm
and is side specific. Two screws can be inserted through the
Table 3: Mode of injury proximal part, an 8.4 mm neck screw and a 6.5 mm anti-
rotation screw. Open reduction was required in five cases and
No. of Cases Percentage%
in 2 cases we used cerclage wire to hold the reduced
RTA 14 58%
Fall from height 8 33%
comminuted fragment. Muller et al. [19] compared the cerclage
Trivial fall 2 9% group with uncerclage group of subtrochanteric fractures, as a
result the cerclage achieves satisfactory reduction and also
Table 4: Seinsheimer classification maintains the integrity of the medial cortex and reduces the
risk of non-union and failure. Kim et al. [20] managed
Fracture type No. of Cases Percentage% subtrochanteric fractures with percutaneous cerclage and
I - - intramedullary fixation. Christophe Sadowski MD et al. [21]
II a 4 16.66% studied 39 cases of subtrochanteric femur fractures of which
II b 5 20.83%
19 cases treated with 95° DCS and 20 cases with PFN, he
II c 1 4.1%
concluded that at one year follow up, the rate of implant
III a 5 20.83%
III b 6 25%
failure, the number of major reoperations were both lower for
IV 1 4.1% patients treated with PFN. Because of the complicated
V 2 9% anatomy of the subtrochanteric region, its management is
quite challenging and even with various advancements in
Table 5: Time for union implant techniques, there hasn’t been much reduction in
complication rate [22]. According to David J. Hak et al. [23],
No of weeks No .of Cases Percentage% there are high chances of complications like malunion,
By 12 weeks 7 29.16% delayed union and non-union with implant failure while
12-18 weeks 12 50%
managing a case of subtrochanteric fracture. Mohammed
18-24 weeks 5 20.84%
Mansour Elzohairy [24], Shrinand V Vaidya et al. [25] and C.
Krettek et al. [26] used dynamic condylar screw for fixation of
Discussion
subtrochanteric fracture and found that the failure rate upto
Subtrochanteric fractures take place in the proximal regions of
9.7% in their study. We did not come across any implant
the femur, the anatomical definition of which is still difficult
related complications as compared to the 11% complications
and controversial. Boyd and Griffith were one of the first to
seen in the study by Menezes et al. [27]. In our study the
try and define subtrochanteric fractures as fractures occurring
clinical union was achieved at an average time of clinical
between the lesser trochanter and a point 5cm distal to it.
union was between 12 and 18 weeks for most cases which is
Subtrochanteric fractures are most commonly seen in the
comparable to the study conducted by Smith et al. Series [28].
elderly, although they can occur in younger patients after high
This study has clearly demonstrated the advantage of using
energy trauma. Parker et al. [4] reviewed the epidemiology of
long PFN in the treatment of subtrochanteric fractures.
subtrochanteric fractures and showed that the average age of
Fractures united in all cases and postoperative functional
the patients was 74 years. Average age of the patients in our
outcome was satisfactory. It is relatively easy procedure.
study is 52 years. This may be due to the increase in the
Long PFN is biomechanically stable construct allowing early
incidence of fractures in younger patients due to high energy
weight bearing and rehabilitation.
trauma.50% of patients who underwent conservative
The limitations of our study include the limited number of
treatment showed unfavourable results in a study conducted
cases and the absence of a control group treated with other
by Velasco et al. in 1978 [17]. The subtrochanteric region is
methods.
area of great stress concentration due to the muscular
deforming forces acting on it. Due to its precarious
Conclusion
vascularization and complex fractures with medial support
Long PFN is an effective, efficient and biomechanically
failure there is a large role of fixation failure and reoperations.
stable device for the treatment of subtrochanteric fractures
This is the reason that non-surgical management of
with a high rate of bony union and good functional outcome.
subtrochanteric fracture femur is no more considered an
Early mobilization and rehabilitation is possible due to closed
option. The method of open reduction and fixation using DCS
intramedullary nailing.
(Dynamic condylar screw plate), DHS (Dynamic hip screw),
Angle plates or even PF-LCP (Proximal femoral locking
References
compression plates) leads to extensive muscle stripping
1. Fielding JW. Subtrochanteric fractures. Clin Orthop Relat
around the fracture site, loss of fracture hematoma, increased
Res 1973;(92):86-99.
surgery time and disturbs the logical integrity of the region.
2. Gokul Nath R, Sah Ansari. Role of Proximal Femoral
Hence several studies have reported unsatisfactory results in
Locking Plate in treatment of Subtrochanteric Fractures;
almost 70% of cases.
Case series. Med Pulse International Journal of
The proximal femoral nail (PFN) is a new intramedullary
Orthopedics 2017;3(1):01-07.
device designed by AO in 1996 which introduces the benefit
3. Ibrahim S, Meleppuram JJ. A retrospective analysis of
of the closed technique to the treatment of subtrochanteric
surgically-treated complex proximal femur fractures with
fractures. The Indian versions of PFN are now available and
proximal femoral locking compression plate. Rev Bras
have been used in our study. They are available in two
Ortop 2017;52(6):644-650.
varieties, the standard and the long cannulated. The standard
4. Parker MJ, Dutta BK, Sivaji C. Subtrochanteric fractures
PFN consist of a 240 mm long nail. Its proximal part is 14mm
~ 272 ~
International Journal of Orthopaedics Sciences www.orthopaper.com

of femur. Injury 1997;28:91-95. 23. Hak DJ, Wu H, Dou C, Mauffrey C, Stahel PF.
5. Edwards SA, Pandit HG, Clarke HJ. The long Gamma Challenges in subtrochanteric femur fracture
nail a DGH experience. Injury 2000;31(9):701-709. management. Orthopedics 2015;38(8):498-502.
6. Kyle RF, Cabanela ME, Russel TA. Fractures of the 24. Elzohairy MM. Management of Comminuted
proximal part of femur, Instr Course Lect 1995;44:227- Subtrochanteric Femur Fractures by Indirect Reduction
253. and Biological Fixation with Dynamic Condylar Screw. J
7. Leung KS, So WS, Shen WY. Gamma nails and dynamic Trauma Treat 2012;1:136.
hip screws for proximal femoral fractures: a randomised 25. Vaidya Shrinand V, Devesh B, Dholakia, Anirban
prospective study in elderly patients. J bone joint Surg Br Chatterjee. The use of a dynamic condylar screw and
1992;74(3):345-351. biological reduction techniques for subtrochanteric femur
8. Radford PJ, Needoff M, Webb JK. A prospective fracture. Injury 2003;34.2:123-128.
randomised comparison of proximal femoral nail and 26. Krettek C, Schandelmaier P, Nliclau T, Tscherne H.
dynamic hip screw. J bone joint Surg Br 1993;75(5):789- Minimally invasive percutaneous plate osteosynthesis
793. (MIPPO) using the DCS in proximal and distal femoral
9. Seinsheimer F. Subtrochanteric fractures of femur. J fractures. Injury 1997;28:20-30.
Bone Joint Surg Am 1978;60(3):300-306. 27. 27. Menezes DF, Gamulin, A, Noesberger B. Is the
10. Verettas DA, Galanis B, Kazakos K. Fractures of the Proximal Femoral Nail a Suitable Implant for Treatment
proximal part of the femur in patients under 50 years of of All Trochanteric fractures? Clin Orthop Relat Res
age. Injury 2002;33(1):41-45. 2005;439:221-7.
11. Warwick DJ, Circhlow TP, Langkamer VG. The 28. Smith JT, Goodman SB, Tischenko G. Treatment of
proximal femoral nail in the management of comminuted femoral subtrochanteric fractures using the
subtrochanteric fractures of the femur. Injury Russell-Taylor reconstruction intramedullary nail.
1995;26(4):241-244. Orthopedics 1991;14(2):125-9.
12. McLaurin TM, Lawler EA. Treatment modalities for
subtrochanteric fractures in the elderly. Techniques in
Orthopaedics 2008;23(3):232-48.
13. Joglekar SB, Lindvall EM, Martirosian A. Contemporary
management of Subtrochanteric fractures. Orthop Clin
North Am 2015;46(1):21-35.
14. Chakraborty M, Thapa P. Fixation of subtrochanteric
fracture of the femur: Our experience. J Clin Diagnostic
Res 2012;6(1):76-80.
15. Cole PA, Bhandari M. What’s new in orthopaedic
trauma. Journal of Bone and Joint Surgery-Series A
2005;87(12):2823-2838.
16. Simmermacher RKJ, Bosch AM, Van der Werken C. The
AO/ASIF- proximal femoral nail (PFN): a new device for
the treatment of unstable proximal femoral fractures.
Injury 1999;30:327-32.
17. Velasco RU, Comfort TH. Analysis of treatment
problems in subtraochanteric fractures of the femur. J
Trauma 1978;18(7):513-23.
18. Gadegone WM, Salphale YS. Proximal femoral nail - an
analysis of 100 cases of proximal femoral fractures with
an average follow up of 1 year. Int Orthop
2007;31(3):403-8. Epub 2006 Jun 21.
19. Muller T, Topp T, Kuhne CA et al. The benefit of wire
cerclage stabilisation of the medial hinge in
intramedullary nailing for the treatment of
subtrochanteric femoral fractures: a biomechanical study.
Int Orthop 2011;35:1237e1243.
20. Kim JW, Park KC, Oh JK et al. Percutaneous cerclage
wiring followed by intramedullary nailing for
subtrochanteric femoral fractures: a technical note with
clinical results. Arch Orthop Trauma Surg
2014;134:1227-1235.
21. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R,
Hoffmeyer P. Treatment of Reverse Oblique and
Transverse Intertrochanteric Fractures with Use of an
Intramedullary Nail or a 95° Screw-Plate: a prospective,
randomized study. The Journal of Bone and Joint Surgery
2002;84(3):372-81.
22. De Toledo Lourenço PR, Pires RE. Subtrochanteric
fractures of the femur: update. Revista Brasileira de
Ortopedia, English Edition 2016;51(3):246-53.
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