We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw

Aims. Restoration of proximal medial femoral support is the keystone in the treatment of intertrochanteric fractures. None of the available implants are effective in constructing the medial femoral support. Medial sustainable nail (MSN-II) is a novel cephalomedullary nail designed for this. In this study, biomechanical difference between MSN-II and proximal femoral nail anti-rotation (PFNA-II) was compared to determine whether or not MSN-II can effectively reconstruct the medial femoral support. Methods. A total of 36 synthetic femur models with simulated intertrochanteric fractures without medial support (AO/OTA 31-A2.3) were assigned to two groups with 18 specimens each for stabilization with MSN-II or PFNA-II. Each group was further divided into three subgroups of six specimens according to different experimental conditions respectively as follows: axial loading test; static torsional test; and cyclic loading test. Results. The mean axial stiffness, vertical displacement, and maximum failure load of MSN-II were 258.47 N/mm (SD 42.27), 2.99 mm (SD 0.56), and 4,886 N (SD 525.31), respectively, while those of PFNA-II were 170.28 N/mm (SD 64.63), 4.86 mm (SD 1.66), and 3,870.87 N (SD 552.21), respectively. The mean torsional stiffness and failure torque of MSN-II were 1.72 N m/° (SD 0.61) and 16.54 N m (SD 7.06), respectively, while those of PFNA-II were 0.61 N m/° (SD 0.39) and 6.6 N m (SD 6.65), respectively. The displacement of MSN-II in each cycle point was less than that of PFNA-II in cyclic loading test. Significantly higher stiffness and less displacement were detected in the MSN-II group (p < 0.05). Conclusion. The biomechanical performance of MSN-II was better than that of PFNA-II, suggesting that MSN-II may provide more effective mechanical support in the treatment of unstable intertrochanteric fractures. Cite this article: Bone Joint Res 2020;9(12):840–847

To investigate the utility of virtual reality (VR) simulators in improving surgical proficiency in Orthopaedic trainees for complex procedures and techniques. Fifteen specialty surgeons attending a London Orthopaedic training course were randomised to either the VR (n = 7) or control group (n = 8). All participants were provided a study pack comprising an application manual and instructional video for the Trochanteric Femoral Nail Advanced (TFNA) procedure. The VR group underwent additional training for TFNA using the DePuy Synthes (Johnson and Johnson) VR simulator. All surgeons were then observed applying the TFNA in a Sawbones model and assessed by a blinded senior consultant using three metrics: time to completion, 22-item procedure checklist and 5-point global assessment scale. Participant demographics for the VR and control groups were similar in context of age (mean [SD]: VR group, 31.0 [2.38] years; control group, 30.6 [2.39] years), gender (VR group, 5 [71%] men; control group, 8 [100%] men) and prior experience with TFNA (had applied TFNA as primary surgeon: VR group, 6 [86%]; control group, 7 [88%]). Although statistical significance was not reached, the VR group, on average, outperformed the control group on all three metrics. They completed the TFNA procedure faster (mean [SD]: 18.2 [2.16] minutes versus 19.78 [1.32] minutes; p<0.189), performed a greater percentage of steps correctly (79% versus 66%; p<0.189) and scored a higher percentage on the global assessment scale (75% versus 65%; p<0.232). VR simulators offer a safe and accessible means for Orthopaedic trainees to prepare for and supplement their theatre-based experience. It is vital, therefore, to review and validate novel simulation-based systems and in turn facilitate their improvement. We intend to increase our sample size and expand this preliminary study through a second upcoming surgical course for Orthopaedic trainees in London

In a prospective study from October 2002 to December 2003, we evaluated 102 femoral fractures treated with the new Synthes antegrade femoral nail. It is a titanium femoral nail with a recon locking option, distal dynamisation slot and trochanteric entry point. There were 99 patients (76 males and 23 females), three of whom had bilateral fractures and 42 polytrauma. The mean age was 36 years (13 to 87). The mean Injury Severity Score was 42 (23 to 65). Motor vehicle accidents were the cause of 44 fractures and gunshot injuries the cause of 37. There were 25 transverse fractures (AO 32-A), 37 wedge type fractures (AO 32-B) and 40 complex (AO 32-B) fractures. There were 38 Gustilo type-II and type-III open fractures. Surgery was performed within 24 hours in 80% of the fractures. Nine required open reduction. Unreamed nails were inserted in 38 patients. All fractures united. However, 11 showed angulations greater than 5°. Two patients had shortening of more than 1 cm, one of them requiring reoperation. One patient sustained a iatrogenic fracture, four developed fat embolism syndrome and three had DVT. Three patients had early superficial wound infection and two had late infections with a draining sinus. One locking screw broke. We found this to be a reliable femoral nail with a safe entry point

We present a retrospective clinical and radiological review to assess the use of the AO unreamed femoral nail and spiral blade in the treatment of subtrochanteric fractures. Treatment of the subtrochanteric fracture remains a challenge. A combination of high stress concentration, poor cortical bone quality and comminution leads to a high incidence of problems. The abovementioned implant has been recommended for use in such fractures. However, several authors have reported mechanical failure and spiral blade migration. We have used the unreamed femoral nail since 1996 in 65 femoral fractures, and of these 32 were subtrochanteric fractures. A retrospective clinical and radiological study was undertaken to assess the use of the implant. Clinical notes and radiographs were obtained for patients with subtrochanteric fractures treated with the AO unreamed femoral nail from November 1996 to November 1999. Fracture pattern was classified according to Seinsheimer. Assessments were made of callus formation and fracture healing. Any complication or implant failure was noted. Thirty-two patients required an unreamed femoral nail. There were 20 females and 12 males, with an average age of 75 years. There were 16 fractures due to a fall, 15 pathological fractures, and one due to a car accident. Classification was: Type I: 6; Type II: 13; Type III: 6; Type IV: 3; Type V: 1. Mean follow-up was five months (range 3 to 18). Eight deaths occurred within one month. There were two pain-free non-unions, one revision with bone graft for non-union, and one spiral blade back out. No breakage of implants occurred. We found that this implant provides stable fixation in these difficult fractures if adequate reduction is obtained. We have not experienced the implant failures reported in other series. We recommend the use of the implant, especially in those patients who are elderly or have pathological fractures

Introduction: Distal femoral shaft and supracondylar fractures are now more common. Non-operative treatment of these challenging fractures is difficult and fraught with complications. Retrograde and supracondylar nails have emerged as a good alternative to stabilize these fractures. This study evaluates the outcome of retrograde femoral nails done over a span of 5 years at a University Hospital. Materials and Methods: In this retrospective study, review of case notes and radiographs of 56 patients was done. All patients, who underwent retrograde and supracondylar femoral nailing between 1999 and 2003 were included. Various factors including patient demographics, mechanism of injury and fracture type were studied. Time to union, intra and post -operative complications and need for re-operation were also recorded. Results: 41 retrograde and 15 supracondylar femoral nails were done in the study period. There were 16 males and 40 females. Most of the patients had sustained their fractures due to fall. 3 out of the 56 patients presented with open fractures. 53 patients had insertion of reamed nails and 52 of them had both ends locked. The average time of operation was 2 hours 10 minutes and the average blood loss was 500 ml. Most patients were mobilized early with partial weight bearing. There were 3 superficial wound infections, which resolved with appropriate antibiotics. There were no cases of nerve damage or septic arthritis. 2 patients died with bronchopneumonia in the post- operative period. 55 out of 56 fractures united at an average of 16 weeks. 1 patient required re-operation for non-union, 9 months after the index operation. Conclusion: We conclude from this study that there is a high union rate of distal femoral fractures treated with supracondylar and retrograde nails with very low complication rate. It allows early mobilization, particularly in elderly patients and seems to produce very good functional outcome with low re-operation rate

For operative treatment of trochanteric femoral fractures extramedullary or intramedullary stabilization options exist. The intramedullary systems especially proximal femoral nail (PFN) presents biomechanical advantages compared to existing conventional systems. This prospective study was performed to understand the clinical results after 57 patients having trochanteric femoral fractures managed with the AO/ASIF PFN from January 2003 to March 2004. There were 11 male and 46 female patients and the mean age was 74.7. The most fractures (73.7%) were unstable according to AO/ ASIF classification. The patients were preoperatively evaluated as ASA grade 3 or 4. The operation was performed within 6 days after the injury. The patients were followed up for a minimum of 6 months. Immediate full weight bearing was permitted in 47 patients. Six patients died due to cardiopulmonary complications within 3 months after the operation. Of the surviving 51 patients 7 had cut-outs because of using too short proximal gliding screws. In remaining 43 patients fractures united within 4 months. The patients were evaluated by Salvati and Wilson hip function scoring system. At the final follow up 72 % of the patients had score more than 20 points (out of 40 points). In conclusion PFN is useful and minimal invasive device in the treatment of trochanteric femoral fractures. Femoral nail positioning is critical but biomechanically stable construct can be performed with careful management and early weight bearing is allowed

Purpose: Evaluating the rate of complications with the use of Proximal femoral nail (P.F.N.), and discuss the reasons for the complications and their solution. Material and Methods: During last 4.5 years 308 patients underwent P.F.N. for unstable proximal femoral fracture. The average age of the patients was 75.6 (range 20–96). A.O. classification. A1: 27. A2: 180. A3: 96. In 7 patients a failed dynamic hip screw (D.H.S.) was changed to P.F.N. All the patients were allowed to begin full weight bearing immediately. In 81% of patients short femoral nail was inserted and in the rest long one. Results:. Complications:Malfixation(internal-rotation, varus, valgus, shorting, bad position of the screw in the neck) – 10%. Deep infection 0.7%, nonuonion 1%, cut out 2%,. Nail breakage 0.6%, Broken drills, bad position of locking screws. Solutions:. Re-operation 1.6%, T.H.R. 1.3 %, removal of nail 1.6%, nail change 0.9%. During the last year we began to use a new and improved insertion set with less complications. Conclusions: P.F.N. is a valid solution for unstable proximal femoral fractures enabling immediate full weight bearing. P.F.N. may be used as a good salvage procedure for failed dynamic hip screw. The procedure demands accurate and meticulous operative technique in order to avoid technical complications. In cutout nails T.H.R. is a good salvage procedure in older patients

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery

Purpose: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. Methods: 22 (13 males, mean age 37.5y) consecutive patients were entered into this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group. Results: The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Conclusion: Femoral nailing and reaming induces a second hit response as supported by the post-operative increased levels of IL-6. There appears to be an inverse relationship in the concentrations of IL-6 and HMGB-1. Serum concentration of IL-6 unlike HMGB-1 strongly correlate with ISS. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immune-inflammatory process

We describe a simple method of inserting the distal screws in a locked femoral nail. The method requires no aiming device and no assistant. The only equipment needed is a 3 mm Kirschner wire and an air drill

Femoral nails are thought to be load sharing devices. However, the specific load sharing characteristics and associated stress concentrations have not yet been reported in the literature. The purpose of this study was to use a validated, three dimensional finite element model of a nailed femur subjected to gait loads in order to determine the resulting stresses in the femur and the nail. The results showed that load was shared between the nail and the bone throughout the gait cycle. In addition, high stress concentrations were noted in the bone around the screw holes, and dynamization was of minimal benefit. To determine the stresses in the bone and nail in a femur with a locked, retrograde, intramedullary nail. The retrograde femoral nail is a load sharing device. High stress concentrations occur in the bone around locking screw holes. When only one locking screw is used proximally and distally, stresses in the implant are excessive and may lead to failure. Dynamization was of minimal benefit. This is the first study to use a validated three dimensional finite element model to provide a detailed biomechanical analysis of stress patterns in a retrograde nailed femur under gait loads. The results can help resolve issues of stress shielding, implant removal, number of locking screws and dynamization. In the fully locked condition, loads in the femur were significantly higher than those in the nail for most of the gait cycle. Removal of locking screws to obtain dynamization only increased axial load in the femur by 17 %. However, stresses in the locking screws increased by as much as 250% when fewer than 4 screws were used. Maximum stresses in the bone were found around screw holes. A three dimensional finite element model of the femur and nail was developed. The model was validated by comparing results to a physical saw bone model instrumented with strain gages and subjected to a simple a compressive load. Once good correlation with simple loading patterns was demonstrated, gait loading patterns obtained from literature were incorporated and simulations were run for various conditions

The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. 22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group. The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay > 5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03). Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process

A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes). Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group. When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same

PURPOSE. To evaluate the late radiographic and functional complications occurring after treatment of reverse oblique trochanteric fractures with the proximal femoral nail. PATIENTS. This is a retrospective study which was conducted between October 2004 and October 2009. 55 patients with a reverse oblique trochanteric fracture were treated with the Gamma 3 nail. According to the AO classification, there were 36 type AIII-1, 8 AIII-2, 11 AIII-3 fractures. Closed reduction was achieved in all patients. The long gamma 3 nail was used in 34 fractures. The mean follow up was 18 months (range 9 to 32 months). The patients were evaluated clinically (Harris hip score) and radiographically. RESULTS. No intraoperative complications were recorded. During surgery, satisfactory reduction and acceptable nail insertion was assessed in all patients. No early postoperative technical failures were noticed. Complete union was achieved in 51 patients. The mean Harris hip score was 80.2. The results were excellent in 23 patients (41.8%), good in 19 (34.5%), fair in 9 (16.3%), and poor in 4 patients (7%). Late radiographic complications included secondary varus displacement due to cut-out of the proximal screw in three patients (5.4%), and calcification at the tip of the greater trochanter in nine patients (16%). Stress shielding as evidenced by the lack of cortical hypertrophy at the level of the tip of the implant were detected in 5 patients. Patients treated with a long gamma 3 nail achieved a statistically significant better result (p< 0.005). Three patients (5.5%) required a reconstructive procedure. CONCLUSION. Proximal femoral nailing provides stronger fixation of the proximal part in reverse oblique trochanteric fractures reducing mechanical complications. The implant choice, the accuracy of fracture reduction, and the correct placement of the nail are the key factors influencing the final outcome

To evaluate if adequate restoration of the medial cortical buttress reduces the high reported incidence of mechanical complications when using the AO unreamed femoral nail with spiral blade (UFN-SB) in the management of subtrochanteric femoral fractures. The clinical notes and radiographs of sixty-five patients treated with the UFN-SB between November 1996 and February 1999 were retrospectively reviewed. Twenty-eight of these fractures were subtrochanteric. Mean patient age was seventy-five and thirteen patients had metastatic disease. At the time of review the patients or their doctor were contacted by telephone to establish accurately the associated morbidity and mortality. Follow up information was obtained for every patient. Post-operative radiographs were assessed for accuracy of fracture reduction. The medial cortical buttress was adequately restored in every case. This required open fracture reduction in eleven patients and cerclage wires augmented the reduction in eight of these cases. Open reduction did not significantly increase time to fracture union or transfusion requirement. Every surviving patient was fully weight bearing within three months. One patient required a second operation for spiral blade migration but there were no implant breakages or other mechanical complications after a mean follow-up of thirty-seven months. Conclusion: Adequate restoration of the medial cortical buttress allows the UFN-SB to function as a load-sharing device and achieves reliable skeletal stability in these potentially unstable fractures that typically occur in osteoporotic or pathological bone

Introduction: The proximal femoral nail antirotation (PFNA) system is a cephalomedullary device originally designed to contend with the challenge of unstable tro-chanteric femoral fractures with the novel helical blade component aimed at limiting femoral head limiting cutout. We demonstrate its use in a variety of cases. Methods: This is a prospective study of 370 consecutive patients treated with short and long PFNA systems at a single center with 1-year follow-up. The device was used for unstable trochanteric femoral fractures (AO-classification 31. A.2 and A.3), prophylactic and definitive fixation of pathological fractures and high energy femoral fractures for a wide age range (19–101 years). Clinical outcome involved assessment of general mobility & function, operative and post-operative parameters & complications. Radiological outcome involved assessment of blade tip-apex distance, nail tip-femoral scar distance and distal locking configurations. Results: 17% died within the follow-up period. 72% achieved their pre-trauma mobility status and nearly all fractures healed within 6 months including those in over 85 years. Of 18 problematic cases, serious complications included deep infection, loss of proximal reduction, ipsilateral femoral shaft fracture and periprosthetic supra-condylar fracture. There were no cases of acetabular penetration or blade cut-out. Short PFNA was associated with the majority of femoral shaft fractures and the only significant finding regarding instrumentation. Discussion: This study supports long PFNA design theory demonstrating adequate purchase in the femoral head-neck zone, shown by lack of cut-out. Positive results have been demonstrated in a variety of cases making it a useful option in fractures in all ages and indications alongside unstable trochanteric configurations

Aim: To report our experience with a newly devised Long Proximal Femoral Nail [Long PFN] for treating complex subtrochanteric femoral fractures. The nail has the advantage of providing rotational as well as axial stability in the proximal femur with its hip pin in addition to the strong hip screw and easy operation technique. Methods: Twenty-four consecutive patients with twenty-four displaced subtrochanteric femoral fractures were treated with long PFN. The fractures were classified according to the Seinsheimer’s criteria. In 9 patients, the proximal femur had posteromedial wall comminution with displacement. The average age of the patients was 68.7 years. Closed reduction of the fracture was attempted in all cases and when it failed to achieve satisfactory reduction, a limited open reduction and cerclage cabling of the fracture was performed prior to the nailing with a particular emphasis on the postero-medial wall reconstruction. Result: The average follow up period was 49.7 weeks. All fractures in our series achieved bony union with an average time to union of 24.5 weeks. No patients had implant failure and no deep infection noted in the patients who had limited open reduction. Two patients had chest infection and one had non-fatal pulmonary embolism. Conclusion: Long PFN is a reliable implant in the treatment of complex subtro-chanteric fractures. Posteromedial wall reconstruction of the proximal femur is mandatory when treating sub-trochanteric fractures with Long PFN to avoid mechanical failure and non-union

A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks. Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole. At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms. Discussion: Reconstruction nails such as long PFN are bio mechanically suited for proximal femoral fractures and metastases. Bone cement augmentation has been reported to provide additional support in metastases. Dynamisation of the fracture leads to fracture impaction and promotes fracture healing. In this case implant failure was probably due to non union and fatigue failure of the implant. In spite of ‘spontaneous’ dynamisation (broken static distal screw), union did not occur initially. This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation

Introduction and Aims: Subtrochanteric femoral fractures are associated with high rates of non-union and implant failure, regardless of the method of fixation. This study aims to compare closed intra-medullary nailing without anatomic reduction to open reduction and internal fixation using a fixed angle device, for subtrochanteric femur fractures. Method: All skeletally mature patients admitted to two metropolitan trauma centres with subtrochanteric femur fractures were included in this study. Patients were randomised to intra-medullary nailing (IM) or internal fixation with a 95-degree blade plate (BP). Randomisation was concealed. The IM group were treated by closed insertion of a proximal femoral nail without anatomic reduction. The BP group were treated with open anatomic reduction and rigid fixation using a 95-degree angled blade plate. Bone grafting was at the discretion of the operating surgeon. All patients were mobilised non weight bearing for 12 weeks or until callus was seen on radiographs. Results: A total of 41 patients (20 IM and 21 BP) with a minimum follow-up of six months have been included. There was no significant difference between the two treatment groups with regard to age, time to surgery, length of procedure, blood transfusion requirements, length of stay, or fracture classification (Seinsheimer). The fixation failure rate was 29% (six patients) in the BP group. There were no fixation failures in the IM group. The difference is statistically significant (p< 0.05). An increased infection and mortality rate was noted in the IM group, although it was not statistically significant. Conclusion: Internal fixation of subtrochanteric femur fractures with a 95-degree angled blade plate is associated with increased implant failure and revision compared to closed intra-medullary nailing using a proximal femoral nail