Comparative Study of Proximal Femoral Nail and Dynamic Hip Screw in the Treatment of Subtrochanteric Fractures of Femur

INTRODUCTION: Subtrochanteric fractures have long been recognized as the most difficult of the injuries to treat because most of the fractures are unstable, cortical diaphyseal bone is involved which has poor vascularity and poor healing capacity as compared to the cancellous bone of trochanteric area. There is high stress in this area and powerful muscles pull the fragments in different directions, therefore non-operative treatment often fails. An interest in the end result and functional outcome of subtrochanteric fractures treated with proximal femoral nail or dynamic hip screw, to fulfill the main aim of fracture management i.e. restoration of optimal function in the shortest time by the most reliable and safest method in our hand; is the original impetus of our study. PATIENTS AND METHODS: 40 patients with subtrochanteric fracture of femur reporting at the orthopaedics department of Gandhi Medical College, Bhopal between Dec. 2006 to July 2008 were treated either with dynamic hip screw or proximal femoral nail. 9 patients with follow-up of less than 6 months were excluded from the study. The present study thus comprised of 31 patients of subtrochanteric fracture of femur. Pre-operative data, intra-operative observations and postoperative data were recorded and the two group were compared for statistical significance. OBSERVATIONS AND RESULTS: 14 patients who were treated with dynamic hip screw (Group I) and 17 patients who were treated with Proximal Femoral nail (Group II) were comparable with regard to all their pre-fracture variables including their age, gender, side of affection, injury operation interval, mode of trauma, fracture classification, mobility scores and ASA physical status score. The mean operative time in Group I (93.57 min) was significantly higher than in Group II (80) with a P value of 0.02. Average blood loss in Group I (207.14 ml) was 2.8 times higher than in Group II (72.35 ml) with a P value of 0.036. 93% patients in Group I required blood transfusions as compared to only 23% in Group II (P<0.001). Difference in the postoperative Parker-Palmer mobility score in the two groups was significant (Group I = 7.82, Group II = 7.21) (P = 0.045). The union in Group II (18.25 weeks) was significantly faster than in Group I (20.57 weeks) (P = 0.039). The final results graded as excellent, good fair and poor were similar in both the groups with no statistical differences (P = 0.79). CONCLUSIONS: Proximal Femoral nail for subtrochanteric fractures is a technically demanding procedure and has a steep learning curve. Its application produces minimal amount of surgical trauma to the patients & require less blood transfusion. With proximal femoral nail fixation, there is early functional recovery & return of the patients to pre injury status in majority of patients.