A Comparative Study of Proximal Femoral Nail Antirotation in Peri-Trochanteric Fractures in Lateral Decubitus and Supine Position.

Introduction: One of the most widely used cephalomedullary device for unstable peri-trochanteric fractures is the Proximal Femoral Nail Antirotation (PFNa). There are many factors that can attribute to the ease of reduction and one of these is the positioning technique. The objectives of this study are to determine which position in doing the PFNa offers more advantage than the other, to compare the quality of fixation, adequacy of reduction, bony union and functional outcome in PFNa done in the lateral decubitus and supine position. 

Materials & Method: This study is an open cohort study conducted at the Philippine Orthopedic Center. Adult male and female (21-65 y/o) patients who will have to undergo or already undergone open reduction PFNa either in the supine or lateral position were included in this study. Thirty-nine (39) patients were recruited where 6 were lost to follow-up and 4 had no post-operative radiographs uploaded on the picture archiving and communication system (PACS). A total of twenty- nine (29) patients completed the study. The data were analyzed using the T-test in two population means and Fisher’s Exact Test. 

Results: At 95% level of confidence, the study showed that there are no significant differences on the distribution of Tip-Apex Distance (TAD), adequacy of reduction and bony union at 6 months post-operatively between the lateral and supine position. In contrast, there is a significant difference on the distribution of Cleveland index score of the patients treated using lateral and supine position (p-value 0.0084). With regards to the Harris Hip Score (HHS), there is also a significant difference on the average score between the two groups but all had an excellent functional outcome (p-value 0.0001). 

Conclusion: The preferred surgical position of doing an open reduction PFNa remains controversial. This study shows that the surgical position did not significantly affect the TAD, adequacy of the reduction, and bony union. All patients from both groups had excellent functional outcome at 6 months post-operatively but the lateral position group was superior in terms of the Cleveland index. Surgery with PFNa in lateral decubitus position can be performed in small rural hospitals that lack a fracture table. With proper surgical technique with PFNA in lateral decubitus position, this may be safe, executable and can benefit more patients with peri-trochanteric fractures.

Keywords: Peri-trochanteric fractures, subtrochanteric fractures, cephallomedullary nail