Clinical and radiological results of OUR PFN (Proximal femoral nail) applications in proximal femur fractures

Aim: The aim of this study is to evaluate patients who underwent surgery with proximal femoral nail (PFN) fixation due to proximal femoral fractures; to investigate the factors affecting mortality, especially the mechanical and technical complications that develop due to the use of nails and the causes of these complications, and to increase patient survival and satisfaction by reducing the frequency of morbidity and mortality due to intertrochanteric fractures, which are increasingly common. Method: 71 patients and their data who met the inclusion and exclusion criteria out of 156 patients who applied to our clinic between 01/01/2013 and 01/03/2022 and to whom we applied proximal femoral nail (PFN) due to proximal femoral fracture, were included in the study. Age, gender, side, cause of trauma, preoperative time, operative time, postoperative time, amount of intraoperative bleeding, ASA scores, Comorbidity Scores, Singh Indexes and accompanying traumas of the patients with intertrochanteric fractures were evaluated. Mortality rates and survival times in the first 6 months, 6 months to 1 year or 6-12 months and >1 year were evaluated, and factors associated with mortality were analyzed. Evans Jensen classification, AO/OTA Classification and Boyd-Griffin Classification were used for radiological fracture classification and fracture stability/instability was evaluated. In the proximal femoral nail (PFN) category, differences in postoperative clinical and radiological outcomes were identified among different implant types, nail angles, and nail lengths. The reduction quality of the patients was evaluated with Fogagnolo et al. (Modified Baumgartner) and Chang et al. Reduction criteria. Positions of the patients in the femoral head were determined according to Cleveland Quadrants and tip-apex distance measurements were made. After fixation of the nail on the fractured side and on the contralateral side, the collodiaphyseal angle (CDA) of the patients were calculated and grouped according to varus or valgus differences compared to the healthy hip. Additionally, patients with a CDA <120° and those who were fixed with a CDA ≥120° were grouped. Mechanical and technical complications in postoperative radiographic evaluations, if any, were evaluated and factors causing them were analyzed. Clinical and functional outcomes were analyzed using the Harris Hip Score, Salvati-Wilson Hip Joint Function Evaluation Scale, and Patient Satisfaction Questionnaire (PSQ). These data were obtained retrospectively from the hospital information management system and the patient list and patient information for the specified date range were used only in this study. Study planning, control of the collected data, control of the statistical analysis, control of the literature research and suitability, and finalization of the study and discussion were carried out by Abtullah Milcan. Preoperative fracture classification and postoperative radiological measurements of the patients according to their radiological examinations were made by Hasip Turan Şimşek, Yavuzhan Altın and Elyesa Ergen. Recording of patient data on the data form; evaluation, interpretation and writing of the data were done by Hasip Turan Şimşek. Results: The demographic characteristics of the patients were as follows: 34 (47.9%) were male and 37 (52.1%) were female. Of the patients who presented to the clinic, 62 (87.3%) had a simple fall, 7 (9.9%) had an out-of-vehicle traffic accident, 1 (1.4%) had an in-vehicle traffic accident, and 1 (1.4%) had a fall from a tree. The average age of patients presenting to the clinic was found to be 72.71 (SD = 14.43, min = 20, max = 96). 35 (50%) of our patients were operated within the first 24 hours, 51 (71%) within the first 48 hours, and 56 (78%) within the first 72 hours. All patients had union in n = 59 cases. When the patients' complication status was examined, it was seen that 27 (38.0%) had a complication, whereas 44 (62.0%) had no complications. The most common mechanical and technical complications were: <120° was detected in varus position with CDA. 10 patients (14%) who required revision surgery underwent it. Screw stripping/cut-out/cut-through was also observed in all patients who required revision surgery. In addition, there was screw retraction and CDA <120° in 2 and 5 patients, respectively. 37 patients were evaluated with stable and unstable fractures, respectively. It was concluded that there was a statistically significant relationship between fracture stability and the absence of complications, p=0.04. According to the Chang et al. criteria, 32 (45.1%) had excellent reduction, 26 (36.6%) had acceptable reduction, and 13 (18.3%) had poor reduction. According to the Fogagnolo et al. criterion, 34 (47.9%) had good reductions, 20 (28.2%) had acceptable reductions and 17 (23.9%) had poor reductions. A statistically significant relationship between Fogagnolo criteria and the presence of mechanical/technical complications was detected, p = 0.002. As a result of our analysis, it was concluded that there was no statistically significant difference between nail type, nail length, nail diameter, nail angle and lag screw diameter and the presence or absence of complications (p>0.05). When 10 patients who required revision surgery (all had screw stripping/cut-out/cut through) were examined; Cleveland quadrant location was superior (60%) in the AP plane in 6 of the patients, and posterior (60%) in the lateral plane in another 6 of the patients. Fogagnolo reduction criteria were evaluated as poor in 6 patients (60%). A statistically significant relationship was detected between >25mm Tip Apex Distance (TAD) and Screw Stripping (Cut Out/Cut-Through) complication (p=0.029). Average TAD distance of patients with Screw Stripping, while the average TAD distance of patients without screw stripping was 36.56 mm, it was 23.65 mm. A statistically significant difference was detected between the two groups(p = 0.004). It was determined that the success rate was 67% according to the Harris Hip Score, 74% according to the Salvati-Wilson Scale and 76% according to the Patient Verbal Satisfaction Survey. No statistically significant relationship was detected between Harris Hip Score, Salvati-Wilson Scale and Patient Verbal Satisfaction Questionnaire and the presence of complications and the need for revision (p>0.05). Conclusion: The aim of this study was to evaluate the factors affecting mortality and complications in patients who underwent proximal femoral nail (PFN) fixation for proximal femoral fractures. We retrospectively analyzed the data of 71 patients who met the inclusion and exclusion criteria out of 156 patients who presented to our clinic between 01/01/2013 and 01/03/2022. We used various radiological and clinical criteria to assess the fracture stability, reduction quality, nail position, screw position, and complication status of the patients. We also used statistical methods to analyze the relationship between these factors and mortality and complications. Our results showed that fracture stability was a significant factor for the absence of complications (p = 0.04). This is consistent with the findings of previous studies that reported higher complication rates in unstable fractures than in stable fractures. We also found that the reduction quality according to the Fogagnolo et al. (Modified Baumgartner) criteria was significantly related to the presence of mechanical and technical complications (p = 0.002). This is in agreement with the studies that suggested that poor reduction quality could lead to implant failure and nonunion. However, we did not find any significant difference between nail type, nail length, nail diameter, nail angle and lag screw diameter and the presence or absence of complications (p > 0.05). This contradicts some studies that claimed that certain nail characteristics could affect the outcome of PFN fixation. A possible explanation for this discrepancy could be the small sample size and the heterogeneity of the patient population in our study. Advanced age, number of comorbidities and time before surgery were closely related to 1-year mortality. Fracture instability and poor Fogagnolo et al. reduction quality were associated with screw stripping. Regardless of the implant type, nail angle and nail diameter, the position of the head screw should be central-central or inferior-central, avoiding superior and posterior placements and keeping the Tip Apex Distance below 25 mm is important in protecting against mechanical and technical complications. The limitations of our study include the retrospective design, the small sample size, the lack of a control group, and the short follow-up period. Therefore, our results should be interpreted with caution and further prospective studies with larger sample sizes and longer follow-up periods are needed to confirm our findings. In conclusion, our study suggests that fracture stability and reduction quality are important factors for preventing mechanical and technical complications and reducing mortality rates in patients who undergo PFN fixation for proximal femoral fractures. We recommend careful evaluation of these factors and application of appropriate surgical techniques to improve patient survival and satisfaction.