title: PFNA-II protrusion over the greater trochanter in the Asian population used in proximal femoral fractures.
abstract: BACKGROUND
  The treatment of proximal femoral fractures in geriatric osteoporotic patients continues to be a challenge in orthopaedic trauma. Various kinds of cephalomedullary nails, such as gamma nail, InterTan and PFNA were used clinically. The latest generation PFNA II, specially designed for Asian population, is commonly used for geriatric per-/intertrochanteric fractures. The aim of this study was to determine whether the current PFNA-II proximal segment length is suitable for the greater trochanter height, as assessed by postoperative radiograph measurements.
  
  
  METHODS
  51 consecutive patients with per-/intertrochanteric fractures treated with the PFNA-II between July 2012 and December 2012 were enrolled in this study. There were 19 males and 32 females, with an average age of 78.6 years (range 66-92 years). According to AO/OTA classification system, there were 4 cases of 31A1 fractures, 35 cases of 31A2 fractures, and 12 cases of 31A3 fractures. The nail protrusion height over the lateral greater trochanter and the Parker ratio of the helical blade tip in the femoral head were measured and compared using pelvic digital anteroposterior radiographs taken within 2 weeks postoperatively. Patients were followed up for a minimum period of 1 year to check whether they had lateral trochanter pain.
  
  
  RESULTS
  Postoperative digital anteroposterior (AP) films were used for assessment and any prominence was recorded as positive. Overall, nail protrusion over the greater trochanter occurred in 87.8% of cases. In 60.8% of the cases, protrusion height was >5 mm. The average protrusion height was 6.25 ± 4.27 mm (male average 4.84 ± 4.38 mm, and female average 7.09 ± 4.70 mm). The average Parker ratio of all cases was 51.0 ± 6.9% (male average 49.8 ± 7.5% and female average 51.7 ± 6.5%). Protrusion height was positively correlated (r= 0.394,P= 0.004) with the helical blade position in the femoral head (Parker ratio). Clinically, a total of 42 patients were followed up at an average of 15.0 ± 2.6 months (range 12-24 months) they were able to walk independently or with a stick. There were 13 patients with lateral trochanter pain on the injured side. Protrusion height of these patients was 11.13 ± 3.75 mm, whereas the protrusion height of the remaining 29 patients was 3.87 ± 3.39 mm.
  
  
  CONCLUSIONS
  There was a morphologic mismatch between the proximal segment length of the PFNA-II and the greater trochanter in the Asian population, which may be the cause of postoperative lateral trochanter pain. A modification to shorten the proximal part of the nail is proposed to avoid protrusion over the greater trochanter.
authors.affiliation: Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Sun-Jun
authors.initials: SJ
authors.lastname: Hu
authors.affiliation: Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Shi-Min
authors.initials: SM
authors.lastname: Chang
authors.affiliation: Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Ma
authors.affiliation: Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Shou-Chao
authors.initials: SC
authors.lastname: Du
authors.affiliation: Department of Orthopaedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Liang-Ping
authors.initials: LP
authors.lastname: Xiong
authors.affiliation: Department of Orthopaedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200090, P.R. China.
authors.forename: Xin
authors.initials: X
authors.lastname: Wang
keywords: Intertrochanteric fractures; asciatic race; intramedullary nail; intramedullary nailing; nail protrusion; pain; proximal femoral nail antirotation-II; soft tissue irritation