A retrospective analysis was conducted on ITF patients aged 65 and above who were treated at the Affiliated Central Hospital of Shenyang Medical University between 2020 and 2023. All included patients were informed about the differences between PFNA and THA treatments and selected their preferred surgical approach based on their personal preferences.
Inclusion Criteria:
1. Patients aged 65 and above with newly diagnosed closed fractures.
2. Evans-Jensen IV fracture patients.
3. Patients meeting the surgical indications for PFNA (Proximal Femoral Nail Antirotation) and THA (Total Hip Arthroplasty) procedures.
Exclusion Criteria:
1. Patients with pathological fractures.
2. Patients with severe internal medical conditions preventing surgery.
3. Lost to follow-up patients.
4. Patients whose postoperative limb function assessment was affected by other diseases.
A total of 40 patients were included in this study. Twenty patients received PFNA treatment, designated as the PFNA group, and 20 patients underwent total hip arthroplasty, designated as the THA group. General patient information, including age and gender, was recorded. Additionally, the following parameters were documented for both groups: time to the first postoperative ambulation (T1), time for weight-bearing on the affected limb postoperatively (T2), Harris hip scores for the affected side at 1 month, 3 months, and 6 months postoperatively, and the rate of excellent (90-100 points), good (80-90 points), fair (70-79 points), and poor (below 70 points) outcomes[9]. The SF-36 questionnaire was utilized to assess quality of life, including physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH)[10]. Postoperative complications were also documented.
Perioperative Preparation
All patients received routine analgesia, anticoagulation, nebulization, and functional exercises upon admission. Active treatment of internal medical conditions was undertaken to control indicators such as blood pressure, blood sugar, and cardiopulmonary function within permissible ranges for surgery. Hip joint X-ray images in the anteroposterior position and CT scans with three-dimensional reconstruction were taken preoperatively to clarify the extent of fracture displacement, with patients meeting the criteria for Evans-Jensen IV fractures based on imaging data. All surgeries were performed by the same team of experienced surgeons. Anesthesia was administered through either spinal or general anesthesia. Surgical time and intraoperative blood loss were recorded.
PFNA Group
The patient was placed in a supine position with the affected limb fixed on a traction table. Under fluoroscopic guidance, closed reduction of the fracture ends was performed. A longitudinal incision, approximately 3 cm proximal to the apex of the greater trochanter, was made, and layer-by-layer dissection was carried out to expose the greater trochanter. A guide pin was inserted slightly laterally and at the junction of the anterior 1/3 and posterior 2/3 of the apex of the greater trochanter. Along this guide pin, the main nail was inserted. A helical blade guide pin was then introduced, ensuring it ran parallel to the axis of the femoral neck and was positioned slightly below the long axis of the femoral neck. After penetrating the lateral cortex of the femur, the helical blade was inserted, paying attention to the anterior tilt angle and tip-apex distance. Finally, the distal locking screw and proximal intramedullary nail cap were secured. Muscle contraction exercises for the patient began on the second day postoperatively. Hip joint X-rays were regularly reviewed monthly after surgery, and decisions regarding the timing of getting out of bed and weight-bearing were made based on the fracture healing status.
THA Group
The patient was positioned on the unaffected side in lateral decubitus, utilizing the posterior lateral approach to the hip joint. At the insertion point of the greater trochanter, a portion of the external rotator muscle group was incised, preserving the piriformis muscle and attempting to maintain the internal distance of the femoral neck. Appropriate-sized acetabular cups and liners were installed, paying attention to the abduction and anteversion angles. The small trochanter fracture was reduced and fixed, with titanium cables tied around the proximal femur to prevent fissuring during femoral implantation. An appropriately sized Wagner femoral stem was implanted, taking note of the anteversion angle to ensure equal leg length. The greater trochanter fracture fragment was reduced and secured using tension bands. Postoperatively, functional exercises were initiated based on the patient's condition, and weight-bearing exercises were gradually introduced with the assistance of a walker as needed. (Fig.1a-1d).
Postoperative Management and Follow-Up
After surgery, active management of underlying medical conditions continued to prevent infections and deep vein thrombosis in the lower limbs. Patient data related to surgery and rehabilitation were recorded, including surgical duration (time from skin incision to skin closure) and intraoperative blood loss (amount in suction devices and gauze). The time to the first postoperative ambulation (T1) and the time to full weight-bearing on the affected limb postoperatively (T2) were assessed. Additionally, the evaluation of both groups included Harris hip scores and the rate of excellent (90-100 points) and good outcomes at 1 month, 3 months, and 6 months postoperatively. The SF-36 questionnaire was also administered. Postoperative complications, such as infection, fixation failure, and hip dislocation, were documented.
Statistical Analysis
All analyses were performed using SPSS 26.0 software (IBM, Armonk, NY, USA). Categorical variables were presented as numbers or percentages. Continuous variables were expressed as means ± standard deviations. Categorical variables were evaluated using Fisher's exact test. The Shapiro-Wilk test was used to assess whether continuous variables followed a normal distribution, and independent sample t-tests were employed to analyze normally distributed continuous variables. The significance level for all statistical tests was set at p < 0.05.