Subtrochanteric fractures refer to fractures that occur within a 5 cm distance from the lesser trochanter in the proximal femur. These fractures are a significant challenge in orthopedic surgery due to their complex anatomy and the high mechanical stresses placed on this region. Subtrochanteric fractures account for 25% of all hip fractures and 7-4% of all femur fractures [1-5]. These fractures are often the result of high-energy trauma in younger patients or low-energy falls in the elderly, and their management is crucial for restoring mobility and function. The treatment of subtrochanteric femur fractures has evolved, with various fixation methods being employed to achieve optimal outcomes. Two primary fixation techniques are commonly used in the surgical management of these fractures: intramedullary (IM) fixation and extramedullary (EM) fixation. Intramedullary fixation involves the insertion of a rod into the marrow canal of the femur, providing internal support and stability. This method is known for its minimally invasive nature, shorter operative time, potential for early weight-bearing, biomechanical superiority, minimal invasiveness, and shortening of operation time, which have been noticed [2,4]. Extramedullary fixation, on the other hand, involves the use of plates and screws applied to the outer surface of the bone, offering rigid fixation and stability, particularly in comminuted or complex fractures. Despite the widespread use of both methods, there remains considerable debate among orthopedic surgeons regarding the superiority of one technique over the other. This controversy stems from the varying biomechanical properties, complication rates, functional outcomes, and healing times associated with each method. Therefore, a comprehensive comparison of intramedullary and extramedullary fixation is essential to determine the most effective approach for treating subtrochanteric femur fractures. The purpose of this research paper is to systematically compare the clinical outcomes, complications, and biomechanical effectiveness of intramedullary and extramedullary fixation techniques in the treatment of subtrochanteric femur fractures. By analyzing recent studies and clinical data, this paper aims to provide a clear understanding of the advantages and limitations of each method, ultimately guiding orthopedic surgeons in making informed decisions for optimal patient care. The objective of this study is to evaluate the results of treatment of subtrochanteric femoral fracture using IM (IM femoral nail, proximal femoral nail (PFN)) and EM (95° condylar plate, locked anatomical proximal femoral plate) fixation methods.

This retrospective study was carried out on 85 patients who had undergone surgery for subtrochanteric fractures at the Department of Orthopaedics, Darbhanga Medical College and Hospital, Darbhanga, Bihar (India). The study comprised patients who visited our hospital for a prompt postoperative check-up and underwent X-ray imaging in the correct postures.

Inclusion Criteria:

• Patient Age: Adults aged 18 years to 65 years.
• Fracture Type: Patients with confirmed subtrochanteric femur fractures within 5 cm distal to the lesser trochanter.
• Surgical Intervention: Patients who underwent either intramedullary (IM) or extramedullary (EM) fixation for their subtrochanteric femur fracture.
• Follow-up duration: Minimum follow-up period of 12 months post-surgery.
• Availability of Data: Complete medical records, including preoperative, intraoperative, and postoperative details, as well as radiographic images.

Exclusion Criteria:

• Age: Patients younger than 18 years and older than 65 years.
• Fracture Classification: Patients with periprosthetic, pathological, or open fractures of the subtrochanteric femur.
• Previous Surgery: Patients with a history of previous surgical intervention on the affected femur.
• Incomplete Data: Patients with incomplete medical records or insufficient follow-up data.
• Comorbid Conditions: Patients with severe comorbid conditions that significantly impact fracture healing, such as advanced diabetes, active cancer, or severe osteoporosis.
• Non-Surgical Treatment: Patients who received non-surgical treatment for their subtrochanteric femur fracture.

We removed a total of 22 patients according to specific criteria: four had pathological fractures, seven were either under 18 or over 65 years old, three had pelvic, vertebral, or ipsilateral extremity fractures, and eight had incomplete follow-up or had died. We divided the 85 participants enrolled in the study into two distinct categories. Group A consisted of 62 patients who underwent intramedullary (IM) fixation using either an IM femoral nail or a proximal femoral nail. Group B, on the other hand, included 23 patients who received extramedullary (EM) fixation using either a 95° condylar plate or a locked anatomical proximal femoral plate.

We acquired the patients' history data from the hospital's recording and digital imaging system. If there was suspicion that the fracture extended to the piriform fossa, the patients underwent preoperative anteroposterior X-ray of the pelvis, as well as bilateral radiographs of the hip, femur, and knee of the afflicted side, and CT of the hip and femur. We administered deep vein thrombosis prophylaxis, antimicrobial prophylaxis, and skeletal traction to 36 patients, which accounted for 42.3% of the total, depending on the degree of displacement observed in the subtrochanteric fracture. The traction table was used for all procedures, and we promptly mobilized the patients whenever they were capable. Our study recorded several patient characteristics including age, sex, fractured hip side, etiology, anesthesia type, preoperative waiting time, follow-up length, fracture type, and mechanical problems. The assessment of hip function was categorized as excellent, good, moderate, or poor based on the Harris hip score (HHS). The examination component of the original Harris hip form was eliminated due to the inability to examine certain patients. Instead, we derived the modified HHS by relying on the patient's self-report. This approach demonstrated a strong correlation of 99% with the average HHS [6,7]. The score was multiplied by a factor of 1.1 and then recalculated to be assessed on a scale of 100 points [8]. The postoperative radiographs revealed varus-valgus angulation and procurvatum (flexion) angulation in the sagittal plane, as observed using our hospital's digital imaging system. Angles with a measurement less than 10° were deemed acceptable. We assessed the presence of any shortening in multipart fractures by comparing them with the radiographs of the opposite femur in cases where there was displacement or overlap. We analyzed the time it took for the patients included in the study to achieve union, and we observed the presence of callus in three out of the four cortices on both the anterior-posterior and lateral radiographs.

Statistical Analysis: The collected data was organized into a table using Microsoft Excel 2019. Subsequently, the data was transferred to GraphPad version 8.4.3 for further statistical analysis. Descriptive statistics were employed to calculate and display frequencies and percentages. A p-value of less than 0.05 was taken as a measure of significance.

The study included 85 patients, [Group A: 62 and Group B: 23] with a mean age of 42.9 years, ranging from 16 to 65 years. The sample consisted of 60 (70.59%) males and 25 (29.41%) females. The average follow-up period was 13.42 months. The most frequent cause of subtrochanteric fractures was falling from a height (Table 1). Local anesthesia was used for 64 patients, and general anesthesia was administered to 21 patients.

Table 1: Showing the comparison of baseline demographic and clinical characteristics of the study population

[* Statistically Significant]

We classified subtrochanteric fractures based on the Seinsheimer classification system: three were type 2a, 36 were type 2b, six were type 2c, 15 were type 3a, eight were type 3b, four were type 4, and 13 were type 5. Intramedullary (IM) femoral nails were used in 35 patients (41.18%), proximal femoral nails (PFN) in 25 patients (29.42%), 95° condylar plates in 12 patients (14.11%), and proximal femoral anatomical plates in 13 patients (15.29%). In the study population, six patients exhibited varus deformity, one had flexion deformity, five had both varus and flexion deformities, and seven had limb length discrepancies. Group A had six patients with varus deformity, one with flexion deformity, and five with both varus and flexion deformities. Group B showed no malalignments greater than 10° and only two limb length discrepancies. Late infections were observed in two patients with a proximal femoral locking plate, which was treated by removing the implants. There were eight cases of implant failure: six in Group A and two in Group B. Delayed union and non-union cases were more frequent in Group A but were not statistically significant. Malalignment occurred in 11 patients (17.74%) in Group A and one patient (4.35%) in Group B. There were no significant differences between Groups A and B in terms of non-union, implant failure, or limb length discrepancies, and no alignment issues were found in patients who underwent extramedullary (EM) fixation. Malreduction was detected in 11 out of 62 (17.74%) patients in Group A who received nail fixation (Table 2).

Table 2: Showing the comparison of the complication rate in Group A and Group B

We observed delayed union in seven out of twelve patients with malalignment, implant failure in two patients, and nonunion in two patients. Among the seventy-three patients without malalignment, 13 experienced delayed union, three had non-union, and six encountered implant failure (Table 3). The average Harris Hip Score (HHS) for the general population was 86.5, with no significant difference between the groups in terms of HHS.

Table 3: Showing the comparison of the complication rate in patients with and without malalignment

The choice of fixation procedure for subtrochanteric fractures lacks unanimity. Our study sought to examine the efficacy of intramuscular (IM) and intravenous (IV) procedures in treating these fractures. However, our findings did not reveal a statistically significant difference between the two approaches. Both approaches possess benefits and drawbacks. Intramedullary (IM) procedures are linked to reduced soft tissue damage, provide support to the medial cortex, and have a high ability to bear loads. However, it is important to note that the decrease achieved may not be anatomically precise. EM techniques can provide anatomical reduction, but this may result in increased soft tissue injury and hemorrhage. Consequently, the surgeon's expertise and personal choice become prominent. Subtrochanteric fractures are less prevalent compared to femoral neck fractures or intertrochanteric fractures. The proximal fragment in this region is compelled into flexion and abduction by deforming pressures. Additionally, it serves as a load-bearing area. Consequently, fractures occurring in this particular area pose challenges in terms of treatment. There is a scarcity of research in the literature that compares treatment choices for this specific form of fracture, and determining the optimum approach is a subject of controversy. We anticipate that our study will make a valuable contribution to the existing body of knowledge on this issue.

Our investigation yielded favorable clinical outcomes in both groups. Our investigation has yielded comparable findings to those reported in the existing literature. Mirbolook et al. conducted a retrospective study involving 114 patients to compare the outcomes of using IM femoral nails and proximal femoral locking compression plates in treating subtrochanteric fractures. The study indicated that there was no significant difference in the results between the two groups [9]. Cook et al. analyzed a total of 244 subtrochanteric fractures, out of which 168 were treated using an intramedullary (IM) implant and 75 were treated using an extramedullary (EM) implant. There was no notable disparity between these two groups, except for the elevated rate of blood transfusion in patients with EM implants [10]. Pakuts examined a total of 26 patients, dividing them into two groups: 15 patients received treatment with dynamic condylar screws (DCSs) and 11 patients received treatment with gamma nails. The study revealed that there was no notable disparity between the two groups in terms of clinical outcomes or sequelae. Nevertheless, he asserted that patients in the group that had the nail applied to their nails recovered more rapidly and resumed their normal activities after surgery [11]. Sowmianarayanan et al. conducted a comparative examination of the durability of dynamic hip screws (DHS), DCS, and PFN using the finite element analysis approach. Their findings revealed that all three devices exhibited comparable behavior [12]. In their investigation, they conducted a comparison of several intramedullary (IM) fixation methods. However, they did not demonstrate any clinical superiority of one approach over the other, which is consistent with the findings of our study. Thus, the classification of fixation type continues to be a subject of debate.  Intramedullary (IM) nails provide sufficient strength to endure deforming forces in the subtrochanteric region and the weight-induced stress on the medial cortex. Umer et al. achieved a success rate of 94% when treating subtrochanteric fractures using PFNs [13]. They stated that PFN is suitable for subtrochanteric fractures, except for Seinsheimer type 4 fractures. In their 2015 study, Imerci et al. conducted a comparison between distal femur less-invasive stabilization system (LISS) plates and proximal femoral nail (PFN) for the treatment of 32 subtrochanteric fractures. In this study, the process of consolidation was shown to be slower in the plate group compared to the PFN group. Additionally, the HHS (Harris Hip Score) was higher in the plate group. However, there was no statistically significant difference observed in complication and reoperation rates between the two groups [14]. Due to the acknowledged biomechanical benefits of intramedullary (IM) procedures and advancements in nail technology, nails are becoming more commonly used for the treatment of subtrochanteric fractures. Currently, plates are mostly favored for addressing difficulties such as non-union and malunion. Among our cohort of patients, four individuals experienced non-union, the majority of whom needed revision surgery utilizing electromagnetic fixation with plates.

Ensuring correct alignment is a crucial factor in the management of subtrochanteric fractures. Improper reduction during fixation can lead to mechanical difficulties. In their investigation, White et al. examined 122 subtrochanteric fractures that were treated with intramedullary (IM) nails. They found that the rates of non-union and implant failure were much higher when the implants were applied without adequate reduction [15]. Our study involved a comparison between 12 patients who had malalignment and 73 patients who did not have malalignment. No disparities were seen in relation to delayed union, non-union, and implant failure. Zhou et al. utilized internal fixation using intramedullary (IM) devices in a cohort of 76 patients. Out of the patients, only five were able to perform a successful closed reduction using a traction table. The remaining patients had open reduction with a mini-incision. All patients but one obtained appropriate union, with the exception of delayed union in that particular patient [16]. Riehl et al. treated 35 subtrochanteric fractures with intramedullary nails [17]. Union occurred in 97% of the patients without the need for further surgical intervention. This study investigated the specific type of reduction required in intramedullary nailing. Seven out of 35 patients exhibited angulation of more than 10 degrees in either the anterior-posterior or lateral plane. Delayed union was observed in six out of the seven patients, while non-union was observed in one patient. Lee et al. conducted a comparison between patients who had closed reduction and those who received a minimum open reduction for the treatment of subtrochanteric fractures using IM nails. The study showed that malalignment and non-union occurred more frequently in patients who underwent closed reduction. Therefore, the researchers recommended considering minimum open reduction if closed reduction did not yield adequate outcomes [18]. Malalignment typically manifests as the proximal part inclining towards varus, flexion, and external rotation. This leads to the contraction of the abductor's arm and abductor insufficiency, as well as shortening in that limb, with the trochanter type migrating further towards the proximal end [19]. The DCS implant is frequently utilized for subtrochanteric fractures, particularly in cases of oblique or transverse fractures with short proximal pieces. Neogi et al. utilized this implant in 40 cases of multi-part subtrochanteric fractures and obtained favorable outcomes [20]. Among our cohort of patients, a 95° dynamic condylar plate was utilized in 13 cases. However, one patient experienced delayed union due to a fractured plate and subsequent material failure. Rohilla et al. utilized Dynamic Compression Screws (DCSs) in 43-part subtrochanteric fractures and observed no instances of non-union or implant failure [21].

A proximal femoral locking compression plate is a viable substitute for the Dynamic Compression Screw (DCS), particularly in cases of unstable fractures involving small bone fragments. Prior research has demonstrated favorable outcomes with the utilization of this implant [22-24]. Our investigation involved the application of a proximal femoral locking plate to 10 patients. Two patients were diagnosed with deep infection, one patient experienced delayed union, one patient had non-union, and one patient suffered from implant failure. Fixation of subtrochanteric fractures with EM techniques has several drawbacks, including the need for extensive dissection, more bleeding, longer surgery duration, and a higher risk of infection. Nevertheless, it may offer a more significant decrease. Intramedullary (IM) procedures offer several benefits, including their ability to handle heavy loads, provide support to the medial cortex, and minimize invasiveness. Nevertheless, malalignment is more probable when conducted using a closed reduction technique. The impact of misalignment on the outcomes is likewise subject to interpretation. The literature does not provide a distinct differentiation between these strategies. No notable disparity was observed between the two approaches in our investigation. In our series, both Groups A and B demonstrated clinically adequate outcomes. Subsequent investigations may entail larger cohorts and extended periods of observation. Currently, the surgeon's expertise and personal inclination appear to be of primary importance. The retrospective nature of the study is a disadvantage due to its potential to introduce bias in data gathering. Participants who did not undergo an X-ray in the correct posture were not included in the study. However, radiological assessments were conducted using an X-ray, and the measurements may be influenced by the position of the hip. Nevertheless, we hypothesize that a comparable phenomenon might occur in both cohorts. Due to the preference for IM fixation, there is a significant disparity in the number of patients across the groups. All patients underwent surgery at the same hospital, albeit under the care of separate doctors. None of the groups have any implants. The IM fixation group consists of IM femoral nails and PFN. The EM fixation group consists of a 95° condylar plate and a locked anatomical proximal femoral plate. We believe that this represents a constraint in relation to uniformity. Conducting a prospective, randomized trial with long-term patient follow-up would yield more precise findings when comparing different approaches.

The use of intramedullary and extramedullary fixation procedures has both benefits and drawbacks when it comes to treating subtrochanteric fractures. Intramedullary techniques are characterized by little soft tissue injury, providing support to the medial cortex and exhibiting a good load-bearing capacity. However, it is important to note that the reduction achieved may not be anatomically precise. Extramedullary techniques can accomplish anatomical alignment, but they may also result in increased soft tissue damage, heightened risk of infection, and bleeding. In our investigation, both groups yielded comparable and medically satisfactory outcomes. The matter of fixation procedures continues to be a source of controversy in the literature, and additional research is required to fully explore this topic. IM or EM fixing procedures are preferable for treating subtrochanteric fractures. Both strategies can yield favorable outcomes.

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