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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 26-28

Use of trochanteric femoral nail system in the management of un-united proximal femoral fracture: A case report on surgical technique

Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission23-May-2022
Date of Acceptance06-Jul-2022
Date of Web Publication23-Jan-2023

Correspondence Address:
Mohit Dhingra
Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/juoa.juoa_8_22

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The mode of fixation of proximal femur fracture has evolved immensely. Inspite of use of number of implants the failure of fixation is reported to be between 5 to 14%. The fixation failure is mainly due to loss of fixation in the proximal femur. Quality of bone is the major factor for loss of fixation. Here in our study we present a case report where trochanteric femoral nail advanced system has been used for fixation of proximal femur which had compromised bone quality and had undergone multiple surgeries. We here have highlighted the methodology for use of this implant and along with peroperative experiences.

Keywords: Pertrochanteric fracture, proximal femoral nail, trochanteric femoral nail

How to cite this article:
Sah S, Dhingra M. Use of trochanteric femoral nail system in the management of un-united proximal femoral fracture: A case report on surgical technique. J Uttaranchal Orthop Assoc 2022;1:26-8

How to cite this URL:
Sah S, Dhingra M. Use of trochanteric femoral nail system in the management of un-united proximal femoral fracture: A case report on surgical technique. J Uttaranchal Orthop Assoc [serial online] 2022 [cited 2023 Jun 3];1:26-8. Available from: http://www.juoa.org/text.asp?2022/1/1/26/368391

  Introduction Top

Intramedullary nailing has become the preferred methodology for treating proximal femoral fractures in adults.[1] There has been enormous development in the fixation system used for fractures of the proximal femur.[2] In spite of use of a number of implants, the failure of the fixation system is reported to be between 5% and 14% in different studies.[3] Use of trochanteric fixation nail-advanced (TFNA) system for the management of proximal femur fracture offers added advantage of fixation of neck screw in the osteoporotic bones with the use of specially designed bone cement. TFNA system is the next-generation nail system for the management of pertrochanteric fractures.

This system aims to build on the achievements of the earlier system of proximal femoral nail and tried to overcome their shortcomings. It has the versatility to offer various options to a surgeon planning to manage these fractures.

This article presents such a case of the failed union of the proximal femur with a defect in the lateral wall managed by the TFNA system. The nail was chosen due to the osteoporotic changes in the proximal femur along with the anticipation of fixation of the neck screw to be attained with the help of bone cement injected through it.

  Case Report Top

Patient profile

A 55-year-old male presented with a history of elsewhere operated case of open fracture subtrochanteric femur as a result of gunshot injury. The patient was initially managed by debridement and fixation with a second-generation PFN system. There was persistent pus discharge from the surgical site. The patient was given a trial of debridement again with the instillation of antibiotics in the local area with the use of Stimulan.[4]

The discharge responded for few days but again flared up. The patient was then planned for debridement and implant removal. On removing the implant, it was seen that the discharge was coming from the canal and the lateral wall of the proximal femur was eroded due to persistent infection and movement of loosened neck screw producing osteolysis around it. Antibiotic beads on polymethyl-methacrylate were put inside and outside the canal of the femur.

Futuristic surgical options were either a mega-prosthesis or fixation device which can provide fixation, irrespective of the deficient lateral wall. TFNA system was then planned for the fixation of this fracture.

  Materials and Methods Top

TFNA system is a titanium alloy (Synthes GmbH, Oberdorf, Switzerland) derived from the trochanteric femoral nail and PFN antirotation family of implants. The salient features include nails of varying lengths of 170–480 mm and diameters of 9–12 mm. There is an option of the helical blade as well as a lag screw for cephalomedullary fixation. In addition to all these features, it has the option of head–neck augmentation with bone cement via a specially designed system meant for both helical and lag screws to give extra purchase to the osteoporotic bones.

New features of an anterior bow to match with the femoral bow are seen in these nails, especially for the Asian population.[5] The system also comes with instrumentation designed to make surgery easy by the presence of radiolucent, quick-locking jig with radiographic markers which provide better indicator for the placement of neck screw in the lateral view.

Surgical technique of fixation of the fracture with trochanteric fixation nail-advanced system

  • The patient laid on a fracture table with the operative lower limb painted and draped
  • Removal of the bone cement done from intramedullary and extramedullary sites
  • Since the canal was open due to prior surgery, the guide wire was put in and serial reaming was done till the size of a 12 mm reamer [Figure 1]
  • Proximal reaming was done with the proximal reamer
  • The appropriate nail was then put inside the canal, and the proximal helical screw was put in a standard fashion [Figure 2]
  • Before injecting the cement, a radiopaque dye was injected into the screw system to ensure the joint is not violated by the guide pin or the screw [Figure 3]
  • If the joint is violated and the dye seems to go into the joint, the further procedure of injecting the bone cement is withheld
  • After ensuring the path of the cement, it is then mixed and put inside the screw with the help of special plunger and pressurizing it from behind so that it percolates from the screw holes [Figure 4]
  • After achieving the cement percolation from the screw, distal locking is done in a standard fashion where both the distal screws holes are at angle to each other [Figure 5].
Figure 1: Confirming guide wire placement in anteroposterior and lateral view under C-arm

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Figure 2: Confirming that the selected length on the side-opening cannula corresponds with the length of the helical screw under C-arm

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Figure 3: Radiographic contrast agent does not leak into joint space

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Figure 4: Injecting bone cement in femoral head using syringe

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Figure 5: Percolated cement and well-fixed implant over grafted fracture

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  Discussion Top

In the present day, the management of pertrochanteric fractures is largely successful. Evolution from the use of extramedullary implant dynamic hip screw (DHS) to intramedullary implants of PFN with number of generations has given extra edge to the management of these fractures. Although the outcome of DHS and PFN in cases of stable intertrochanteric fractures shows not much significant difference in terms of postoperative infection, lag screw cut out, and reoperation rate, there is significant difference in terms of blood loss, size of incision, and operative time.[6] There have been reports of complications in PFN system as well, ranging from screw cut out, secondary varus deformity, and impingement of the backed-out screw.[7] Most of these complications arise due to fracture-specific factors such as inadequate reduction and comminution as well as patient-specific factors such as poor bone quality and osteoporosis.[8]

The TFNA system is highlighted to address the shortcoming of its predecessor in terms of implant cut out, more stable fixation in osteoporotic fractures, and accommodating the anterior bow of the femoral bone, radiolucent zigs to provide better precision, and specially designed screw to avoid impingement of the soft tissue on the lateral aspect of thigh.[9] As the TFNA system is a new implant, so there is still no stringent indication for its use over the conventional PFN system. Although, in our institute, we regularly use the standard PFN-A2 system with helical blade in most of the cases of pertrochanteric fractures, we chose this implant in our case due to the following reasons:

  • Defect in the lateral wall in the proximal femur where fixation of helical blade to the lateral wall would have been an issue
  • The presence of osteoporotic changes in the hip due to longstanding un-united fracture and nonweight-bearing in the affected limb
  • The cement available for fixation is 6 ml which needs to be injected after the application of neck screw and confirmation of absence of leakaAQge in the joint. Although, in our case, the percolation of cement was not much from the screw, the desired fixation of the neck screw was achieved at the time of surgery.
  • Although further studies are required to prove its advantages over the conventional PFN-A2 system to indicate its superiority, our case highlights its use for the specific indications and surgical experience.

  Conclusion Top

Although the advantages of TFNA system over its predecessors seem to be admissible, long-term results in large number of patients will decide its edge over them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nayar SK, Ranjit S, Adebayo O, Hassan SM, Hambidge J. Implant fracture of the TFNA femoral nail. J Clin Orthop Trauma 2021;22:101598.  Back to cited text no. 1
Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma 2012;3:15-23.  Back to cited text no. 2
Unsay JC, Chua Tjun Huat I, Kwek Beng Kee E. Early experience with the trochanteric fixation nail-advanced (TFN-A): A descriptive review of thirty-four cases from a single center. Indian J Orthop 2020;54:246-53.  Back to cited text no. 3
STIMULAN® Beads for Bone and Joint Infection – Biocomposites. Available from: https://www.biocomposites.com/our-products/stimulan/. [Last accessed on 2022 May 16].  Back to cited text no. 4
Radiological Assessment of the Femoral Bowing in Japanese Population – PMC. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849268/. [Last accessed on 2022 May 16].  Back to cited text no. 5
Zhang K, Zhang S, Yang J, Dong W, Wang S, Cheng Y, et al. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric fractures: A meta-analysis. Med Sci Monit 2014;20:1628-33.  Back to cited text no. 6
Koyuncu Ş, Altay T, Kayalı C, Ozan F, Yamak K. Mechanical failures after fixation with proximal femoral nail and risk factors. Clin Interv Aging 2015;10:1959-65.  Back to cited text no. 7
Appelt A, Suhm N, Baier M, Meeder PJ. Complications after intramedullary stabilization of proximal femur fractures: A retrospective analysis of 178 patients. Eur J Trauma Emerg Surg 2007;33:262-7.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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