Fracture site was minimally exposed only if reduction by closed means was not successful. The fixation used a proximal femoral nail (9-11mm in diameter), a lag screw (85-105 mm in length) and a antirotation pin (10-15 mm shorter than the lag screw).Cleveland zones [6] and tip apex distance (TAD) [7] was used to assess the placement of lag screw in the femoral head.

The fracture reduction was evaluated on the first post-operative radiograph using the Garden Alignment Index (GAI) [8] and fracture gap (mm) measurement. The results were classified using Garden Alignment Index as very good, good, acceptableor poor[8]. The fracture gap was classified as good (0-3 mm); acceptable (3-5 mm); or poor (> 5 mm).

The active quadriceps strengthening exercises, ankle and toe movements and knee mobilisation exercises were started on the first postoperative day. The mean hospital stay was 5 days (range, 3 - 14). Suture removed on 12th post-operative day. Some complication (intraoperative or postoperative) were also reported during the study period.

The mean follow up period was 12 months (range 9-18). Clinical evaluation was done using Harris hip score [8] and radiologically at 6 weeks, 12 weeks, 6 months, 9 months and thereafter every 6 months. Full weight bearing was allowed once radiological evidence of bone union was evident. Anteroposterior and lateral plain radiographs were taken at every visit to look for the fracture union, tip apex distance, cut-out or lateral migration of lag screw or antirotation pin.

Results

At final follow up, union was found in all patients radiologically trabeculae crossing fracture site atleast three cortices in two views and clinically with no tenderness at fracture site. Average age at time of surgery was 62 years (range 34-84). 60 patients were women and 36 were men.

There were 56% left and 44% right side hip fractures. Mean operative time was 36 minute (range 25-90 min). Average length of follow up period was 12 month. The Cleveland zone 8 (central - inferior) was the most favourable position for lag screw on postoperative radiograph.

81.4% of cases showed fracture gap of less than 3mm and 14.6% cases showed fracture gap on acceptable range (3-5mm). Very good to good Garden alignment index was found in 75% of cases (Table 1). TAD was less than 25mm in 72% of cases.

Moran et al. reported that a delay in surgery of up to four days in patients without an acute medical comorbidity does not increase postoperative mortality, morbidity, or duration of the rehabilitation (9). In our study, the time from fracture to surgery was on average 3.7 days.

Proximal femoral nail is fixed with two screws; the lag screw give compression at fracture site and carry most of load whereas smaller screw provides rotational stability. If antirotation screw is longer than lag screw, vertical forces would increase on antirotation screw and start to induce cut-out or Z-effect. Schipper IB et al., concluded that if antirotation screw was 10 mm shorter than the lag screw, percentage of total load carried by antirotation screw ranged from 8 to 39% (mean 21%), no cut-out of femoral head or fracture displacement were observed. In our study anti rotation screw was 10-15 mm shorter than the lag screw (10).Geller et al. reported 44% incidence of cut outs in intertrochanteric fractures fixation with TAD of > 25 mm and no cut out seen with TAD of < 25 mm [11]. We observe one cut outs in our series with 72% patients had TAD < 25. Nikoloski et al., also recommended the TAD to be kept between 20-30 mm[12].

Jinet al. [13] preferred long proximal femoral nail over the shorter nail when there is excessive anterior curvature of the femur. In our study, we noticed impingement of tip of nail to the anterior cortex in two cases due to excessive bowing and short femur length in Indians. We use long proximal femoral nail in all cases.

Yaozenget al. reported 6 intra operative femoral shaft fractures in their series of 107 intertrochanteric fractures [14]. In our study, we did not notice any intra operative fracture of shaft femur. Risk of this complication can be reduced by adequate reaming of femoral canal especially when using longer nails. Boopalanet al. [15] reported 21% incidence of intra operative lateral wall fractures in 31 unstable intertrochanteric fracture fixations. Study suggested that lateral wall fracture does not affect fracture union.Gotfried reported 24 cases of lateral wall fractures in their study[16]. He observed varus malalignment with medialisation of femoral shaft on x-ray in all these cases. We reported 6 cases of intra operative lateral wall fractures, out of which 1 cases developed secondary varus collapse of 5 degrees. None of these fractures required reoperation.

G.N. Kiran Kumar et al evaluate the outcome of proximal femoral nail antirotation II by using Harris hip score and found Excellent and good results were found in 78% of cases [17].