Treatment of Hip Reverse Oblique Fractures: Gamma Proximal Femoral Nail versus Trochanteric Fixation Nail Advanced

Background:
Reverse oblique fractures are classified as AO/OTA 31-A3 according to the Trauma Association classification system, and they account for 5-23% of all intertrochanteric fractures. Of all trochanteric fractures, reverse oblique fractures are of the most challenging and complex fractures to treat. The Gamma 3-Proximal Femoral Nail (GPFN) and the Trochanteric Fixation Nail Advanced (TFNA) are among the most common devices used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31-A3 fractures, treated with either TFNA or GPFN.

Patients and Methods:
A total of 218 patients with reverse oblique fractures (114 in the GPFN group and 74 in the TFNA group), were treated in our institution between June 2010 and May 2019. Data was collected on postoperative radiological variables including screw or blade location, tip-apex distance (TAD). Data was also collected for non-orthopedic complication rates and orthopedic complications such as union rates, cut-out rates, revisions rates and more surgical data.

Results:
The total prevalence of postoperative orthopedic complications showed no significant difference, with a total of 18 cases in the GPFN group versus 14 cases in the TFNA group, and with a p-value of 0.205. Moreover, the frequency of revisions surgeries did not differ significantly between the two groups: with 14 cases in the GPFN group and 4 cases in the TFNA group (p=0.273). The main orthopedic complication in the GPFN group was cutout of the peg from the femoral head; cutout occurred in 7 cases (38.8%) in the GPFN group as opposed to 1 case in the TFNA group (7.1%). The main orthopedic complication in the TFNA group was postoperative bleeding requiring blood transfusion, which occurred in 11 cases (78.5%). The TAD did not significantly differ between the groups. Further analysis, comparing the different outcomes regarding the length of the nail, showed 6 cut-outs in the short GPFN group as opposed to 1 in both the 235mm TFNA and long GPFN groups although this difference came out to be insignificant. When comparing mal/nonunion rates between long GPFN and 235mm TFNA (5.6% and 0% respectively) p-value was 0.057. Revisions rates did not differ between the sup-groups (p=0.637).

Conclusion:
According to this study, the relatively new TFNA showed no inferiority to the GPFN in treating reverse oblique intertrochanteric fractures. More over the 235mm TFNA showed superiority in cutout and union rates when compared to the GPFN in treating these fractures although the difference came out to be insignificant. Further research with larger groups is required.