The proximal femoral nail antirotation (PFNA) in the treatment of proximal femoral fractures.

Proximal femoral fractures, especially in elderly persons with osteoporosis, present a challenge for the traumatologist. While the dynamic hip screw (DHS) became the implant of choice for the treatment of stable fractures, the ideal implant for the treatment of unstable fractures remains an issue. In our experience, Proximal Femoral Nail Antirotation (PFNA) is an excellent device for osteosynthesis as it can be easily inserted, it provides angular and rotational stability and allows early weight bearing on the affected limb. Between February 2007 and August 2009, 76 patients underwent the PFNA fixation for proximal femoral fractures (15 men and 61 women). Forty seven fractures were pertrochanteric, 14 subtrochanteric, 2 pathological and 5 ipsilateral trochanteric and diaphyseal fractures whereas in 8 cases the PFNA was used in reosteosynthesis. The mean age of patients was 73.4 years (range 22-91 years). The fractures were reduced on a traction table and the implant was inserted using minimally invasive technique. Four patients developed superficial postoperative wound infection. No cases of implant breakage have been recorded; there was one cut-out; delayed union was noted in three patients. The majority of patients regained their pre-injury mobility status. The PFNA is an excellent implant for stabilisation of both trochanteric and complex combination fractures as well as an exceptional device for reosteosynthesis. It is easily inserted with few intra- and postoperative complications and allows early weight bearing on the affected limb as well as quicker rehabilitation of patients.

Influence of postoperative analgesia on systemic inflammatory response and postoperative cognitive dysfunction after femoral fractures surgery: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: To investigate the possible effect of postoperatively applied analgesics-epidurally applied levobupivacaine or intravenously applied morphine-on systemic inflammatory response and plasma concentration of interleukin (IL)-6 and to determine whether the intensity of inflammatory response is related to postoperative cognitive dysfunction (POCD). METHODS: This is a randomized, prospective, controlled study in an academic hospital. Patients were 65 years and older scheduled for femoral fracture fixation from July 2016 to September 2017. Inflammatory response was assessed by leukocytes, neutrophils, C reactive protein (CRP) and fibrinogen levels in four blood samples (before anesthesia, 24 hours, 72 hours and 120 hours postoperatively) and IL-6 concentration from three blood samples (before anesthesia, 24 hours and 72 hours postoperatively). Cognitive function was assessed using the Mini-Mental State Examination preoperatively, from the first to the fifth postoperative day and on the day of discharge. RESULTS: The study population included 70 patients, 35 in each group. The incidence of POCD was significantly lower in the levobupivacaine group (9%) than in the morphine group (31%) (p=0.03). CRP was significantly lower in the levobupivacaine group 72 hours (p=0.03) and 120 hours (p=0.04) after surgery. IL-6 values were significantly lower in the levobupivacaine group 72 hours after surgery (p=0.02). The only predictor of POCD in all patients was the level of IL-6 72 hours after surgery (p=0.03). CONCLUSIONS: There is a statistically significant association between use of epidural levobupivacaine and a reduction in some inflammatory markers. Postoperative patient-controlled epidural analgesia reduces the incidence of POCD compared with intravenous morphine analgesia in the studied population. TRIAL REGISTRATION NUMBER: NCT02848599.