Fractures of the proximal femur are among the most frequently encountered injuries in orthopaedic practice and are associated with significant morbidity and mortality.1 Epidemiological studies indicate that the incidence of these fractures is steadily increasing due to the rising life expectancy of the general population. Subtrochanteric fractures account for approximately 7–44% of all proximal femoral fractures2. The subtrochanteric region extends from the lower border of the lesser trochanter to the isthmus of the femoral shaft, with the commonly accepted distal limit being about 5 cm below the lesser trochanter. Although these fractures occur across all age groups, they exhibit a bimodal distribution.3 In younger patients, they usually result from high-energy trauma such as motor vehicle or motorcycle accidents, often producing displaced and comminuted fracture patterns. In contrast, elderly patients typically sustain subtrochanteric fractures following low-energy trauma such as minor slips and falls, which are commonly spiral fractures with relatively less comminution. The subtrochanteric region is one of the highest stress-bearing zones of the femur, subjected to high compressive forces on the medial cortex and tensile forces on the lateral cortex. This unique biomechanical environment predisposes implants to fatigue failure and contributes to delayed fracture healing4. Additionally, this region represents a transition zone between the cancellous bone of the trochanteric area and the dense cortical bone of the femoral shaft, further increasing the risk of complications.5 Conservative management has no definitive role in the treatment of subtrochanteric fractures due to high rates of non-union and malunion, along with increased morbidity and mortality related to prolonged immobilization. Reported mortality rates following non-operative treatment range from 17.5% to 40%, with prolonged hospital stays averaging 8–10 weeks, particularly in geriatric patients. Surgical fixation has therefore become the standard of care for subtrochanteric femoral fractures. However, operative management remains technically challenging because achieving accurate reduction and stable fixation is difficult in this region.6,7 A durable, long implant anchored securely above and below the fracture site is essential to allow early weight bearing and functional rehabilitation. Various fixation devices have been employed, including angled blade plates, dynamic hip screws, flexible intramedullary devices such as Ender’s nails, locking compression plates, and rigid intramedullary devices like proximal femoral nails8. The primary goal of treatment is to obtain anatomical reduction with stable fixation, permitting early mobilization. Traditional extramedullary implants such as dynamic hip screws and dynamic condylar screw plates have been associated with higher complication rates in unstable fracture patterns, including varus collapse, limb shortening, and screw cut-out. Cephalomedullary nails have demonstrated improved biomechanical stability compared to extramedullary devices, with similar operative times and fewer mechanical failures. Long Proximal Femoral Nail A2 (Long PFN A2) is a newer intramedullary implant that allows controlled impaction, provides anti-rotational stability, acts as a load-sharing device, and enables biological fixation with minimal soft tissue disruption.9,10 Locking compression plates, introduced in the 21st century, offer angular-stable fixation and are particularly useful in osteoporotic and comminuted fractures. In this study, an attempt was made to evaluate and compare the functional and radiological outcomes of femoral locking compression plates and Long PFN A2 in the treatment of subtrochanteric femoral fractures.11 AIM To compare the Radiological and Functional Outcome of Subtrochanteric Fractures treated with proximal femoral nail (LONG PFN A2) and locking plate.

The present study was designed as a hospital-based prospective randomized study conducted in the Department of Orthopaedics, S.M.S. Hospital, Jaipur, over a period from May 2012 to December 2013. The study included patients admitted with subtrochanteric fractures of the femur who fulfilled the predefined eligibility criteria. After obtaining informed consent, patients were randomly allocated into two treatment groups—Long Proximal Femoral Nail A2 (Long PFN A2) group and Locking Compression Plate (LCP) group—using a random number–based chit box method, ensuring unbiased allocation. The sample size was calculated based on a study power of 80% and an α error of 0.05, which determined that a minimum of 26 patients in each group was required to achieve statistical significance. Patients were included in the study if they had a subtrochanteric femoral fracture, were skeletally mature, and were willing to participate by providing informed consent. Patients were excluded if they had compound (open) fractures, local infection or unsuitable skin conditions such as blebs, burns, or bedsores around the operative site, inability to walk independently prior to injury, or were deemed to have poor anesthetic risk. This strict selection ensured homogeneity of the study population and allowed for a reliable comparison of clinical, functional, and radiological outcomes between the two fixation methods.

TABLE 1: Age distribution of participants Age group (years) GROUP 1 (LONG PFN A2) GROUP 2 (LCP) 18-37 9(34.6%) 16(61.53%) 38-57 9(34.6%) 6(23.07%) 58-77 7(26.92%) 3(11.53%) 78 and above 1(3.84%) 1(3.84%) Total 26 26 A total of 52 patients were included in this study. All were skeletally mature. Patients age range from 18 years to 80 years. Mean age of patients in group 1 was 44.80 years. Table 2: shows the distribution of fracture type among patients. GROUP Seinsheimer’s classification Total IIA IIB IIC IIIA IIIB IV Group 1 7(26.9%) 8(30.7%) 1(3.8%) 6(23.07%) 3(11.5%) 1(3.8%) 26 Group 2 4(15.4%) 9(34.6%) 1(3.8%) 3(11.5%) 6(23.07) 3(11.5) 26 Total 11 17 2 9 9 4 52 The most common type of fracture encountered in our study was type IIB. The least common pattern of fracture encountered in our study was IIC type. Table 3: Duration of surgery of group-I & group-2 patients Parameter Mean + Sd P-value Significane Group-I (LONG PFN A2 ) Group-2 (LCP) postop stay(In days) 3.15±1.084 4.42±1.858 duration of Surgery 53.85 + 15.44 70.77 + 14.26 < .001 HS Table 4: POST OP BLOOD TRANSFUSION: Blood transfusion Group 1 Group 2 No 19 (73.07%) 1 (3.84%) 1 unit 7 (26.93%) 20 (76.93%) 2 unit 0 5(19.23%) Total 26 26 TABLE 5: Mean + Sd of partial weight bearing, full weight bearing and union of bone (in wks) of group-I & group-2 patients Parameter Mean + Sd P-value Significance Group-I (LONG PFN A2) Group-II (LCP ) Partial weight bearing (in wks) 6.15 + 1.37 6.62 + 1.94 > .05 NS Full weight bearing (in wks) 11.68 + 1.97 12.40 + 1.63 > .05 NS Union of bone (in wks) 13.88 + 1.67 14.32 + 1.8O > .05 NS Average time of initiation of partial weight bearing in LONG PFN A2 group was 6.15 weeks and 6.62 weeks in LCP group. There was no significant difference.Mean duration of initiation of full weight bearing in LONG PFN A2 group was11.68 + 1.97 weeks as compared to 12.40 + 1.63 weeks of LCP group. There was no significant difference between these groups. Table 6: Distribution according to Limb length discrepancy: LIMB LENGTH DISCREPANCY GROUP 1 GROUP 2 Shortening present 1 (3.84%) 2 (7.69%) Shortening absent 25(96.16%) 24(92.31%) TOTAL 26 26 There was 2 patients with shortening in group 1 one of which was due to comminution at fracture site and other was due to varus mal union at the fracture site. Table 7: Complications Complications Group-I (LONG PFN A2 ) Group-II (LCP) No. % No. % Infection 1 3.84 % 3 11.54 % LL discrepancy 1 3.84 % 2 7.69 % Malunion/Nonunion 1 3.84 % 2 7.69 % Delayed union 1 3.84 % 2 7.69 % Implant failure 1 3.84 % 1 3.84% 5 patients out of 26 in LONG PFN A2 required opening of the fracture site (minimally open approach) for reduction. Table 8: Distribution according to Modified Harris Hip Score Modified Harris Hip Score Group-I (LONG PFN A2 ) Group-II (LCP) No. % No. % < 69 1 3.84 2 7.69 70-79 1 3.84 2 7.69 80-89 6 23.07 12 46.16 90 + 18 69.25 10 38.46 Total 26 100.00 26 100.00 The final result in our study was determined by a modified Harris hip score.18 patients in group 1 had excellent scores while 10 patients in group 2 had excellent scores.

Subtrochanteric femur fractures demand meticulous management due to strong deforming forces and are usually caused by high-energy trauma with significant displacement. Extramedullary implants are associated with varus collapse and implant failure, while newer locking plates improve stability but at the cost of extensive exposure and soft-tissue damage. Intramedullary devices, especially proximal femoral nails, offer biomechanical and biological advantages with reduced stress at the nail tip, though the procedure is technically demanding. Most of the patients in our study were 20-37 years (47%) of age group. The second peak of age group was 40-60 years .Mean age was 42.03±12.31 years. Patients in our study group were comparatively younger than other studies for this fracture operated with various implants. The peak of age in young adults can be explained on the basis of their active outdoor life, exposing them to road traffic accidents. RTA was the most common mode of injury in both the groups in our study (65%) followed by fall from height (26%).In 8% cases mode of injury was slip and fall(low energy trauma).According to A S SIDHU et al (2010)12 in study of per and subtrochanteric fracture high energy trauma (RTA and FFH) accounted for 63.3% cases and 36.7% were because of low energy trauma10. The mean duration of surgery in our study in group 1 was 53.85 min and in group 2 was 70.77 min. The time duration in LONG PFN A2 group was from minimum 40 min to maximum 1 hour 30 minutes and in LCP group ranges from minimum 50 min to maximum 1 hour 45 min. There was an increased requirement of blood transfusion in group 2(LCP) compared to LONG PFN A2 group. 96.15% patients in the LCP group with an average of 1.15 units and 26.92% in LONG PFN A2 group with an average of 0.23 units required blood transfusion which was significant statistically.Hotz et al (1999)13 required blood transfusion in 83 % of their patients while using recon nails. Mean full weight bearing time in our study was 11.68 weeks in LONG PFN A2 group and 12.40 weeks in LCP group. This difference was not statically significant. Early weight bearing in LONG PFN A2 group can be explained because LONG PFN A2 is an intramedullary implant which has load sharingability and transmits the weight along the long axis of the femur. In a study by A S Sidhu et al for LONG PFN A2 full weight bearing in 73.4%cases was possible at 8 weeks post operatively12. Mean time for union in LONG PFN A2 group was 13.88+ 1.64weeks while in LCP group 14.16+ 1.99 weeks. Union was slightly earlier in LONG PFN A2 group then LCP because fracture site was not opened in majority of cases and minimal soft tissue and periosteal stripping done in LONG PFN A2 group. Although the difference was not statically significant. In our study there was an increased infection rate in LCP group (11.53%) as compared to LONG PFN A2 group (3.84%).Higher rate of infection was due to increased soft tissue exposure and stripping and increased duration of surgery. The difference was not significant statistically. The incidence of complications in this study was compared with other Implant failure was 1(3.84%) in each group. In LONG PFN A2 group this was due to single hip screw (There was intraoperative difficulty in inserting hip pin) insertion. The implant was broken in this patient. In the LCP group there were various collapses of fracture fragments. Reoperation was undertaken in both these patients.14 Complications in both groups when compared to other studies were comparable and there was no significant difference in both groups. Functional outcome was evaluated in terms of modified Harris hip score. This score takes into account pain, limp, support, distance walked, climbing of stairs, putting on shoes and socks, entering public transportation, limb length discrepancy and range of motion. The total score is 100, with the outcome graded as excellent, good, poor and fair.. There was a significant difference in both groups. Average score in LONG PFN A2 group was 91.36 and 86.32 in LCP group. Patients in the LCP group had experienced more pain around the hip which was due to bursitis because of friction at the level of greater trochanter.15 In our study union time (radiological outcome) were more or less similar in both groups but infection, duration of surgery and functional outcome shows intramedullary implant LONG PFN A2 a better option than extramedullary implant. The main pitfall of our study was limited sample size and short duration of study. Subtrochanteric fractures have bimodal age distribution but in our study most of the patients were of the young adult age group.16

Considering functional outcome and fracture biology, LONG PFN A2 emerges as a safe, reliable, and successful implant for the management of subtrochanteric femoral fractures. It combines the advantages of closed intramedullary fixation—shorter operative time, minimal soft-tissue disruption, and preservation of fracture hematoma—with controlled fracture collapse that enhances stability and union. Its intramedullary position near the weight-bearing axis minimizes stress on the implant, prevents medialisation of the shaft, and facilitates early rehabilitation. The trochanteric entry point reduces damage to hip abductor musculature, while the smaller distal diameter and additional anti-rotational hip pin improve biomechanical stability and reduce stress concentration compared to earlier cephalomedullary nails. Optimal outcomes depend on meticulous preoperative planning, accurate reduction, precise implant positioning, and diligent postoperative follow-up. Although technically demanding with a learning curve, LONG PFN A2 offers distinct biological and biomechanical advantages, resulting in high union rates, minimal soft-tissue injury, and favorable functional recovery

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