Problems with PFN: is TFNA a solution for trochanteric fractures in old

[@ragulajay7197]

thank you sir..wonderful and clear presentation !!.. the implant failure case immediate post-op looked perfectly fine... couldn't believe even it could fail so bad

[@parkaviyanr6397]

Please briefly put one video about DHS with trochanteric support plate versus PFN

[@IcchyJich]

Firstly, nice video. And for people, who have not used it, the Blade can be left in a dynamic mode as well, if you want to have post-operative compression of the fracture. My question to You would be, don't You think the static locking of the blade increases the chance of cut-through complications - if the fracture collapses, the blade can't move and thus probably will protrude from the head. Just a question. Having used both I truly think TFNA is superior, although a bit more expensive, but I prefer it to PFNA.

[@Justorthothings]

Thanks for the comment. In very old patients like 80+, we face the problem of early blade loosening very frequently. They have very weak bones, like we don't even need a proximal ream to insert the nail. Just a small awl entry is sufficient to insert the nail. With PFNA2, the blade is extremely loose and can slide very easily. With TFNA, we do allow some sliding as we loosen the set screw half-turn back after fully tightening. That allows some sliding but with a kind of resistance not as free as PFNA2. But in cases when we want the nail to function like a locked contruct, we get max compression intraoperatively and lock the blade fully. Here the healing occurs due to low strain and maximal contact at fracture ends. To avoid the risk of cut out, we keep the blade in the posteroinferior quadrant and tip on a higher side of TAD, roughly just further to the center of the femoral head.

[@bhavinidhi]

one or two Implant company in my region modified the PFNA2 & Providing lockinh of Helical Blade of screw which is not allowing collapse or migration after fixtion.....

[@GHGH-f7p]

Do the end cap of pfna nail prevents the toggling / migration ?

[@Justorthothings]

So, different nails have their own mechanism to block the blades or screws from free sliding. In J&J ones, the set screw sufficiently blocks the sliding, but in some other designs there is long-tip end cap that blocks free sliding.

[@saptarshimukherjee6002]

Can you suggest which companies provide tfna??

[@Justorthothings]

Double Medical and Johnson & Johnson (Synthes/AO)

[@saptarshimukherjee6002]

@@Justorthothings whats your opinion regarding intertan instead of pfna2??

[@Justorthothings]

@saptarshimukherjee6002 Good implant for young bone. Similar issues with osteoporotic bone: no blade option, cannot lock screw during intraop compression, the problem of mandatory compression which is bound to happen with the second screw is inserted (may be good for slightly distracted fracture) and one major issue is that in most geriatric fractures the neck diameter is small and the two screw construct eats up most of the bone in neck.

[@cristmas6757]

Additionally Stryker g2

[@DrRizwanortho]

Does an indian company make TFNA? Any leads..

[@Justorthothings]

The less costly version available in India is of “Double Medical”. I am not aware of any Indian manufacturer version.

[@saketprakash2853]

miraclus

[@AnwarKhan-xi4rh]

It is not mandatory compression. It is rather simple locking of blade. During locking you rotate the driver clock wise which push the outer tube ( lateral part of the blade) to slide over the inner( medial part held in head and neck). No compression occurs.

[@Justorthothings]

Thanks for your feedback. See, what you are saying is correct regarding blade design and its principle. But that may not be correct in all cases. The motion of the spiral part and the outer part is relative to each other, which means both have to close the gap. In that attempt in some osteoporotic hip fractures, the spiral part comes closer to the outer tube owing to weak purchase in bone rather than the outer tube going towards the spiral part. That creates a mismatch in the intended TAD vs. TAD we actually got at the end of screwdriver disengagement. The latter becomes large. The mandatory compression here means the shortening of the gap between the spiral part and the outer tube, not always the fracture compression. Like in the example shown in the video, it's the gap closure without bringing compression at the fracture site.

[@AnwarKhan-xi4rh]

@ thanks for explaining. But the point is the outer cortex is over-drilled and free sliding of the outer tube is must/ extremely easy. If we say the osteoporosis may allow pull-out of helical blade from head, then every DHS would fail at tightening of lag screw. Still every DHS survive not only insertion but also compression.

[@Justorthothings]

@AnwarKhan-xi4rh technically thats because DHS had deep pitch threads and pfn has a blade, the previous one is inserted by rotation and the latter gets hold because of impaction. I dont have any experience with DHS with spiral blade, if thats what you want to convey. Also, I feel osteoporosis is definitely the issue for poor hold of spiral blade, otherwise there wouldn’t have been the need to design cement augmentation for these fractures.

[@khadirkhan1044]

Hello, sir. Your videos are very helpful for beginners like me. I'm experiencing some issues with a regular bone awl, and beginners often struggle with bone entry. I kindly request your suggestion for a bone awl that can facilitate better entries. Thanks.

[@Justorthothings]

See, for the purpose of making medial entry and control guidewire from being angulated, the awl in this link below is sufficient. I have used this, it helps in positioning guidewire correctly without any soft tissue pressure as cannulated part is far from the holding part. Also, since the cannuted part is straight, the direction of guidewire can be better controlled. www.amazon.in/Cannulated-Bone-Awl-Surgical-Instrument/dp/B09W2MK7DP

[@khadirkhan1044]

Thanks a lot ​@@Justorthothings

[@SREEHARI70]

What about pfn

[@Justorthothings]

Two screw PFN should never be used in unstable trochanteric fractures (screws loosening, collapse and Z effect issues), pfna can be used with blade in suboptimal bone quality but to be avoided in severely osteoporotic bones. Nails that control rotation and some sliding of blade/screw should be preferred.

[@drsaiprasaddv]

If you are locking the sliding of screw...then entire principle of controlled compression is gone....it will lead to screw cut out into acetabulum

[@Justorthothings]

Right! In most cases, yes sliding is the requirement. But tightening a block over the blade once you have achieved rigid compression intraop especially in an unstable fracture, it is going to help. Like I told in previous comments, the tightening is done is such a manner that it allows movement in a controlled rather than free manner. The blade faces some resistance during sliding which is helpful in unstable fractures.

[@Justorthothings]

And as far as cut out risk in concerned, the TAD rules do not apply for blades. So higher TAD is our preference in such cases.