new generation hip surgeons choose proximal femoral nail.but many of the experienced surgeons still bet on dynamic hip screw,are they really comparable,which one is superior.this presentation is a debate between the opponents and proponents.very vividly demonstrated by dr mohamed ashraf, HOD, orthopaedics,govt TD medical college hospital,alleppey,kerala, india

1. DR MOHAMED ASHRAF
HEAD OFORTHOPAEDICS
GOVT TD MEDICAL COLLEGE
ALLEPPEY,KERALA,INDIA
drashraf369@gmail.com

2. More positioning related complications
More procedure related complications
likefemoral shaft fractures
More reaming related complications
BUT …
Long term function and satisfaction
same
Anglen et al ,Bhandari et al

3. Orthopaedics is evolving
Fixation principles changing
Surgical technics changing
Implants changing

4. THERE ARE MANY WAYS
TO TREAT A FRACTURE

5. Experimentation
Enthusiasm
Skepticism
Complications and despair
Judicious use

6. Type of surgical training
Industry and market forces
Evidence based medicine

7. REDUCTION STABILITY
REDUCTION STABILITY
BONE QUALITY
FRAGMENT GEOMETRY
IMPLANT PLACEMENT
IMPLANT DESIGN
FIXATION OUTCOME
DEPENDS ON….

9. ARE THEY COMPARABLE
Yes –implants for proximal femur
comparison ends there
Because
principles are different
technic different

11. WHAT THEY SAY………

12.  Time tested
 Technically easier
 Less instrumentation
 Less radiation
 Neck can be exposed through same
approach
 Controlled collapse
 Additional implant extensions
eg.ARS,extension plates,
 Additional procedures-
grafting,stabilisation,tbw,ss wiring
 Undisturbed abductor mechanism

14. May not be possible in pfn
May be possible in DHS

16.  Medullary cavity
maintained
 Abductor mechanism
preserved
 Possibility of distal
locking stress raisers

19. in unstable situations
If poor bone quality
To fix lesser trochanter
To fix greater trochanter
ADDITIONAL
IMPLANTS

20.  dimon houston
 Trochanteric extension plating
 Anti rotation screw
 Bone grafting

21.  Trochanteric fracture with distal
plate

22. Trochanteric fracture
with stiff hip

23. Fixation with valgus
osteotomy

24. Deformed medullary cavity

25.  Trochanteric fracture with GT
avulsion

26.  Pathological subtrochanteric fractures

27. Greater trochanter split

29.  Central screw placement
 ARS in basal and unstable fractures
 Minimum 4 hole plate
 135 degree barrel
 Allow impaction in porotic bone
 Give compression in strong
good quality bone

31. Upto 34 %
If not in the safe zone
TAD must be less than
25mm[Baumgaertner]
Applicable to any neck screw
 herman et al

32. You continue to perform whatever
you think is best in your hand
Even after debate implant choice
depends on given situation
10% of trochanteric fractures end
up in complication whatever
implant you put
AFTER
DEBATE?

33. THANK YOU

34. DR MOHAMED ASHRAF
MBBS [GMC CALICUT]
D ORTHO [GMC TRIVANDRUM]
MS ORTHO [MMC MADRAS]
DNB , MNAMS [NEW DELHI]
drashraf369@gmail.com