How would you like your proximal femoral nail - with a monocortical recon plate, with cable, or neat? A functional and radiological study of reverse oblique (AO/OTA 31-A3) intertrochanteric femur fractures.

Objective: Intertrochanteric femur fractures (ITFF), more so reverse oblique fractures (AO/OTA 31-A3), are the most challenging clinically, with significant morbidity and mortality. Early stable fixation should be achieved to allow early mobilization and reduce complications. This study evaluates the functional and radiological outcomes of three Proximal Femoral Nail (PFN) techniques - PFN alone, Cable + PFN, and Monocortical reconstruction plate (MRP) + PFN- in managing reverse oblique ITFF, to determine the most ideal of them.

Methods: A retrospective analysis was performed on 106 patients treated from 2015 to 2022. The patients were classified by the surgical intervention: Cable + PFN (n = 37), MRP + PFN (n = 29), and PFN (n = 40). The critical parameters analyzed included healing time, quality of reduction, rates of complications, and functional outcomes of Trendelenburg gait.

Results: The bone healing time was significantly faster in the Cable + PFN group and MRP + PFN group as compared to the PFN group, 4.43 ± 0.92 and 4.44 ± 0.90 months versus 6.40 ± 2.41 months, respectively (p < 0.001). Compared with the PFN group, the number of cases with Trendelenburg gait in the Cable + PFN group was significantly lower, 10.8%. The number of patients showing the Trendelenburg gait trended lower in the MRP + PFN group but was insignificant (p = 0.075). Radiological outcomes did not differ significantly among the groups.

Conclusion: The use of Cable + PFN and MRP + PFN techniques has superior outcomes with earlier bone union and far less incidence of Trendelenburg gait than PFN alone. These findings can help hint that perhaps the usage of cables and recon plates enhances the stability and functional restoration in patients who have sustained reverse oblique ITFF.

Level of evidence: III.