• Wu Chean Lee, Siaw Meng Chou, Chee Wei Tan, Li Sing Chng, Gui Jie Michael Yam, and Tjun Huat Ivan Chua.
• Department of Orthopaedic Surgery, Annex 1 Level 2, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. Electronic address: leewuchean@yahoo.com.
• Injury. 2021 Apr 1; 52 (4): 926-932.

IntroductionThe lesser trochanter (LT) fragment in the multifragmentary intertrochanteric femur fracture (AO 31A2.2) may extend distally. If the fragment extends too distally, fixation with a short proximal femoral nail antirotation (PFNA-II) device may not be sufficient. The exact length of distal extension that can be tolerated by the short PFNA-II is not known, therefore it is our objective to determine it.Materials And MethodsA finite element analysis was performed on AO 31A2.2 fracture fixed with a 200mm length size 10 PFNA-II. The construct was loaded vertically to clinical failure of 10mm displacement. This was repeated with the size of the LT fragment increasing distally at intervals, up to 120mm from the base of the LT. The process was also repeated with the bone properties substituted with osteoporotic properties. The stiffness, maximum vertical reaction force, and the plastic deformation area were investigated.ResultsIn both non-osteoporotic and osteoporotic model, the stiffness and the maximum vertical reaction force of the construct dropped significantly when the LT fragment is larger than 40mm. Beyond 40mm of LT fragment size, there was a rapid increase in the area of plastic deformation of the cortical bone distal to the intertrochanteric fracture, signifying structural failure of the construct.ConclusionA long PFNA-II should be considered when fixing a multifragmentary intertrochanteric fracture if the LT fragment extends 40mm distal to the distal base of the LT as the construct fails rapidly upon uniaxial load to failure. Clinically, this threshold may be smaller to account for the multi-axial and dynamic stresses.Copyright © 2020 Elsevier Ltd. All rights reserved.

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