Orthopedics · Medical Literature
Early Postoperative Effects of Mechanical Versus Manual Femoral Canal Opening During Proximal Femoral Nail Antirotation Fixation of Pertrochanteric Femoral Fractures.
Abstract
Background and Objectives: The method of femoral canal opening during intramedullary fixation may influence the biological response to surgery. The aim of this study was to compare the early biological responses associated with mechanical canal opening and manual canal opening during Proximal Femoral Nail Antirotation (PFNA) fixation in patients with pertrochanteric femoral fractures, with a particular focus on inflammation, coagulation, organ dysfunction, and bone metabolism. Materials and Methods: This single-centre prospective randomised study consisted of 60 participants (50 women) with a mean age of 80.33 ± 11.13 years, who were randomly assigned to either manual femoral canal opening (n = 30) or mechanical canal opening (n = 30). Outcomes were assessed preoperatively and postoperatively during a 72 h follow-up period. This study was registered at ClinicalTrials.gov (ClinicalTrials.gov ID NCT07648719; registration date: 15 June 2026; study start: 1 March 2025). Results: Across all participants, surgery was associated with a significant decrease in haemoglobin levels, calcium, and estimated glomerular filtration rate, while fibrinogen, urea, creatinine, CRP (C-reactive protein), and NT-proBNP (N-terminal pro-B-type natriuretic peptide) significantly increased postoperatively. Patients in the mechanical canal opening group demonstrated significantly higher postoperative levels of leukocytes (p = 0.002), CRP (p = 0.001), NT-proBNP (p = 0.002), fibrinogen (p = 0.026), activated partial thromboplastin time (p = 0.035), urea (p = 0.001), and creatinine (p = 0.018), as well as greater reductions in haemoglobin (p < 0.001), compared with the manual canal opening group. Bone turnover markers also differed between groups: postoperative bone-specific alkaline phosphatase levels were significantly higher in the mechanical canal opening group (p = 0.001), whereas the increase in total procollagen type 1 N-terminal propeptide was more pronounced in the manual canal opening group (p = 0.045). Conclusions: The method of femoral canal opening during PFNA fixation significantly influences early postoperative systemic inflammation, coagulability, organ stress, and bone turnover dynamics. Manual opening of the femoral canal was associated with lower early systemic and bone stress biomarker responses compared with mechanical canal opening. Whether these differences translate into improved clinical outcomes, particularly in elderly patients with limited physiological reserve, remains to be determined.
Clinical relevance
This study addresses an underexplored intraoperative variable — the method of femoral canal opening during PFNA fixation — that may meaningfully affect the early postoperative biological milieu in a high-risk population. Pertrochanteric femoral fractures disproportionately affect elderly patients with limited physiological reserve, in whom amplified systemic inflammation, coagulopathy, and organ stress carry significant morbidity and mortality implications. The findings are clinically timely given the growing emphasis on optimizing every modifiable surgical detail to reduce postoperative complications in frail, older adults.
Key findings
1. Mechanical canal opening was associated with significantly higher postoperative leukocyte counts compared with manual opening (p = 0.002), indicating a greater systemic inflammatory burden. 2. CRP levels were significantly elevated in the mechanical canal opening group versus the manual group (p = 0.001), corroborating the leukocyte findings and suggesting amplified acute-phase inflammatory response. 3. Markers of cardiopulmonary and renal stress were significantly worse in the mechanical group: NT-proBNP (p = 0.002), urea (p = 0.001), and creatinine (p = 0.018) were all higher, pointing to greater end-organ strain within the 72-hour postoperative window. 4. Coagulation was more perturbed in the mechanical group, with significantly higher fibrinogen (p = 0.026) and prolonged activated partial thromboplastin time (aPTT; p = 0.035), suggesting a heightened procoagulant and inflammatory coagulation response. 5. Haemoglobin reduction was significantly greater in the mechanical canal opening group (p < 0.001), indicating higher perioperative blood loss or haemolytic burden with this technique. 6. Bone turnover markers diverged between groups: bone-specific alkaline phosphatase (a marker of osteoblastic activity/bone remodeling stress) was higher in the mechanical group (p = 0.001), while total procollagen type 1 N-terminal propeptide (P1NP) increase was more pronounced in the manual group (p = 0.045), suggesting qualitatively different bone metabolic responses to each technique.
Practice implications
Orthopedic surgeons performing PFNA fixation in elderly patients with pertrochanteric fractures should consider manual femoral canal opening as the preferred technique where technically feasible, given its association with attenuated systemic inflammation, reduced coagulopathy, less end-organ stress, and lower perioperative blood loss within the critical 72-hour postoperative period. Patients with pre-existing renal impairment, cardiac compromise (elevated baseline NT-proBNP), or anaemia may represent a particularly high-risk subgroup in whom avoiding mechanical canal opening could be most consequential, and perioperative monitoring of renal function, coagulation parameters, and haemoglobin should be intensified if mechanical technique is used. Longer-term randomized data are needed to determine whether the observed early biomarker differences translate into clinically meaningful endpoints such as major adverse cardiac events, thromboembolic complications, transfusion rates, or 30- and 90-day mortality before definitive practice-changing recommendations can be issued.