Trial Review

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Trial registered on ANZCTR


Registration number
ACTRN12618001431213
Ethics application status
Approved
Date submitted
6/08/2018
Date registered
27/08/2018
Date last updated
27/08/2018
Type of registration
Prospectively registered

Titles & IDs
Public title
Evaluating the treatment methods of proximal femur fractures in elderly trauma patients
Scientific title
A multi-centre, single blinded prospective randomised controlled trial of the Gamma 3 intramedullary nail to the unlocked and locked Intertan intramedullary nail for the treatment of proximal femur fractures.
Secondary ID [1] 295194 0
None
Universal Trial Number (UTN)
U1111-1215-6062
Trial acronym
ProFNUL
Proximal Femoral Nail Unlocked vs. Locked
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Proximal femur fracture 308331 0
Condition category
Condition code
Injuries and Accidents 307330 307330 0 0
Fractures
Emergency medicine 307331 307331 0 0
Other emergency care
Musculoskeletal 307332 307332 0 0
Other muscular and skeletal disorders
Surgery 307334 307334 0 0
Surgical techniques

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Neck of femur fractures are common, and generally treated with surgery. One of the commonly used devices is an intramedullary (IM) nail with proximal fixation extending into the femoral head. There are numerous devices on the market, all with individual data, but there is very little comparative evidence. The majority of IM nail designs have a proximal ‘lag screw’ which can be used in either static or dynamic modes. There is no published evidence regarding which of these modes is better.

The study will follow a prospective randomized controlled design at the Royal Adelaide Hospital, with patients also recruited at Flinders Medical Centre, The Queen Elizabeth Hospital and Lyell McEwin Hospital (South Australia). We aim to recruit a total of 900 trauma patients aged over 60 years, who will be randomly assigned to receive one of two different femoral nail designs (both designs are current standards on the market), as well as two different locking modes. Patients will be randomised to receive either the INTERTAN™ nail (Locked proximally), the INTERTAN™ nail (Unlocked proximally), or a Gamma nail (Unlocked proximally) for fracture fixation, after a decision to undergo surgical treatment for their fracture has already been made. Patients who refuse to consent to the study will not be included in the study and routine clinical practice will be carried out. For patients consenting to the study, we will follow the patients for a minimum of six months (or until the fracture has healed) and compare the outcomes of the groups.

The patients will undergo surgery at the earliest opportunity in line with local protocols and surgery will be carried out by the normal surgical team at the hospital for that day – no changes will be made to timings or personnel involved. The device and mode of locking will be as per the randomization outcome.

Post operatively all patients will be mobilised fully weight bearing as able, and follow a standard physiotherapy / rehabilitation regime.

Each surgery will be conducted by an orthopaedic surgeon and will take approximately 30-45 minutes. Fidelity of the procedure will be assessed via radiographic image intensifier via the normal orthopaedic surgical team operating on that day.
Intervention code [1] 301532 0
Treatment: Surgery
Intervention code [2] 301533 0
Treatment: Devices
Comparator / control treatment
Unlocked Gamma 3 nail
Control group
Active

Outcomes
Primary outcome [1] 306441 0
The primary outcome measure for the trial is 'failure of the device' at any point up to six months following surgery. (% of failure for each device). This will be assessed via anterior-posterior (AP) and lateral plain film radiographs.

'Device failure' is defined as any of the following occurring :
- Lag screw cut-out requiring revision surgery
- Nail fracture
- Locking screw fracture
- A change in Tip-Apex distance of more than 10mm
Timepoint [1] 306441 0
Six months after intervention commencement
Secondary outcome [1] 348542 0
Number of Injury specific complications (including per-operative technical complications, surgical site infection, unplanned surgery, death).

This data will be collected through a series of four forms that a clinician/orthopaedic surgeon will complete. These forms are electronic, allowing the data to be automatically compiled into a spreadsheet. One form is completed peri-operatively (medical imaging and operative information), one at patient discharge (medical records and clinical assessment), one at the six week follow up review (clinical assessment and patient reported), and one at the six month follow up review (clinical assessment and patient reported). Complications data will be collected indirectly as part of these forms. Additionally, if patients report complications and thus present to clinic, these patients will be clinically reviewed by a clinician and x-rays taken, as per standard procedure. In these events, the occurrence of these complications are recorded against the patients hospital number.
Timepoint [1] 348542 0
Up to 12 months after intervention commencement
Secondary outcome [2] 348544 0
Functional independence assessed via Functional Independence Measure (FIM score)
Timepoint [2] 348544 0
Baseline (taken pre-operative), and at discharge, six weeks and six months after intervention commencement
Secondary outcome [3] 348545 0
Timed Up and Go test
Timepoint [3] 348545 0
At six weeks, six months and 12 months after intervention commencement
Secondary outcome [4] 348546 0
Re-operation for any reason.

Operation data will be collected through a form, completed by one of the orthopaedic surgeons of surgical team. This information is collected by the anaesthesia team’s notes as well as the orthopaedic surgeon’s case notes.
Timepoint [4] 348546 0
Up to 12 months after intervention commencement
Secondary outcome [5] 348548 0
General medical complications (grouped and collected on a tick-list).

This is collected by the medical team as the patient is enrolled into the study onto a series of forms which the clinicians will complete. (Forms outlined in secondary outcome [1]).
Timepoint [5] 348548 0
Up to 12 months after intervention commencement

Secondary outcome [6] 348550 0
Return to mobility circumstances (i.e. use of services at six and 12 months compared to pre-fracture)

This information will be collected at discharge through a form, completed by one of the ward nurses. This information is patient reported.
Timepoint [6] 348550 0
At six weeks, six months and 12 months after intervention commencement
Secondary outcome [7] 348551 0
Gross motor activity (human rest-activity cycles).

This will be collected via a wrist worn actigraphy device.
Timepoint [7] 348551 0
At six weeks, six months and 12 months after intervention commencement
Secondary outcome [8] 350986 0
Operation time
Timepoint [8] 350986 0
At the time of intervention commencement
Secondary outcome [9] 350987 0
number of intra-operative complications
Timepoint [9] 350987 0
At the time of intervention commencement
Secondary outcome [10] 350988 0
Fluoroscopy time
Timepoint [10] 350988 0
At the time of intervention commencement
Secondary outcome [11] 350989 0
Tip-Apex Distance of femoral nail lag screw.

This operation data will be collected through a form, completed by one of the orthopaedic surgeons of surgical team. This information is collected by the orthopaedic surgeon’s case notes.
Timepoint [11] 350989 0
At time of intervention commencement
Secondary outcome [12] 350990 0
Return to mobility circumstances.

This information will be collected at discharge through a form, completed by one of the ward nurses. This information is patient reported.
Timepoint [12] 350990 0
Up to 12 months after intervention commencement
Secondary outcome [13] 350992 0
Hip joint range of motion.

This will be collected using objective measures from gait analysis
Timepoint [13] 350992 0
At six weeks, six months and 12 months after intervention commencement.
Secondary outcome [14] 350993 0
Hip joint contact forces and moments.


This will be collected using objective measures from gait analysis
Timepoint [14] 350993 0
At six weeks, six months and 12 months after intervention commencement.
Secondary outcome [15] 350994 0
Post operative hip muscle function (abductors, flexors, extensors).


This will be collected using objective measures from gait analysi and musculoskeletal modelling.
Timepoint [15] 350994 0
At six weeks, six months and 12 months after intervention commencement.
Secondary outcome [16] 350995 0
Post operative hip muscle asymmetry.


This will be collected using objective measures from gait analysis and musculoskeletal modelling.
Timepoint [16] 350995 0
At six weeks, six months and 12 months after intervention commencement.
Secondary outcome [17] 350996 0
Nail and screw sizes used by the operating orthopaedic surgeon.

This operation data will be collected through a form, completed by one of the orthopaedic surgeons of surgical team. This information is collected by the anaesthesia team’s notes as well as the orthopaedic surgeon’s case notes.
Timepoint [17] 350996 0
At the time of intervention commencement.
Secondary outcome [18] 350997 0
Harris Hip Score (HHS)
Timepoint [18] 350997 0
at six weeks, six months and 12 months after intervention commencement
Secondary outcome [19] 350998 0
Visual Analog Scale (VAS) pain score
Timepoint [19] 350998 0
At six weeks, six months and 12 months after intervention commencement
Secondary outcome [20] 350999 0
Functional Independence Measure (FIM)
Timepoint [20] 350999 0
At six months after intervention commencement

Eligibility
Key inclusion criteria
1. Traumatic extracapsular hip fracture
2. Closed injury
3. Patient aged over 60 years
4. Ability to be followed for up to six months
5. Presentation to hospital within 14 days of injury
Minimum age
60 Years
Maximum age
No limit
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
1. Patients with concomitant injuries affecting treatment and rehabilitation of the affected limb.
2. Patients with associated neurovascular injuries requiring immediate surgery
3. Patients where consent is refused
4. Patient with limited English proficiency including family members

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Allocation concealment is done via centralised computerised randomisation (Griffith Randomisation Service).

Allocation concealment is the same for all participants enrolled in the study.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Randomisation using computerised generation with stratified allocation factors of gender and Abbreviated Mental Health Test Score (ATMS) for all participants consenting to the study.
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?
The people receiving the treatment/s


Intervention assignment
Parallel
Other design features
Phase
Not Applicable
Type of endpoint/s
Safety/efficacy
Statistical methods / analysis
Gamma nail failure rates in the literature have been reported to vary from 2 to 15%, so a mid-range value is 7.5%. Abram et al (2013) used mechanical failure (complete lag screw cut-out, nail or locking screw fracture) as an end point and found a 7.2% failure rate over a 5 year period from 299 cases. A clinically significant difference between the control group (Gamma3 Nail) and each of the intervention groups separately (unlocked and locked intertan nail) would be difference of 5% between the 2 intervention groups. Therefore using a significance level of 0.05 and power of 80%, allowing for 30% loss to follow up at 6 months (including 10% mortality) and a 1.5 variance inflation factor to allow for repeated measurements over time results in a requirement for approximately 300 patients in each of the 3 groups (control group - Unlocked Gamma3 Nail, and each of the Intervention Groups - Unlocked & Locked Intertan Nail).

Continuous data such as the FIM, HHS and pain scores will be analysed using a two-sided t-test to compare the two-independent groups. Categorical outcomes will be analysed using a chi-squared test. The statistician performing the analysis will be blinded to the treatment groups.

Data from the gait analysis, musculoskeletal modelling and activity monitoring will be assessed in combination with the randomised groups and analysed using a linear mixed model.

Abram SG, Pollard TC, Andrade AJ. Inadequate 'three-point' proximal fixation predicts failure of the Gamma nail. The bone & joint journal. 2013:31018.

Recruitment
Recruitment status
Not yet recruiting
Date of first participant enrolment
Anticipated
11/09/2018
Actual
Date of last participant enrolment
Anticipated
25/12/2020
Actual
Date of last data collection
Anticipated
20/12/2021
Actual
Sample size
Target
900
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
SA
Recruitment hospital [1] 11263 0
The Royal Adelaide Hospital - Adelaide
Recruitment hospital [2] 11264 0
Flinders Medical Centre - Bedford Park
Recruitment hospital [3] 11265 0
The Queen Elizabeth Hospital - Woodville
Recruitment hospital [4] 11266 0
Lyell McEwin Hospital - Elizabeth Vale
Recruitment postcode(s) [1] 23142 0
5000 - Adelaide
Recruitment postcode(s) [2] 23143 0
5042 - Bedford Park
Recruitment postcode(s) [3] 23144 0
5011 - Woodville
Recruitment postcode(s) [4] 23145 0
5112 - Elizabeth Vale

Funding & Sponsors
Funding source category [1] 299781 0
Commercial sector/Industry
Name [1] 299781 0
Smith & Nephew Pty Ltd
Country [1] 299781 0
Australia
Primary sponsor type
Individual
Name
A/Prof Mark Rickman
Address
Dept. of Orthopaedics & Trauma, Royal Adelaide Hospital
Port Road
Adelaide SA 5000
Country
Australia
Secondary sponsor category [1] 299128 0
Individual
Name [1] 299128 0
A/Prof Dominic Thewlis
Address [1] 299128 0
Adelaide Health and Medical Science Building,
Cnr North Terrace and George Street
Adelaide SA 5000
Country [1] 299128 0
Australia
Secondary sponsor category [2] 299337 0
Individual
Name [2] 299337 0
Arjun Sivakumar
Address [2] 299337 0
Adelaide Health and Medical Science Building,
Cnr North Terrace and George Street
Adelaide SA 5000
Country [2] 299337 0
Australia

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 300670 0
Central Adelaide Local Health Network Human Research Ethics Committee
Ethics committee address [1] 300670 0
Ethics committee country [1] 300670 0
Australia
Date submitted for ethics approval [1] 300670 0
16/11/2017
Approval date [1] 300670 0
24/02/2018
Ethics approval number [1] 300670 0
HREC reference number: HREC/17/RAH/433, CALHN Reference number: R20171010 Rickman

Summary
Brief summary
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 84410 0
A/Prof Mark Rickman
Address 84410 0
Dept. of Orthopaedics & Trauma, Royal Adelaide Hospital
Port Road
Adelaide SA 5000
Country 84410 0
Australia
Phone 84410 0
+61427722738
Fax 84410 0
Email 84410 0
[email protected]
Contact person for public queries
Name 84411 0
Mark Rickman
Address 84411 0
Dept. of Orthopaedics & Trauma, Royal Adelaide Hospital
Port Road
Adelaide SA 5000
Country 84411 0
Australia
Phone 84411 0
+61427722738
Fax 84411 0
Email 84411 0
[email protected]
Contact person for scientific queries
Name 84412 0
Dominic Thewlis
Address 84412 0
Centre for Orthopaedic & Trauma Research, University of Adelaide
Cnr North Terrace and George Street
Adelaide SA 5000
Country 84412 0
Australia
Phone 84412 0
+61883137096
Fax 84412 0
Email 84412 0
[email protected]

No information has been provided regarding IPD availability


What supporting documents are/will be available?

No Supporting Document Provided



Results publications and other study-related documents

Documents added manually
No documents have been uploaded by study researchers.

Documents added automatically
SourceTitleYear of PublicationDOI
EmbaseProximal Femoral Nail Unlocked versus Locked (ProFNUL): A protocol for a multicentre, parallel-armed randomised controlled trial for the effect of femoral nail mode of lag screw locking and screw configuration in the treatment of intertrochanteric femur fractures.2020https://dx.doi.org/10.1136/bmjopen-2019-032640
EmbaseGait biomechanics after proximal femoral nailing of intertrochanteric fractures.2023https://dx.doi.org/10.1002/jor.25427
N.B. These documents automatically identified may not have been verified by the study sponsor.