Percutaneous cerclage wiring followed by intramedullary nailing for subtrochanteric femoral fractures: a technical note with clinical results

Background

Although intramedullary nailing is an ideal treatment for subtrochanteric femoral fractures, it is technically challenging in fractures extending into the nail entry area and/or involving the lesser trochanter. Although the application of circumferential wire may facilitate reduction in these situations, its use remains controversial due to possible blood supply disturbances to underlying bone. In the present study, we evaluated complex subtrochanteric fractures treated by percutaneous cerclage wiring followed by intramedullary (IM) nailing for anatomical fracture reduction and union.

Methods

Twelve patients (mean age 48.3 years) with an unstable subtrochanteric fracture were prospectively treated. Indications of percutaneous cerclage wiring followed by IM nailing were a fracture extending proximally into the nail entry area deemed difficult to treat by anatomical reconstruction by IM nailing or a fracture with long oblique or spiral component. One or two cerclage wires were percutaneously applied for the temporary reduction of main fragments, and then, a cephalo-medullary or a reconstruction nail was fixed. We assessed radiologic results (union time, alignment), functional results, and complications.

Results

All 12 cases healed, without a bone graft, at an average of 19.1 weeks after surgery (range 16–24). In 11 cases, acceptable alignment was achieved (mean, valgus 0.3° extension 0.6°) with minimal leg-length discrepancy; the other exhibited 1 cm of shortening. All patients were able to return to pre-injury activity levels, and median Merle d’Aubigne score was 16.9 (15–18). No infection or implant-related complication was encountered to latest follow-up (minimum 12 months postoperatively).

Conclusion

Temporary reduction by percutaneous wiring offers a means of satisfactory nailing in difficult subtrochanteric femoral fractures, and affords anatomical reconstruction and favorable bony union.     

The challenge of non-union in subtrochanteric fractures with breakage of intramedullary nail: evaluation of outcomes in surgery revision with angled blade plate and allograft bone strut

Purpose

Subtrochanteric fractures have a bimodal age distribution. They usually require open reduction and internal fixation. Closed reduction and intramedullary nail fixation rate are increased for this type of fracture. As a result, the hardware breakage and non-union rate is high among such patients. Our purpose is to evaluate the outcomes of the role of blade plate and bone strut allograft in the management of subtrochanteric non-union by femoral nailing.

Materials and methods

We reported a group of 22 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail with medial femoral allograft bone and lateral blade plate and wire (PS) s; and a group of 13 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail treated with lateral blade plate and screws (CG). The chosen criteria to evaluate the two group during the clinical and radiological follow-up were the quality of life, measured by The Short Form (12) Health Survey (SF-12), the hip function and quality of life related to it, measured by the Harris Hip Score (HHS), bone healing, measured by Radiographic Union Score (RUS) by XR and CT at 1 year after the surgery, and postoperative complications. The evaluation endpoint was set at 12 months.

Results

The Bone healing measured by RUS occurred and also the full recovery before the first trauma measured by SF-12 and HHS are better in PS group. We only had three unimportant complications in PS while four breakage hardware in CG.

Conclusion

We conclude that in complicated non-unions, the use of blade plate and bone strut allograft has a definite positive role in the management of such cases.

     

Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis

Background

The best options of internal fixation for unstable intertrochanteric femoral fractures in elderly osteoporotic patients remain controversial. We determined whether intramedullary nail or extramedullary plate provides better treatment for unstable intertrochanteric fractures using a decision analysis tool that considers quality of life.

Methods

A decision analysis model was constructed containing final outcome score and the probability of mortality within 1 year, infection, and mechanical complications. Final outcome was defined as health-related quality of life and was used as a utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by asking 30 orthopedic experts to complete a questionnaire. A roll back tool was used to determine the best surgical option, and sensitivity analysis was performed to compensate for decision model uncertainty.

Results

The decision model favored intramedullary nailing in terms of quality of life. In one-way sensitivity analysis, intramedullary nailing was more beneficial than the extramedullary plating, when probability of mechanical complication after intramedullary nailing was below 0.258.

Conclusions

In terms of quality of life, the decision analysis model showed that intramedullary nailing was more beneficial for patients with an unstable intertrochanteric fracture.     

Problems of bridging plate fixation for the treatment of forearm shaft fractures with the locking compression plate

Introduction  

Treatment of diaphyseal forearm fractures by open reduction and internal plate fixation is a well-accepted strategy. In a variety of fracture localizations, the use of bridging plate fixation with locking compression plates (LCP) has been shown to improve biomechanical and biological characteristics. Only very limited clinical data are available on bridging plate fixation using LCPs for the treatment of diaphyseal forearm fractures. The aims of this study were to assess both clinical outcomes of LCP fracture treatments, and the implant-specific advantages and disadvantages.     

Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children

Background  

There is no consensus on treatment of closed femoral-shaft fractures in children. We compared hip spica cast with titanium elastic nailing (TEN) in the treatment of femoral-shaft fractures in children.     

Hybrid外固定支架治疗高能量损伤胫骨远端骨折

目的探讨Hybrid外固定支架治疗高能量损伤胫骨远端骨折的疗效。方法采用Hybrid外固定支架治疗15例高能量损伤致胫骨远端骨折患者。结果 15例均获随访,时间12-30个月。骨折愈合时间4-22（5.7±2.1）个月。其中1例因骨不连二期改用钢板内固定加自体髂骨植骨后愈合。根据AOFAS踝关节和后足评分为52-100（88±14）分。结论 Hybrid外固定支架治疗高能量损伤的胫骨远端骨折能有效维持骨折稳定性,软组织愈合佳。     

Systematic review of the complications of plate fixation of clavicle fractures

Background  

The number of displaced midshaft clavicle fractures treated surgically is increasing and plate fixation is often the treatment modality of choice. The study quality and scientific levels of evidence at which possible complications of this treatment are presented vary greatly in literature.     

Pertrochanteric fractures: tips and tricks in nail osteosynthesis

Introduction

Intramedullary fixation of intertrochanteric fractures has become the standard method of fixation especially in unstable fracture types. Even though there have been developments on implant design and technology, the surgical technique of reduction and implant positioning remains the mandatory factor in treating these fractures successfully. The advantages of nailing in the mainly elderly patients sustaining intertrochanteric femur fractures are a short lever arm and a lateral support in the trochanter supplied by the nail. The disadvantages are that it is often harder to achieve a closed reduction of a displaced fracture and to maintain the reduction with the intramedullary implant.

Tips and tricks

To obtain and maintain anatomic reduction and a secure fracture fixation, the surgical approach and fixation technique is of great importance. It starts with correct patient positioning, fracture reduction (accounting for varus dislocation and dislocation of flexed fragments), choosing the correct nail entry point and perfect lag screw positioning within the head-neck fragment and distal locking. To maintain the reduction achieved intraoperatively, the decision has to be made to use a cerclage wiring or to tolerate fracture gaps in the metaphyseal area. Intraoperative controlled compression of the neck or the subtrochanteric area is of great importance to reduce delayed unions or nonunions.

Summary

Intramedullary fixation of unstable per-, inter- or subtrochanteric fractures shows biomechanical advantages compared to extramedullry fixation techniques. Even though there have been several amendments and developments of implants, a better implant does not compensate for an inadequate surgical approach or deficient surgical techniques which are paramount for successful treatment. When fixing fractures with intramedullary nailing systems, the surgeon should always try to achieve anatomic reduction and a perfect implant positioning to allow immediate full weight bearing without an increased risk of cut-out, non-union and implant failure.     

Changing pattern of femoral fractures in osteogenesis imperfecta with prolonged use of bisphosphonates

Purpose  

Osteogenesis imperfecta (OI) has been treated with bisphosphonates for many years, with some clear clinical benefits. In adults, there are reports of a new pattern of atraumatic subtrochanteric fractures with bisphosphonate treatment. This study assesses if bisphosphonate treatment leads to an altered pattern of femoral fractures.     

Treatment of pertrochanteric fractures with a proximal femur locking compression plate

Background

Pertrochanteric femoral fractures are one of the most common fractures in old patients. However, fixing pertrochanteric fractures properly is clinically challenging. There are also no routine treatments for this facture. Here, we report the clinical trial of pertrochanteric fracture treatment with a proximal femur locking compression plate (PFLCP). By recording and analysing the radiographic and clinical results from patients treated with PFLCP, we found that PFLCP could provide three-dimensional fixation mechanical advantages compared with conventional treatments, even in the case of unstable fractures in the osteoporotic bone.

Methods

The report included a total of 110 patients (72 females and 38 males) with pertrochanteric femoral fractures who were subjected to PFLCP treatment. The mean age of the patients was 75 (48-93) years. Pertrochanteric fracture includes both intertrochanteric and subtrochanteric femoral fractures: intertrochanteric fractures were classified according to Jensen (1980), whereas subtrochanteric fractures were classified according to Zickel (1980). Detailed clinical conditions of all patients, including blood loss, drainage and length of incision, were recorded individually. The duration of image intensification was also monitored. Patients were revisited at 6 weeks, 3 months, 6 months and 1 year after the operation. The progress of healing, as well as the occurrence of complications, was recorded.

Results

Amongst the 110 patients, 108 (98%) were available for follow-up check-up at 6 weeks, 104 (95%) at 3 months, 100 (91%) at 6 months and 94 (85%) at 1 year. The other patients were lost to follow-up because of death. The union rate was 95% (99/104), 98% (98/100) and 100% (94/94) at the 3-month, 6-month and 1-year period during the follow-up check-up, respectively. The patients healed satisfactorily and had no complications, such as cut-out in most cases. However, there was one case of breakage of the implant and one case of non-union at the 3-month period during the follow-up check-up. Amongst all patients, 77 cases were successfully reduced with traction on a fracture table under fluoroscopy; the others were opened to correct the displacement. The average operation time was 35.5 min, and the mean bleeding amount was 150 ml (including operative blood loss and wound drainage). The mean image intensifier time was 5 min and the mean length of incision was 9 cm.

Conclusion

The PFLCP can be a feasible alternative to the treatment of pertrochanteric fractures. Treatment with a PFLCP can provide good-to-excellent healing for pertrochanteric fractures, with a limited occurrence of complications.     

Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing

Objective

Intramedullary nailing is widely used in the treatment of long bone fractures. But some patients suffer from nonunion after receiving intramedullary nailing. This paper investigates the methods and effects of locking compression plate (LCP) in the treatment of long bone nonunion after intramedullary nailing.

Methods

A total of 6 patients (4 males, 2 females) with long bone nonunion were enrolled. All these patients had previously undergone intramedullary nailing for fractures of long bones (4 femurs, 2 tibiae). The average time from injury to LCP treatment was 12.2?months. The locking compression plate was applied over the intramedullary nail, and unicortical purchase achieved with locking head screws due to underlying nails. Autologous bone grafting was done in all cases.

Results

Six patients were followed up for 12–20?months (mean 14.2?months). X-ray imaging showed bone callus at the broken ends of the fracture at 3–7 (mean 4.5)?months after surgery. All patients did not have any complications such as infection, breaking or loosening of the LCPs.

Conclusion

LCP can be used for the treatment of long bone nonunion after intramedullary nailing for its convenience, minimal invasion and curative effect.     

Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail.

Seventy-nine nonconsecutive patients with subtrochanteric femur fractures were divided into three groups based on the method of fracture fixation. Group I consisted of 21 patients treated with a Zickel nail, Group II comprised 25 patients treated with a 95 degrees blade plate, and Group III included 33 patients treated with an interlocking nail. All patients in Group I and Group II had open reduction and internal fixation of their fractures. Ninety-four percent of the patients in Group III were treated by closed intramedullary nailing. The average operating times for Groups I, II, and III were 212, 272, and 181 min, respectively, while blood loss averaged 900, 1,500, and 600 ml for each group, respectively. Group I had one infection, ten malunions, and one nonunion. Group II had one infection, six malunions, and two nonunions. Group III had no infections, two malunions, and one nonunion. We conclude that closed interlocking nailing is the treatment of choice for acute nonpathologic subtrochanteric femur fractures in adults. There is decreased blood loss, reduced operating time, and fewer complications than with either the Zickel nail or the 95 degrees blade plate regardless of the fracture pattern or the degree of fracture comminution.     

Subtrochanteric fractures after long-term treatment with bisphosphonates: a European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and International Osteoporosis Foundation Working Group Report

Summary

This paper reviews the evidence for an association between atypical subtrochanteric fractures and long-term bisphosphonate use. Clinical case reports/reviews and case?Ccontrol studies report this association, but retrospective phase III trial analyses show no increased risk. Bisphosphonate use may be associated with atypical subtrochanteric fractures, but the case is yet unproven.

Introduction

A Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and the International Osteoporosis Foundation has reviewed the evidence for a causal association between subtrochanteric fractures and long-term treatment with bisphosphonates, with the aim of identifying areas for further research and providing recommendations for physicians.

Methods

A PubMed search of literature from 1994 to May 2010 was performed using key search terms, and articles pertinent to subtrochanteric fractures following bisphosphonate use were analysed.

Results

Several clinical case reports and case reviews report a possible association between atypical fractures at the subtrochanteric region of the femur in bisphosphonate-treated patients. Common features of these ??atypical?? fractures include prodromal pain, occurrence with minimal/no trauma, a thickened diaphyseal cortex and transverse fracture pattern. Some small case?Ccontrol studies report the same association, but a large register-based study and retrospective analyses of phase III trials of bisphosphonates do not show an increased risk of subtrochanteric fractures with bisphosphonate use. The number of atypical subtrochanteric fractures in association with bisphosphonates is an estimated one per 1,000 per year. It is recommended that physicians remain vigilant in assessing their patients treated with bisphosphonates for the treatment or prevention of osteoporosis and advise patients of the potential risks.

Conclusions

Bisphosphonate use may be associated with atypical subtrochanteric fractures, but the case is unproven and requires further research. Were the case to be proven, the risk?Cbenefit ratio still remains favourable for use of bisphosphonates to prevent fractures.     

Evaluation of proximal femoral locking plate in unstable extracapsular proximal femoral fractures: Surgical technique & mid term follow up results

Background

Stable trochanteric femur fractures can be treated successfully with conventional implants such as sliding hip screw, cephalomedullary nails, angular blade plates. However comminuted and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment of complex, comminuted proximal femoral fractures.

Method

We reviewed 30 patients with unstable inter or subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average operative time was 80 min. Patients were followed up for a period of 3 years (June 2010–June 2013). Patients were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-shaft angle), limb shortening, and hardware failure.

Result

All patients showed signs of union at an average of 9 weeks (8–10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5.

Conclusion

PF-LCP represents a feasible alternative for treatment of unstable inter- or subtrochanteric fractures.     

Complications and failures of titanium elastic nailing in pediatric femur fractures

Objective  

Flexible intramedullary nailing has become a popular method of fixation of femur fractures in children. The purpose of this study was to analyze complications following titanium elastic nailing in pediatric femur fractures.     

倒置LISS钢板治疗累及股骨干的不稳定性股骨转子间及转子下骨折

目的 :探讨倒置LISS(less invasive stabilization system)钢板治疗累及股骨干的不稳定性股骨转子间及转子下骨折的临床疗效。方法:回顾性分析2012年1月至2015年1月收治的24例累及股骨干的不稳定性股骨转子间及转子下骨折患者,男16例,女8例;年龄35~81岁,平均62.5岁。受伤原因:交通伤8例,高处坠落伤3例,摔伤13例。受伤至手术时间2~12 d,平均5.2 d;采用倒置LISS进行治疗,随访时拍摄股骨正侧位X线片。记录患者的手术时间、术中出血量、住院天数,术后疗效评价采用Harris髋关节功能评分标准。结果:24例均获随访,时间18~36个月,平均16.2个月。手术时间(68.22±48.36)min,术中出血量(256.28±182.46)ml,住院天数(14.8±5.2)d。全部病例获得骨性愈合,平均愈合时间4.8个月(3~8个月)。未发生深部感染、下肢深静脉血栓、肺栓塞、骨不连等并发症。末次随访时Harris评分为76.49±12.28,其中优15例,良6例,可3例。结论:倒置LISS钢板治疗累及股骨干的不稳定性股骨转子间及转子下骨折疗效满意,术后需严格随访,不应强调过早负重。     

Reconstruction plate fixation of subtrochanteric femoral fractures in children

Pediatric subtrochanteric femoral fractures are rare and have received limited attention in the literature Treatment is controversial. Different treatment options are used: skin traction, 90/90 skeletal traction, spica casting, cast bracing, internal fixation and external fixation. The aim of this study is to present our results with internal fixation of subtrochanteric femoral fractures in children using a reconstruction plate. Between 2000 and 2004, eighteen patients with closed subtrochanteric femoral fractures were treated in the Mansoura Emergency Hospital. The average age at the time of injury was 8.2 years (range 5.3 years to 11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Eight patients had head injuries and/or multiple injuries. In all cases a single 4.5 mm contoured reconstruction plate was used and a 6.5 mm cancellous screw was inserted through the plate into the femoral neck. Average follow-up was 38 months (range, 12 to 47 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6 to 12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. Internal fixation with a reconstruction plate appears as a good treatment option for children with subtrochanteric femoral fractures.     

Treatment of ipsilateral concomitant fractures of proximal extra capsular and distal femur

Objectives

Ipsilateral concomitant fractures of proximal extracapsular and distal femur are rare injuries and pose a great challenge for orthopaedics. In this study, we reviewed and examined the approaches and outcomes of this complex injury.

Methods

From August 2002 to January 2010, seven patients (six males and one female) with a mean age of 39 years (range, 20-48 years) were involved in the study. They had suffered from ipsilateral concomitant fractures of proximal extracapsular and distal femur, with two cases of unstable intertrochanteric fractures, three cases of subtrochanteric fractures and two cases of extracapsular femoral neck fractures. The distal femoral fractures were categorised based on the Arbeitsgemeinschaft für Osteosynthes (AO) classification: 2, A3; 2, C1; 2, C2 and 1, C3, and the proximal femoral fractures were stabilised via nailing, whilst the distal ones via less-invasive stabilisation system-distal femur (LISS-DF) plating in all six patients. In the one with the ‘floating knee’ injury, the subtrochanteric fracture was stabilised by reversed LISS-DF, and the distal one, by retrograde nailing. The healing of each femoral fracture was evaluated radiologically and clinically with follow-up. The functional outcomes were assessed through the Friedman and Wyman system.

Results

The mean follow-up interval was 2 years (range, 1.5-3 years). Six femoral fractures healed uneventfully, whilst the one with the ‘floating knee’ injury developed a delayed union postoperatively due to metal failure in 6 months, and, eventually, a malunion with coxa vara deformity 1.5 years later. The clinical functions at the final follow-up were found to be good in five cases, and fair and poor in one case each.

Conclusion

The nailing of a proximal femoral fracture and an LISS-DF fixation of a distal one could be a reliable and effective approach to handle ipsilateral concomitant fractures of a proximal extracapsular and distal femur.     

A meta-analysis of plate fixation versus intramedullary nailing for humeral shaft fractures

Background

There is a lack of consensus on whether intramedullary nailing (IMN) or plating is superior for humeral shaft fractures.

Methods

In this meta-analysis, we combined data from PubMed, the Excerpta Medica Database (Embase), the Cochrane Library, and the Chinese National Knowledge Infrastructure (CNKI) (all to Dec 31, 2011). Six randomized controlled trials (RCTs) and two quasi-RCTs including 384 participants were selected and assessed by use of an 11-item scale. Heterogeneity was assessed by use of the standard chi-squared test and the I ² statistic.

Results and conclusions

The results indicated that two primary outcomes (total number of complications and functional measurement) were significantly better for plate fixation. Significantly lower risk of delayed-union, restriction, impingement of the shoulder, shoulder pain, and re-operation were found for the plating group, which suggested that plating is superior to IMN for humeral shaft fractures.

Level of evidence

Level II; meta-analysis of RCTs and quasi-RCTs; treatment study.