The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: a retrospective review of 465 patients

The clinical efficacy of Medial Sustain Nail(MSN) and Proximal femoral nail anti-rotation(PFNA) for fixation of medial comminuted trochanteric fractures: a prospective randomized controlled trial

PURPOS

To evaluate the clinical efficacy of the Medial Sustain Nail (MSN) for medial comminuted trochanteric fractures fixation in comparison to Proximal Femoral Nail Antirotation (PFNA) through a clinical study.

METHODS

A non-inferiority randomized controlled trial was conducted at a single centre between July 2019 and July 2020. Fifty patients diagnosed comminuted trochanteric fractures were randomly assigned to either the MSN group (n = 25) or the PFNA group (n = 25). A total of forty-three patients were included in the final study analysis. The primary outcome measure was Short Form 36 health surgery physical component summary (SF-36 PCS) score. Secondary outcomes included the Oxford Hip Scores (OHS), weight bearing, complication relate to implant and so on. This study was not blined to surgeons, but to patients and data analysts.

RESULTS

The MSN demonstrated significantly better functional outcomes as measured by SF-36 PCS and OHS at six months postoperative compared to PFNA (p < 0.05). Union of fractures in the MSN group reached 90.9% at three months after surgery, whereas the PFNA group achieved a union rate of 57.1% (p < 0.05). Furthermore, weight-bearing time of MSN group was earlier than PFNA group (p < 0.05). Additionally, complications related to implant usage were more prevalent in the PFNA group (33.3%) compared to the MSN group (4.5%) (p < 0.05).

CONCLUSION

MSN exhibited superior quality of life outcomes compared to PFNA at six months postoperative. This indicates that MSN effectively reconstructs medial femoral support in patients with comminuted trochanteric fractures, which facilitates early weight-bearing and accelerates the recovery process.

TRIAL REGISTRATION

Trial registration number: NCT01437176, Date of the trial registration:2011-9-1, Date of commencement of the study:2011-9, Date of enrolment/recruitment of the study subjects:2019-7.

Preventing Atrophic Long-Bone Nonunion: Retrospective Analysis at a Level I Trauma Center

Background: Among the risk factors for nonunion are unchangeable patient factors such as the type of injury and comorbidities, and factors that can be influenced by the surgeon such as fracture treatment and the postoperative course. While there are numerous studies analyzing unchangeable factors, there is poor evidence for factors that can be affected by the physician. This raises the need to fill the existing knowledge gaps and lay the foundations for future prevention and in-depth treatment strategies. Therefore, the goal of this study was to illuminate knowledge about nonunion in general and uncover the possible reasons for their development; Methods: This was a retrospective analysis of 327 patients from 2015 to 2020 from a level I trauma center in Germany. Information about patient characteristics, comorbidities, alcohol and nicotine abuse, fracture classification, type of osteosynthesis, etc., was collected. Matched pair analysis was performed, and statistical testing performed specifically for atrophic long-bone nonunion; Results: The type of osteosynthesis significantly affected the development of nonunion, with plate osteosynthesis being a predictor for nonunion. The use of wire cerclage did not affect the development of nonunion, nor did the use of NSAIDs, smoking, alcohol, osteoporosis and BMI; Conclusion: Knowledge about predictors for nonunion and strategies to avoid them can benefit the medical care of patients, possibly preventing the development of nonunion.

Residual lateral wall width predicts a high risk of mechanical complications in cephalomedullary nail fixation of intertrochanteric fractures: a retrospective cohort study with propensity score matching

PURPOSE

The purpose of this study is to determine whether the integrity of the entry portal of head-neck implant is related to postoperative mechanical complications.

METHODS

We retrospectively reviewed consecutive patients with pertrochanteric fractures in our hospital treated from January 1, 2018, to September 1, 2021. Based on the integrity of the entry portal for head-neck implants on the femoral lateral wall, patients were divided into two groups, including the ruptured entry portal (REP) group and the intact entry portal (IEP) group. After 4:1 propensity score-matched analyses were used to balance the baseline of the two groups, a total of 55 patients were extracted from the original participants, including 11 patients in the REP group and 44 matched patients in the IEP group. The anterior to posterior cortex width on the mid-level of the lesser trochanter was measured and defined as the residual lateral wall width (RLWW).

RESULTS

Compared with the IEP group, the REP group was correlated with postoperative mechanical complications (OR = 12.00, 95% CI 1.837-78.369, P = 0.002) and hip-thigh pain (OR = 26.67, 95% CI 4.98-142.86). RLWW ≤ 18.55 mm indicated a high likelihood (tau-y = 0.583, P = 0.000) of becoming the REP type postoperatively and being more likely to suffer from mechanical complications (OR = 30.67, 95% CI 3.91-240.70, P = 0.000) and hip-thigh pain (OR = 14.64, 95% CI 2.36-90.85, P = 0.001).

CONCLUSION

Rupture of entry portal is a high-risk factor for mechanical complications in intertrochanteric fractures. RLWW ≤ 18.55 mm is a reliable predictor of the postoperative REP type.

Treatment of irreducible intertrochanteric femoral fracture with a minimally invasive clamp reduction technique via the anterior approach

OBJECTIVE

To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures.

METHODS

From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. The average age of the patients was 78.7 (45-100 years old). The types of injuries were falls (91 cases), traffic accidents (12 cases), smashing (6 cases), and high falling (6 cases). The duration between injury and surgery ranged from 1 to 14 days, with an average of 3.9 days. The distribution of AO classification was as follows: 31-A1 in 15 cases, type 31-A2 in 67 cases and 31-A3 in 33 cases.

RESULTS

All patients achieved good reduction, with fracture reduction times ranging from 10 to 32 min (mean of 18 min), and were followed up for 12-27 months after surgery (mean of 17.9 months). Two patients with pronation displacement of the proximal fracture segment died of infection or hypostatic pneumonia after internal fixation failure; one patient with failed internal fixation switched to joint replacement. After internal fixation, the lateral wall of six reversed intertrochanteric femoral fractures showed repronation and abduction displacement, but all fractures achieved bony healing. The rest of the patients did not lose fracture reduction, and all fractures achieved bony healing with a healing time ranging from 3 to 9 months (mean of 5.7 months). While two patients died and one patient exhibited failed internal fixation and thus switched to joint replacement, 91 of the remaining 112 patients had an excellent Harris score of the hip joint function at the final follow-up, while 21 patients had a good Harris score.

CONCLUSION

The minimally invasive clamp reduction technique via the anterior approach for the treatment of irreducible intertrochanteric femoral fractures is simple, effective and minimally invasive. In the case of irreducible intertrochanteric femoral fractures associated with lateral wall displacement, the lateral wall needs to be strengthened after clamp reduction and intramedullary nail fixation to avoid loss of reduction and failure of internal fixation.

The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis

PURPOSE

The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures.

METHODS

MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring.

RESULTS

Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002).

CONCLUSIONS

Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.

Subtrochanteric Femur Fractures Treated With Femoral Nail: The Effect of Cerclage Wire Augmentation on Complications, Fracture Union, and Reduction: A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVE

To perform a systematic review and meta-analysis of subtrochanteric femur fractures treated with an intramedullary nail, augmented with or without cerclage wiring, comparing the risk of reoperation, nonunion, loss of fixation, and implant failure; fracture reduction and time to union.

DATA SOURCE

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed through MEDLINE, EMBASE, PubMed, Web of Science, and Scopus databases using a combination of controlled vocabulary and keywords on September 30, 2020.

STUDY SELECTION

All comparative (prospective and retrospective) studies of subtrochanteric fractures managed with intramedullary nail, that compared the addition of cerclage wire to without in patients 16 years of age or older were included. Pathological, atypical bisphosphonate, and segmental fractures were excluded, as were non-English literature.

DATA EXTRACTION

Data from each study were independently recorded by 2 investigators.

DATA SYNTHESIS

Agreement was obtained on 18 studies (all retrospective) for final inclusion, with 378 patients receiving cerclage wire and 911 without. A random-effects meta-analysis was used to analyze the pooled aggregate data.

CONCLUSIONS

There is no statistically significant advantage in using cerclage wire with femoral intramedullary nail when treating subtrochanteric femur fractures regarding risk of reoperation, nonunion, loss of fixation, and implant failure or time to union. An advantage favoring cerclage wire was seen for accuracy of fracture reduction. Cerclage wiring was used more often in cases associated with high-energy trauma. Given the relatively small number of events available to be modelled, a clinical benefit for cerclage wiring may still exist for certain fracture types.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of subtrochanteric fractures in the geriatric population: better pre-fracture condition but poorer outcome than pertrochanteric fractures: evidence from the Spanish Hip Fracture Registry

Background

Clinical management in orthogeriatric units and outcome indicators are similar for extracapsular fragility hip fractures, without discriminating between subtrochanteric and pertrochanteric fractures.

Hypothesis

Geriatric patients, 75 years or older, with subtrochanteric fractures have worse clinical and functional outcomes than those with pertrochanteric fractures.

Materials and methods

Retrospective observational study of data prospectively collected by the Spanish Hip Fracture Registry including patients 75 years or older, admitted for extracapsular hip fractures from January 2017 to June 2019. Demographic and baseline status, pre-operative, post-operative and 30-day follow-up data were included.

Results

A total of 13,939 patients with extracapsular hip fractures were registered: 12,199 (87.5%) pertrochanteric and 1740 (12.5%) subtrochanteric. At admission, patients with subtrochanteric fractures were younger (86.5 ± 5.8 versus 87.1 ± 5.6 years old), had better pre-fracture mobility (3.7 ± 2.7 versus 3.9 ± 2.8) (1-to-10 scale, 1 being independent) and were more likely to be living at home; those with pertrochanteric fractures had worse cognitive function (Pfeiffer 3.3 ± 3.3 versus 3.8 ± 3.5). The subtrochanteric fracture group showed worse post-fracture mobility (7.3 ± 2.7 versus 6.7 ± 2.7) and greater deterioration of mobility (3.7 ± 3.0 versus 2.9 ± 2.7). Among individuals living at home at baseline, those with subtrochanteric fractures were more likely to remain in an assisted facility at 30-day follow-up. In-hospital mortality during acute admission was higher for the subtrochanteric group (5.6% versus 4.5%) (p = 0.028). To our knowledge, this is the first paper highlighting the differences between these two fracture groups in the geriatric population.

Conclusions

Subtrochanteric fractures in the older population are a different and worse entity, with greater morbimortality and functional decline than pertrochanteric fractures. Despite being younger and fitter at admission, older patients with subtrochanteric fractures have a higher risk of remaining non-weight bearing and undergoing re-operation and institutionalization. Orthogeriatric units should be aware of this and manage subtrochanteric fractures accordingly.

Level of evidence: IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-022-00637-8.

The role of cerclage wiring in the management of subtrochanteric and reverse oblique intertrochanteric fractures: a meta-analysis of comparative studies

PURPOSE

Subtrochanteric and reverse oblique intertrochanteric fractures are challenging and often difficult to reduce. While intramedullary nailing (IMN) is considered the standard treatment, achieving anatomic reduction prior to fixation is essential. This study aimed to assess the impact of cerclage wiring with IMN on the outcomes and complication rate in treating subtrochanteric and reverse oblique intertrochanteric fractures.

METHODS

This meta-analysis was conducted in line with PRISMA guidelines. The primary outcome was the time to union. The secondary outcomes were operative time, blood loss, quality of reduction, reduction alignment (if in varus), complications and reoperations. PubMed, Cochrane, Web of Science and Google Scholar were searched till July 2021. Articles that compared intramedullary nailing (IMN) versus intramedullary nailing and cerclage wiring (IMN-C) in the treatment of subtrochanteric and reverse oblique intertrochanteric fractures were included. The risk of bias was assessed using the Newcastle-Ottawa scale.

RESULTS

This meta-analysis included 415 patients with subtrochanteric and reverse oblique intertrochanteric fracture from six comparative studies. Our findings showed that IMN-C was significantly associated with higher mean duration of surgery and blood loss. However, IMN-C had significantly lower mean time to union compared to IMN alone. In addition, IMN-C had lower pooled prevalence of varus reduction and overall complications.

CONCLUSION

This study showed that the use of cerclage wiring is associated with lower time to union, lower prevalence of varus reduction and overall complications. Therefore, cerclage wiring augmentation is a safe technique with low complication rate and may be advised whenever open reduction is needed in the management of subtrochanteric and reverse oblique intertrochanteric fractures.

The Clinical Efficacy of Minimally Invasive Clamp-Assisted Reduction and Open Reduction with Wire Cerclage for Unstable Subtrochanteric Fractures

The purpose of this study was to compare the clinical effectiveness of minimally invasive clamp-assisted reduction and open reduction with wire cerclage and intramedullary nails for unstable subtrochanteric fractures. Between January 2016 and October 2019, 68 patients who had unstable subtrochanteric fractures experienced intramedullary nail surgery in this retrospective study. There were 41 cases in the minimally invasive clamp or closed reduction group (group A) and 27 cases in the open reduction with wire cerclage group (group B). There were 3 cases of complications in group A and 2 cases of complications in group B. Remarkable distinction was observed between the two groups in the operation time (p < 0.05), quality of reduction (p < 0.05), and union time (p < 0.05). For the successful surgical treatment of unstable femoral subtrochanteric fractures, an anatomical reduction is crucial. Reduction and wire cerclage are cut to give medial support for the anatomical reduction, which has a positive effect on fracture healing.

Management of subtrochanteric femur fractures: is open reduction associated with poor outcomes?

Purpose

The aim of this study was to identify factors associated with the need for open reduction in subtrochanteric femoral fractures and investigate the effect of cerclage wiring compared to open reduction alone, on the development of complications, especially infection and non-union.

Methods

All consecutive patients with a fracture involving the subtrochanteric region were retrospectively identified, over an 8-year period. Data documented and analysed included patient demographics, fracture characteristics, patient comorbidities, time to fracture union and development of complications.

Results

A total of 512 patients met the inclusion criteria (523 fractures). Open reduction was performed in 48% (247) of the fractures. Following matching and regression analysis, we identified diaphyseal extension of the fracture to be associated with an open reduction (OR: 2.30; 95% CI 1.45–3.65; p < 0.001). Open reduction was also associated with an increased risk of superficial infection (OR: 7.88; 95% CI 1.63–38.16; p = 0.010), transfusion within 48 h following surgery (OR: 2.44; 95% CI 1.96–4.87; p < 0.001) and a prolonged surgical time (OR: 3.09; 95% CI 1.96–4.87; p < 0.001). The risk of non-union, deep infection and overall mortality was not increased with open reduction. The use of cerclage wires [50 out of 201 fractures (24.9%) treated with an open reduction] to achieve anatomical reduction as compared to open reduction alone significantly reduced the risk of non-union (OR: 0.20; 95% CI 0.06–0.74; p = 0.015).

Conclusion

Open reduction of subtrochanteric fractures is not associated with an increased risk of deep infection and non-union, even though it is associated with an increased risk of superficial infection, prolonged surgical time and transfusion. The use of cerclage wire is associated with reduced risk of non-union with little evidence of an increase in complications.

Level of evidence

III.

[Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not]

OBJECTIVE

To formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.

METHODS

A clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.

RESULTS

The 244 patients were divided into reducible-group ( n=164, 67.21%) and irreducible-group ( n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.

CONCLUSION

The classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.

[Effectiveness of proximal femoral nail anti-rotation and cerclage fixation for complicated femoral subtrochanteric fractures]

OBJECTIVE

To investigate the effectiveness of proximal femoral nail anti-rotation (PFNA) and cerclage fixation for complicated femoral subtrochanteric fractures.

METHODS

A clinical data of 74 patients with complicated femoral subtrochanteric fractures, who were admitted between March 2016 and March 2019 and met the criteria, was retrospectively analyzed. Among them, 39 patients were treated with limited open reduction and PFNA combined with cerclage fixation (observation group) and 35 patients were treated with closed reduction and PFNA fixation (control group). There was no significant difference in gender, age, cause of injury, side and type of fracture, and the time from injury to operation ( P>0.05). The ratio of postoperative hemoglobin (1, 3, and 5 days) to the preoperative hemoglobin, the operation time, the first weight-bearing time after operation, and the hospital stay were recorded. X-ray films were taken to observe fracture healing in the two groups and bone resorption around the cerclage in the observation group, and the fracture healing time was recorded. Hip function was evaluated by Harris scoring.

RESULTS

The operation time of the observation group was significantly longer than that of the control group ( P<0.05), but the first weight-bearing time and hospital stay were significantly shorter ( P<0.05). All patients were followed up 12 months. There was no significant difference in the ratios of post- to pre-operative hemoglobin (1, 3, and 5 days) between the two groups ( P>0.05). X-ray film reexamination showed that the fractures of the two groups healed smoothly, and the fracture healing time of the observation group was significantly shorter than that of the control group ( t=-12.989, P=0.000). No bone resorption around the cerclage occurred in the observation group. The Harris scores of the observation group were better than those of the control group at 7 days and 1, 2, and 3 months after operation ( P<0.05), and there was no significant difference between the two groups at 6 months after operation ( t=1.329, P=0.180).

CONCLUSION

Compared with PFNA fixation, PFNA combined with cerclage fixation for the complicated femoral subtrochanteric fractures has a shorter operation time, and can obtain immediate stability after fixation, which can meet the needs of patients for early functional exercise.

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over an 8-year period. Basic demographics, fracture characteristics, fracture union, revision operation, mortality and other complications were reported and analysed. Variables deemed statistically significant (p-value < 0.05) were then included into a revised adjusted model of logistic regression analysis, where we reported on the odds ratio (OR). Results: The overall incidence of infection was 6.4% (n = 36/561; superficial: 3.7%; deep: 2.7%). Associations with deep infection included: non-union (OR 9.29 (2.56–3.38)), the presence of an open fracture (OR 4.23 (3.18–5.61)), the need for massive transfusion (OR 1.42 (2.39–8.39)), post-operative transfusion (OR 1.40 (1.10–1.79)) and prolonged length of stay (OR 1.04 (1.02–1.06)). The Commonest causes of superficial infection were Staphylococcus aureus (28.5%), enteric flora (23.8%) and mixed flora (23.8%); whereas coliforms (60%) and Staphylococcus aureus (26.7%) were the commonest micro-organisms isolated in deep infection. Polymicrobial infection was identified in 38.5% and 80% of superficial and deep infections, respectively. Conclusion: Causative micro-organisms identified in both superficial and deep infection were similar to those reported in post-traumatic osteomyelitis. In an attempt to minimise infection, the treating clinician should focus on modifiable risk factors with adequate patient optimisation, prompt surgical treatment, adequate antibiotic coverage and wound care when treating patients with subtrochanteric femur fracture.

[Treatment of irreducible intertrochanteric femoral fracture with minimally invasive clamp reduction technique via anterior approach]

OBJECTIVE

To explore the effectiveness of minimally invasive clamp reduction technique via anterior approach in treatment of irreducible intertrochanteric femoral fractures.

METHODS

Between January 2015 and January 2019, 59 patients with irreducible intertrochanteric femoral fractures were treated with minimally invasive clamp reduction technique via anterior approach. There were 29 males and 30 females with an average age of 77.9 years (range, 45-100 years). The causes of injury included falling in 46 cases, traffic accident in 6 cases, smashing in 2 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.8 days). The fractures were classified as AO type 31-A1 in 12 cases, type 31-A2 in 25 cases, type 31-A3 in 22 cases.

RESULTS

All fractures were reduced well and the fracture reduction took 10 to 30 minutes, with an average of 19 minutes. All patients were followed up 13-25 months, with an average of 17.6 months. Among them, 2 cases of pronation displacement of proximal fracture segment died for infection or falling pneumonia after internal fixation failed. Six patients with reversed intertrochanteric femoral fractures experienced re-pronation and abduction displacement of the lateral wall after internal fixation, but the fractures all healed. The rest of the patients had no fracture reduction loss, and the fractures healed with an average healing time of 5.9 months (range, 3-9 months). Except for 2 patients who died, the Harris score of hip joint function of the remaining 57 patients was excellent in 49 cases and good in 8 cases at last follow-up.

CONCLUSION

The minimally invasive clamp reduction technique via anterior approach for irreducible intertrochanteric femoral fractures is simple and effective. For irreducible intertrochanteric femoral fractures related to lateral wall displacement, after clamp reduction and intramedullary nail fixation, the lateral wall should be reinforced in order to avoid reduction loss and internal fixation failure.

[Impairment of the blood supply by cerclages: myth or reality? : An overview of the experimental study situation]

INTRODUCTION

The use of a cerclage for osteosynthesis is a controversially discussed topic. They are said to damage the periosteal blood circulation and therefore impair bony healing. This article examines the available evidence on whether cerclages actually lead to a relevant reduction in periosteal perfusion.

METHODS

A systematic review of the literature was performed in the PubMed library, searching for experimental studies concerning the influence of cerclages on periosteal blood supply.

RESULTS

No experimental study exists which used a fracture model to investigate the influence of cerclages on the periosteal blood supply of fractured bones. A total of seven experimental studies could be identified. Of these studies two used human cadaver femora, which showed no relevant impairment of the blood supply. The other five investigations were animal experiments carried out on live animals. In rabbit femora the blood perfusion was shown by scintigraphy to be postoperatively decreased by 45-56% . In contrast, three other studies using dog femora and one using equine radii showed no relevant impairment of the periosteal blood supply. One study used an osteotomy model, the others used intact bones.

CONCLUSION

Only one study using a rabbit model could demonstrate a relevant reduction of the periosteal blood supply by cerclages. In four other investigations on animal models over longer postoperative time periods the blood perfusion of the bones showed no impairment. In two series of experiments on human cadaveric femora no negative effects were also found. At least in the mid-term and long-term run the fear that cerclages could impair the blood supply of intact bone or postosteotomy cannot be confirmed by experimental studies. There is no experimental study using a fractured bone model.

Case series and finite element analysis of PFNA combined with cerclage wire for treatment of subtrochanteric fracture of femur

Objective

To retrospectively analyze the clinical efficacy of PFNA combined with a cerclage wire in the treatment of 52 patients with unstable subtrochanteric fracture of the femur and to analyze the biomechanical effect of ligature on a fracture model.

Methods

In this study, 52 patients with unstable subtrochanteric fractures were treated in our orthopedic trauma center from June 2013 to July 2018. The Seinsheimer type IV fracture model was established using the patient’s CT data, and the joint surface of the distal femoral condyle and the external condyle were restrained. The femoral head was used as the loading point, and a force of 500 N was applied vertically along the long axis of the femoral shaft.

Results

All 52 patients were followed up for 12 to 37 months, with an average of 18.07 ± 4.38 months. According to the Sanders hip function score, 28 cases were excellent (55–60 points), 22 cases were good (45–54 points), and 2 cases were poor (35–44 points), with an excellent and good rate of 96.15%. Postoperative deep vein thrombosis occurred in 3 cases, and fracture nonunion occurred in 1 case. No infection, loose fracture of internal fixation or hip varus deformity occurred. The finite element analysis indicated that the displacement of the whole model decreased slightly and the relative sliding of the fracture block decreased, but the maximum stress of the femur increased after the addition of the cerclage wire.

Conclusion

The treatment of unstable subtrochanteric fracture of the femur with PFNA combined with cerclage wire has the advantages of simple operation, satisfactory reduction of fracture, stable fixation, and good recovery of limb function. The finite element analysis suggested that the biomechanical strength fixation was enhanced after the addition of cerclage wire. However, the local stress concentration of the tie may increase the risk of failure.

The Use of Twisting and Tightening Tool to Strengthen the Cerclage and Tension Band Wiring

Cerclage and tension band wiring are being used in most bone surgeries in different disciplines. The regularity of the twist on the node of a cerclage and tension band is thought to determine cerclage stability. For this purpose, a novel twisting and tightening tool was designed. This tool maintains extremely regular twists on the node, which we consider to be important for stability. In the present biomechanical trial, we aimed to investigate the consistency of the twists forming the cerclage node. This study was performed on a total of 30 cerclage loops. In group A (n = 15), the cerclage wire was tightened manually by a clipper, while in group B (n = 15), it was tightened using the twisting and tightening tool. In biomechanical tests, the cerclage loops were pulled apart by 2 hooks connected to the biomechanical device. The velocity was adjusted to 20 mm/min. On statistical analysis, there was a significant difference in the ultimate strength (P = .03) and the mean tensile strength (P = .01) between groups A and B. It was found that the strength of the cerclage wire can be increased by maintaining more regular twists. The twisting and tightening tool is a reasonable and useful device for both clinical and experimental usages.

A Comparative Study of Intramedullary Nail Strengthened with Auxiliary Locking Plate or Steel Wire in the Treatment of Unstable Trochanteric Fracture of Femur

Objective

To compare the clinical outcomes of unstable femoral trochanteric fracture treated by proximal femoral intramedullary nail enhanced with lateral locking plate versus cerclage steel wire.

Methods

A retrospective study was conducted on 83 patients who received open reduction and internal fixation with proximal femoral intramedullary nail combined with lateral enhanced fixations for unstable femoral trochanteric fractures from March 2015 to January 2017 in our hospital. Of these patients, 39 received the lateral enhanced fixation with locking plate, while the remaining 44 had cerclage wire as additional fixation. The clinical data were compared between the two groups.

Results

All the patients in the study had surgical procedures performed smoothly. Although the plate group had significantly longer operation times and significantly higher hospitalization expenses than the wire group (P < 0.05), no statistically significant differences in intraoperative blood loss and hospital stay were proved between the groups (P > 0.05). The follow‐up period lasted for 12–24 months with an average of (16.81 ± 2.92) months. The plate group returned to full‐weight bearing significantly earlier than the wire group (P < 0.05). The Harris Hip Score (HHS) significantly increased in both groups over time postoperatively (P < 0.05). The plate group achieved a higher HHS than the wire group, which was statistically significant at 3 months (P < 0.05), whereas it became insignificant at 6 and 12 months postoperatively (P > 0.05). Regarding radiographic assessment, an excellent rate of fracture reduction was proved in 71.79% of the plate group, compared to 45.45% of the wire group, which was statistically significant (P < 0.05). In addition, fracture healing was achieved significantly earlier in the plate group than the wire group (P < 0.05); nevertheless, no statistically significant difference was noted in neck‐shaft angle at the latest follow‐up between the two groups (P > 0.05). At the latest follow‐up, two cases of implant loosening and two cases of coxa varus were found in the plate group, while one case of femoral head necrosis and three cases of coxa varus were revealed by radiographs in the wire group.

Conclusion

The cerclage wire has benefits of saving time and operation costs; however, the locking plate has the advantages of improving fracture reduction quality, shortening time to full weight bearing and fracture healing, and improving hip function recovery due to the lateral additional fixations to proximal femoral intramedullary nail for unstable trochanteric fractures.