Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures?

Sciatic Nerve Entrapment from Cerclage Wiring in Intramedullary Nail Fixation

Cerclage wiring may be used to optimize the stability of intramedullary nail or plate fixations in comminuted proximal femoral fractures, periprosthetic fractures, and other selected cases. In this article, we presented a novel case of iatrogenic sciatic nerve entrapment from cerclage wiring used to supplement intramedullary nail fixation. We also illustrate and highlight the role of ultrasound in assessing the sciatic nerve to make a timely diagnosis.

Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion

Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.

Posterior Protrusion Measures (PPM) for Three-Dimensional (3D) CT Classification of Pertrochanteric Fractures

Introduction We introduced a novel numerical index known as posterior protrusion measures (PPM), derived from lateral plain radiograph images, which effectively serves to distinguish stable from unstable pertrochanteric fractures. The present study aims to scrutinize PPM values among two classified fracture patterns, stable and unstable, within the three-dimensional (3D) CT classification system, establishing a numeric threshold for PPM to differentiate between these groups; explore the potential relationship between the PPM index and unclassified categories; investigate how groups divided by the PPM threshold value can predict fracture stability based on 3D CT. Materials and methods In this study, three observers were tasked with measuring PPM on a single occasion. The chi-square test assessed the association between each demographic parameter on a categorical scale and stable/unstable groups. Continuous variables were also subject to examination. Receiver operating characteristic (ROC) analysis was employed to determine optimal cut-off points of PPM for predicting the presence of stable versus unstable groups. Additionally, the chi-square test examined the linear relation between separated groups based on the defined threshold PPM value and the stable/unstable groups. Results A total of 106 pertrochanteric fractures were identified using CT scan images and plain radiographs in the 3D CT classification system, revealing the stable group of 35 patients and the unstable group of 71 patients. The PPM values for stable/unstable fractures were, on average (± standard deviation), 0.34±0.25/0.50±0.29 for observer 1, 0.31±0.23/0.57±0.31 for observer 2, and 0.41±0.29/0.57±0.26 for observer 3, respectively (p<0.01). We established 0.3 as the cut-off value for PPM. The average PPM value among three observers represented each patient to assess fracture stability. The group with PPM <0.3 included 27 patients (16 stable and 11 unstable), and the group with PPM ≥0.3 group comprised 79 patients (19 stable and 60 unstable; p<0.005). Conclusion The present study revealed a significant difference in PPM values among stable and unstable 3D CT classification groups. Additionally, a threshold PPM value of 0.3 suggests a pivotal point for differentiating fracture stability. This innovative methodology makes a substantial contribution to clinical endeavors, potentially circumventing the necessity for 3D CT scanning.

Biomechanical evaluation of three implants for treating unstable femoral intertrochanteric fractures: finite element analysis in axial, bending and torsion loads

Purpose: How to effectively enhance the mechanical stability of intramedullary implants for unstable femoral intertrochanteric fractures (UFIFs) is challenging. The authors developed a new implant for managing such patients. Our aim was to enhance the whole mechanical stability of internal devices through increasing antirotation and medial support. We expected to reduce stress concentration in implants. Each implant was compared to proximal femoral nail antirotation (PFNA) via finite element method. Methods: Adult AO/OTA 31-A2.3 fracture models were constructed, and then the new intramedullary system (NIS), PFNA, InterTan nail models were assembled. We simulated three different kinds of load cases, including axial, bending, and torsion loads. For further comparison of PFNA and the NIS, finite element analysis (FEA) was repeated for five times under axial loads of 2100 N. Two types of displacement and stress distribution were assessed. Results: Findings showed that the NIS had the best mechanical stability under axial, bending, and torsion load conditions compared to PFNA and InterTan. It could be seen that the NIS displayed the best properties with respect to maximal displacement while PFNA showed the worst properties for the same parameter in axial loads of 2100 N. In terms of maximal stress, also the NIS exhibited the best properties while PFNA showed the worst properties in axial loads of 2100 N. For bending and torsion load cases, it displayed a similar trend with that of axial loads. Moreover, under axial loads of 2100 N, the difference between the PFNA group and the NIS group was statistically significant (p < 0.05). Conclusion: The new intramedullary system exhibited more uniform stress distribution and better biomechanical properties compared to the PFNA and InterTan. This might provide a new and efficacious device for managing unstable femoral intertrochanteric fractures.

Preventing the Slide in High-Energy Intertrochanteric Fractures With Intramedullary Nails

LEVEL OF EVIDENCE

Therapeutic Level V.

The Impact of Banana-Shaped Fragments on Trochanteric Hip Fractures Treated by PFNA

Background

Regarding trochanteric hip fractures, one type of posterior coronal fragments was described as the "banana-shaped fragment", while the impact of the banana-shaped fragment on mechanical stability has not been further studied. The current study investigated the association between the banana-shaped fragment and mechanical complications after surgery.

Methods

This retrospective cohort study included 273 patients treated by proximal femoral nail antirotation (PFNA) in the full analysis. The age, the sex, the fracture side, the follow-up time, the American Society of Anesthesiologists classification, the operators, the fracture classification, the tip-apex distance, the blade positions, the reduction quality and the bone mineral density were analyzed in relation to mechanical complications, through univariate and multivariate approaches.

Results

Mechanical complications happened in 33 patients. The banana-shaped fragment (adjusted odds ratio 5.240, 95% CI 2.172 to 12.641; p < 0.001), the tip-apex distance and the reduction quality showed significant association with mechanical complications in both univariate and multivariate analysis. Moreover, for 118 patients with the banana-shaped fragment, we found that the use of wire cerclage couldn't significantly lower the rates of mechanical complications (p = 0.648).

Conclusions

The banana-shaped fragment had a negative impact on mechanical stability of trochanteric hip fractures treated by PFNA. In the perioperative period, the BSF should be carefully evaluated, and its specific handling deserves further study.

A Scientific Proposal for Surgical Decision-Making in Occult Intertrochanteric Fractures Based on Finite Element Analysis

Background In the treatment of femoral intertrochanteric fractures, there is still a lack of consensus on the optimal approach for isolated greater trochanteric fractures and insufficient intertrochanteric fractures. The limited number of patients and restricted access to accurate assessment of fracture extension using magnetic resonance imaging contribute to the unclear treatment strategy. This study aims to utilize finite element (FE) analysis to analyze stress values at the fracture line and investigate their influence on intertrochanteric fracture extension under different loading conditions. The hypothesis is that fracture extension occurs following certain conditions, supporting the need for surgery based on scientific evidence. Methodology Osseous data from a computed tomography (CT) scan was used to create a proximal femur FE model using FEA software. CT scan data were converted to Digital Imaging and Communications in Medicine format and used to generate the FE model. Trabecular bone and cortex were meshed into tetrahedral elements. The model consisted of 1,592,642 elements and 282,530 nodes. Two models were created, namely, healthy proximal femur (HF) and femoral insufficient intertrochanteric fracture (FIF). Material properties were assigned based on CT values and conversion equations. The distal end of the femur was constrained. Stress analysis using the dynamic explicit approach was performed. Von Mises stresses were calculated for the proximal femur. The number of elements exceeding yield stress was counted to predict fracture risk by focusing on fracture line spots. In this study, the distribution of von Mises stress was compared between the HF and the FIF models. Six loading combinations were considered, namely, two weight-bearing conditions (3 W loading simulating for walking and 1/3 W for touch-down standing) and three hip flexion angles (0°, 15°, and 23°). Results Under 3 W loading, no significant stress elevations were observed in the HF model at any flexion angles. However, the FIF model exhibited increased stress at the site of the posterior fracture line extension. This stress-induced element destruction was observed in both cortical and cancellous bone. For the 1/3 W loading condition, only minimal stress elevation was observed in both HF and FIF models. To assess the influence on fracture extension, the number of yielded elements was evaluated along the fracture line edges (greater trochanter and middle of the intertrochanteric ridge). Under 3 W loading, the HF model had only one yielded element, indicating minimal fracture risk. In contrast, the FIF model exhibited a notable presence of yield elements in various regions (total/greater trochanter/shaft) at different flexion angles: 0° (115/16/28), 15° (265/158/23), and 23° (446/233/34). Under the 1/3 W loading condition, neither the HF nor the FIF models showed any yielding elements, regardless of the direction of external force. Conclusions The results demonstrated elevated stress levels at the fracture line in the FIF model, particularly during walking, indicating a higher risk of fracture extension at the flex position. However, under reduced weight-bearing conditions, the stress at the fracture site remained within the yield stress range, suggesting a relatively low risk of fracture extension. These findings hold significant clinical implications for developing surgical protocols that consider patients' compliance with weight-bearing restrictions.

The development, incidence and treatment trends of trochanteric fractures in Germany: a cohort study

BACKGROUND

Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments.

METHODS

Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences.

RESULTS

985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures.

CONCLUSIONS

We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.

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.

Use of minimally invasive cerclage wiring for displaced major fragments of femoral shaft fractures after intramedullary nailing promotes bone union and a functional outcome

BACKGROUND

Femoral shaft fractures caused by high energy trauma can be very challenging due to the large variability in fracture morphology and poor functional outcomes. Displaced major fragments of femoral shaft fractures are difficult to manage after closed reduction and intramedullary nailing (IMN). The minimally invasive cerclage wiring (CW) procedure has become an optimal tool for major fragment resetting and stabilization after IMN. However, arguments continue for the potential risk of arterial injury, blood supply disruption, and delayed bone union or non-union with the CW procedure. The surgical algorithm for treating femoral shaft fractures with displaced major fragments remains controversial. Thus, emphasis is placed on whether the CW procedure can promote the bone union rate and improve functional outcomes without significant complications.

METHODS

We performed a retrospective study on all patients of femoral shaft fractures with displaced major fragments between June 2015 and August 2019 in our trauma centre. Eligible patients were included and stratified into the CW group and IMN group. Demographics, radiological data, callus formation, union time, and functional outcomes were critically compared between the two groups.

RESULTS

Thirty-seven patients were included in the present study according to our inclusion/exclusion criteria, of whom 16 (43.2%) were stratified into the CW group, and 21 (56.8%) into the IMN group. The modified radiographic union score for femorae (mRUSH) in the CW group and IMN group was significantly different (11.94 ± 1.29 vs. 7.95 ± 0.74, 6 months; 15.88 ± 0.50 vs. 10.33 ± 0.91, 12 months) (p < 0.0001). The mean union time was significantly different between the CW and IMN groups (7.9 ± 3.2 months vs. 20.1 ± 8.48 months) (p < 0.0001). Bone union at 12 months differed significantly between the CW and IMN groups (15 vs. 5) (p < 0.05). The Harris Hip Score in the CW group was significantly higher than that in the IMN group (88.19 ± 4.69 vs. 76.81 ± 5.26, 12 months; 93.19 ± 4.68 vs. 87.57 ± 5.38, 24 months) (p < 0.01). The Hospital for Special Surgery Knee Score was significantly different between the CW and IMN groups (78.50 ± 5.65 vs. 67.71 ± 4.65, 12 months; 89.50 ± 5.05 vs. 75.81 ± 8.90, 24 months) (p < 0.0001).

CONCLUSIONS

Minimally invasive CW is an optimal supplement for IMN in the treatment of femoral shaft fractures with displaced major fragments. As illustrated, the benefits of CW potentially include promotion of the bone union rate and improvement in functional outcomes.

Posterior Protrusion Measures (PPM) as an Innovative Index in Classifying Plain Lateral Radiograph Images of Pertrochanteric Fracture Using the Revised AO Foundation/Orthopaedic Trauma Association (AO/OTA) Classification

Introduction The absence of a precise fracture classification system that classifies pertrochanteric fractures into either stable or unstable contributes to a burden on healthcare and has several major implications. We propose an innovative graphical index, which we refer to as posterior protrusion measures (PPM), using plain lateral view radiograph images for the revised AO Foundation (Arbeitsgemeinschaft für Osteosynthesesfragen)/Orthopedic Trauma Association (AO/OTA) classification system. This study aims to: (i) introduce the use of PPM for classifying fractures into stable or unstable under the revised AO/OTA classification system and set the threshold numeric value, (ii) elucidate the reproducibility of inter and intra-observer agreement, and investigate the consistency of fracture classification using PPM versus computed tomography (CT) scan images. Materials and methods Out of 146 patients identified from the database, a total of 126 patients were enrolled in the study. Pertrochanteric fractures were classified as either stable or unstable. Three surgeons were assigned for PPM determination. Regarding the demographical data, the chi-square test was used to assess the significance of each parameter on a categorical scale between the two groups. The independent sample t-test or the Mann-Whitney U test was used to compare the two independent groups. Interclass correlation coefficient (ICC) values for continuous variables and kappa values (κ) for categorical variables were calculated to assess inter-observer and intra-observer agreement. Receiver-operating characteristic (ROC) analysis was used to determine optimal cut-off points of PPM to predict consistency between separate fracture classification groups, one using PPM values with a threshold derived from plain radiograph images, and the other using CT scan images. Results Among a total of 126 pertrochanteric fractures, the A1 (stable) group consisted of 39 patients (10 males, 29 females), whereas the A2 (unstable) group consisted of 87 patients (14 males, 73 females) (not significant, NS). Intraclass correlation coefficient (ICC) values of PPM for the inter-observer agreement were 0.796 (0.723-0.852), 0.664 (0.554-0.751), and 0.702 (0.601-0.781) at first examination and 0.729 (0.635-0.801) at the second. The intra-observer agreement was 0.869 (0.819-0.906) and 0.603 (0.480-0.703). We examined for consistency of fracture classification group of PPM values with a threshold of 0.4 (A1<0.4, A2=0.4 or more) and CT-based group. For the first examination, there was mostly "moderate" agreement in fracture classification (stable or unstable) between plain radiograph and CT scan images, κ (95%CI): 0.427 (0.266-0.588), 0.493 (0.335-0.651), and 0.359 (0.176-0.544), and for the second, 0.418 (0.251-0.585), and 0.451 (0.284-0.620), respectively. Conclusion We propose a supplementary tool, namely PPM that allows for possible alternative classification of pertrochanteric fractures into A1 (stable) and A2 (unstable) using plain radiograph images under the revised AO/OTA classification system. In this study, a PPM threshold value of 0.4 demonstrated a moderate inter- and intra-observer agreement. It is noteworthy to mention that there was a satisfactory consistency of fracture classification using PPM derived from plain radiograph images when compared to classification using CT scan images. In addition, the PPM method provides a numerical score.

Finite-Element Analysis of a Novel Cephalomedullary Nail for Restricted Sliding to Reduce Risk of Implant Failure in Unstable Intertrochanteric Fractures

Objective

How to restrict sliding of cephalomedullary nail and rigid reconstruct medial support for unstable intertrochanteric fractures remains a challenge. This study aims to explore the feasibility of a novel cephalomedullary nail for restriction sliding and reconstruction of medial femoral support to prevent failure in unstable trochanteric fractures through finite element analysis.

Methods

The DICOM files of a unilateral femur spiral computed tomography (CT) scans from a elderly female were converted into STL files, and the most common clinical trochanteric fracture model with the absence of medial support, AO/OTA 31‐A2.3 was simulated by removing the posterior medial femur. The model of a novel medial sustain nail (MSN‐II) and a widely used nail (proximal femoral nail anti‐rotation PFNA‐II) were modeled according to the manufacturer‐provided engineering drawing. Different loads were applied to the femoral head to simulate the postoperative weight bearing gait. The sliding distance of helical blade in femoral neck, maximum stress of femur and nail, displacement of proximal fragment were analyzed to revealing the mechanical stability of unstable trochanteric fracture stabilized by different implant.

Results

The sliding distance of helical blade in the femoral neck, the maximum stress on the femur and nail, the displacement of proximal fragment in MSN‐II under 2100N axial load were 0.65 mm, 689 MPa, 1271 MPa, 16.84 mm respectively, while that were 1.43 mm, 720.8 MPa, 1444 MPa, 18.18 mm, respectively in PFNA‐II. The difference between the two groups was statistically significant (P < 0.05) and the stress was mainly distributed in medial distal side of nail but helical blade and the proximal aperture for the nail in MSN‐II. Compared to PFNA‐II, MSN‐II demonstrates biomechanical merit against femur medialization, cut‐out and coax varus.

Conclusion

The sliding distance of helical blade in femoral neck, the maximum stress on the femur and nail, and the displacement of proximal fragment of MSN‐II were less than those of PFNA‐II in the treatment of unstable intertrochanteric fractures. Therefore MSN‐II has better stability than PFNA‐II and it may have the potential to avoid femur medialization and cut out. It might be an option in unstable trochanteric fracture because of its superiority in restricted sliding and medial support reconstruction.

A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images

Objective

Fracture classification evolves dynamically with new and enhanced imaging modalities. This paper aims to introduce a novel hypothesis of a sophisticated fracture classification system for the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images and accommodate the clinical requirement of the worldwide outbreak of geriatric hip fractures with large amounts of surgical operations.

Methods

In the current practice of widely preoperative 3D-CT application and cephalomedullary nailing, we attempt to propose a new comprehensive classification system to describe the fracture characteristics in a more detailed and sophisticated architecture, and pay the most important concern to the parameters that contribute to fracture stability reconstruction in osteosynthesis.

Results

The new four-by-four comprehensive classification system, followed the structure of the AO/OTA system, incorporates many fracture characteristics as dividing indexes into multiple grade levels, such as fracture line direction, the number of fragments, the lesser trochanter fragment and its distal extension (>2 cm), the posterior coronal fragment and its anterior expansion (to the entry portal of head–neck implant at the lateral cortex), the lateral wall and anterior cortex fracture, and the anteromedial inferior corner comminution. From a panoramic perspective, there are four types and each type has four subtypes. A1 is simple two-part fractures (20%), A2 is characterized by lesser trochanter fragment and posterior coronal fractures (62.5%), A3 is reverse obliquity and transverse fractures with complete lateral wall broken (15.5%), and A4 is medial wall comminution which further lacks anteromedial cortex transmission of compression force (2%). For subtypes, A2.2 is with a banana-like posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior expansion of the posterior coronal fragment(s) to the entry portal of head–neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region.

Conclusion

Classification represents diversity under consistency. The four-by-four sophisticated classification system delineates fracture characteristics in more detail. It is applicable in the time of rapid outbreak of trochanteric fractures in the older population, the large amounts of surgical operations, and incorporates various rare and/or more complicated subtypes which is unclassifiable before.

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.

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.

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures

Background

Maintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails.

Methods

This retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change.

Results

Anteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group.

Conclusions

Good reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

[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.