Minimally invasive plate osteosynthesis of subtrochanteric femur fractures with a locking plate: a prospective series of 20 fractures

Minimally invasive dual plating of a complex femoral fracture; a case report

Complex femur fractures are defined as combined fractures of shaft and proximal or the distal femur. It usually occurs in young adults due to high energy trauma. Treatment of this type of fracture is challenging. Herein, we present the management of multi-level complex femoral fracture in 38 years old using minimally invasive overlapping dual plating with bridge proximal femoral locking plate from above and distal femoral locking plate from below. Favourable clinical and radiologic outcomes were observed. The result demonstrates dual plating of complex femoral fracture using MIPO could be considered as a suitable treatment option for complex femoral fracture.

The Influence of Static Load and Sideways Impact Fall on Extramedullary Bone Plates Used to Treat Intertrochanteric Femoral Fracture: A Preclinical Strength Assessment

Hip fracture accounts for a large number of hospitalizations, thereby causing substantial economic burden. Majority (> 90%) of all hip fractures are associated to sideways fall. Studies on sideways fall usually involve loading at quasi-static or at constant displacement rate, which neglects the physics of actual fall. Understanding femur resonance frequency and associated mode shapes excited by dynamic loads is also critical. Two commercial extramedullary implants, proximal femoral locking plate (PFLP) and variable angle dynamic hip screw (VA-DHS), were chosen to carry out the preclinical assessments on a simulated Evans-I type intertrochanteric fracture. In this study, we hypothesized that the behavior of the implant depends on the loading types-axial static and transverse impact-and a rigid implanted construct will absorb less impact energy for sideways fall. The in silico models were validated using experimental measurements of full-field strain data obtained from a 2D digital image correlation (DIC) study. Under peak axial load of 3 kN, PFLP construct predicted greater axial stiffness (1.07 kN/mm) as opposed to VA-DHS (0.85 kN/mm), although the former predicted slightly higher proximal stress shielding. Further, with greater mode 2 frequency, PFLP predicted improved performance in resisting bending due to sideways fall as compared to the other implant. Overall, the PFLP implanted femur predicted the least propensity to adverse stress intensities, suggesting better structural rigidity and higher capacity in protecting the fractured femur against fall.

The utility of reverse distal femur locking compression plate in minimally invasive osteosynthesis for type C subtrochanteric fractures of the femur: technical description and a clinical series of 50 cases

BACKGROUND

Establishing fracture consolidation and avoiding postoperative complications of comminuted subtrochanteric fractures of the femur are technically challenging. The authors delineated a technical description of minimally invasive plate osteosynthesis (MIPO) by using a reverse distal femur locking compression plate (LCP-DF) and retrospectively reviewed the outcomes of these particular fractures.

METHODS

Fifty patients with 51 type C subtrochanteric fractures of the femur were operated on by MIPO and reverse LCP-DF fixation. The collected data included postoperative complications, union times, and clinical outcomes.

RESULTS

All fractures were united with a mean union time of 19.4 weeks (range 16-22). Regarding postoperative complications, asymptomatic valgus angulation occurred in five patients and trochanteric pain in six. According to Harris hip score, nine patients were determined to be excellent, 36 to be good and five to be fair.

CONCLUSION

MIPO by reverse LCP-DF is reliable and effective for type C subtrochanteric fractures of the femur particularly in situations where intramedullary nailing is not feasible.

Osteoperiosteal Decortication and Autogenous Cancellous Bone Graft Combined with Bridge Plating for Non-hypertrophic Diaphyseal Nonunion

Backgroud

The aim of this study was to evaluate results of osteoperiosteal decortication and autogenous cancellous bone graft combined with a bridge plating technique in atrophic and oligotrophic femoral and tibial diaphyseal nonunion.

Methods

We retrospectively reviewed 31 patients with atrophic or oligotrophic femoral and tibial diaphyseal nonunion treated with osteoperiosteal decortication and autogenous cancellous bone graft between January 2008 and December 2018. Patients with hypertrophic nonunion, infected nonunion, and nonunion treated with autogenous cancellous bone graft alone were excluded. The nonunion site was exposed by using the Judet technique of osteoperiosteal decortication. Nonunion with a lack of stability was stabilized with a new plate using a bridge plating technique or augmented by supplemental fixation with a plate. Nonunion with malalignment was stabilized with a new plate after deformity correction. Autogenous cancellous bone graft was harvested from the posterior iliac crest and placed within the area of decortication. A basic demographic survey was conducted, and the type of existing implants, mechanical stability of the implants, the type of implants used for stabilization, the operation time, the time to bone union, and postoperative complications were investigated.

Results

The average follow-up period was 33.3 months (range, 8–108 months). The operation time was 207 minutes (range, 100–351 minutes). All but 1 nonunion (96.7%) were healed at an average of 4.2 months (range, 3–8 months). In 1 patient, bone union failed due to implant loosening with absorbed bone graft, and solid union was achieved by an additional surgery for stable fixation with a new plate, osteoperiosteal decortication, and autogenous cancellous bone graft. There were no other major complications such as neurovascular injuries, infection, loss of fixation, and malunion.

Conclusions

Osteoperiosteal decortication and autogenous cancellous bone graft combined with stable fixation by bridge plating showed reliable outcomes in atrophic and oligotrophic diaphyseal nonunion. This treatment modality can be effective for treating atrophic and oligotrophic diaphyseal nonunion because it is very helpful stimulating bone union.

Importance of firm isthmic fixation in high-energy induced subtrochanteric fracture of the femur: retrospective observational study in a level I trauma center

INTRODUCTION

This study aimed to report the surgical outcomes in patients with high-energy induced subtrochanteric fracture and determine the risk factors for nonunion using statistical analysis.

METHODS

This study evaluated 88 patients with high-energy induced subtrochanteric fractures who underwent surgeries with indirect reduction technique and intramedullary nailing between March 2015 and December 2020. Outcome measures, including union time and nonunion incidence, were assessed by radiologic evaluation. Multiple logistic regression analyses were performed to identify the risk factors for nonunion, using age, sex, injury severity score, body mass index, preoperative mobility score, implant, and isthmic fixation as covariates.

RESULTS

Five nonunions and two delayed unions were identified. The average union time was 17.4 weeks. Multiple logistic regression analyses showed that poor isthmic fixation was the only risk factor for nonunion (odds ratio 15.294, 95% confidence interval 1.603-145.894, P value 0.018). Out of five nonunion cases, four were confirmed as hypertrophic, and one was confirmed as atrophic.

CONCLUSION

Although surgical treatment using an indirect reduction technique and intramedullary nailing showed good outcomes, hypertrophic nonunion due to distal instability could occur if a firm fixation at the level of the isthmus cannot be achieved.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Single lag screw and reverse distal femur locking compression plate for concurrent cervicotrochanteric and shaft fractures of the femur: biomechanical study validated with a clinical series

BACKGROUND

The optimal surgical management of concurrent cervicotrochanteric and shaft fractures of the femur has not been consensual. The authors investigated the reliability of combined single lag screw and reverse distal femur locking compression plate (LCP-DF) by finite element (FE) study and retrospectively described the present technique for these dual fractures.

METHOD

Intact femurs were derived from CT data, and the implant models were created by using CAD software. The fractured femur and implant models were virtually aligned based on the surgical techniques before converting to the FE model. In the FE model, applied boundary conditions included body weight, muscle forces, and constraint of the joints. Regarding clinical series, three patients with these dual fractures of the femur and 2 with cervicotrochanteric fractures with subtrochanteric extension were operated on by the proposed technique. The collected data include operative time, postoperative complications, union times, and clinical outcomes.

RESULTS

Equivalent von Mises stress exhibited on dynamic hip screws with an anti-rotational screw was higher than the other techniques, close to the yield stress of the material. Multiple screw fixation produced better stability for transcervical fractures whereas the proposed technique of combined single lag screw and reverse LCP-DF provided better stability for intertrochanteric fractures. No significant difference in cortical bone stress was found between multiple screw construct and the proposed technique. The proposed technique presented a lower risk of secondary fractures, as the strain energy density (SED) in cancellous bone was lower than multiple screw construct. Regarding clinical series, all fractures were united with a mean union time of-16.1 weeks (range 12-20). There were no any postoperative complications. Regarding the Harris score, 1 was determined to be excellent value, and 4 to be good.

CONCLUSION

By the FE results, a combination of a single lag screw and reverse LCP-DF is an effective technique for fixation of cervicotrochanteric fractures. Empowered by the clinical results, this proposed technique could be an alternative for concurrent cervicotrochanteric and shaft fractures of the femur especially when either single-system or dual-system devices seem not to be suitable.

Comparative finite element analysis of three implants fixing stable and unstable subtrochanteric femoral fractures: Proximal Femoral Nail Antirotation (PFNA), Proximal Femoral Locking Plate (PFLP), and Reverse Less Invasive Stabilization System (LISS)

BACKGROUND

The optimal type of fixation implant for managing subtrochanteric fractures (STFs) is debated, as uncertainty continues to surround the comparative biomechanical performance of the proximal femoral nail antirotation (PFNA), proximal femoral locking plate (PFLP), and reverse less invasive stabilisation system (LISS). No studies have used finite element analysis (FEA) to compare these three devices. The objective of this study was to use FEA to compare the PFNA, PFLP, and LISS used to treat STFs based on the following criteria: (1) stress distribution on the femur and implant, (2) peak stress and stress on the medial side of the femur near the fracture site, and (3) smallest axial displacement of the femoral head.

HYPOTHESIS

Of the three implants, the PFNA has the best biomechanical performance when used for STF fixation.

METHODS

FEA was used to assess synthetic bone responses to the three implants used to fix three STF types, namely, Seinsheimer I, III, and IV, characterised by increasing bone loss and/or comminution with subsequent instability. Loading was with 1400N axial compression force.

RESULTS

The LISS and PFLP exhibited similar biomechanical properties in all three fracture types. However, with the Seinsheimer IV fracture, the triangular configuration of the PFLP resulted in stress concentration at the medial and lateral sides of the implant junction. With the Seinsheimer I and III fractures, the PFNA resulted in higher peak stress (183.85MPa and 364.58MPa, respectively) compared to the PFLP (102.90MPa and 177.52MPa) and LISS (116.55MPa and 227.97MPa). With the Seinsheimer IV fracture, peak stress was highest with LISS (2310.40MPa) and was higher with PFLP (2054.90MPa) than with PFNA (1313.30MPa). With the Seinsheimer I and III fractures, the axial femoral head displacement was greater with the PFNA (0.74mm and 1.13mm, respectively) than with the PFLP (0.48mm and 1.02mm) and LISS (0.52mm and 0.92mm). With the Seinsheimer IV fracture, in contrast, the PFNA produced less axial femoral head displacement (4.1mm) compared to the PFLP (12.03mm) and LISS (16.56mm).

DISCUSSION

With unstable (Seinsheimer IV) STFs, fixation stability was better with the PFNA compared to the PFLP and LISS. In contrast, with stable STFs (Seinsheimer I and III), the PFLP and LISS offered greater stability, with similar biomechanical effects. However, with Seinsheimer III fractures, the stress on the implant-femur interface was greater with the LISS.

LEVEL OF EVIDENCE

IV, basic science study.

A review of atypical subtrochanteric femoral fractures in Northern Ireland between 2010 and 2014

The term atypical femoral fractures most commonly occur in the subtrochanteric area. Concerns exist regarding the role of bisphosphonate treatment in their aetiology. Which surgical intervention provides the best outcome remains contentious. We reviewed all atypical subtrochanteric femoral fractures treated in Northern Ireland over 5 years, specifically investigating incidence, prodromal symptoms, association with bisphosphonates and optimal fixation methods. All subtrochanteric fractures treated in the region were identified and reviewed for atypical features. Case notes and imaging were then reviewed for each patient. A total of 364 subtrochanteric femoral fractures were identified during the 5-year study period. Twenty-six of these met the criteria for an atypical fracture (7%). Thirteen patients (50%) had presented with prodromal symptoms prior to complete fracture, six of which had radiological evidence of an incomplete fracture of the lateral cortex. Thirteen patients had a history of bisphosphonate treatment. All were treated operatively, with twenty-five cephalomedullary nails and one dynamic hip screw. Twenty-one patients had follow-up for greater than 2 months, nine of which (42.9%) achieved radiological union with a mean time to union of 297 days. Dynamically locked nails had a higher union rate than statically locked (80% versus 33.3%). Four patients required major revision surgery (15.4%). The quality of reduction was statistically significant in predicting need for revision. Atypical fractures often present with prodromal symptoms. Complete fractures are difficult to successfully manage with longer than expected times to union. Treatment with a dynamically locked, cephalomedullary with a good reduction provided the best results.

Comparative study between biologic plating and intramedullary nailing for the treatment of subtrochanteric fractures: Is biologic plating using LCP-DF superior to intramedullary nailing?

BACKGROUND

The objective of this study is to evaluate the outcome measures of subtrochanteric fractures between biologic plating and intramedullary nailing and determine if biologic plating is superior to intramedullary nailing.

METHODS

Between March 2009 and December 2015, 81 patients with subtrochanteric fractures were enrolled (52 males and 29 females; 31 treated with biologic plating and 50 with intramedullary nailing). Biologic plating was conducted consecutively between May 2011 and March 2013 and intramedullary nailing was performed for the rest of period. Perioperative outcomes including operation time and blood loss during the operation; postoperative radiologic outcomes including union, time to union, coronal alignment, and shortening of the femur; and clinical outcomes including walking ability and pain were evaluated. The biologic plating group was compared with the intramedullary nailing group as a historical control.

RESULTS

No significant differences were identified for bony union and time to union between the two different fixation methods Coronal alignment was significantly better in the biologic plating group than in the intramedullary nailing group (p<0.016). Postoperative coronal alignment was the only risk factor associated with the nonunion of subtrochanteric fractures (unadjusted OR: 1.915, 95% CI: 0.190 - 19.273; adjusted OR: 0.042, 95% CI: 0.000 - 21.517; p=0.320).

CONCLUSION

Surgical outcomes using LCP-DF are comparable to those using intramedullary nailing. Further clinical studies with a larger sample size are required to show the advantage of biologic plating for the treatment of subtrochanteric fractures.

Surgical Outcomes of Biologic Fixation for Subtrochanteric Fracture Using Locking Compression Plates

PURPOSE

This study aimed to evaluate the surgical outcomes of biologic plating using locking compression plate-distal femur (LCP-DF) in patients with subtrochanteric fracture of the femur.

MATERIALS AND METHODS

Between January 2010 and December 2013, 28 consecutive patients with subtrochanteric fractures of the femur, treated with biologic fixation using LCP-DF, were enrolled. Preoperative values, including patient age, sex, body mass index, fracture type, type of lung injury, and surgical timing from injury to surgery, were retrospectively evaluated. Radiologic assessments included time to union, coronal alignment, rotational alignment, and complications such as implant breakage and screw breakage. Adverse events, including postoperative fat embolism and adult respiratory distress syndrome, infection during the follow-up period, and walking ability at the last follow-up visit, were assessed.

RESULTS

Union was achieved in 27 patients (96.4%) after a mean duration of 5.4 months (range, 3-14 months). No patients developed fat embolism or adult respiratory distress syndrome during the hospitalization period of this study.

CONCLUSION

Biologic fixation using locking compression plates may represent a safe surgical option which can be utilized in patients with subtrochanteric fracture regardless of injury severity, surgical timing, fracture type, and presence of lung injury.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes

BACKGROUND

Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures.

METHODS

Patients older than 18 years of age with a minimum follow-up time of 1 year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system.

RESULTS

18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53 ± 4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1° ± 2.16°. The mean HHS was 77.90 ± 4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p = 0.385, p = 0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p < 0.05). There was no correlation between Singh index and reduction quality (p = 0.865). Singh index was only correlated with the patient's age (p = 0.000, rho = -0.595). There were 2 infections and, 2 backing of the proximal screws.

CONCLUSION

Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.

Plate fixation in periprosthetic femur fractures Vancouver type B1-Trochanteric hook plate or subtrochanterical bicortical locking?

INTRODUCTION

Proximal plate fixation in periprosthetic femur fractures can be improved by plate anchorage in the greater trochanter (lateral tension band principle) or bicortical locking screw placement beside the prosthesis stem in an embracement configuration. Both concepts were compared in a biomechanical test using a femoral hook plate (hook) or a locking attachment plate (LAP).

METHODS

After bone mineral density (BMD) measurement in the greater trochanter, six pairs of fresh frozen human femora were assigned to two groups and instrumented with cemented hip endoprostheses. A transverse osteotomy was set distal to the tip of the prosthesis, simulating a Vancouver B1 fracture. Each pair was instrumented using a plate tensioner with either hook or LAP construct. Cyclic testing (2Hz) with physiologic profile and monotonically increasing load was performed until catastrophic failure. Plate stiffness was compared in a four-point-bending-test. Paired student's-t-test was used for statistical evaluation (p<0.05).

RESULTS

Mean BMD was 250mgHA/ccm±47. The hook construct exhibited a significantly (p=0.015) lower number of cycles and load to failure (26'177cycles±2777; 3'118N±778) correlating significantly with BMD (R²=0.83; p=0.04) compared to the LAP construct (37'423cycles±5'299; 4'242N±1'030) (R²=0.71;p=0.11). BMD was a significant covariate (p=0.01). Plate stiffness was in a comparable range (hook Plate 468N/mm±7; LCP 445N/mm±6).

CONCLUSION

Subtrochanterically placed LAP provides an increased fixation strength under repetitive loading compared to hook plate fixation in the greater trochanter. Trochanteric fixation is highly BMD dependent and may be restricted to major greater trochanteric involvement requiring stabilization.

The outcome of unstable proximal femoral fracture treated with reverse LISS plates

BACKGROUND

The Russel-Taylor type 2B fractures compromised the trochanteric region and medial buttress of proximal femur. This fracture pattern limits the choice of implants and raises the risk of adverse outcomes. We aimed to (i) determine the outcome of Russel-Taylor type 2B fractures treated using reverse less invasive stabilization system plates (LISS-DF) and to (ii) learn what factors affected outcomes after osteosynthesis with reverse LISS plates.

DESIGN

A retrospective study SETTING: The study was conducted at a Level III trauma center in Taiwan.

METHODS

Twenty-five consecutive patients presenting with a Russel-Taylor type 2B fracture were enrolled. All cases were treated with reverse LISS plates. A Modified Radiographic Union Scale for Femur (RUSF), Radiographic parameters, functional scores, and complications were assessed.

RESULTS

Union occurred in 21 cases at an average of 18.8 weeks. The average immediate postoperative neck-shaft angle was 130° (range: 122-135°) compared with 139° (range: 135-141°, p=0.05) on the contralateral side. Two cases had complications of proximal screws cutting out and two cases had broken implants. Finally, all 4 cases required repeated surgeries (16%). Malunion occurred in 4 patients and early mechanical failure (proximal screws cut out) occurred in 2. There was a significant difference in the purchase index of the proximal screws between cases with redisplacement and those without (26.4mm and 98.6mm, p=0.01).

CONCLUSIONS

The use of reverse LISS plate appeared to be an alternative procedure for the specific pattern in the present study. We recommend using this reverse locking plate to treat unstable proximal femoral fractures with meticulous techniques of placing plates. Adequate purchase of the proximal locking screws might decrease the risks of complications.

Nonunion of subtrochanteric fractures: Comminution or Malreduction

Objective:

This study aimed to investigate the impact on nonunion of the extent of comminution and postoperative displacement in patients surgically treated for subtrochanteric fractures.

Methods:

From 2008 to 2013, 44 patients with subtrochanteric fractures underwent surgery and follow-up. Retrospective data collection showed that it had 32 male and 12 female. Their mean age was 45 years. The case distribution according to Seinsheimer classification was as follows: IIA,8; IIB, 5; IIC, 7; IIIA, 8; IIIB, 3; IV, 9; and V, 4. Cephalomedullary nails were used in 28 cases; ordinary nails, in 9; and plates, in 7. After surgery, the fractures were evaluated for displacement on anteroposterior (AP) and lateral radiography.

Results:

Of the 44 patients, 37 achieved union from primary surgery at a mean time of 8.4 months. Five cases did not show union within the follow-up period. Two cases of nail breakage were diagnosed as non-union. Among the non-union cases, two were Seinsheimer classification IIIA; 3, IV; and 2, V. Displacement was observed on the lateral and A Pradiographs of 4 cases, on only the lateral radiographs of two cases, and in neither radiograph of one case. The risk of non-union was approximately 15.4 and 24.2 times higher when displacement was observed on the AP (95% confidence interval [CI]: 1.33–176.82) and lateral images (95% CI: 1.76–335.67), respectively.

Conclusion:

When displacement occurred after surgical treatment for subtrochanteric fractures, the risk of nonunion increased owing to the difficulty achieving stable fixation.

Clinical outcome of conventional versus biological fixation of subtrochanteric fractures by proximal femoral locked plate

INTRODUCTION

Surgical fixation is the standard management of the subtrochanteric fractures. Proximal femoral locked plating (PF-LCP) provides a strong construct for fixation with a high success rate. However, some studies reported implant failure due to loss of the postero-medial bone support and recommended an anatomical reduction. Other studies reported excellent to good results with indirect (biological) fixation without anatomical reduction. In this study, we reviewed the short-term clinical results of PF-LCP fixation for subtrochanteric fractures using both conventional and biological fixation.

MATERIALS AND METHODS

Forty six patients (34 males and 12 females) with comminuted subtrochanteric fractures were included aged between 18 and 74 (mean 44.3 years). They were treated in a single-blind random manner by either conventional (open, direct) or biological (indirect) reduction method and internal fixation with PF-LCP. Intra-operative variables including; duration of surgery, blood loss, fluoroscopy time and any complications were recorded. Post-operative differences including; duration of healing, implant failure, complications and the final clinical outcome by Harris Hip Score (HHS) were documented.

RESULTS

44 cases continued to the final follow-up (23 of the open fixation group and 21 of the biological fixation group). Patients of open group demonstrated greater blood loss (756±151 vs. 260±39ml; P<0.0001), longer operative times (129±16.9 vs. 91±8min; P<0.0001) and incisions (s) length (20.4±3 vs. 13.4±1cm; P<0.0001). More patients needed blood transfusion in open group (11 patients vs. six in closed group; P<0.0001). Patients of biological group demonstrated longer fluoroscopy time (80.9±7.3 vs. 47.2±5.8sec.; P<0.0001). For each group, one case of implant failure was recorded. Low patient compliance was a detrimental factor for the implant failure in both cases. No much difference was demonstrated for the healing rate (open group; 18.3±3.7 vs. biological group16.5±4 weeks; P<0.058) and for the functional outcome (open group; excellent/good: 54%/37%, biological group; excellent/good: 57%/33%; P=0.766).

CONCLUSION

PF-LCP provided a strong construct for fixation of the comminuted subtrochanteric fractures either by open or biological techniques. Low patient compliance is an influential factor for implant failure in both types.

Biomechanical Evaluation of Four Methods for Internal Fixation of Comminuted Subtrochanteric Fractures

Subtrochanteric fractures are common and result in significant morbidity and mortality. Various kinds of implants have been used to fix it. The aim of this study was to compare the biomechanical performance of PFN, DHS, DCS, and the PFLP in the treatment of subtrochanteric comminuted fractures.A total of 32 antiseptic human femurs from 16 donors were randomly allocated to 4 groups for fixation with PFN, DHS, DCS, and PFLP. A 2-cm cylindrical bone fragment was removed 1 cm below the lesser trochanter to simulate OTA/AO 32-C3.2 post instrumentation fracture. All specimens in single-leg stance situation were preloaded 5 times at 100 N in the axial direction to eliminate the time effect of relaxation and settling, followed by cyclic testing at a rate of 1 Hz with stepwise increasing load. Keeping the valley load at a constant level of 100 N during the entire cyclic test, the peak load, starting at 200 N, was increased by 100 N at 300-cycle steps until a maximum of 1500 cycles or until failure of the bone-implant construct occurred. Each specimen was kept unloaded under 100 N compression for 30 minutes between the 300-cycle steps.Femoral head displacement after 1500 cycles was 1.09 mm ± 0.13 for PFN, 1.78 mm ± 0.25 for DHS, 2.63 mm ± 0.46 for DCS, and 2.26 mm ± 0.16 for PFLP, with significant difference between any 2 implants (P < 0.01). The required load to reach 1-mm femoral head displacement was 563.04 N ± 158.34 for PFN, 485.73 N ± 147.27 for DHS, 258.44 N ± 97.23 for DCS, and 332.68 N ± 100.34 for PFLP. Significant differences were detected between any 2 implants (P < 0.001), except between DCS and PFLP and between DHS and PFN. The number of cycles until 1-mm femoral head displacement was 1458 ± 277 for PFN, 908 ± 184 for DHS, 369 ± 116 for DCS, and 603 ± 162 for PFLP. Significant differences were detected between any 2 implants (P < 0.01), except between DCS and PFLP.From biomechanical point of view, comminuted subtrochanteric fractures OTA/AO 32-C3.2 revealed in the current test setup highest fixation strength with PFN, followed by DHS, PFLP, and DCS.

Combination of modified free vascularized fibular grafting and reverse Less Invasive Stabilization System (LISS) for the management of femoral neck nonunion in patients thirty years of age or younger

Femoral neck nonunion (FNN) is a potential complication in patients with displaced femoral neck fractures, occurring in 33%. This may lead to early hip dysfunction or arthroplasty. Combination of modified free vascularized fibular grafting (FVFG) and a reverse LISS may provide a reasonable means to salvage a painless, functional and native hip. Between August 2010 and August 2012, sixteen patients with femoral neck nonunion were treated with a combined procedure involving modified free vascularized fibular grafting and a reverse LISS. The average age of them is 20.3 years (range 12.0-28.0 years). After removing old implants, the nonunion site was debrided, reduced and fixed with a LISS. The fibular grafts were compacted into a trough in the femoral neck. The Harris Hip score system was used to assess hip function and anteroposterior and frog-lateral hip roentgenograms were used to evaluate bone healing. All femoral neck nonunion healed without severe complications. The mean follow-up time was 32.9 months (range 23.0-47.0 months) and the average union time was 7.6 months (range 5.0-10.0 months). All coxa vara deformities and retroversions of the femoral head were corrected. The Harris hip scores (HHS) were improved 36.6 points on average (59.6 points preoperatively to 96.2 points postoperatively). No incidences of osteonecrosis of the femoral head were observed. The combined modified FVFG and reverse LISS plating is a suitable procedure for the management of femoral neck nonunion in patients younger than 30 years, especially for those patients with a revision history.

Nailing or plating for subtrochanteric femoral fractures: a non-randomized comparative study

BACKGROUND

The aim of the present study was to compare the outcomes of reverse less invasive stabilization system for distal femur (LISS-DF) plates and proximal femoral nail antirotation (PFNA) in the treatment of patients with subtrochanteric fracture.

METHODS

Thirty-one patients with 32 fractures were included in this study. The PFNA group consisted of 16 patients, and the reverse LISS-DF plate group consisted of 15 patients. Intraoperative data such as surgical time (min), amount of blood transfusion (units and erythrocyte suspensions) and radiation time (seconds) were noted. Time elapsed until fracture consolidation (weeks), time until full weight bearing (weeks), mean Harris hip score and length of stay (LOS) at hospital (days) were recorded postoperatively.

RESULTS

The reverse LISS-DF group had a significantly longer elapsed time until fracture consolidation (p < 0.05). The mean radiation time was significantly longer (p < 0.05), and the Harris hip scores at last control were significantly higher (p < 0.05) compared with the PFNA group. No significant differences were determined in terms of complications and re-operation rates.

CONCLUSION

This study demonstrated that in the reverse LISS-DF-treated group, the mean time for bone union was longer and weight bearing was delayed. Considering the surgical technique, minimal surgical approach, reduced amount of blood transfusion and superior functional results following surgery, we concluded that the PFNA system offers advantages over reverse LISS-DF plating in the treatment of subtrochanteric femur fractures.

Expert tibia nail for subtrochanteric femoral fracture to prevent thermal injury

INTRODUCTION

Subtrochanteric femoral fractures are relatively uncommon, accounting for 7-15% of all hip fractures and treatment of these fractures are considered challenge for orthopaedic surgeons. Although several treatment options are reported with up to 90% of satisfactory results, the choice of the appropriate implant is still a matter of debate. Some authors reported thermal injury after reaming for intramedullary nail fixation in patients with narrow medullary canal.

PRESENTATION OF CASE

A 21-year-old female patient was admitted to our hospital because of right subtrochanteric femoral fracture. The narrowest diameter of medullary canal of her femur was about 7mm but she refused open reduction and internal fixation with plate due to large scar formation. We used expert tibia nail instead of femoral intramedullary nail to prevent thermal injury.

DISCUSSION

Subtrochanteric femoral fractures are difficult to treat because of their biomechanical and anatomical characteristics. Although several implants are reported for the surgical treatment of these fractures, intramedullary nails have been advocated due to their biological and biomechanical advantages. However, under certain circumstances with associated injury or anatomic difference we might consider another treatment options.

CONCLUSION

Expert tibia nail may be considered one of the treatment options for subtrochanteric femoral fracture with narrow medullary canal. We also emphasize the importance of preoperative evaluation of the medullary canal size for these risky fractures.

Contemporary management of subtrochanteric fractures

Cephalomedullary interlocking nails that allow for trochanteric entry and minimally invasive fixation have revolutionized the contemporary management of subtrochanteric fractures with improved union rates and decreased incidence of fixation failure. The most successful alternative to intramedullary fixation remains the angled blade plate. Despite biomechanical superiority of contemporary intramedullary implants to previous intramedullary devices, the importance of achieving and maintaining satisfactory fracture reduction prior to and during hardware insertion cannot be overemphasized. In comminuted and more challenging fractures, additional techniques, such as limited open reduction with clamps and/or cables, can allow for canal restoration and more anatomic reductions prior to and/or during nail insertion.

A comparison of proximal femoral locking compression plates with dynamic hip screws in extracapsular femoral fractures

INTRODUCTION

The potential value of proximal femoral locking compression plate (PFLCP) for extracapsular femoral fractures has been discussed in several case reports; however, clinical control studies are lacking. Therefore, we performed a case control study to assess: (1) If PFLCP offers better functional results and fewer complications than dynamic hip screws (DHS)? (2) Which kind of extracapsular femoral fractures would benefit from PFLCP fixation?

HYPOTHESIS

The PFLCP fixation offers better functional results and fewer complications than the DHS for the treatment of extracapsular fractures.

PATIENTS AND METHODS

A total of 83 patients with extracapsular femoral fractures were recruited. Forty-one patients underwent PFLCP fixation, and 42 patients underwent DHS fixation. Patient information, operative time, blood loss, functional level (as assessed by Sanders' traumatic hip rating scale), bone union, and implant complications were compared for the two treatment groups.

RESULTS

Patients with stable intertrochanteric fractures who underwent PFLCP fixation demonstrated shorter bone union time than the DHS fixation group (3.3 ± 0.2 vs. 4.3 ± 0.1 month; P<0.0001); however, both groups had 100% bone union and good to excellent scores on Sanders' traumatic hip rating scale (P=1.000). Patients with unstable intertrochanteric fractures who underwent PFLCP fixation experienced greater blood loss (619.0 ± 23.9 vs. 474.1 ± 19.8 ml; P<0.0001), which was mainly due to the need for open reduction (64.3% vs. 12.5%; P=0.003), compared to the DHS fixation group. No differences were identified with respect to bony union, functional level, or complications. Patients with subtrochanteric fractures who underwent PFLCP fixation demonstrated significantly shorter operative times (82.1 ± 4.3 vs. 102.2 ± 2.2 minutes; P<0.0001), less blood loss (751.8 ± 25.4 vs. 987.6 ± 32.0 ml; P<0.0001), shorter bone union times (5.2 ± 0.4 vs. 8.8 ± 1.0 month; P=0.006), more good to excellent Sanders' traumatic hip rating scale scores (92.9% vs. 55.5%; P=0.009), and fewer complications (14.2% vs. 66.6%; P=0.005) than the DHS fixation group.

CONCLUSION

PFLCP fixation offers better functional outcomes and fewer complications for subtrochanteric femoral fractures but not for intertrochanteric femoral fractures.

LEVELS OF EVIDENCE

Case control study, level III.

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.

Post-operative outcomes of atypical femoral subtrochanteric fracture in patients on bisphosphonate therapy

Management of bisphosphonate-associated subtrochanteric fractures remains opinion- or consensus-based. There are limited data regarding the outcomes of this fracture.

We retrospectively reviewed 33 consecutive female patients with a mean age of 67.5 years (47 to 91) who were treated surgically between May 2004 and October 2009. The mean follow-up was 21.7 months (0 to 53). Medical records and radiographs were reviewed to determine the post-operative ambulatory status, time to clinical and radiological union and post-fixation complications such as implant failure and need for second surgery.

The predominant fixation method was with an extramedullary device in 23 patients. 25 (75%) patients were placed on wheelchair mobilisation or no weight-bearing initially. The mean time to full weight-bearing was 7.1 months (2.2 to 29.7). The mean time for fracture site pain to cease was 6.2 months (1.2 to 17.1). The mean time to radiological union was 10.0 months (2.2 to 27.5). Implant failure was seen in seven patients (23%, 95 confidence interval (CI) 11.8 to 40.9). Revision surgery was required in ten patients (33%, 95 CI 19.2 to 51.2).

A large proportion of the patients required revision surgery and suffered implant failure. This fracture is associated with slow healing and prolonged post-operative immobility.

Cite this article: Bone Joint J 2014;96-B:658–64.

High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate

INTRODUCTION

Stable reconstruction of proximal femoral (PF) fractures is especially challenging due to the peculiarity of the injury patterns and the high load-bearing requirement. Since its introduction in 2007, the PF-locking compression plate (LCP) 4.5/5.0 has improved osteosynthesis for intertrochanteric and subtrochanteric fractures of the femur. This study reports our early results with this implant.

METHODS

Between January 2008 and June 2010, 19 of 52 patients (12 males, 7 females; mean age 59 years, range 19-96 years) presenting with fractures of the trochanteric region were treated at the authors' level 1 trauma centre with open reduction and internal fixation using PF-LCP. Postoperatively, partial weight bearing was allowed for all 19 patients. Follow-up included a thorough clinical and radiological evaluation at 1.5, 3, 6, 12, 24, 36 and 48 months. Failure analysis was based on conventional radiological and clinical assessment regarding the type of fracture, postoperative repositioning, secondary fracture dislocation in relation to the fracture constellation and postoperative clinical function (Merle d'Aubigné score).

RESULTS

In 18 patients surgery achieved adequate reduction and stable fixation without intra-operative complications. In one patient an ad latus displacement was observed on postoperative X-rays. At the third month follow-up four patients presented with secondary varus collapse and at the sixth month follow-up two patients had 'cut-outs' of the proximal fragment, with one patient having implant failure due to a broken proximal screw. Revision surgeries were performed in eight patients, one patient receiving a change of one screw, three patients undergoing reosteosynthesis with implantation of a condylar plate and one patient undergoing hardware removal with secondary implantation of a total hip prosthesis. Eight patients suffered from persistent trochanteric pain and three patients underwent hardware removal.

CONCLUSIONS

Early results for PF-LCP osteosynthesis show major complications in 7 of 19 patients requiring reosteosynthesis or prosthesis implantation due to secondary loss of reduction or hardware removal. Further studies are required to evaluate the limitations of this device.

Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator

BACKGROUND

Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture.

METHODS

Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique.

RESULTS

There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°-9°) in the coronal plane and 1.2° (range 0°-8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3-38.4 weeks) and a mean follow-up of 20.8 months (range 13.5-31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation.

CONCLUSIONS

Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.

Internal fixation of intertrochanteric hip fractures: a clinical comparison of two implant designs

Objective. To compare two internal fixation devices clinically in stabilisation of intertrochanteric femur fractures. Methods. Eighty-seven patients were randomised upon their admission to the hospital using a sealed envelope method. Forty-five were treated with proximal femur nail antirotation (PFNA) and 42 with reverse less invasive stabilisation system (LISS). The perioperative data were recorded and compared in relation to fracture type. Results. In each type of fractures, no significant differences were found with respect to the blood loss, the quality of reduction, the time to bony healing, and the Harris hip score between the 2 groups. The mean duration of surgery was significantly longer in reverse LISS group than in PFNA group. Conclusion. Both the PFNA and the reversed LISS are effective in the treatment of different types of intertrochanteric femur fractures. PFNA is superior to reverse LISS in terms of surgical time, weight-bearing, and perhaps fluoroscopy time.

Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate

INTRODUCTION

Subtrochanteric fractures are difficult fractures associated with high incidence of complications and various implants, both intramedullary and extramedullary, are available for their fixation. Traditional extramedullary implants are associated with higher rate of implant failure and varus collapse while the biomechanically better intramedullary nails are technically demanding and are associated with higher re-operation rates. This study was done to evaluate the outcome following biological (indirect) fixation of unstable comminuted subtrochanteric fractures with proximal femur-locking compression plate (PF-LCP).

METHODS

Thirty-five consecutive patients with comminuted subtrochanteric fractures were operated upon with PF-LCP by using an indirect reduction technique. Seinsheimer types 3-5 fractures were included in the study. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications. The Harris Hip Score was used to document hip function at final follow-up.

RESULTS

Thirty-two patients with average age of 44.7 years were available for final evaluation. The mean operating time was 79.5min and total blood loss averaged 233.13ml. Union was achieved in all cases with an average time of 15.62 weeks. Complications included two cases of delayed union and two cases of infection. Two cases had a shortening of 1cm and one case had malunion with external rotation. No instances of implant failure or nonunion were recorded.

CONCLUSION

Biological fixation of comminuted subtrochanteric fractures with PF-LCP provides stable fixation with high union rate and fewer complications.

Auxiliary locking plate improves fracture stability and healing in intertrochanteric fractures fixated by intramedullary nail

BACKGROUND

Intertrochanteric fractures present a significant management challenge due to their low inherent stability. The objective of this study was to determine whether an auxiliary locking plate decreases interfragmentary motions and improves fracture healing in intertrochanteric fractures treated by intramedullary nail.

METHODS

Biomechanical tests and a clinical retrospective study in intertrochanteric to subtrochanteric nonunions were performed. Six synthetic femurs were osteotomized intertrochanterically and fixated with a long gamma nail and an additional locking compression plate. Mechanical tests were conducted that simulated the hip joint force during gait cycle. Following the initial test, the locking compression plate (LCP) was removed from each specimen and the test was repeated. Interfragmentary motions, strains on implants and osteosynthesis stiffness were determined. For the clinical part of the study, 13 intertrochanteric to subtrochanteric nonunions were treated with revisional long gamma nail and additional locking compression plate. Complications and time to union were determined.

FINDINGS

Biomechanically, interfragmentary rotation was 48% smaller (P=0.047) and interfragmentary shear movement was 42% smaller (P=0.007) with locking compression plate. Strains on the nail decreased by 20-27% (P<0.027) and the osteosynthesis stiffness increased by 23% (P=0.005) with locking compression plate. Clinically, fracture healing was achieved in eleven out of 13 patients after 9.0months (range 4 to 22months).

INTERPRETATION

The findings of our study indicate that auxiliary locked plating considerably improves biomechanical performance and results in successful healing of unstable intertrochanteric to subtrochanteric femur fractures.

Folded free vascularized fibular grafts for the treatment of subtrochanteric fractures complicated with segmental bone defects

BACKGROUND

Subtrochanteric fractures of the femur complicated with segmental bone defects are uncommon injuries and challenging to manage. We evaluated the effect of reconstructing extensive bone defect in the subtrochanteric area (mean, 6.9 cm) with folded free vascularized fibular graft (FVFG).

METHODS

Between 2001 and 2007, 14 cases of subtrochanteric fractures complicated with huge bone defects treated by folded FVFG transfer in our hospital were retrospectively reviewed. The defect was reconstructed by folded FVFG transfer and locking plate stabilization in 10 patients with no sign of infection at admission (group 1). In the other four patients presented with infections (group 2), the defect was reconstructed by folded FVFG transfer and external fixator fixation. The average follow-up period was 67.4 months.

RESULTS

Bone union was achieved in all of the cases at an average of 5.4 months (range, 4-6 months). Primarily, bone union was achieved in all of the cases in group 1, but one stress fracture occurred in group 2. The full weight bearing time was 5.4 months (range, 5-6 months) in group 1 and 8.5 months (range, 8-9 months) in group 2. Seven patients in group 1 had the locking plate removed in an average of 27 months (range, 18-38 months). In group 2, the external fixator removal time was 13 months (range, 10-18 months). There was no varus deformity at the final follow-up in group 1. The neck-shaft angle measured during the postoperative period and at final follow-up was 129.6 degrees and 129.4 degrees, respectively. In group 2, the neck-shaft angle at the final follow-up was significantly less than the angle measured at the postoperative period (115.5 vs. 129.5 degree, p = 0.021). The range of motion of the hip and knee joint (extend and flex) was 100 degrees or more in all patients at the final follow-up.

CONCLUSIONS

The results of this study showed that huge subtrochanteric bone defects reconstructed by folded FVFG and locking plate were highly successful in achieving bone union, reducing risks of postoperative stress fracture and preventing malunion. When huge bone defects in the subtrochanteric area complicated with acute or chronic infections, the technique of external fixator offers an alternative to reconstruct the stability of the proximal femur after folded FVFG. However, because of the inadequate stabilization, the risks of varus malunion and postoperative stress fracture could be increased after external fixator fixation.

LEVEL OF EVIDENCE

V, therapeutic study.

Comparison of proximal femoral nail antirotation blade and reverse less invasive stabilization system-distal femur systems in the treatment of proximal femoral fractures

OBJECTIVE

To compare the effects of proximal femoral nail antirotation blade (PFNA) and reverse less invasive stabilization system-distal femur (Liss-DF) systems in the treatment of proximal femoral fractures.

METHODS

Between June 2007 and October 2009, 41 proximal femoral fractures were treated, 22 with PFNA (group A) and 19 with reverse LISS-DF plates (group B). The time to starting full weight-bearing, fracture healing time, functional recovery (Parker and Palmer mobility score), neck-shaft angle discrepancies with the intact contralateral hip, preoperative American Society of Anesthesiologists (ASA) scores, the operation durations and amount of intraoperative bleeding were recorded and compared.

RESULTS

The mean follow-up period was 11.2 months (range, 10-12 months). Compared with Group A, Group B showed a statistically longer mean time to bear full body weight and heal their fractures, but a smaller neck-shaft angle discrepancy (all P < 0.05). The groups were similar in ASA score, operation duration, amount of intraoperative bleeding and Parker and Palmer mobility score.

CONCLUSION

Both PFNA and reverse Liss-DF were satisfactory for the treatment of proximal femoral fractures, but had different advantages. PFNA allowed earlier weight-bearing and accelerated fracture healing. Reverse Liss-DF more effectively avoided coxa vara and may be indicated for patients with very severe osteoporosis.

Less invasive stabilization system (LISS) versus proximal femoral nail anti-rotation (PFNA) in treating proximal femoral fractures: a prospective randomized study

OBJECTIVE

To evaluate the outcome and efficacy of LISS (Less Invasive Stabilization System; Synthes USA, Paoli, PA) for the treatment of proximal femoral fractures to find another appropriate minimally invasive surgery for these fractures in which intramedullary nailing may be difficult.

DESIGN

A consecutive prospective randomized clinical study.

SETTING

University teaching hospital.

PATIENTS

Between May 2006 and March 2008, 64 consecutive patients who had a proximal femoral fracture were randomized to be treated with fixation with either LISS or PFNA (Proximal Femoral Nail Anti-rotation; Synthes USA).

INTERVENTION

LISS or PFNA fixation of proximal femoral fractures.

MAIN OUTCOME MEASUREMENTS

Intraoperative time, intraoperative blood loss, length of hospitalization, hip function (Harris score), general complications, fracture complications.

RESULTS

Fifty-nine patients were evaluated with a mean follow-up time of 26.8 months (range, 21-36 months). No statistical differences in general complications, intraoperative blood loss, length of hospitalization, or hip function could be found between the two groups. The average operative time was longer in the LISS group (98.25 minutes) compared with the PFNA group (65.36 minutes) (P < 0.05). One PFNA case had intrapelvic penetration of the helical blade; two LISS cases had breakage of the screws.

CONCLUSION

There were no major differences in outcome or complications between the treatment groups. LISS can be used effectively in treating proximal femoral fractures, especially for complex fractures patterns in which intramedullary nailing may be difficult.

LEVEL OF EVIDENCE

Therapeutic Level II. See page 128 for a complete description of levels of evidence.

Use of a linear-circular hybrid external skeletal fixator for stabilization of a juxta-physeal proximal radial fracture in a deer (Odocoileus virginianus)

This report documents the successful use of a hybrid linear-circular fixator for the stabilization of a closed, oblique, comminuted fracture of the proximal right radial diaphysis in a 3-mo-old female deer (Odocoileus virginianus). Under fluoroscopic guidance, a hybrid fixator was applied for fracture stabilization, with consideration given to the risk of inducing further fissuring of the proximal segment, attaining adequate fixation in the short juxta-physeal segment, and possibly disrupting physeal growth. Three divergent wires were used as ring fixation elements to secure the proximal fracture segment. Mild fissure propagation occurred during fixation pin placement. All subsequent fixation pins chosen were of a smaller diameter and were placed without further deterioration of the existing fissures. Although willing to ambulate upon recovery, the deer placed the dorsum of the hoof on the ground initially after surgery, which resolved by the sixth day. The hybrid fixator was well-tolerated and was removed 4 wk postoperatively. In addition, proximal radial physeal growth was not disrupted and both radii had similar lengths after fixator removal. Hybrid linear-circular external skeletal fixation was advantageous for stabilization of the juxta-physeal fracture in this deer; with appropriate application techniques and configuration, we believe that hybrid fixators can be used successfully in several wildlife species with maximum acceptance and minimal complications.

The use of a cementless modular stem in the treatment of subtrochanteric femoral fractures in conjunction with ipsilateral coxarthrosis

Subtrochanteric fractures of the femur below an arthritic hip are uncommon and challenging to orthopedic surgeons. Most of these fractures occur in elderly patients with advanced osteoporosis. The treatment choices consist of treatment of the fracture and the above hip joint versus treatment of the fracture alone. This study evaluates the clinical and radiological outcomes of arthroplasties performed to treat both conditions in a single surgery with the use of a cementless modular revision stem. Twelve subtrochanteric femoral fractures of 12 patients (9 women, 3 men) with a mean age of 76.4 years (range, 62-88 years) were treated with cementless modular revision stems. Total hip arthroplasty was performed with cementless femoral and acetabular component fixation. All hips received the same femoral and acetabular implants. All patients had comorbidities and the average American Society of Anesthesiologists score was 2.3 (range, 1-3). Ten of the 12 hips (83%) required an assistance device for ambulation before the trauma. There were 2 Dorr Type A (17%), 3 Dorr type B (25%), and 7 Dorr type C (58%) femora. The mean postoperative Harris Hip Score was 83 (range, 72-92) with a mean follow-up of 4.3 years (range, 2-7 years). At final follow-up, 9 hips (75%) were ambulatory without support (P=.016). Ten hips (83%) were able to both ambulate and walk up and down stairs. Two hips (17%) were able to ambulate but could not climb and descend stairs. Union was achieved in all femora at an average of 22.3 weeks (range, 16-32 weeks). Radiographic findings demonstrated stable ingrowth of the femoral prosthesis with no evidence of subsidence in 11 hips (92%). The average Engh score for all femora was 20.2 (range, 10-26). There was no relationship between the bone morphology (Dorr type) of the femoral medullary canal and the bone ingrowth scores of Engh (P=.639).

Subtrochanteric fracture treatment: a retrospective study of 46 patients

OBJECTIVE

To investigate whether or not reconstruction of the medial cortex in subtrochanteric fracture can reduce the risks of internal fixation failure, fracture malunion, and nonunion.

SUBJECTS AND METHODS

Between 2005 and 2008, 46 patients with subtrochanteric fracture were treated with intramedullary nailing and followed up. The average age was 42 years. According to the Seinsheimer classification, 26 patients were type IIIA, 7 were type IIIB, 11 were type IV and 2 were type V. Medial cortex alignment was achieved under traction in 40 cases. In 5 cases, the medial fractures were too far away and we used minimally invasive open reduction with wire or titanium cable cerclage. In 1 case of type IIIA subtrochanteric fracture, the displaced medial fracture was not reconstructed and was fixed with a long Gamma nail. We reviewed all patients' radiographs before and after treatment to evaluate bone healing.

RESULTS

The 46 patients were followed up for an average of 24.3 months. Bone union was achieved within an average of 18.7 weeks in 45 cases. One case, a type IIIA fracture nonunion with displaced medial fracture, was not reconstructed. Instead, we used a free fibular transplantation on the medial side and fracture union was achieved 6 months after revision surgery.

CONCLUSIONS

In reconstructing the medial cortex in subtrochanteric fracture treatment, continuity and integrity are important. They can reduce the failure of internal fixation and the incidence of nonunion.

Fixation failure of the LCP proximal femoral plate 4.5/5.0 in patients with missing posteromedial support in unstable per-, inter-, and subtrochanteric fractures of the proximal femur

The LCP proximal femoral plate 4.5/5.0 (PF-LCP) represents a new generation of extramedullary fixation devices for stable and unstable trochanteric and/or subtrochanteric fractures. We report four cases of secondary varus collapse of the fracture with hardware failure of the implant.