Safe zones and a technical guide for cerclage wiring of the femur: a computed topographic angiogram (CTA) study

Identifying iliotibial band graft length and incision site may minimise the potential risk of harming adjacent structures: A novel approach for surgeon guidance

PURPOSE

The Iliotibial band (ITB) is a fibrous thickening of the fascia lata originating at the iliac crest and inserting at Gerdy's tubercle on the lateral tibia. The ITB significantly contributes to lateral knee stabilisation. Due to its size, tensile strength and easy access, it is widely used in orthopaedic surgery as an autograft during reconstruction procedures. Although ITB harvesting may result in complications, such as reduced knee extension or hip flexion, no safety margins or guidelines have been proposed for the procedure. Our aim was to determine the maximal safe length of an ITB graft, that is, that does not harm the lateral collateral ligament (LCL), tensor fasciae latae (TFL), gluteus maximus (GM) or adjacent structures, and reduce the complication rate.

METHODS

The study included 50 lower limbs of 25 human cadavers, previously fixed in 10% formalin solution. The inclusion criterion was the lack of visible signs of surgical interventions in the study region. Forty lower limbs were included in the study: 16 female (mean age 83.1 ± 3.4 years) and 24 male (mean age 84.2 ± 6.8 years). Dissection was performed with a previously established protocol. Morphometric measurements were then obtained twice by two researchers.

RESULTS

The mean femur length was 404.8 mm [female (F) = 397.3 mm, male (M) = 409.9 mm, standard deviation (SD): F = 23.8 mm, M = 24.1 mm]. The mean ITB length was 318.9 mm (F = 309.4 mm, M = 325.2 mm, SD: F = 25.7 mm, M = 33.7 mm). Longer femurs were associated with longer ITB (p < 0.05). The mean distance from the insertion of the GM to the myofascial junction of TFL and ITB was 34.6 mm (F = 34.5 mm, M = 34.6 mm, SD: F = 3.2 mm, M = 3.3 mm). The longer femurs or ITBs demonstrated a greater distance from GM insertion to the myofascial junction of the TFL and ITB (p < 0.05).

CONCLUSION

ITB grafts longer than 21 cm may contribute to the greater risk of TFL rupture. Based on simple measurements of the femur length, the surgeon may assess approximate ITB length, and thus assess the length of the maximal graft length. Moreover, to avoid harming the LCL, the incision should be performed 5 cm proximal to the articular surface of the lateral femoral condyle or 13 mm proximal to the lateral femoral epicondyle. Such preparation and preoperative planning may greatly reduce the risk of complications during ITB harvesting, while performing, for instance, the over-the-top technique for anterior cruciate ligament reconstruction in skeletally immature patients.

LEVEL OF THE STUDY

Basic I.

Iatrogenic femoral artery injury due to cerclage wiring for diaphyseal femoral fracture: A case report and review the literature

INTRODUCTION AND IMPORTANCE

During femoral fracture osteosynthesis, the superficial femoral artery can be incarcerated in the cerclage wiring. We report a case that had an iatrogenic superficial femoral artery injury due to cerclage wiring during femoral osteosynthesis.

CASE PRESENTATION

I reported a 57-year-old patient presented with a fracture at the distal third of the left femur. He had undergone a femoral nailing and a cerclage wiring. Four hours postoperative, his left leg was colder, and his dorsalis pedis and posterior tibial pulse were absent. A CTA revealed his left superficial femoral artery entrapment by cerclage wire. After cerclage removal, the superficial femoral artery and vein had normal flow. The dorsalis pedis and posterior tibial pulse could be palpated. One day following, there was no compromising of blood flow, sensation, or motor-nerve function.

CLINICAL DISCUSSION

Cerclage wiring in the proximal half of the femur was less risk to the femoral artery than in the distal part. The SFA entrapment into a femoral cerclage wire requires an urgent diagnosis and treatment. A missed diagnosis could lead to necrosis of the lower extremity and even death.

CONCLUSION

Our case shows that the superficial femoral artery can be incarcerated in the cerclage wiring during osteosynthesis. Cerclage wiring in the proximal half of the femur was less risk to the femoral artery than in the distal part. We recommend using a suitable cerclage passer precautionary in any femur fracture, particularly in the distal third of the femur.

LEVEL OF EVIDENCE

A case report.

Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series

PURPOSE

Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA.

METHOD

Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures.

RESULTS

Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection.

CONCLUSION

Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.

Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results

BACKGROUND

Surgical treatment of Seinsheimer type V subtrochanteric fractures is extremely challenging due to the difficulty of obtaining and maintaining anatomic reduction and effective fixation. The purpose of this study was to describe a surgical technique for minimally invasive clamp-assisted reduction and long InterTAN nail fixation to manage Seinsheimer type V subtrochanteric fractures and report the clinical and radiological results.

METHODS

A retrospective study was conducted on patients with Seinsheimer type V subtrochanteric fractures between March 2015 and June 2021. A total of 30 patients treated via minimally invasive clamp-assisted reduction, long InterTAN nail fixation and selective augmentation with a cerclage cable were included. The following data were collected and evaluated: patient demographics, operative time, blood loss, reduction quality, tip apex distance (TAD), time to bone union, Harris hip score (HHS), visual analog score (VAS), and complications.

RESULTS

The mean age of the 30 patients was 64.8 years (range: 36-90 years). The mean operative time was 102.2 min (range: 70-150 min). The mean loss of blood was 318.3 ml (range: 150-600 ml). The reduction quality involved 27 cases of anatomic reduction and 3 cases of satisfactory reduction. The mean TAD was 16.3 mm (range: 8-24 mm). The mean follow-up time was 18.9 months (range: 12-48 months). The mean fracture healing time was 4.5 months (range: 3-8 months). The mean Harris score was 88.2 (range: 71-100), and the VAS score was 0.7 (range: 0-3). Delayed union of the subtrochanteric fracture site occurred in two patients. The limb length discrepancy, which was determined in 3 patients, was < 10 mm. There were no significant complications.

CONCLUSION

Our results indicate that minimally invasive clamp-assisted reduction with long InterTAN nail fixation is encouraging for Seinsheimer Type V subtrochanteric fractures, resulting in excellent reduction and fixation. Additionally, this reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible.

Cerclage Wiring Improves Biomechanical Stability in Distal Tibia Spiral Fractures Treated by Intramedullary Nailing

BACKGROUND

Partial weight-bearing after operatively treated fractures has been the standard of care over the past decades. Recent studies report on better rehabilitation and faster return to daily life in case of immediate weight-bearing as tolerated. To allow early weight-bearing, osteosynthesis needs to provide sufficient mechanical stability. The purpose of this study was to investigate the stabilizing benefits of additive cerclage wiring in combination with intramedullary nailing of distal tibia fractures.

METHODS

In 14 synthetic tibiae, a reproducible distal spiral fracture was treated by intramedullary nailing. In half of the samples, the fracture was further stabilized by additional cerclage wiring. Under clinically relevant partial and full weight-bearing loads the samples were biomechanically tested and axial construct stiffness as well as interfragmentary movements were assessed. Subsequently, a 5 mm fracture gap was created to simulate insufficient reduction, and tests were repeated.

RESULTS

Intramedullary nails offer already high axial stability. Thus, axial construct stiffness cannot be significantly enhanced by an additive cerclage (2858 ± 958 N/mm NailOnly vs. 3727 ± 793 N/mm Nail + Cable; p = 0.089). Under full weight-bearing loads, additive cerclage wiring in well-reduced fractures significantly reduced shear (p = 0.002) and torsional movements (p = 0.013) and showed similar low movements as under partial weight-bearing (shear 0.3 mm, p = 0.073; torsion 1.1°, p = 0.085). In contrast, additional cerclage had no stabilizing effect in large fracture gaps.

CONCLUSIONS

In well-reduced spiral fractures of the distal tibia, the construct stability of intramedullary nailing can be further increased by additional cerclage wiring. From a biomechanical point of view, augmentation of the primary implant reduced shear movement sufficiently to allow immediate weight-bearing as tolerated. Especially, elderly patients would benefit from early post-operative mobilization, which allows for accelerated rehabilitation and a faster return to daily activities.

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.

Vascular Safe Zone During Percutaneous Pinning of the Distal Femur

PURPOSE

During percutaneous pinning of the pediatric distal femur, iatrogenic vascular damage in the medial thigh is a frequent concern. The proximity of a proximal-medial pin to these vessels has never been studied in children. This study describes a radiologic vascular safe zone that is easily visualized during surgery (wherein the superficial femoral vessels are safely posterior).

METHODS

Patients ≤16 years old with magnetic resonance imaging of one or both femora between 2005 and 2020 were retrospectively reviewed. The "at-risk level" (ARL) was defined as the distal-most axial image with a femoral vessel anterior to the posterior condylar axis. A standardized retrograde lateral-to-medial pin was templated. A correlation matrix and least squares regression identified age and physeal width (PW) as ideal independent variables. A vascular safe zone above the medial femoral condyle (MFC) was modeled as a multiple of PW (i.e. x*PW) and needed to satisfy 3 age-dependent criteria: (1) at the ARL, the pin is medial to the vessels, (2) the pin exits the medial thigh before the ARL, and (3) the chosen "vascular safe zone" (x*PW) is always distal to the ARL.

RESULTS

Forty-three patients averaging 7.1±3.9 (0.3-16) years old were included. Intra-Class correlation coefficients were excellent (0.92-0.98). All measurements strongly correlated with age ( r =0.76-0.92, P <0.001) and PW ( r =0.82-0.93, P <0.001). All patients satisfied criteria 1. Criteria 2 was satisfied in all patients ≥6 years old, 86% of children 4-5, and only 18% of children ≤3. In children >3 years old, the largest safe zone that satisfied criteria 3 was 2×PW. On average, the ARL was 2.5×PW (99% CI 2.3-2.7) above the MFC. The average ARL in children ≥6 years old was significantly higher than 2×PW (162 mm vs. 120 mm, P <0.001).

CONCLUSION

During passage of a distal femur pin into the medial thigh, children ≥6 years old have a vascular safe zone that extends 2×PW proximal to the MFC. Surgeons should be cautious with medial pin placement in children 4-5 years old and, if possible, avoid this technique in children ≤3.

LEVEL OF EVIDENCE

IV.

Safe and dangerous zones for the superficial femoral artery in femoral surgery

The proximity of the superficial femoral artery (SFA) to the femur exposes the SFA to risks that have serious complications. Although surgeons have used the lateral or medial approach to lessen these risks, they have not been eliminated. Therefore, this study aimed to identify dangerous and safe zones in terms of the SFA that can be used during femoral surgical procedures, using anatomical reference points. Computed tomography angiography (CTA) of 50 patients aged between 16 and 60 years obtained from the local institution's database was examined. Radiological and clinical measurements were performed to determine the position of the SFA relative to the femur. The mean age of the patients included in this study was 38.08 ± 9.44 (16-60) years. The average ratio of the distance between the proximal and distal borders of the dangerous zone and the lateral joint spaces (LJS) to the distance between the greater trochanter (GT) and LJS was 0.5722 ± 0.053, respectively. The average ratio of the distance between the end of the dangerous zone and LJS to the distance between the GT and LJS was 0.4108 ± 0.05026. This study found that 40% and 60% of the clinically measured distance between the GT and LJS can be used to determine safe and dangerous zones during femoral surgery. Additionally, the half distance between the anterior superior iliac spine (ASIS) and medial joint space (MJS) and one-fourth of the distance between the ASIS and LJS can be used to determine safe and dangerous zones in patients whose GT are not easily palpated.

Surgical outcomes of retrograde nailing enhanced with minimally invasive cerclage cable fixation for infra-isthmal femoral fracture

BACKGROUND

Infra-isthmal femoral fracture has been known as one of the risk factors for femoral nonunion. Retrograde intramedullary nailing can provide reliable stability of the distal fragment in infra-isthmal femoral fracture, but adequate reduction is required to achieve a successful outcome. This study aimed to evaluate the surgical outcomes of retrograde nailing enhanced with minimally invasive cerclage cable fixation for infra-isthmal femoral fracture.

METHODS

Between March 2013 and July 2017, 15 patients with infra-isthmal fractures treated with retrograde nailing and minimally invasive cerclage cable fixation were included in this study. Cerclage cable was applied for reduction aid (reduction cable) or prevention of further displacement in non-displaced extension of the distal spiral fracture (prevention cable). Number and function of cerclage cables, operation time, additional surgery, and complications were assessed. Further displacement of the wedge after nailing, coronal and sagittal alignment, displacement of the main fragment, and time from injury to union were evaluated as radiologic outcomes.

RESULTS

Of the 15 patients in this study, 14 were treated with reduction cables. Average postoperative coronal and sagittal angulation was 1.7° (1° varus to 4° valgus) and 1.6° (2° flexion to 11° extension). Mean displacement between the main fragments was 3.5 mm (range 0-22 mm). Four of the 14 cases used additional prevention cables combined with reduction cable. Only one case was treated solely with a prevention cable. A total of five prevention cables were maintained without further displacement. All patients achieved bone union, and the average time to union was 22.7 weeks (range 9-44 weeks). There were no complications as a result of surgery, such as infection or major neurovascular injury.

CONCLUSIONS

The minimally invasive cerclage cable technique could be a useful and safe enhancement in retrograde nailing for infra-isthmal femoral fracture in order to prevent further displacement and to reduce the main fracture.

Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study

PURPOSE

This study evaluated major vascular injury risk in distal femoral osteotomy (DFO) via the subvastus approach and examined the relationship between the posterior border of the vastus medialis (VM) and the superficial femoral artery (SFA) and vein (SFV).

METHODS

Eighty limbs from 80 patients were evaluated using lower extremity computed tomographic venography. The positional relationship between the VM, SFA, and SFV was evaluated by measuring the angle between each structure and the horizontal reference point (VMA: VM angle, FAA (femoral arterial angle), FVA (femoral venous angle) and the distance between VM and the SFA and SFV (VMAD: VM-arterial distance, VMVD: VM-venous distance) in each axial slice (0/10/20/30/40 mm) proximal to the level of the superior patellar margin. The proximity of the posterior border of the VM and the SFA/SFV as a vertical distance, measured between the slice of the superior border of the patella and the slice where the posterior border of the VM contacted the SFA was evaluated. Single and multiple regression analyses were performed using the vertical distance as the objective variable.

RESULTS

As the slice shifted proximally, the VMA significantly increased (24.9 ± 8.5, 36.3 ± 8.8, 47.4 ± 11.8, 59.9 ± 14, 70.3 ± 13.7 degrees, respectively, p < 0.001 between all slices) and moved posteromedially from a medial direction. FAA (94.2 ± 7, 86.9 ± 9.2, 78.4 ± 9.7, 71.4 ± 9.8, 66.6 ± 10.5 degree, respectively, p < 0.001 between all slices) and FVA (100.6 ± 4.9, 98.3 ± 5.9, 93.7 ± 7.5, 88 ± 9.2, 81.1 ± 10.5 degrees, respectively, p < 0.001 between all slices) decreased and moved from a posterolateral to a posteromedial direction, while VMAD (35.4 ± 7.8, 24.1 ± 7.3, 14.3 ± 6, 8.4 ± 7, 6.2 ± 6.3 mm, respectively, p < 0.001 between all slices) and VMVD significantly decreased (42.7 ± 7.3, 32 ± 7.4, 22.4 ± 6.8, 14.5 ± 10.6, 8.7 ± 7.1 mm, respectively, p < 0.001 between all slices). The average vertical distance was 36 ± 9.3 mm (range 18.6-61.5 mm). The body height and the patellar length significantly affected the vertical distance.

CONCLUSION

The posterior border of the VM shifted posteromedially from distal to proximal and contacted the SFA at an average of 36 mm from the suprapatellar border. Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy.

LEVEL OF EVIDENCE

Case series, Level IV.

Iatrogenic sciatic nerve injury due to cerclage wiring for proximal periprosthetic femoral fracture: A rare case report

Cerclage wiring is used to reinforce the stability of fractures and optimize plate fixations for femoral fractures such as periprosthetic fractures. However, cerclage wiring requires attention to neurovascular structures to prevent injuries. We have presented a case of iatrogenic sciatic nerve injury after osteosynthesis with cerclage wiring. A 71-year-old woman underwent osteosynthesis with cerclage wiring for a proximal periprosthetic femoral fracture. Immediately after the operation, the patient developed motor and sensory disorders, particularly in the sciatic nerve area, leading to a suspicion of nerve injury. Consequently, reoperation showed that the right sciatic nerve was strangulated by the cerclage wire, but the nerve was functional. Since the sciatic nerve was partially continuous and retained sensation to some extent, strangulation release was performed. Subsequently, both sensory and motor disorders improved. This case suggests that attention should be given to not only the blood vessels in the anterior region but also the sciatic nerve in the posterior region when performing cerclage wiring for femoral fractures.

Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction

Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure.

Materials and methods

We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal—pertrochanteric, subtrochanteric—or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected.

Results

A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure.

Conclusion

Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

A modified cable wiring technique with C-shaped passer through a mini-open approach to assist reduction in femoral fractures

Femur fractures reduction can be technically challenging due to the deforming forces exerted by the muscles causing displacement of the fracture fragments. Cerclage wiring is one of the reduction techniques frequently performed, allowing anatomical reduction of the fragments and a more stable fixation when an accurate closed reduction is not possible. We describe a modified cerclage wiring through a minimally invasive technique, using a conventional cannulated C-shaped passer.

Surgical outcomes of minimally invasive cerclage clamping technique using a pointed reduction clamp for reduction of nonisthmal femoral shaft fractures

BACKGROUND

We modified the general application method of the pointed reduction clamp, focusing on the function of encompassing the fracture site, and applied it to femoral shaft fractures. The purpose of the present study is to describe the minimally invasive cerclage clamping technique (MICC) and compare radiological and clinical results of MICC with that of percutaneous cerclage wiring (PCW).

MATERIALS AND METHODS

A retrospective comparative study was performed in two institutions from 2010 to 2019. Patients aged ≥18 years with acute femoral shaft fractures that were treated with intramedullary nailing and reduced using MICC or PCW were included. Patients with open fractures, atypical fractures, and follow-up less than 12 months were excluded. A total of 68 patients were finally included and divided into two groups based on the reduction technique each patient underwent. We then compared radiological and clinical results between the two groups, including coronal and sagittal alignment, time for union, and complications.

RESULTS

The average time needed for the technique in the MICC group was shorter than that in the PCW group (7.1±4.6 min vs. 11.5±4.8 min, P < 0.001). There was no significant difference in the quality of reduction or alignment between the two groups. The mean union time was not different between the two groups (24.1±8.7 weeks vs. 24.1±8.6 weeks, P = 0.990). The MICC group had one nonunion patient and the PCW group had one postoperative infection patient. There were no cases of major neurovascular injury such as femoral artery injury or sciatic nerve palsy.

CONCLUSIONS

MICC, using a pointed reduction clamp for nonisthmal femoral shaft fractures, demonstrated satisfactory reduction and favorable surgical outcomes with intramedullary nailing. We believe that MICC can be a reliable and safe reduction method for femoral shaft fractures.

Anthropometric Factors on Safe Distances between Popliteal Vessels to the Femur for Cerclage Wiring of the Distal Femoral Fracture: A Magnetic Resonance Imaging Study

Background and Objectives: The proximity of the popliteal vessels in the distal femur may increase the risk of iatrogenic vascular injury during cerclage wiring. In this study, the closest location and distance of the popliteal vessels to the femur was examined using magnetic resonance imaging (MRI). The associations between anthropometric factors and the distance that would guide the placement of wires safely during surgery were also identified. Materials and Methods: We reviewed adult knee magnetic resonance images and recorded: (1) the relation and the shortest horizontal distance (d-H) from the femoral cortex to the popliteal vessels in axial images and (2) the vertical distance (d-V) from the adductor tubercle to the axial level of the d-H values in coronal images. The effects of anthropometric factors (sex, age, body height, body weight, body mass index, thigh circumference, femoral length and femoral width) on these distances were analysed. Results: Analysis of 206 knee magnetic resonance images revealed that the closet locations of popliteal vessels were at the posteromedial aspect of the femur. The d-H and d-V were 7.38 ± 3.22 mm and 57.01 ± 11.14 mm, respectively, and were both shorter in women than in men (p < 0.001). Multivariate analysis identified thigh circumference and femoral length as the most influential factors for the d-H and d-V, respectively (p < 0.001). Linear regression demonstrated a strong positive linear correlation between the thigh circumference and the d-H and between the femoral length and the d-V (Pearson’s r = 0.891 and 0.806, respectively (p < 0.001)). Conclusions: The closet location and distance of the popliteal vessels to the femur provide useful information for wire placement during distal femoral fracture surgery while minimising the risk of vascular injury. Given that patients with a smaller thigh circumference and a shorter femoral length are more likely to have a smaller d-H and a shorter d-V, respectively, cautious measures should be taken in such cases.

Surgical outcomes of simple distal femur fractures in elderly patients treated with the minimally invasive plate osteosynthesis technique: can percutaneous cerclage wiring reduce the fracture healing time?

INTRODUCTION

Achieving adequate reduction is difficult when performing minimally invasive plate osteosynthesis (MIPO) in elderly patients with simple distal femur fracture. This study aimed to evaluate the elderly patients who had undergone percutaneous wiring-assisted reduction with MIPO for simple distal femur fractures to determine the effect of this technique on reduction quality and fracture union.

MATERIALS AND METHODS

Between January 2009 and September 2017, 56 patients (56 femurs) with displaced simple distal femur fractures treated with MIPO at three trauma centers were finally enrolled. The MIPO technique with percutaneous cerclage wire reduction was performed in 25 patients (Group A). Among them, 12 patients had a simple spiral metaphyseal fracture (Group A*). In comparison, MIPO without percutaneous cerclage wire reduction was performed in 31 patients (Group B). Among them, seven patients had a simple spiral metaphyseal fracture (Group B*). Medical records containing surgical records were retrospectively reviewed to investigate demographic data, comorbidities, complications, operative time, and fluoroscopic time. Radiographs were evaluated for assessing the quality of the reduction and fracture union.

RESULTS

The mean fracture union time of Group A* was 21.7 weeks, which was significantly shorter than that of Group B* (28.6 weeks). The mean coronal and sagittal angulation in Group A* was 0.6° and 0.7°, respectively, which were significantly lesser than those in Group B* (2.4° and 3.2°, respectively). Mean translation in Group A* was 1.43 mm, which was significantly shorter than that in Group B* (3.81 mm). Nonunion occurred in two patients in Group B.

CONCLUSION

Surgical treatment of simple spiral distal femur fractures with percutaneous cerclage wiring-assisted reduction and the MIPO technique in elderly patients resulted in better reduction and faster union time. Therefore, this technique could be a good solution if used in accordance with the indication.

Supplemental cerclage wiring in angle stable plate fixation of distal tibial spiral fractures enables immediate post-operative full weight-bearing: a biomechanical analysis

Purpose

Distal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis.

Methods

In eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed.

Results

With supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p < 0.001). Under full weight-bearing static loads, a supplemental cerclage revealed reduced axial (− 55%; p = 0.001) and shear movement (− 83%; p < 0.001), and also lowered shear movement (− 42%; p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p < 0.001).

Conclusion

Supplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

Neurovascular Bundle Entrapment and Through Knee Amputation After Cerclage Cabling of Distal Femoral Peri-implant Fracture: A Case Report

CASE

We report the case of an 82-year-old woman with diabetes, arteriosclerosis, chronic heart failure, and hypertension treated with an anatomical locking plate and multiple cables for a spiral-wedged periprosthetic fracture of the distal femur which was complicated by direct occlusion of the femoral artery and crush of the sciatic nerve, resulting in leg necrosis and, ultimately, through-knee disarticulation despite early recognition and arterial repair.

CONCLUSIONS

Neurovascular injury is a potential complication of cerclage cables placement around the femoral shaft during complex fracture fixation. Devastating complications cannot always be corrected despite early vascular intervention.

There are no safe areas for avoiding the perforating arteries along the proximal part of the femur: A word of caution

Knowledge about the variable course of the perforating arteries near the body of the femur is essential during surgical procedures (e.g., percutaneous cerclage wiring, plate osteosynthesis, Ilizarov technique). Our aims were to determine the number of perforating arteries, and to identify safe zones along the body of the femur within which perforating arteries are unlikely to pass toward the back of the thigh. The number of perforating arteries was determined in both legs of 100 formalin‐fixed anatomic specimens of both sexes. The level of passage of perforating arteries near the body of the femur was measured in reference to a line from the anterior superior iliac spine to the medial femoral condyle. In each leg, two to seven perforating arteries were present. In 64% of legs, at least one artery divided into two to four branches before entering the back of the thigh. Thus, the total number of branches passing near the body of the femur varied between two to nine. Perforating arteries passed to the back of the thigh at every level between 14.0 and 36.5 cm from the anterior superior iliac spine (16–39% of the leg length). Within this distance, no safe zones along the body of the femur could be identified. The present study shows the high variability regarding number and course of the perforating arteries. Surgeons can be faced with an artery at every level on the posteromedial aspect of the body of the femur between 14.0 and 36.5 cm distally to the anterior superior iliac spine. Clin. Anat. 33:507–515, 2020. © 2019 Wiley Periodicals, Inc.

Technical note and surgical outcomes of percutaneous cable fixation in subtrochanteric fracture: A review of 51 consecutive cases over 4 years in two institutions

BACKGROUND

The main purpose of this study is to introduce our surgical technique and report surgical outcomes for percutaneous cable fixation in the treatment of subtrochanteric femoral fractures.

METHODS

Between May 2013 and April 2017, 51 patients with subtrochanteric femoral fractures treated with closed intramedullary nailing and percutaneous cable fixation were enrolled in this study. Postoperative angulation, union rate, time from injury to union, and femoral shortening were also evaluated to assess radiologic outcomes. Clinical outcomes, including range of hip flexion, walking ability, and Harris hip score at the last follow-up were evaluated.

RESULTS

Average coronal and sagittal angulation after surgery were 0.9 (range 0-5) and 0.3 (range 0-5), respectively. There was no postoperative angulation of more than 5°. Average shortening of the femur at 1-year follow-up was 2.7 mm (range 0-15). Bone union was achieved in 50 patients (98.0%) and average time to union was 18.6 weeks (range 12-48). Hip flexion, walking ability and Harris hip score at the last follow up were 115.6° (90-120), 7.9 (5-9), and 88.3 (65-100), respectively.

CONCLUSION

Percutaneous cerclage cable fixation can provide a greater likelihood of achieving anatomical reduction and increased stability of fracture, while preserving biology around the fracture site. Thus, percutaneous cerclage cable fixation can be an effective surgical technique for the treatment of complex subtrochanteric fractures.

[Special reduction instruments]

Special and specialized instruments help perform reduction more effectively and in a tissue-preserving manner. In addition to other articles, the application and advantages of the following instruments are presented: colinear reduction forceps, cerclage, cerclage passer, distal radius reduction clamp, modular external fixator, extension table, distraction frame, joystick, manipulators, distractor and assistance of reduction with elastic nails.