Risk factors for nonunion after intramedullary nailing of subtrochanteric femoral fractures

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

[Nonunions after intertrochanteric and subtrochanteric femoral fractures]

INTRODUCTION

The overall frequency of proximal femoral fractures means that we are repeatedly confronted with failed healing and implant failure, despite a relatively low nonunion rate especially in intertrochanteric fractures (< 5%). The aim of this paper is to present our approach to treating these nonunions of the proximal femur and discuss the treatment results.

MATERIAL AND METHODS

Between 2009 and 2023, patients with nonunion of the proximal femur were retrospectively identified and analyzed. Age, gender, time to revision, the Weber-Cech classification of pseudarthrosis and radiographic imaging before and after revision were analyzed.

RESULTS

A total of 66 patients were analyzed. The mean age was 58 years (range 25-88 years). The overall healing rate was 88% with a mean consolidation time of 8 months (range 2-29 months). The main osteosynthesis procedures were plate osteosynthesis (n = 45, of which 44 were blade plates), and nail replacement (n = 12). Other procedures included augmentative plate osteosyntheses (n = 4), isolated cancellous bone graft (n = 2), nail dynamization (n = 2), and the use of a dynamic hip screw (n = 1).

DISCUSSION

The analysis of our treatment data as well as the current literature, revealed a trend towards intramedullary revision procedures. Implants that can be used to correct the CCD angle, such as the blade plate, remain a predictable option to achieve correction, especially in nonunions with an increased degree of varus. Particularly in the subtrochanteric region, fractures can also be treated in a targeted manner by a combination of mechanical and biological methods with a reamed nail change to a larger caliber implant.

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach

PURPOSE

To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone.

METHODS

Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement.

RESULTS

All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up.

CONCLUSIONS

In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications.

LEVEL OF EVIDENCE

Therapeutic level IV.

Varus mal-alignment and residual displacement are associated with delayed union in subtrochanteric femur fracture- A retrospective observational study

Background

Subtrochanteric femoral (ST) fractures are associated with high rates of delayed and non-union. The aim of this study was to analyse the risk factors associated with delayed/non-union in ST fractures.

Methods

All patients with surgical stabilisation of ST fractures during the period 2014 to 2019 were identified in an electronic patient records database in two trauma centres. Exclusion criteria were incomplete clinical/radiological data, pathological fractures and loss to follow-up. Radiographs at about 6 months post-surgery were assessed for fracture union using Radiographic Union Score for Hip (RUSH). Fracture was deemed to be un-united if RUSH score was <18. CCD (caput-collum-diaphyseal) angle of operated and uninjured hip, residual displacement at fracture site and 3-point relationship was calculated on operative or immediate post-operative images in both groups. Student's t-test was used to compare CCD angle difference between operated and uninjured sides and the residual fracture displacement between delayed union and united fractures group. Chi-square test was used for 3-point relationship. Observational analysis was performed on implant failure rates including distal screw breakage.

Results

During the study period, there were total of 278 patients. 193 with inadequate data and 22 with pathological fractures were excluded. Advanced age and female sex had significantly higher rate of delayed union (p value of 0.043 and 0.003 respectively). Delayed union group (26) had a mean RUSH score of 14.1 and united group (37) had a mean RUSH score of 26.3 (p = 0.019). The mean CCD angle difference between operated and uninjured sides was -5.77° for delayed union and -2.33° for united fractures (p = 0.03). Residual displacement at fracture site showed statistically significant difference between delayed union and united fractures on anteroposterior and lateral views (p = 0.001 each). There was no statistical difference in 3-point relationship of implant in two groups (p = 0.775). 10 revision procedures were performed for implant failures. Distal screw failure (3 cases) was not a precursor for non-union in this study.

Conclusion

This study confirms varus alignment of hip and residual fracture displacement after fracture fixation of subtrochanteric fracture are surgeon associated significant risk factors for delayed union at 6 months. Fracture contact and alignment are key to reduce failures in these group of fractures. Among patient factors, advancing age and female sex predisposes to higher rate of delayed union.

Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis

INTRODUCTION

Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface.

MATERIALS AND METHODS

In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model.

RESULTS

Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa).

CONCLUSIONS

Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.

Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years?

BACKGROUND/PURPOSE

Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients.

METHODS

This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months.

RESULTS

This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities.

CONCLUSION

Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.

Reconstruction intramedullary nailing for a failed subtrochanteric Seinsheimer type IIB fracture: a case report

Introduction

A case of subtrochanteric Seinsheimer II B fracture was retrospectively analyzed to determine the causes of failure and the possible problems with femoral reconstruction intramedullary nailing.

Methods

This study focused on a case of an elderly patient with Seinsheimer type IIB fracture treated with minimally invasive femoral reconstruction intramedullary nailing. By retrospectively analyzing the intraoperative and postoperative course, we can identify the reasons that may lead to the surgical failure in order to avoid similar problems in the future.

Result

It was observed that the nail was dislodged after surgery, and the broken end was displaced again. Through our analysis and research, we believe that non-anatomical reduction, deviation of needle insertion point, improper selection of surgical methods, mechanical and biomechanical effects, doctor-patient communication and non-die-cutting cooperation, and non-compliance with doctor's orders may be related to the success of surgery.

Conclusion

Femoral reconstruction intramedullary nailing is used for the treatment of subtrochanteric Seinsheimer II B fractures; however, non-anatomical reduction, choice of needle insertion point, inappropriate choice of surgical method, mechanical and biomechanical effects, doctor-patient communication and cooperation without die-cutting, and non-compliance with doctor's advice may result in surgical failure. According to the analysis of individuals, under the premise of an accurate needle entry point, minimally invasive closed reduction PFNA or open reduction of broken ends and intramedullary nail ligation for femoral reconstruction can be used in Seinsheimer type IIB fractures. It can effectively avoid the instability of reduction and the insufficiency of the biomechanics caused by osteoporosis.

Nail breakage in patients with hypertrophic pseudoarthrosis after subtrochanteric femur fracture: treatment with exchanging nail and decortication

In this study, we aimed to show the results of exchange nail and decortication in patients whose subtrochanteric femur fractures were treated with intramedullary nails and subsequently developed fracture nonunion and nail breakage com- plications. This study consisted of patients presenting with subtrochanteric femur fractures between January 2013 and April 2019 who underwent surgery and later experienced nail breakage due to hypertrophic nonunion. There were a total of 10 patients aged 26-62 years (Avg 40,30, SD: 9,989). Nine patients were smokers, and 1 patient had diabetes and hypertension. Three patients were admitted to the trauma center due to a car accident and 7 patients were admitted because of a fall. The infection parameters of all patients were normal. All patients had pathological movement complications and pain at the fracture site. Preoperatively, medulla diameter was measured with standard radiography in all patients. The diameters of the old nails applied to the patients ranged from 10 to 12 mm, and the diameters of the newly applied nails ranged from 14 to 16 mm. The fracture lines of all patients were opened to remove the broken nails, and decortication was performed. No additional autograft or allograft was applied to any patient. Union was achieved in all patients. We conclude that the use of larger diameter nails in conjunction with decortication will prevent nail breakage, improve healing and provide early union in patients with subtrochanteric femur fractures with hypertrophic pseudoarthrosis.

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

BACKGROUND

The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the 'gold standard' of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal.

OBJECTIVES

The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post-operatively.

METHODS

Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8-year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow-up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra-operative transfusion or transfusion during the first 48 h post-operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post-operatively.

RESULTS

Incidence of blood transfusion was 6.0% pre-operatively, compared to 62.7% post-operatively. A total of 230 patients (52.3%) required either intra-operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post-operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30-day (p = 0.033) and one-year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post-operative hours was a pre-operative Hb <100 g/L (OR 6.64); a nail/canal ratio <70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre-operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30-day mortality (OR 12.07).

CONCLUSION

Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48-h post-operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and mortality risk.

LEVEL OF EVIDENCE

III.

The role of an augmentative plating in the management of femoral subtrochanteric nonunion

INTRODUCTION

Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation.

MATERIALS AND METHODS

Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months.

RESULTS

Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed.

CONCLUSIONS

Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.

3D reconstruction of proximal femoral fracture from biplanar radiographs with fractural representative learning

A femoral fracture is a severe injury occurring in traumatic and pathologic causes. Diagnosis and Preoperative planning are indispensable procedures relying on preoperative radiographs such as X-ray and CT images. Nevertheless, CT imaging has a higher cost, radiation dose, and longer acquisition time than X-ray imaging. Thus, the fracture 3D reconstruction from X-ray images had been needed and remains a challenging problem, as well as a lack of dataset. This paper proposes a 3D proximal femoral fracture reconstruction from biplanar radiographs to improve the 3D visualization of bone fragments during preoperative planning. A novel Fracture Reconstruction Network (FracReconNet) is proposed to retrieve the femoral bone shape with fracture details, including the 3D Reconstruction Network (3DReconNet), novel Auxiliary class (AC), and Fractural augmentation (FA). The 3D reconstruction network applies a deep learning-based, fully Convolutional Network with Feature Pyramid Network architecture. Specifically, the auxiliary class is proposed, which refers to fracture representation. It encourages network learning to reconstruct the fracture. Since the samples are scarce to acquire, the fractural augmentation is invented to enlarge the fracture training samples and improve reconstruction accuracy. The evaluation of FracReconNet achieved a mIoU of 0.851 and mASSD of 0.906 mm. The proposed FracReconNet's results show fracture detail similar to the real fracture, while the 3DReconNet cannot offer.

Mechanical Complications After Intramedullary Fixation of Extracapsular Hip Fractures

Extracapsular hip fractures occur frequently in the elderly as a result of low-energy trauma. Achieving stable fixation in osteoporotic bone to allow early weight bearing is a key objective in the treatment of these injuries. Many of the intraoperative decisions facing surgeons are directed by first determining fracture stability. Unstable fracture patterns should be fixated with intramedullary nails, aiming to control motion around the implant and at the fracture site. Torsion control devices provide additional stability and control, although their exact indications are not precisely defined. Complications that arise as a result of the early loading can be avoided with a good surgical reduction, meticulous technique, and proper implant selection. Mechanical complications include cutout, inordinate proximal femoral shortening, delayed union, early implant fracture, nail toggle, and cut through/medial migration.

Medialized Trochanteric Entry Nailing Is a Safe and Effective Method for High-Energy Subtrochanteric Femur Fracture Treatment

Fixation of subtrochanteric femur fractures using intramedullary nails can provide high rates of osseous union. However, a lateral starting point or a medial trajectory can result in varus alignment, typically seen with trochanteric entry nails. Even with piriformis nails, medial comminution can result in secondary malalignment and varus. Varus can predictably result in nonunion and need for repeat operations. Medialized trochanteric entry nailing has been reported previously as a method to prevent varus alignment in low-energy, atypical subtrochanteric femur fractures in association with bisphosphonate use. We present a surgical technique using a medialized trochanteric nail entry point to provide proper alignment and avoidance of varus malreduction in 24 patients with a subtrochanteric femur fracture after a high-energy traumatic event.

Subtrochanteric femoral fractures: A case series of 194 patients treated with long and short intramedullary nails

BACKGROUND

IM nails are the gold standard of subtrochanteric fractures management. Indications to use a short rather than a long nail remain unclear. Operative complications of subtrochanteric fractures reach up to 25%.

OBJECTIVE

Retrospectively compare clinical and radiographic outcome of subtrochanteric fractures treated by long and short intramedullary nailing, analysing rates of complications.

METHODS

390 patients were chosen from the archives. 194 patients were available: 70 treated with a short intramedullary nail (Group A), while 124 with long one (Group B). Radiographic evaluation at 6 and 12 months assess failure of the osteosynthesis. Clinical outcomes were the return to normal activities prior trauma and VAS scale. Group A mean age was 81.37 years, group B mean age was 78.9 years (29-99, SD: 15.38).

RESULTS

Radiografic Healing was found in 66 patients (94.28%) in group A, while in 116 patients (94.54%) in group B. Pseudarthrosis was found in 4 cases (5.71%) in group A, while in 8 cases (6.45%) in group B. Implant failure occurred in 5 cases: one required revision of fixation, while 4 require hip replacement. 59 patients of group A (84.29%) returned to social life, while 102 patients (81.94%) in group B. Group A mean VAS was 1.55, Group B mean VAS was 1.49.

CONCLUSION

Comparison of the two group showed no differences. Complication percentages are in line with literature. Optimal reduction and fixation allow high percentage of healing and return to social life.

Effectiveness and Biomechanical Analysis of the Ortho-Bridge System on Femoral Fracture Healing: A Retrospective Analysis

BACKGROUND

Among the surgical methods for femoral fractures, the Ortho-Bridge System (OBS) appears to heal fractures via an uncommon process. We compared its effectiveness and biomechanical aspects to those of a locking compression plate (LCP) and explained the healing process demonstrated by the OBS.

METHODS

Eleven femoral shaft fracture cases treated with OBS between July 2017 and May 2020 were retrospectively reviewed. Clinical and radiographic data were collected during regular postoperative follow-up visits and assessed via the Harris Hip Score and Knee Society Score. We performed biomechanical experiments of OBS. We simulated different fracture conditions and selected appropriate screw holes at the fracture's far and near segments. The OBS module was placed according to the position of LCP's locking hole at both ends of the fracture; then, a static three-point bending test was performed.

RESULTS

All patients had contralateral callus growth with secondary fracture healing. Healing time was 3-5 months with excellent hip and knee function. When the key screw distance was 22-34 mm, the OBS was significantly less stiff than the LCP (P < 0.05). The stiffness of LCP and OBS decreased significantly when the key screw distance was 49-82 mm, with the LCP being slightly stronger (P < 0.05).

CONCLUSIONS

Femoral shaft fracture treatment with OBS demonstrated secondary healing. When the distance between the key screws was 20-40 mm, the elasticity was higher in OBS than in LCP, possibly producing axial micro-motion to stimulate callus formation and promote fracture healing, which differ from the plate's primary healing process.

CT analysis of femoral malrotation after intramedullary nailing of trochanteric fractures

PURPOSE

Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures.

MATERIALS AND METHODS

The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon's experience as possible risk factors for limb malrotation after trochanteric fracture surgeries.

RESULTS

The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error.

CONCLUSION

Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.

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.

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

INTRODUCTION

Intramedullary (IM) nails are considered the 'gold' standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population.

AIMS/OBJECTIVES

Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit.

METHODS

A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan-Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0).

RESULTS

A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan-Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit.

CONCLUSION

We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.

Biomechanical Study of Intramedullary Versus Extramedullary Implants for Four Types of Subtrochanteric Femoral Fracture

Objectives

To compare the biomechanical performance of proximal femoral nail anti‐rotation (PFNA), the “upside‐down” less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures.

Methods

Thirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant‐femur constructs were tested under axial compression load (0–1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed.

Results

PFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01).

Conclusion

The axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS.

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature

Objective:

To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.

Data Sources:

A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.

Data Extraction:

Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.

Results:

Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.

Conclusions:

Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure.

Level of Evidence: IV

The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review

Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.

Exchange nailing and medial wall reconstruction following implant failure in a subtrochanteric femoral fracture

Failure of fixation of subtrochanteric fractures has been reported in as high as 20% of cases. Several associations have been suggested to contribute to failed fixation. Discontinuity of the medial wall/column is considered to be one of the most significant risk factors for non-union and subsequent implant failure, especially if this defect is not addressed during the revision surgery. We present a case of failed fixation of a subtrochanteric fracture in an 86-year-old female where revision surgery paid special attention to restoring the medial wall continuity via bone grafting resulting in satisfactory union of the fracture. We advocate the necessity of reconstructing the medial column in similar cases in order to enhance healing and restore the biomechanical support of the subtrochanteric region.

Development and Validation of a Post-Operative Non-Union Risk Score for Subtrochanteric Femur Fractures

Background: Our objective was to develop and validate a predictive model for non-union following a subtrochanteric fracture of the femur. Methods: Following institutional board approval, 316 consecutive patients presenting to our institution (84 non-unions) who fulfilled the inclusion criteria were retrospectively identified. To identify potential unadjusted associations with progression to non-union, simple logistic regression models were used, followed by a revised adjusted model of multiple logistic regression. Results: Having established the risk factors for non-union, the coefficients were used to produce a risk score for predicting non-union. To identify the high-risk patients in the early post-operative period, self-dynamisation was excluded. The revised scoring system was the sum of the following: diabetes (6); deep wound infection (35); simple or severe comminution (13); presence of an atypical fracture (14); lateral cortex gap size ≥5 mm (11), varus malreduction (5–10 degrees) (9); varus malreduction (>10 degrees) (20). On the ROC (receiver operating characteristic) curve, the area under the curve (0.790) demonstrated very good discriminatory capability of the scoring system, with good calibration (Hosmer–Lemeshow test; p = 0.291). Moreover, 5-fold cross validation confirmed good fit of the model and internal validity (accuracy 0.806; Kappa 0.416). The cut-point determined by Youden’s formula was calculated as 18. Conclusion: This study demonstrates that the risk of non-union can be reliably estimated in patients presenting with a subtrochanteric fracture, from the immediate post-operative period. The resulting non-union risk score can be used not only to identify the high-risk patients early, offering them appropriate consultation and in some cases surgical intervention, but also informs surgeons of the modifiable surgery related factors that contribute to this risk.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of evidence

III.

Plate-Tensioned-Nail for Salvage of Failed Subtrochanteric Intramedullary Motorized Limb Lengthening: A Case Report

CASE

A 43-year-old insulin-dependent man with a 4.4-cm posttraumatic femoral limb length discrepancy sustained a subtrochanteric femur fracture associated with failure of a motorized intramedullary limb lengthening nail during distraction osteogenesis. The patient requested a single-stage salvage operation. After implant removal, the femur was stabilized and compressed with a plate-tensioned-nail construct consisting of 4.5-mm locking compression plate tensioned and linked to a femoral reconstruction nail through interlocking screws with immediate weight-bearing.

CONCLUSION

A plate-tensioned-nail construct is a single-stage salvage option for a length-unstable subtrochanteric nonunion which permits immediate full weight-bearing.

Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures

OBJECTIVE

To explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail.

METHOD

From February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self-made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double-stranded steel wire was introduced into a self-made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x-rayed front and side fractures before and after surgery and the maximum displacement and formation of the three-dimensional CT-scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery.

RESULT

A total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X-ray and three-dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair.

CONCLUSION

For refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

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

Management of Subtrochanteric Femoral Fracture Nonunions

Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.

Retrograde entry portal for cephalomedullary nailing in difficult subtrochanteric fractures

An entry point medial to the tip of the greater trochanter is considered optimal for antegrade femur nailing. The deforming forces in a subtrochanteric fracture often make it difficult to establish a perfect entry point during antegrade cephalomedullary nailing. To overcome this problem, we report a simple technique of making a retrograde entry portal for select difficult subtrochanteric fractures. The technique was used in 12 subtrochanteric fractures. Our indications were morbid obesity, revision nailing and atypical fractures. The technique involves creating a nail entry portal through the fracture from distal to proximal taking advantage of the abducted proximal fragment. Fracture reduction and nail insertion then proceeds in a standard manner. Additional reaming of the thick endosteal lateral cortex through the fracture was performed in atypical fractures. Satisfactory fracture reduction was achieved in all patients and 11 out of the 12 fractures united in the series. 1 patient developed an infected nonunion and was considered failure of treatment. The retrograde entry portal is a valuable alternative method that can be considered in nailing of difficult subtrochanteric fractures to establish an ideal entry point and nail trajectory.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications

Backgroundand Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialisand Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017-2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81-89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction-3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

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.

Management of Refractory Aseptic Subtrochanteric Non-union by Dual Plating

BACKGROUND

Subtrochanteric fractures are challenging to treat because of their anatomical and biomechanical behaviours. Non-unions of this region become much more difficult to treat because of the previous surgical scar, fibrosis, mal-reduction, presence of an implant, compromised soft tissue, and osseous vascularity, bone-mass loss etc. The aim is to provide a stable mechanical environment by PF-LCP, augmented by LCP (dual plating) where biology can work uneventfully. Biology is re-initiated by decortication (shingling) and autologous cancellous bone graft.

METHODS

Twelve cases of failed aseptic subtrochanteric non-union either with intact or broken implant were included in this study in a period of 3 years from August 2016 to July 2019. The interposing fibrous tissue resected in patients with mal-aligned fragments. The mechanical stabilization is achieved by orthogonal dual plating. PF-LCP on lateral and 4.5 mm LCP anteriorly, decortication, and cancellous graft applied before applying for the anterior plate. Patients were encouraged for a toe-touch walk with walking-frame from 3rd post-operative day. Functional outcomes were assessed using Parker Mobility Score (PMS).

RESULTS

All fractures united in 7 ± 1.53 months. ROM at the knee remained unchanged but improved at the hip after revision surgery. Average PMS improved to 7.58 from pre-revision 1.75 validating the efficacy of this protocol.

CONCLUSION

Adequate stability by dual-plate construct and re-initiation of cellular and biochemical processes by decortication and cancellous bone-graft reunited ununited subtrochanteric fractures. This particular combination of plates and decortication has not been employed earlier as per our review of the literature.

AIM

To offer a new paradigm for the management of surgically failed subtrochanteric non-unions.

Dynamic hip screw fixation of subtrochanteric femoral fractures

Introduction

A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct.

Materials and Methods

We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014–May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality.

Results

During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm² compared to 288.86 mGy cm² in the IMN group.

Conclusion

Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.

The Cost and Consequences of Failed Osteosynthesis of Intertrochanteric Femur Fractures: A Matched Cohort Study

BACKGROUND

We aimed to evaluate the cost and consequences of failed osteosynthesis of intertrochanteric femur fracture (ITFF) patients and compare with primary ITFF patients.

METHODS

We retrospectively evaluated 689 patients who underwent surgery due to ITFF via cephalomedullary nail. 31 patients (5.8%) had revision surgery because of osteosynthesis failure of ITFF. Each revision case included in the study was matched with four primary ITFF cases as control group based on age, gender, year of operation, type of fracture and American Society of Anesthesiologists (ASA) grade. Total cost for the admission that patients underwent surgery, mortality rate at first year, infection rate, length of stay at hospital, length of stay at intensive care unit, and erythrocyte transfusion amounts were recorded from hospital registry records. Tip apex distances (TAD) were noted.

RESULTS

The mean total cost of the revision cases and primary cases was 10,027 ± 6387 and 5261 ± 1773 Turkish Liras, respectively (p < 0.001). TAD was ≥ 20 mm in 32.3% (10/31) of patients in revision group while 2.4% (3/124) of the patients in control group (p < 0.001). The mean length of stay at hospital, length of stay at intensive care unit, erythrocyte transfusion amounts, infection rate and mortality rate at first year were significantly higher in revision cases compared to matched primary control cases (p < 0.05).

CONCLUSION

Revision surgeries due to failed osteosynthesis of ITFFs with cephalomedullary nail have at least two times higher mean total cost than primary cases. The awareness of the cost, morbidity and mortality of the revision surgeries may reduce the modifiable risk factors of osteosynthesis failure including maintenance of TAD below 20 mm, obtaining optimal lag screw position and reduction quality.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Hardware considerations in infection and nonunion management: When and how to revise the fixation

The occurrence of both nonunion and fracture-related infection provides challenges for both the patient and the treating orthopaedic surgeon, with the potential need for complex reconstructive procedures to achieve union and/or eradicate infection. In addition to addressing the multiple different factors that often contribute to nonunion, surgeons are often forced to deal with difficult hardware issues at the time of revision surgery including infected hardware, loose or failing hardware, malaligned hardware, or inappropriate hardware constructs. This article reviews common causes of nonunions with emphasis on infection management and provides indications and techniques for hardware removal in the context of an algorithmic approach to nonunion management with illustrative case examples.