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Direder M, Naß C, Andresen JR, Dannenmann T, Bur F, Hajdu S, Haider T. Distal femoral fractures: periprosthetic fractures have four times more complications than non-periprosthetic fractures and cerclage should be avoided: retrospective analysis of 206 patients. J Orthop Traumatol 2024; 25:41. [PMID: 39225851 PMCID: PMC11371989 DOI: 10.1186/s10195-024-00782-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Distal femoral fractures account for less than 1% of all fractures. The therapy of choice is usually surgical stabilization. Despite advances in implant development over the past few years, complication rate remains comparatively high. The aim of this study is to analyze our results with plate fixation of distal femoral fractures with a focus on complication and fracture healing rates. METHODS In this retrospective cohort study, patients (> 18 years) with distal femoral fractures treated at an urban level I trauma center between 2015 and 2022 were analyzed. RESULTS In total, 206 patients (167 female, 39 male) with an average age of 75 (SD 16) years were diagnosed with a fracture of the distal femur. One hundred fourteen of these patients were treated surgically by means of plate osteosynthesis. In 13 cases (11.41%), a revision procedure had to be performed. The indication for surgical revision was mechanical failure in eight cases (7.02%) and septic complication in five cases (4.39%). Periprosthetic fractures were more likely to cause complications overall (19.6% versus 4.76%) and further included all documented septic complications. The analysis of modifiable surgical factors in the context of plate osteosynthesis showed higher complication rates for cerclage in the fracture area compared with plate-only stabilizations (44.44% versus 22.22%). CONCLUSIONS The data show an increased amount of revisions and a significantly higher number of septic complications in the treatment of periprosthetic fractures of the distal femur compared with non-periprosthetic fractures. The detected combination of plates together with cerclage was associated with higher complication rates. Level of evidence Level III retrospective comparative study.
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Affiliation(s)
- Martin Direder
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria.
| | - Cornelia Naß
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
| | - Julian Ramin Andresen
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
| | - Theresa Dannenmann
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
| | - Florian Bur
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
| | - Thomas Haider
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Lazarettgasse 14, 1090, Vienna, Austria
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2
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Lee YJ, Lim JR, Choi JH, Yoon TH, Choi YR, Chun YM. Comparing the Biomechanical Stability of Cerclage Cable with Plate Insert Versus Locking Screw in Periprosthetic Humeral Fracture. J Bone Joint Surg Am 2024; 106:817-822. [PMID: 38381844 DOI: 10.2106/jbjs.23.00830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND In the setting of periprosthetic humeral fractures, the humeral stem of the implant represents a substantial challenge to the optimal method of proximal fixation. This study aimed to compare the initial biomechanical stability provided by cerclage cables with a locking plate insert versus bicortical locking screws (i.e., the gold standard for fixation) in fresh cadaveric humeri. METHODS After calculating the sample size, we utilized 10 sets of cadaveric specimens and created a 5-mm osteotomy gap 120 mm distal to the tip of the greater tuberosity, simulating a Wright and Cofield type-B periprosthetic humeral fracture on each specimen. Using 3 locking screws for distal fragment fixation, identical in all specimens, the specimens were assigned to Group A (3 cerclage cables with a plate insert) or Group B (3 locking bicortical screws) for proximal fragment fixation. Biomechanical tests included stiffness in varus and valgus bending, torsion, and axial compression, and a single load to failure. RESULTS No significant differences were observed in the biomechanical metrics between the 2 groups. CONCLUSIONS Our study revealed that fixation with use of cerclage cables with a plate insert demonstrated biomechanical stability comparable with that of bicortical locking screw fixation when addressing the proximal fragment in Wright and Cofield type-B periprosthetic humeral fractures. CLINICAL RELEVANCE For proximal fragment fixation of periprosthetic humeral fractures, cerclage cables with a plate insert can be utilized as an effective fixation method that offers initial fixation strength that is comparable to the use of 3 locking bicortical screws.
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Affiliation(s)
- Yong-Jun Lee
- Arthroscopy and Joint Research Institute, Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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3
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Oh SH, Suh YS, Eghan-Acquah E, Yurevich KM, Won SH, Baek MJ, Lee SJ, Choi SW. Unstable Vancouver B1 periprosthetic femoral fracture fixation: A biomechanical comparison between a novel C-shaped memory alloy implant and cerclage wiring. J Int Med Res 2024; 52:3000605241240946. [PMID: 38534086 PMCID: PMC10981230 DOI: 10.1177/03000605241240946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/04/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND To compare the biomechanical stability of a novel, C-shaped nickel-titanium shape memory alloy (SMA) implant (C-clip) with traditional cerclage wiring in the fixation of a Vancouver B1 (VB1) periprosthetic femoral fracture (PFF). METHODS In total, 18 synthetic femoral fracture models were constructed to obtain unstable VB1 fracture with an oblique fracture line 8 cm below the lesser trochanter. For each model, the distal portion was repaired using a 10-hole locking plate and four distal bi-cortical screws. The proximal portion was repaired using either three, threaded cerclage wirings or three, novel C-shaped implants. Specimens underwent biomechanical testing using axial compression, torsional and four-point bending tests. Each test was performed on three specimens. RESULTS The C-clip was statistically significantly stronger (i.e., stiffer) than cerclage wiring in the three biomechanical tests. For axial compression, medians (ranges) were 39 (39-41) and 35 (35-35) N/mm, for the C-clip and cerclage wiring, respectively. For torsion, medians (ranges) were, 0.44 (0.44-0.45) and 0.30 (0.30-0.33) N/mm for the C-clip and cerclage wiring, respectively. For the four-point bending test, medians (ranges) were 39 (39-41) and 28 (28-31) N/mm; for the C-clip and cerclage wiring, respectively. CONCLUSION Results from this small study show that the novel, C-shaped SMA appears to be biomechanically superior to traditional cerclage wiring in terms of stiffness, axial compression, torsion and four-point bending, and may be a valuable alternative in the repair of VB1 PFF. Further research is necessary to support these results.
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Affiliation(s)
- Seog-Hyun Oh
- Department of Biomedical Engineering, Inje University, Gimhae, 50834, 197 Inje-ro, Gimhae-si, Gyeongsangnam-do, Republic of Korea
| | - Yu-Sung Suh
- Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, Seoul, 04401, 59 Daesagwan-ro, Yongsan-gu, Seoul, Republic of Korea
| | - Emmanuel Eghan-Acquah
- Department of Biomedical Engineering, Inje University, Gimhae, 50834, 197 Inje-ro, Gimhae-si, Gyeongsangnam-do, Republic of Korea
| | - Kollerov Mikhail Yurevich
- Department of Materials Science and Materials Technology, Moscow Aviation Institute, 121552, Kom.1, Dom 5, Orshanskaya Str. Moscow, Russia
| | - Sung-Hun Won
- Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, Seoul, 04401, 59 Daesagwan-ro, Yongsan-gu, Seoul, Republic of Korea
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, Bundang CHA Hospital, Seongnam, 13496, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sung-Jae Lee
- Department of Biomedical Engineering, Inje University, Gimhae, 50834, 197 Inje-ro, Gimhae-si, Gyeongsangnam-do, Republic of Korea
| | - Sung-Woo Choi
- Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, Seoul, 04401, 59 Daesagwan-ro, Yongsan-gu, Seoul, Republic of Korea
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4
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Mahmoud AN, Echeverry-Martinez MF, Horwitz DS. Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:389-395. [PMID: 37540245 DOI: 10.1007/s00590-023-03665-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
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.
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Affiliation(s)
- Ahmed Nageeb Mahmoud
- Geisinger Medical Center, Geisinger Musculoskeletal Institute, 100 N Academy Ave, Danville, PA, 17821, USA.
- Department of Orthopedic Surgery, Ain Shams University, Cairo, Egypt.
| | - Maria F Echeverry-Martinez
- Geisinger Medical Center, Geisinger Musculoskeletal Institute, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Daniel Scott Horwitz
- Geisinger Medical Center, Geisinger Musculoskeletal Institute, 100 N Academy Ave, Danville, PA, 17821, USA
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5
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Pengrung N, Sa-ngasoongsong P, Sabsuantang K, Thongchuea N, Warinsiriruk E. Effectiveness of laser welding in cerclage wiring fixation: a biomechanical study. Front Surg 2023; 10:1134986. [PMID: 37841817 PMCID: PMC10570461 DOI: 10.3389/fsurg.2023.1134986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Cerclage wiring is a common orthopedic procedure for fracture fixation. However, previous studies reported wiring-related perioperative complications, such as wire loosening or breakage, with an incidence rate of up to 77%. Recently, the use of laser welding on medical implants was introduced to connect biomedical materials. This study used laser technology to weld between wires after conventional cerclage fixation. We hypothesized that the laser welding could significantly increase the biomechanical properties of cerclage wiring fixation. Materials and methods Twenty-five wiring models underwent biomechanical tests in five cerclage wiring configurations (five models per group), namely, (1) single loop, (2) single loop with laser welding, (3) double loop, (4) double loop with one-side laser welding, and (5) double loop with two-side laser welding. Characteristics such as load to failure, mode of failure, and wiring failure were compared between groups. The biocompatibility for a 316L stainless steel wire with laser welding was evaluated via an in vitro hemolysis test. Results Mean load to failure of the double loop with one-side and two-side laser welding groups were 3,596 ± 346 N and 3,667 ± 240 N, which were significantly higher than for the double-loop group (2,919 ± 717 N) (p = 0.012 and p = 0.044, respectively). Conversely, no significant difference was shown in the comparison of the mean load to failure between the single loop and the single loop with laser-welded cerclage wire (1,251 ± 72 N, 1,352 ± 122 N, and p = 0.12). Untwisted wire and wire breakage were the most common mode of failure. All welding specimens revealed non-hemolytic effects from in vitro hemolysis test. Conclusion Laser welding on cerclage wiring significantly increases the biomechanical property of double cerclage wire fixation. However, further biocompatibility tests and clinical studies are still recommended.
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Affiliation(s)
- Nachapan Pengrung
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Paphon Sa-ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Konlawat Sabsuantang
- Chakri Naruebodindra Medical Institute (CNMI), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Nutchanat Thongchuea
- Department of Industrial Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
| | - Eakkachai Warinsiriruk
- Department of Industrial Engineering, Faculty of Engineering, Mahidol University, Nakhon Pathom, Thailand
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6
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Streeter SS, Hebert KA, Bateman LM, Ray GS, Dean RE, Geffken KT, Resnick CT, Austin DC, Bell JE, Sparks MB, Gibbs SL, Samkoe KS, Gitajn IL, Elliott JT, Henderson ER. Current and Future Applications of Fluorescence Guidance in Orthopaedic Surgery. Mol Imaging Biol 2023; 25:46-57. [PMID: 36447084 PMCID: PMC10106269 DOI: 10.1007/s11307-022-01789-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
Fluorescence-guided surgery (FGS) is an evolving field that seeks to identify important anatomic structures or physiologic phenomena with helpful relevance to the execution of surgical procedures. Fluorescence labeling occurs generally via the administration of fluorescent reporters that may be molecularly targeted, enzyme-activated, or untargeted, vascular probes. Fluorescence guidance has substantially changed care strategies in numerous surgical fields; however, investigation and adoption in orthopaedic surgery have lagged. FGS shows the potential for improving patient care in orthopaedics via several applications including disease diagnosis, perfusion-based tissue healing capacity assessment, infection/tumor eradication, and anatomic structure identification. This review highlights current and future applications of fluorescence guidance in orthopaedics and identifies key challenges to translation and potential solutions.
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Affiliation(s)
- Samuel S Streeter
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA.
| | - Kendra A Hebert
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - Logan M Bateman
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA.,Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA
| | - Gabrielle S Ray
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Ryan E Dean
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Kurt T Geffken
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Corey T Resnick
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Daniel C Austin
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - John-Erik Bell
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Michael B Sparks
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Summer L Gibbs
- Oregon Health & Science University, Portland, OR, 97239, USA
| | - Kimberley S Samkoe
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - I Leah Gitajn
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA
| | - Jonathan Thomas Elliott
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA.,Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA.,Dartmouth Cancer Center, Dartmouth Health, Lebanon, NH, 03756, USA
| | - Eric R Henderson
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA.,Department of Orthopaedics, Dartmouth Health, Lebanon, NH, 03756, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, 03755, USA.,Dartmouth Cancer Center, Dartmouth Health, Lebanon, NH, 03756, USA
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7
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Gipsman AM, Ihn HE, Iglesias BC, Azad A, Stone MA, Omid R. Spatial Anatomy of the Radial Nerve in the Extended Deltopectoral Approach. Orthopedics 2023; 46:e31-e37. [PMID: 36206514 DOI: 10.3928/01477447-20221003-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The goal of this study was to define safe zones to prevent radial nerve injury in an extended deltopectoral approach. Relative distances of the upper margin (UMRN) and lower margin (LMRN) of the radial nerve to the proximal and distal borders of the pectoralis major and deltoid insertions were measured in 20 cadaveric arms. Four proximal humeral zones were identified (zone I, proximal border of the pectoralis major tendon to the proximal border of the deltoid tendon; zone II, proximal border of the deltoid tendon to the distal border of the pectoralis major tendon; zone III, distal border of the pectoralis major tendon to the distal border of the deltoid tendon; and zone IV, distal to the distal border of the deltoid tendon). On fluoroscopic measurement, mean distances between the UMRN and the proximal border of the pectoralis major tendon and the proximal border of the deltoid tendon were 71.6±2.1 mm and 26.2±2.5 mm, respectively. The incidence of the radial nerve in the spiral groove within each defined zone was as follows: zone I, 0%; zone II, 50%; zones III and IV, 100%. There was a significant association between anatomic zone and radial nerve entry into the spiral groove, χ2(3, N=88)=64.53, P<.001. The proximal border of the pectoralis major tendon to the proximal border of the deltoid tendon (zone I) is a safe location to avoid injury to the radial nerve. We recommend placing cerclage wires proximal to zone I from lateral to medial to avoid entrapment of the radial nerve. [Orthopedics. 2023;46(1):e31-e37.].
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Wendler T, Fischer B, Brand A, Weidling M, Fakler J, Zajonz D, Osterhoff G. Biomechanical testing of different fixation techniques for intraoperative proximal femur fractures: a technical note. Int Biomech 2022; 9:27-32. [DOI: 10.1080/23335432.2022.2142159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Toni Wendler
- ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
- Institute of Anatomy, Leipzig University, Leipzig, Germany
| | - Benjamin Fischer
- ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
- Department of Orthopaedics Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - Alexander Brand
- Department of Orthopaedics Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - Martin Weidling
- ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
- Department of Neurosurgery, Leipzig University, Leipzig, Germany
| | - Johannes Fakler
- Department of Orthopaedics Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - Dirk Zajonz
- ZESBO Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
- Department of Orthopaedics Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
- Department of Orthopaedic, Trauma and Reconstructive Surgery, Zeisigwaldkliniken Bethanien, Chemnitz, Germany
| | - Georg Osterhoff
- Department of Orthopaedics Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
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Hägerich LM, Dyrna FGE, Katthagen JC, Michel PA, Heilmann LF, Frank A, Raschke MJ, Schliemann B, Riesenbeck O. Cerclage performance analysis - a biomechanical comparison of different techniques and materials. BMC Musculoskelet Disord 2022; 23:1037. [PMID: 36451236 PMCID: PMC9714204 DOI: 10.1186/s12891-022-05983-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 10/11/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Wire cerclages play a fundamental role in fracture fixation. With an increasing variety of designs being commercially available the question arises which cerclage should be used. This study investigates the biomechanical properties of metallic and non-metallic cerclages and their different application-types. Furthermore, potential influence of muscular interposition between bone and cerclage constructs was tested. METHODS Samples of the following four different cerclage types were tested on 3D printed models of human humeri as well as on human cadaveric humeri with and without muscular interposition: Titanium Cable Cerclage (CC), Steel Wire Cerclage (SWC), Suture Tape (ST), Suture Tape Cerclage (STC) with both single- (sSTC) and double-loop application (dSTC). A preinstalled self-locking mechanism secured by the provided tensioner in the STCs being the main difference to the STs. Cyclic loading was performed to 1 kN and then linearly to a maximum load of 3 kN. Statistical analysis was performed using either one-way ANOVA and post-hoc Tukey or Kruskal-Wallis and post-hoc Dunn test depending on normalization of data (p < 0.05). RESULTS Whilst all cerclage options could withstand high loads during failure testing, only within the CC and dSTC group, all samples reached the maximal testing load of 3000 N without any failure. The SWC reached 2977.5 ± 63.6 N, the ST 1970.8 ± 145.9 N, and the sSTC 1617.0 ± 341.6 N on average. Neither muscular interposition nor bone quality showed to have a negative influence on the biomechanical properties of the cerclage constructs, presenting no significant differences. CONCLUSION All tested cerclage constructs produce reliable stability but differ in their resulting compression forces, in a simplified fracture model. Therefore, non-metallic cerclage alternatives can provide similar stability with less compression and stiffness to metallic cable constructs, but they may offer several advantages and could possibly provide future benefits. Especially, by offering more elasticity without losing overall stability, may offer a biologic benefit. Installing any cerclage constructs should be performed carefully, especially if poor bone quality is present, as the tightening process leads to high forces on the construct.
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Affiliation(s)
- L. M. Hägerich
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - F. G. E. Dyrna
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - J. C. Katthagen
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - P. A. Michel
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - L. F. Heilmann
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - A. Frank
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - M. J. Raschke
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - B. Schliemann
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - O. Riesenbeck
- grid.16149.3b0000 0004 0551 4246Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
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10
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Gupta R, Schmidt EC, Namdari S, Stone MA, Hast MW. The addition of cerclage wiring does not improve proximal bicortical fixation of locking plates for Type C periprosthetic fractures in synthetic humeri. Clin Biomech (Bristol, Avon) 2022; 97:105709. [PMID: 35780699 PMCID: PMC10096358 DOI: 10.1016/j.clinbiomech.2022.105709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/05/2022] [Accepted: 06/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of proximal humerus periprosthetic fractures is challenging. It remains difficult to achieve robust fixation of the proximal fragment to the locking plate using cerclage wiring and/or unicortical screws. Use of polyaxial tangentially directed bicortical locking screws increases screw purchase, but it is unclear if this option provides robust fixation. This biomechanical study compares fixation of constructs using cerclage wires, bicortical locking screws, and a hybrid method utilizing both methods. METHODS Uncemented humeral stems were implanted into synthetic humeri and Type C periprosthetic fractures were simulated with a 1 cm transverse osteotomy. Distal ends of locking plates were secured with bicortical non-locking screws. The proximal ends were supported by either isolated cerclage wires, polyaxial locking screws, or a hybrid combination of both (n = 6 for each group). A universal test frame was used for non-destructive torsion and cyclic axial compression tests. 3-D motion tracking was employed to determine stiffnesses and relative interfragmentary motions. FINDINGS Isolated screw constructs showed significantly increased resistance against torsional movement, bending, and shear, (p < 0.05) in comparison to cerclage constructs. The hybrid construct provided no significant changes in stability over the isolated screw construct. INTERPRETATION Addition of cerclage wires in this synthetic bone model of Type C periprosthetic humerus fractures did not add significant stability to proximal bicortical locking plate fixation. Considering risks of tissue stripping and nerve injury, usage of cerclage wires in a similar clinical setting should be chosen carefully, especially when bicortical fixation around the prosthetic stem can be achieved.
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Affiliation(s)
- Richa Gupta
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elaine C Schmidt
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Michael A Stone
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael W Hast
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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11
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The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:4761-4774. [PMID: 35618854 DOI: 10.1007/s00068-022-02003-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures. METHODS MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring. RESULTS Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002). CONCLUSIONS Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.
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12
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Malige A, Beck M, Mun F, Goss M, Boateng H, Nwachuku C. Stabilization of Vancouver B Periprosthetic Femur Fractures With Cerclage Wiring: A Retrospective Chart Review. Cureus 2022; 14:e25063. [PMID: 35719784 PMCID: PMC9201787 DOI: 10.7759/cureus.25063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/05/2022] Open
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13
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Bäcker HC, Heyland M, Wu CH, Perka C, Stöckle U, Braun KF. Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure. Eur J Med Res 2022; 27:7. [PMID: 35027077 PMCID: PMC8756694 DOI: 10.1186/s40001-021-00630-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117, Berlin, Germany.
| | - Mark Heyland
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Chia H Wu
- Department of Orthopedics & Sports Medicine, Baylor College of Medicine Medical Center, Houston, TX, USA
| | - Carsten Perka
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Ulrich Stöckle
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Karl F Braun
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital Berlin, Chariteplatz 1, 10117, Berlin, Germany.,Department of Traumatology, University Hospital Rechts Der Isar, Technical University Munich, Munich, Germany
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Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study. BMC Musculoskelet Disord 2022; 23:40. [PMID: 34996409 PMCID: PMC8742345 DOI: 10.1186/s12891-021-04956-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability. Methods Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured. Results No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW. Conclusions Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04956-5.
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15
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Novi M, Porcellini G, Donà A, Tarallo L, Micheloni G, Giorgini A, Paladini P, Catani F. A Long-Term Follow-Up of Post-Operative Periprosthetic Humeral Fracture in Shoulder Arthroplasty. Geriatr Orthop Surg Rehabil 2021; 12:21514593211039908. [PMID: 34595045 PMCID: PMC8477678 DOI: 10.1177/21514593211039908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Abstract
Background During the last decades, the growing number of shoulder replacement has increased the associated complications. Periprosthetic fractures have a low incidence but can be a severe clinical condition, especially in elderly population. There are still no guidelines to define the best treatment protocol for post-operative periprosthetic humeral fractures. Factors associated to these fractures and consequently the decision-making for the best treatment seem to be patient-related but also correlated with the type of implant. The aim of this study is to analyze the patient’s risk factors, fracture pattern, implant type and treatment, evaluating the outcome with a long-term follow-up. Methods A retrospective study was performed on more than 2700 shoulder prostheses implanted over 10 years in two specialized centers, identifying 19 patients who underwent surgery for post-operative periprosthetic fracture. Gender, age, comorbidities, type of prosthetic implant, type of fracture, and cortical index of each patient were evaluated. All patients underwent surgery and were evaluated with a mean follow-up of 5 years with radiographic controls and functional assessment with the Constant–Murley score. Results Complete healing was achieved in 18 of 19 patients. All patients presented a lower Constant–Murley score than the pre-fracture score, there were no significant differences between prosthetic implants, and the cortical index was lower than the threshold level in more than 60% of cases. Conclusion The results of this study showed that a correct preoperative planning is essential to evaluate the type of implant and possible signs of stem mobilization. With a stable stem, it is preferable to maintain it and proceed to a synthesis. The decision process is more complex in periprosthetic fractures with a reduced cortical index, when some radiolucency lines are present in stems with high primary stability, because it is not always indicative of an unstable stem. Level of Evidence Therapeutic III
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Affiliation(s)
- Michele Novi
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Porcellini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Donà
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi Tarallo
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianmario Micheloni
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Giorgini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Paladini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Catani
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Modena, Italy
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16
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Camacho-Carrasco P, Renau-Cerrillo M, Campuzano-Bitterling B, Martinez-de-la-Mata J, Vives-Barquiel M. A modified cable wiring technique with C-shaped passer through a mini-open approach to assist reduction in femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1407-1413. [PMID: 34532756 DOI: 10.1007/s00590-021-03119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Pilar Camacho-Carrasco
- Orthopaedic and Traumatology Department, Hospital Clínic de Barcelona, Calle Villarroel 170, 08036, Barcelona, Catalonia, Spain
| | - Marina Renau-Cerrillo
- Orthopaedic and Traumatology Department, Hospital Clínic de Barcelona, Calle Villarroel 170, 08036, Barcelona, Catalonia, Spain
| | - Borja Campuzano-Bitterling
- Orthopaedic and Traumatology Department, Hospital Clínic de Barcelona, Calle Villarroel 170, 08036, Barcelona, Catalonia, Spain
| | | | - Marian Vives-Barquiel
- Orthopaedic and Traumatology Department, Hospital Clínic de Barcelona, Calle Villarroel 170, 08036, Barcelona, Catalonia, Spain.
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17
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Ott N, Harland A, Hackl M, Prescher A, Leschinger T, Müller LP, Wegmann K. Primary stability of fixation methods for periprosthetic fractures of the humerus: a biomechanical investigation. J Shoulder Elbow Surg 2021; 30:2184-2190. [PMID: 33581277 DOI: 10.1016/j.jse.2020.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/19/2020] [Accepted: 12/27/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence of periprosthetic fractures of the proximal humerus is gradually increasing, following an increase in reverse shoulder arthroplasties in recent years. Locking plate fixation and revision arthroplasty are both valuable treatment methods. However, the primary stability of fixation methods for periprosthetic fractures has not been investigated in detail. The aim of this study was to analyze and compare the primary stability of the common treatment measures. MATERIALS AND METHODS Cemented reverse total shoulder arthroplasty (Delta Xtend; DePuy Synthes, Warsaw, IN, USA) was performed in 5 shoulders, and a distal, mid-diaphysis humeral fracture (Wright and Cofield type B) was induced. The implant was left in place, and 3 distinct fixation scenarios were tested: osteosynthesis using 4.5-mm locking plate fixation (subgroup A), 4.5-mm locking plate fixation with an additional 3.5-mm locking plate (subgroup B), and 4.5-mm locking plate fixation with an additional K-wire cerclage (subgroup C). The specimens were tested in a biomechanical setup simulating activities of daily living including rotation. Strain gauges (4-wire strain at 120 Ω; Vishay Measurements Group, Chartres, France) mounted on the 4.5-mm locking plates were used to evaluate the strain of the fixation and to give an estimate of primary stability. RESULTS Regarding the simulation of activities of daily living, no statistically significant differences were found in the measured strains on the locking plate between subgroups A, B, and C. A maximum measured strain of 216.85 μm/m in subgroup A resulted in bending of the locking plate (length, 134 mm) of 0.03 mm. In subgroup B (277.01 μm/m), the plate strained 0.04 mm compared with a strain measurement of 0.01 mm in subgroup C (75.93 μm/m). CONCLUSION Additional K-wire cerclages or additional 3.5-mm locked plating did not increase primary stability. With a stable prosthetic implant in place, 4.5-mm locked plating is sufficient to address periprosthetic humeral shaft fractures in the present in vitro setup.
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Affiliation(s)
- Nadine Ott
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany.
| | - Arne Harland
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy -Prosektur-, RWTH Aachen, Aachen, Germany
| | - Tim Leschinger
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Lars Peter Müller
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Kilian Wegmann
- Department of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
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Wang TH, Chuang HC, Kuan FC, Hong CK, Yeh ML, Su WR, Hsu KL. Role of open cerclage wiring in patients with comminuted fractures of the femoral shaft treated with intramedullary nails. J Orthop Surg Res 2021; 16:480. [PMID: 34364374 PMCID: PMC8348994 DOI: 10.1186/s13018-021-02633-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction The role of open cerclage wiring in comminuted femoral shaft fracture treatment with intramedullary nails remains unclear. Here, we analyzed the effect of open cerclage wiring and the risk factors for nonunion after interlocking nailing in comminuted femoral shaft fracture treatment. We hypothesized that open cerclage wiring can be applied in patients with severe comminuted femoral shaft fractures without affecting bone healing. Patients and methods This retrospective cohort study used data from consecutive patients who underwent interlocking nail fixation of a comminuted femoral shaft fracture between January 1, 2009, and December 31, 2016. First, eligible patients were divided into the wire and no wire groups according to the surgical technique used, and their union rate was recorded. The patients were then divided into the union and nonunion groups, and their perioperative data were analyzed. Results In total, 71 comminuted femoral shaft fractures treated with interlocking nail fixation were included: 38 fractures (53.5%) augmented with the open wiring technique and 33 reduced with closed or mini-open techniques without wiring. The wire group demonstrated significant improvements in fracture reduction compared with the no wire group, whereas no significant difference was observed in the union rate between the wire and no wire groups (p = 0.180). Moreover, 46 (65%) of 71 fractures achieved union smoothly, and no significant difference was observed in any perioperative data between the union and nonunion groups. Discussion Augmentation with open cerclage wiring is indicated for comminuted femoral shaft fractures treated with intramedullary nails, even when the fragments are large or greatly displaced. Thus, open cerclage wiring can be used for fracture treatment without decreasing the union rate.
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Affiliation(s)
- Tzu-Hao Wang
- Department of Orthopaedics, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan, R.O.C.,Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C
| | - Hao-Chun Chuang
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan, R.O.C.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan, R.O.C
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.. .,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan, R.O.C.. .,Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan, R.O.C.. .,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung, Tainan, Taiwan, R.O.C..
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Biomechanical comparison of different cerclage types in addition to an angle stable plate osteosynthesis of distal tibial fractures. Injury 2021; 52:2126-2130. [PMID: 33785189 DOI: 10.1016/j.injury.2021.03.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Different stand-alone cerclage configurations and their optimal twisting techniques have been investigated over the years. This study tests for the stabilizing effect of different supplemental cerclage materials in combination with locked plating of distal tibia fractures. METHODS Locking plate fixation of a distal tibial spiral fracture was tested as stand-alone and with supplemental cerclage materials (one cable, two cables, wire, fiber tape). Construct stiffness and fracture gap movements were investigated under quasi-static and dynamic loads and compared to the stand-alone locking plate. RESULTS With each of the tested cerclages, stiffness was significantly higher than for a solitary plate osteosynthesis. Most reduction in fracture gap movement was achieved by cable cerclages, followed by double-looped wire and double-looped fiber tape cerclages. Under dynamic loading an additional cable cerclage reduces excessive gap movement. CONCLUSION Compared to solitary plate osteosynthesis all supplemental cerclage materials were generally superior with reduced fracture gap movements whereas cable cerclages showing the greatest stabilizing effect.
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Treatment of Vancouver B1 periprosthetic femoral fractures using Intrauma Iron Lady® locking plate: A retrospective study on 32 patients. Injury 2021; 52:2459-2462. [PMID: 33731290 DOI: 10.1016/j.injury.2021.02.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/27/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Periprosthetic femoral fractures (PFF) actually represent a serious public health problem. They are reported to occur in 0,1-4.5% of all patients undergoing total hip replacement (THR). PFF are commonly distinguished using the Vancouver classification. This study principal aim is to evaluate results obtained using the Intrauma Iron Lady® Conical Coupling locking plate for the treatment of Vancouver type B1 periprosthetic femoral fractures. MATERIALS AND METHODS We enrolled 32 patients affected by Vancouver B1 PFF and treated with the same device. Metal cerclages were additionally used in 12 (38%) patients. A clinical and radiographical post-operative follow-up was then planned at 1, 3 and 6 months after surgery; than the follow-up was annually fixed. RESULTS Mean age at the moment of trauma was 76,7 years. All involved femoral stem were uncemented and the they were all radiographically and intraoperativelly judged to be stable. Mean post-operative follow-up period was 5,8 years. 29 patients (91%) presented healed fracture at 6 months follow-up. 9% patients developed a superficial surgical site infection. DISCUSSION AND CONCLUSIONS Literature highlights that Vancouver B1 PFF should be treated with open reduction and internal fixation (ORIF) using polyaxial locking plates. However, no single technique has gained universal acceptance to be superior that the other. The current reported healing rate ranges from 40 to 100%. Using the Intrauma Iron Lady® Conical Coupling locking plate, we obtained a healing rate of 91%; this data is consistent with recent literature. Moreover, the role of cerclages in addition to femoral plating is actually controversial because they potentially damage the soft callus vascularization. Our results showed no difference in term of healing rate between patients with and without cerclages, according with some of most recent articles. A prospective study with a higher number of patients should be carried out in order to better evaluate the role of cerclages on healing rate but also the complications frequency after PFF surgical treatment.
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A Tensionable Suture-based Cerclage Is an Alternative to Stainless Steel Cerclage Fixation for Stabilization of a Humeral Osteotomy During Shoulder Arthroplasty. J Am Acad Orthop Surg 2021; 29:e609-e617. [PMID: 32947346 DOI: 10.5435/jaaos-d-20-00047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/12/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Fixation of periprosthetic humeral fractures is most commonly obtained with steel-based wires or cables; however, disadvantages with these constructs are numerous. Suture-based cerclages offer the advantage of easy handling, less radiographic interference, and risk of metallosis, as well as decreased risk of cutting into the soft humeral bone. Therefore, the purpose of this study was to compare a suture-based cerclage to a stainless steel wire cerclage (SSWC) for stabilization of the humerus during shoulder arthroplasty. METHODS In part I of the study, SSWC fixation was compared with single-looped tape cerclage and a double-looped tape cerclage (DLTC) fixation. In part II, a subsidence test was performed on 12 cadaveric humeri. After an osteotomy, the humeri were secured with either a SSWC or DLTC. Subsequently, a metal wedge was introduced into the humerus to simulate the stem of a shoulder arthroplasty. RESULTS In part I, load to 2-mm displacement was significantly higher for the DLTC construct compared with the SSWC construct (2,401 ± 483 N versus 750 ± 33 N; P < 0.0001). Load to failure was 935 ± 143 N with the SSWC, 1,737 ± 113 N with the single-looped tape cerclage, and 4,360 ± 463 N with the DLTC constructs, and all differences were statistically significant (P < 0.05). In part II, load at 20-mm subsidence was higher for the DLTC (320 ± 274 N) compared with the SSWC (247 ± 137 N), but no significant difference was observed (P > 0.05). However, gap displacement at 20 mm subsidence was significantly lower with the DLTC construct (0.33 ± 0.31 mm versus 0.77 ± 0.23 mm; P = 0.009). Load to failure was higher with the DLTC construct compared with the SSWC construct (4,447 ± 2,325 N versus 1,880 ± 1,089 N; P = 0.032), but the final gap displacement did not differ significantly (DLTC 5.23 ± 6.63 mm versus SSWC 6.03 ± 8.82 mm; P > 0.05). DISCUSSION A DLTC has higher load to failure and trends toward lower gap displacement compared with a SSWC. The DLTC construct may therefore be a viable alternative for fixation of periprosthetic fractures or osteotomies of the humeral shaft during shoulder arthroplasty.
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Wu G, Chen YQ, Chen CY, Lin ZX, Xie QY, Ye JJ, Xie Y. Clinical outcomes of doubled-suture Nice knot augmented plate fixation in the treatment of comminuted midshaft clavicle fracture. BMC Surg 2021; 21:270. [PMID: 34049539 PMCID: PMC8164245 DOI: 10.1186/s12893-021-01274-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Free bone fragments were difficult to be fixed in many comminuted midshaft clavicle fractures, and the absence of cortical alignment in comminuted fractures had direct influence on the stability of fixation. This survey was performed to assess the efficacy of doubled-suture Nice knot augmented plate fixation in the treatment of comminuted midshaft clavicle fractures. Methods Between 2013 and 2018, all patients with comminuted midshaft clavicle fractures treated with doubled-suture Nice knot augmented plate fixation were retrospectively reviewed and included in this research. Demographic data of the patients, characteristics of the fractures, intraoperative parameters and follow-up data of the patients were evaluated and summarized. Results
A total of 56 patients were included in this study. The mean follow-up time was 25.6 months (range, 12–60 months). The number of male patients was 38 (67.9 %) and of the female patients was 18 (32.1 %). The average age of all patients was 47.89 ± 16.5 years. The mean time of surgery was 85.6 ± 24.0 min. The average length of incision was 9.2 ± 1.9 cm. The number of doubled-suture Nice knot applied ranged from 1 to 5 knots. All the patients reached bone union after the treatment. There was no implant failure or neurovascular injury observed. And most of the patients showed good functional outcome. Conclusions The doubled-suture Nice knot could provide reliable fixation for small bone fragments in comminuted clavicle fractures. Combination of the doubled-suture Nice knot and plate screws fixation was a safe and effective method in comminuted midshaft clavicle fractures treatment.
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Affiliation(s)
- Gui Wu
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China.
| | - Yao-Qing Chen
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China
| | - Chun-Yong Chen
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China
| | - Zhang-Xiong Lin
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China
| | - Qi-Yang Xie
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China
| | - Jun-Jian Ye
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China
| | - Yun Xie
- Department of orthopedics, First affiliated hospital, Fujian Medical University, Fujian, 350005, Fuzhou, China.
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Zajonz D, Pönick C, Edel M, Möbius R, Pfeifle C, Prietzel T, Roth A, Fakler JKM. Results after surgical treatment of periprosthetic proximal femoral fractures. Osteosynthesis with prosthesis preservation vs. prosthesis change. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2020; 9:Doc02. [PMID: 33214984 PMCID: PMC7656975 DOI: 10.3205/iprs000146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Periprosthetic fractures (PPF) of the femur close to the hip joint have serious consequences for most geriatric affected patients. In principle, apart from the highly uncommon conservative therapy, there are two therapeutic options. On the one hand, the prosthesis-preserving treatment by means of osteosynthesis using plates and/or cerclages in general is available. On the other hand, a (partial) change of the prosthesis with optionally additive osteosynthesis or a proximal femoral replacement can be performed because of prosthesis loosening or non-reconstructable comminuted fractures as well as most cemented stem variations. The aim of this retrospective study is the analysis of periprosthetic proximal femoral fractures in the presence of a total hip arthroplasty (THA). The outcome of the operated patients is to be investigated depending on the type of care (osteosynthesis with prosthesis preservation vs. prosthesis change). Material and methods: In a retrospective case analysis, 80 patients with THA and PPF were included. They were divided into two groups. Group I represents the osteosynthetic treatment to preserve the implanted THA (n=42). Group II (n=38) includes those patients who were treated by a change of their endoprosthesis with or without additional osteosynthesis. Specifics of all patients, like gender, age at fracture, interval between fracture and implantation, length of in-patient stay, body mass index, osteoporosis, corticomedullary index and complications such as infections, re-fracture, loosening, material failure or other complications, were recorded and compared. Furthermore, the patients were re-examined by a questionnaire and the score according to Merle d’Aubigné and Postel. Results: In group I the mean follow-up time was 48.5±23 months (4 years) whereas group II amounted 32.5±24.5 months (2.7 years) (p=0.029). Besides, there were significant differences in age (81± 11 years vs. 76±10 years, p=0.047) and length of in-patient stay (14.5±8.6 days vs. 18.0±16.7 days, p=0.014). According to the score of Merle d’Aubigné and Postel, there were significantly better values for the pain in group II with comparable values for mobility and walking ability. Conclusion: The treatment of periprosthetic proximal fractures of the femur is dependent on the classification (Vancouver and Johannsen) and in particular on the prosthetic anchoring as well as the extent of the comminution zone. Older patients and patients with osteoporosis are more frequently treated with an endoprosthesis revision. Patients, who have been treated with an osteosynthesis for preserving their endoprosthesis, showed a shorter length of in-patient stay and fewer complications than people with replacement surgery. In contrast to that, patients with prosthesis revision had better outcomes concerning the score of Merle d’Aubigné and Postel.
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Affiliation(s)
- Dirk Zajonz
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany.,Clinic for Orthopaedics, Trauma and Reconstructive Surgery, Zeisigwald Hospital Bethania, Chemnitz, Germany
| | - Cathleen Pönick
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Melanie Edel
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany
| | - Robert Möbius
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany
| | - Christian Pfeifle
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany
| | - Torsten Prietzel
- ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany.,Clinic for Orthopaedics, Trauma and Reconstructive Surgery, Zeisigwald Hospital Bethania, Chemnitz, Germany
| | - Andreas Roth
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopaedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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Eyberg BA, Walker JB, Harmsen SM, Gobezie R, Denard PJ, Lederman ES. Suture cerclage for stabilizing the humeral shaft during shoulder arthroplasty. JSES Int 2020; 4:688-693. [PMID: 32939507 PMCID: PMC7478986 DOI: 10.1016/j.jseint.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background In shoulder arthroplasty, cerclage fixation techniques are used to stabilize osteotomies, fractures, and allografts. Fixation techniques including cerclage with metal and polymer cables have been described. The purpose of this study was to evaluate suture cerclage fixation of the humeral shaft during shoulder arthroplasty. Materials and methods Shoulder arthroplasty cases performed from 2012-2017 by 3 fellowship-trained shoulder arthroplasty surgeons were reviewed. Cases in which suture cerclage was used for osteotomy, fracture, or allograft fixation were identified. Demographic data, indications, implant types, fixation techniques, and complications were reviewed. Postoperative radiographs were analyzed for union, component loosening, and loss of fixation. American Shoulder and Elbow Surgeons and Single Assessment Numeric Evaluation scores were collected preoperatively and postoperatively. Results A total of 27 patients (3 primary and 24 revision cases) with a mean age of 69.6 years (range, 28-88 years) were available for follow-up at a mean of 12.6 months (range, 0.8-42.3 months) postoperatively. Humeral osteotomy alone was performed in 15 cases. Allograft alone was used in 1 case. Both allograft and osteotomy were used in 6 cases. Complications occurred in 3 patients (11%), comprising 1 postoperative periprosthetic fracture and 2 prosthetic joint infections; all required further surgery. Radiographs at final follow-up showed healing of all osteotomies and fractures. No hardware failure or implant loosening occurred. The mean postoperative American Shoulder and Elbow Surgeons and Single Assessment Numeric Evaluation scores were significantly improved (α = .05) compared with preoperative scores, from 21.4 to 44.5 (P = .002) and from 26.7 to 74.1 (P < .001), respectively. Conclusion Suture cerclage is safe and effective for humeral fixation in shoulder arthroplasty.
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Affiliation(s)
- Blake A Eyberg
- The University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - J Brock Walker
- The University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Samuel M Harmsen
- The University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA.,The Orthopedic Clinic Association, Phoenix, AZ, USA
| | | | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, OR, USA.,Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Evan S Lederman
- The University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA.,Banner Health, Phoenix, AZ, USA
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González del Pozo J, Andrés-Cano P, Belascoain Benítez E, Giráldez Sánchez M, Cano-Luis P, Moreno Domínguez R, Martín Antúnez J. Surgical treatment of periprosthetic humerus fractures and algorithm. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020. [DOI: 10.1016/j.recote.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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González Del Pozo J, Andrés-Cano P, Belascoain Benítez E, Giráldez Sánchez MA, Cano-Luis P, Moreno Domínguez R, Martín Antúnez J. Surgical treatment of periprosthetic humerus fractures and algorithm. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:213-222. [PMID: 31974058 DOI: 10.1016/j.recot.2019.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 05/14/2019] [Accepted: 09/23/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Periprosthetic humerus fractures are infrequent and sometimes difficult to treat. There is limited literature and no consensus on the handling of these fractures. The objective of this study was to compare our results with those published in the literature, in order to improve our care and propose a management algorithm. MATERIAL AND METHOD Observational study of 10cases of periprosthetic humerus fractures with a mean follow-up of the patients of 23months. An analysis of sociodemographic, radiological and surgical variables was performed. They were reviewed clinically and by telephone using the UCLA Shoulder Score and Quick-DASH scales. A systematic search was made in Pubmed for periprosthetic humerus fractures, for a literature review with which to compare our series. RESULTS We analysed 10patients with an average age of 69.4years (37-91). Of the patients, 90% underwent surgery through open reduction and internal fixation. Nine of the ten patients consolidated in a mean time of 6.2months (range 5-12), the remaining suffered a new fracture 5months after the intervention, who were reoperated and a new osteosynthesis performed with bone allograft. In the UCLA scale there was a decrease of 10.66points, and an increase of 27.3points in the Quick-DASH, at the end of the follow-up. CONCLUSIONS In our series of cases we found similarities in the literature, in relation to demographic aspects and obtaining good radiographic results, which do not correspond to the functional outcome of patients.
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Affiliation(s)
- J González Del Pozo
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - P Andrés-Cano
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - E Belascoain Benítez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - M A Giráldez Sánchez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - P Cano-Luis
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Moreno Domínguez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Martín Antúnez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen del Rocío, Sevilla, España
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Canton G, Fazzari F, Fattori R, Ratti C, Murena L. Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:8-13. [PMID: 31821278 PMCID: PMC7233712 DOI: 10.23750/abm.v90i12-s.8974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 11/24/2022]
Abstract
Background and aim of the work: Post-operative periprosthetic shoulder fractures incidence is gradually raising due to aging of population and increasing of reverse total shoulder arthroplasty (RTSA). Management of this complication represents a challenge for the orthopedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of post-operative periprosthetic humeral fractures occurring on RTSA. Methods: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. Results: 31 studies including reviews, meta-analysis, case reports, clinical and biomechanical studies were selected. Conclusions: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation and revision arthroplasty are both valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate. (www.actabiomedica.it)
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Affiliation(s)
- Gianluca Canton
- Orthopaedics and Traumatology Unit, Cattinara Hospital, Department of Medical, Surgical and Life Sciences, Trieste University, Trieste (Italy).
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A review of metallic and non-metallic cerclage in orthopaedic surgery: Is there still a place for metallic cerclage? Injury 2019; 50:1627-1633. [PMID: 31326103 DOI: 10.1016/j.injury.2019.06.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/04/2019] [Accepted: 06/30/2019] [Indexed: 02/02/2023]
Abstract
Cerclage techniques are simple, yet effective techniques to treat certain fractures and are known as one of the first operative techniques in orthopaedic surgery. The days when a twisted metal wire was the only available cerclage technique nonetheless have passed and today there are many different materials and techniques available. This review evaluates the differences between metallic and non-metallic cerclage techniques, thereby looking at biomechanical, technical and biological aspects. It also provides an overview of clinical applications for non-metallic cerclages. The use of metallic versus non-metallic cerclage might differ depending on indication, location and involved tissues. Currently metallic cerclage is mostly used to repair fractures because of its believed higher absolute strength. More recently though, non-metallic cerclage has been proven to withstand the same loads, while having a lower complication rate. This review suggests that mainly in the upper limb a non-metallic cerclage technique might become the golden standard, while in the lower limb both metallic and non-metallic cerclage techniques are complementary and dependent on indication.
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Kadar A, Kahan JB, Leslie MP, Yoo BJ, Baumgaertner MR. Safe Zones for Cerclage Wiring of the Humeral Diaphysis. Clin Anat 2019; 33:552-557. [PMID: 31301242 DOI: 10.1002/ca.23433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/24/2019] [Accepted: 07/08/2019] [Indexed: 11/07/2022]
Abstract
Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Assaf Kadar
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
- Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Michael P Leslie
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Brad J Yoo
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Michael R Baumgaertner
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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Karayiannis P, James A. The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: a retrospective review of 465 patients. Eur J Trauma Emerg Surg 2019; 46:969-975. [PMID: 30612147 DOI: 10.1007/s00068-018-01071-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 12/29/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the potential impact of using cerclage cables or wires when undertaking fixation of unstable intertrochanteric and subtrochanteric fractures. METHODS Patients were identified from a validated hospital database which included patients from all trauma units within Northern Ireland from 2008 to 2015. The primary outcome measure was return to theatre for any reason. Secondary outcome measures included quality of reduction, tip-apex distance, length of stay, mortality at 3 and 12 months and functional outcomes assessed by Barthel Index and mobility. RESULTS 465 patients were included (157 in the cerclage/wire group and 308 without). Mean age of 79.6 years, with 330 females and 135 males. There was no statistical difference between the groups in relation to baseline demographics and risk factors for complications. 24 patients required further surgery, 13 (8.3%) in the cerclage group and 11 (3.6%) in those without (p < 0.03). Cabling of intertrochanteric fractures resulted in further surgery in 9.1% versus 3.4% without. Quality of reduction was improved in the cerclage group (p < 0.01), however improvements were less noticeable in intertrochanteric fractures (32.3% classified as good) compared to subtrochanteric fractures (52.4% good). Length of stay was longer in the cerclage group (p < 0.01). No differences were noted in mortality, Barthel score or mobility at 3 and 12 months. CONCLUSIONS Cerclage cables/wires can augment fixation in subtrochanteric fractures with potential benefits including improving quality of reduction. Evidence for their use in intertrochanteric fractures is much more contentious and we would advise they only be used where a definite improvement in reduction can be obtained with the minimum number possible.
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Affiliation(s)
- Paul Karayiannis
- Ulster Hospital, Belfast, Northern Ireland, UK. .,, 221 Mealough Road, Lisburn, BT27 5LE, Northern Ireland, UK.
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Gao YS, Guo YJ, Yu XG, Chen Y, Chen C, Lu NJ. A novel cerclage wiring technique in intertrochanteric femoral fractures treated by intramedullary nails in young adults. BMC Musculoskelet Disord 2018; 19:359. [PMID: 30292231 PMCID: PMC6173908 DOI: 10.1186/s12891-018-2284-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intertrochanteric femoral fractures (IFFs) in young adults, generally due to severe trauma, are increasingly presented. Different from IFFs in the geriatric population, these fractures in young adults are always comminuted and substantially displaced. Natural traction induced by musculature following IFFs determines closed reduction on a fracture table is extremely difficult. METHODS To achieve anatomical reduction before intramedullary nail (IMN) fixation, we made an extended or a mini petrotrochantetic incision to facilitate temporary reduction using a pointed clamp. Subsequently, a curved and cannulated wire-passer was employed to pass through a multistrand cable to surround displaced fragments and strengthen intertrochanteric fixation. Afterward, a standard procedure was conducted to nail the fracture. RESULTS We used the surgical technique in 9 young patients with an age range of 28~ 48 years old. The fractures were categorized as AO/OTA 31-A2.2 (3 cases) and 31-A2.3 (6 cases). The injury-to-surgery interval was 2.5 days on average. Mean operation time was 55 min. All fractures achieved anatomical reduction and healed within 14 weeks postoperatively without cable breakage, implant irritation or deep infection. CONCLUSIONS In conclusion, the surrounding technique with cerclage wire in IFFs in young adults is an effective surgical technique with easily achieved anatomical reduction to facilitate operative maneuvers and fracture healing.
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Affiliation(s)
- You-Shui Gao
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Yan-Jie Guo
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Xin-Gang Yu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Yang Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Chen Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Nan-Ji Lu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
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Reduction techniques for difficult subtrochanteric fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:197-204. [PMID: 29855787 DOI: 10.1007/s00590-018-2239-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/24/2018] [Indexed: 01/26/2023]
Abstract
Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.
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Chen KK, Nayyar S, Davidovitch RI, Vigdorchik JM, Iorio R, Macaulay W. Cemented Compared with Uncemented Femoral Fixation in the Arthroplasty Treatment of Displaced Femoral Neck Fractures. JBJS Rev 2018; 6:e6. [DOI: 10.2106/jbjs.rvw.17.00119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Grechenig S, Hohenberger G, Bakota B, Staresinic M, Grechenig P, Ernstberger A. Humeral shaft cerclage wiring: a safe technique to prevent radial nerve injury. Injury 2017; 48 Suppl 5:S12-S14. [PMID: 29122115 DOI: 10.1016/s0020-1383(17)30732-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Humeral periprosthetic fractures are a challenging problem and their occurrence has increased, particularly over the last decade. The role of cerclage wires or cables in these fractures includes revisions with longer stems, and augmentation of a plate osteosynthesis in which the stem does not allow additional screw placement or structural bone grafts as supplementary fixation. These procedures are demanding because of the proximity of the radial nerve within the operating field. Placing a cerclage wire or cable around the fractured fragments offers a simple and safe procedure to avoid radial nerve injury or palsy in the treatment of complex humeral shaft fractures. This new technique is a simple and safe procedure to place a cerclage wire or cable around the humeral shaft.
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Affiliation(s)
- Stephan Grechenig
- Clinic of Trauma Surgery, University of Regensburg, Regensburg 93053, Germany.
| | | | - Bore Bakota
- Trauma and Orthopaedics Department, Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Peter Grechenig
- Clinic of Trauma Surgery, University of Graz, 8010 Graz, Austria
| | - Antonio Ernstberger
- Clinic of Trauma Surgery, University of Regensburg, Regensburg 93053, Germany
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Combination of low-contact cerclage wiring and osteosynthesis in the treatment of femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:397-406. [PMID: 26983607 DOI: 10.1007/s00590-016-1761-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 03/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Objectives were (1) to evaluate results after cerclage wiring technique for femoral primary and periprosthetic fracture (PPF); (2) to report the incidence of complications and their treatment; (3) to analyze possible prognostic factors. PATIENTS AND METHODS We analyzed 54 patients treated with different techniques associated with low-contact cerclage wires for femoral fracture. Fractures were stratified according to AO, Vancouver or Rorabeck classification. Cerclage was used as an exclusive implant in four PPFs or combined with internal devices in 50 cases. Comorbidities were assessed using Charlson Comorbidity Index. The Glasgow Outcome Scale was used to compare activities of daily living pre/postoperatively. RESULTS Cerclage wires with three or four spacers were used in 22 and 32 cases, respectively. Nine patients died within 6 months. Mean follow-up of the remaining 42 patients was 10.5 months. Fracture healing was achieved in 38/42 patients (71 %), with a mean time to callus formation of 57 days and to radiographic union of 3 months (1.5-9 months). Four patients had nonunion. Survival to major complications was 92 and 70 % at 1 and 2 years, respectively, significantly better in cerclage wires with three spacers than those with four spacers (p = 0.0188). No other statistical correlations were found. CONCLUSION Cerclage wiring in difficult femoral fractures offers minimally invasive reduction and fixation technique, low cost and early holding. We reinforce the concept of "reduce with cerclage cables first, then nail" for displaced long subtrochanteric fractures and support the use of cerclage wiring for challenge PPF using low-contact wires. LEVEL OF EVIDENCE Therapeutic study, Level IV.
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Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management. INTERNATIONAL ORTHOPAEDICS 2015; 39:1965-9. [PMID: 26318881 DOI: 10.1007/s00264-015-2972-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to record the incidence and management of periprosthetic humeral fractures (PHF) using reverse total shoulder arthroplasty (RTSA) in our institution. METHODS We performed a retrospective study of 203 RTSA implanted in 200 patients between 2003 and 2014. The mean follow-up was 78.82 months (range, 12-141). Mean age of the study cohort was 75.87 years (range, 44-88). There were only 25 male patients (12.5 %). We assessed the presence of periprosthetic humeral fractures studying the medical files and X-rays of all patients. RESULTS We identified seven periprosthetic humeral fractures in 203 RTSA (3.4 %): three intra-operative (1.47 %) and four post-operative (1.97 %). The average age at the time of the fracture was 75.14 years (59-83). All patients were women (100 %). Three patients with post-operative fractures type B were treated by osteosynthesis, and one patient with post-operative fracture type A was treated conservatively. All intra-operative fractures needed cerclage wire and in one case long cemented stem. All our periprosthetic fractures healed. CONCLUSIONS Surgical treatment with osteosynthesis in type B post-operative fractures with a stable stem is recommended. Conservative treatment is sufficient in non-displaced type A post-operative fracture. Special attention should be paid to bone quality patients using non-cemented stems in primary surgery but especially in revision shoulder surgery.
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