Combination of low-contact cerclage wiring and osteosynthesis in the treatment of femoral fractures

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

INTRODUCTION AND IMPORTANCE

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

LEVEL OF EVIDENCE

A case report.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The race for the classification of proximal periprosthetic femoral fractures : Vancouver vs Unified Classification System (UCS) - a systematic review

Background

Periprosthetic femoral fractures (PFFs) represent a major cause for surgical revision after hip arthroplasty with detrimental consequences for patients. The Vancouver classification has been traditionally used since its introduction in 1995. The Unified Classification System (UCS) was described in 2014, to widen the spectrum by aiming for a more comprehensive approach. The UCS also aimed to replace the Vancouver classification by expanding the idea of the Vancouver classification to the whole musculoskeletal apparatus. After introduction of the UCS, the question was raised, whether the UCS found its place in the field of analysing PFFs. Therefore, this systematic review was performed to investigate, the use of the UCS compared to the established Vancouver classification.

Methods

Medline was searched for reports published between 1 January 2016 and 31 November 2020, without language restriction. Included were original articles, irrespective of the level of evidence and case reports reporting on a PFF and using either the Vancouver or the UCS to classify the fractures. Excluded were reviews and systematic reviews.

Results

One hundred forty-six studies were included in the analysis. UCS has not been used in a single registry study, giving a pooled cohort size of 3299 patients, compared to 59,178 patients in studies using the Vancouver classification. Since 2016, one study using UCS was published in a top journal, compared to 37 studies using the Vancouver classification (p=0.29). During the study period, the number of yearly publications remained stagnant (p=0.899).

Conclusions

Despite valuable improvement and expansion of the latter UCS, to date, the Vancouver system clearly leads the field of classifying PFFs in the sense of the common use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05240-w.

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

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

Surgical Selection of Unstable Intertrochanteric Fractures: PFNA Combined with or without Cerclage Cable

Due to the instability of unstable intertrochanteric fractures, the selection of a suitable internal fixation has always been a challenge for orthopedic surgeons. This study is aimed at comparing the clinical efficacy of PFNA combined with cerclage cable and without cerclage cable and finally recommend a stable internal fixation method to provide the basis for clinical therapy. From January 2014 to January 2018, we retrospectively analyzed all cases of unstable intertrochanteric fractures who received treatment in the Orthopedics Department of our hospital and finally screened 120 cases, 51 of whom were treated with cerclage cable, 69 without cerclage cable. The follow-up period was one year. HHS, BI, and RUSH scores were given within the specified time. We divided the patients into the PFNA+cable (PFNA combined with cerclage cable) group and the PFNA group. The time of fracture healing and weight-bearing in the PFNA+cable group was shorter than that in the PFNA group. With regard to HHS, BI, and RUSH, the PFNA+cable group was higher than the PFNA group at 1 month, 3 months, 6 months, and 12 months after operation. For HHS rating, the PFNA+cable group has a higher excellent rate than the PFNA group, which was 96.1% and 84.1%, respectively. All the results mentioned above were statistically significant. Compared with the group without cerclage cable, the application of cerclage cable can reduce the incidence of complications. From the comparison between the two groups, it can be seen that the surgical method of PFNA combined with cerclage cable can not only help to improve the stability of fracture reduction, shorten the time of fracture healing and postoperative weight-bearing, and significantly improve patients' self-care ability but also reduce the incidence of postoperative complications. Therefore, we think PFNA combined with cerclage cable is a good choice.

More than a reposition tool: additional wire cerclage leads to increased load to failure in plate osteosynthesis for supracondylar femoral shaft fractures

INTRODUCTION

Surgical treatment of supracondylar femoral fractures can be challenging. An additional wire cerclage is a suggested way to facilitate fracture reduction prior to plate osteosynthesis. Denudation to the periosteum remains a problematic disadvantage of this procedure. This study analyzed the effect of an additional wire cerclage on the load to failure in plate osteosynthesis of oblique supracondylar femoral shaft fractures.

MATERIALS AND METHODS

On eight pairs of non-osteoporotic human femora (mean age 74 years; range 57-95 years), an unstable AO/OTA 32-A2.3 fracture was established. All specimens were treated with a polyaxially locking plate. One femur of each pair was randomly selected to receive an additional fracture fixation with a wire cerclage. A servohydraulic testing machine was used to perform an incremental cyclic axial load with a load to the failure mode.

RESULTS

Specimens stabilized with solely plate osteosynthesis failed at a mean load of 2450 N (95% CI: 1996-2904 N). In the group with an additional wire cerclage, load to failure was at a mean of 3100 N (95% CI: 2662-3538 N) (p = 0.018). Compression deformation with shearing of the condyle region through cutting of screws out of the condylar bone was the most common reason for failure in both groups of specimens. Whereas axial stiffness was comparable between both groups (p = 0.208), plastic deformation of the osteosynthesis constructs differed significantly (p = 0.035).

CONCLUSIONS

An additional wire cerclage significantly increased the load to failure. Therefore, an additional cerclage represents more than just a repositioning aid. With appropriate fracture morphology, a cerclage can significantly improve the strength of the osteosynthesis.

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

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Femoral artery entrapment after cerclage wiring of distal femoral shaft fracture: A case report

Femoral artery injury after femoral fracture fixation is a rare complication. Previous literature studies focused mostly on proximal femur fracture. We described a case of superficial femoral artery entrapment after internal fixation augmented with cerclage wire. An 80-year-old female underwent fixation with distal femur locking compression plate augmented with cerclage wire. Six hours after the operation, she developed pulseless limb and computed tomography angiogram showed femoral artery entrapped by cerclage wire. After vascular exploration and cerclage wire removal, the femoral artery returned to normal flow without further complication. We review available literature studies on vascular injury after cerclage wiring especially in the distal part of the femur, the so-called safe zone, for the great care needed before cerclage wiring and the importance of immediate diagnosis and treatment.

The effect on outcomes of the application of circumferential cerclage cable following intramedullary nailing in reverse intertrochanteric femoral fractures

INTRODUCTION

The aim of this study was to evaluate the effect on union results of the application of cerclage cable around the lateral femoral wall (LFW) in postoperative fracture displacement.

PATIENTS AND METHODS

A retrospective evaluation was made of all the cases of reverse intertrochanteric fractures over a 7-year period in a trauma center. The study included 69 fractures treated with intramedullary nailing. The age of the patients, postoperative reduction quality and complications such as mechanical failure and non-union (1.4%) were obtained from the medical records. Changes in the neck-shaft angle, the amount of LFW displacement and telescoping of proximal femoral nail antirotation blades and lag screws were measured on anteroposterior and lateral radiographs. The functional evaluation of the Harris Hip Score was recorded at the final follow-up examination.

RESULTS

The mean age of the patients was 56.31 years (range 18-93 years). Closed reduction was applied in 37 (53.7%) cases, open reduction in 10 (14.5%) and with cerclage cable in 22 (31.8%). Mechanical failure developed in 8 (11.5%) cases where cerclage cable was not used. In 2 of these 8 cases, open reduction was successful. In the patients where cerclage cable was applied, no mechanical failure developed and no case underwent revision surgery. In the cases where cerclage cable was not used, a significantly higher rate of telescoping was found. (p = 0.001). The application of cerclage cable was seen to significantly reduce the amount of LFW displacement (2.23 mm vs 8.86 mm) and shorten the time to partial weight bearing (p = 0.000).

CONCLUSION

In reverse intertrochanteric fractures, the application of circumferential cerclage cable with cephalomedullary nailing contributes to primary stability and accelerates mobilization. Therefore, it can be considered a good option. It reduces the risk of failure internal fixation for intertrochanteric fracture.

A novel cerclage wiring technique in intertrochanteric femoral fractures treated by intramedullary nails in young adults

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.

Reduction techniques for difficult subtrochanteric fractures

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.

Vascular complication after percutaneous femoral cerclage wire

Cerclage wire is an effective fracture fixation method. However, its mechanical benefits are countered by local ischemia. Its efficacy for treating femoral periprosthetic fractures has been demonstrated since femoral fixation is possible even there is a stem in the diaphysis. It securely holds the proximal femur typically with an additional plate. The development of minimally-invasive surgery with plate fixation has led to the cerclage wire being inserted percutaneously. Here, we report on a case of secondary femoral ischemia following percutaneous cerclage wire of a periprosthetic femoral fracture. This was a Vancouver type B1 fracture. On the 3rd day after admission, minimally-invasive fixation with a femoral locking plate was performed with five cerclage wires added percutaneously. During the immediate postoperative course, the patient developed ischemia of the operated leg that required vascular surgery after confirmation by CT angiography. An arterial stop was visible with deviation of the superior femoral artery, which was not properly surrounded by the cerclage wire. The latter pulled perivascular tissues towards the femur. When combined with reduced arterial elasticity due to severe atherosclerosis, it resulted in arterial plication. The postoperative course was marked by multiple organ failure and death of the patient. Percutaneous surgery is an attractive option but has risks. The presence of severe atherosclerosis is a warning sign for loss of tissue elasticity. This complication can be prevented by preparing the bone surfaces and carefully positioning the patient on the traction table to avoid forced adduction. The surgeon must also be familiar with alternative techniques to cerclage wire such as polyaxial screws and additional plates.