Intramedullary nailing for irreducible spiral subtrochanteric fractures: A comparison of cerclage and non-cerclage wiring

PURPOSE

Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages. However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment. This study was performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures.

METHODS

Patients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed. The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group. The patients' clinical data, including the operative time, intraoperative blood loss, hospital stay, reoperation rate, fracture union time, and Harris hip score, were compared between these 2 groups. Categorical variables were compared using Chi-square or Fisher's exact test. Continuous variables with normal distribution were presented as mean ± standard deviation and analyzed with Student's t-test. Non-normally distributed variables were expressed as median (Q1, Q3) and assessed using the Mann-Whitney test. A p value < 0.05 was considered significant.

RESULTS

In total, 69 patients were included in the study (35 patients in the non-cerclage group and 34 patients in the cerclage group). The baseline data of the 2 groups were comparable. There were no significant difference in the length of hospital stay (z = -0.391, p = 0.696), operative time (z = -1.289, p = 0.197), or intraoperative blood loss (z = -1.321, p = 0.186). However, compared with non-cerclage group, the fracture union time was shorter (z = -5.587, p < 0.001), the rate of nonunion was lower (χ2 = 6.030, p = 0.03), the anatomical reduction rate was higher (χ2 = 5.449, p = 0.03), and the Harris hip score was higher (z = -2.99, p = 0.003) in the cerclage group, all with statistically significant differences.

CONCLUSIONS

Intramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures. This technique can improve the reduction effect, increase the stability of fracture fixation, shorten the fracture union time, reduce the occurrence of nonunion, and contribute to the recovery of hip joint function.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Adjunctive intraosseous wiring fixation technique for the comminuted distal humeral fractures

Distal humeral fractures are among the most challenging injuries to treat. Although precise repair of the articular surface is essential during surgery, accurate reconstruction of the metaphysis contributes to the overall stability of the fracture construct. The intraosseous wiring technique has been used for small-fragment fractures. However, its efficacy as an adjunct for distal humerus fixation has yet to be thoroughly investigated. This study aimed to demonstrate the applicability of this technique to comminuted, distal humeral fractures. In this retrospective case series, we describe 6 cases of intra-articular distal humerus fractures treated with this technique, followed by dual plating. We observed successful bone union in all patients, with the Mayo Elbow Performance Scores indicating "good" to "excellent" clinical outcomes for this procedure at the final follow-up. We believe that this intraosseous wiring technique should be an integral part of the toolbox of every surgeon because it is a relatively simple and highly effective procedure that requires no special instrument and can be used on various types of fractures.

Hybrid Tension Band Wiring for Olecranon Fractures

Tension band wiring (TBW) is a standard surgical technique for treating olecranon fractures (OFs). We devised a hybrid TBW (HTBW) combining TBW using wires with eyelets and cerclage wiring. Twenty-six patients with isolated OFs with Colton classification groups 1-2C were subjected to HTBW, and the data was compared with those treated with conventional TBW (38 patients). The mean operation time and hardware removal rate were 51 versus 67 minutes (p < 0.001) and 42% versus 74% (p < 0.012), respectively. The HTBW group had one patient (4%) with surgical wire breakage. The conventional TBW group had 14 patients (37%) with symptomatic backout of Kirschner wires, three patients (8%) with loss of reduction, two patients (5%) with surgical site infection and one patient (3%) with ulnar nerve palsy. The motion and functional score ranges of the elbow were not significantly different. Therefore, this procedure may be a feasible alternative. Level of Evidence: Level V (Therapeutic).

Management of comminuted inferior patellar pole fractures with cerclage-wire-augmented separate vertical wiring: a retrospective clinical study

PURPOSE

Comminuted inferior patellar pole fractures are challenging injuries and require effective treatment due to the extension mechanism of the knee. This study aims to evaluate the outcome of above fractures treated with a modified technique of cerclage-wire-augmented separate vertical wiring (SVW) with cerclage wiring passed through the proximal patella.

METHODS

Retrospective analysis (1/2017-1/2020) were performed for patients that were treated with three SVWs through the posterior margin of proximal fragment and directly to the anterosuperior border of patella, combined with a cerclage wiring passed through the proximal patella. Patients who experienced comminuted inferior patellar pole fractures within 3 weeks were included, and the outcome was evaluated radiologically and clinically by Bostman score after a minimum of 12 months following surgery. Further evaluation included the operation time and complication rate.

RESULTS

A total of 20 patients (10 males, 10 females) with a mean age of 54 ± 14.5 years (26-83 years) and a follow-up of 18.9 ± 6.6 months (12-36 months) were evaluated. The average operation time was 45.7 ± 8.8 min (30-60 min). At final follow-up, the average range of motion was 131.3° ± 3.5° (125°-135°), and the mean Bostman score was 29.4 ± 0.7 points (28-30) and graded excellent in all cases. Two patients experienced occasional giving way of the knee. Radiologically no loss of reduction, implant breakage, nonunion or skin irritation was observed.

CONCLUSIONS

The cerclage-wire-augmented SVW with cerclage wiring passed through the proximal patella appears to be a safe and simple technique which can effectively treat the comminuted inferior patellar pole fractures.

Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature

Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.

The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis

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.

Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study

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.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of evidence

III.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Morphology Specific Lateral Wall Reconstruction Techniques Using Cerclage Wires in Unstable Trochanteric Fractures

Trochanteric lateral wall fracture (LWF) indicates instability and is found to be an important predictor of reoperations following trochanteric fracture fixation. A single unified technique for lateral wall reconstruction may not adequately stabilize all the fracture patterns. We have presented morphology specific lateral wall reconstruction techniques using cerclage wire around proximal femoral nails. Various LWF patterns have been simplified into three types. Type-specific lateral wall reconstruction techniques using cerclage wire were adopted in 49 consecutive unstable trochanteric fractures presented to our institute between 2016 and 2018. We analyzed the fracture pattern, fixation method used, union time, and complications. The functional outcome was analyzed using the Harris hip score (HSS). The mean follow-up period was 13 months (range 10-36 months). The mean age of the population was 66 years (range 36-91 years). There were 15 patients with type 1 LWF pattern, 26 patients with type 2, and 8 were of type 3 pattern. The mean operating time was 66 min. The mean union time was 14 weeks (10-24 weeks). HSS was excellent in 9 patients, good in 33 patients, fair in 4 patients, and poor in 5 patients. Complications include one patient with avascular necrosis (AVN) of the femoral head, varus collapse with non-union in one patient, screws back out in one patient, superficial infection in 4 patients, and distal screw breakage in one patient. Type 2 is the most common LWF type in our study. In unstable trochanteric fractures, morphology specific lateral wall reconstruction using cerclage wire loops around the proximal femoral nail is a simple technique with promising results with minimal complications.

Management of comminuted patellar fracture fixation using modified cerclage wiring

Background

Although there are several different kinds of fixation techniques for displaced comminuted patellar fracture, the treatment remains a challenge for orthopaedic surgeons. The purpose of this study is to evaluate the effectiveness and safety of a fixation technique for comminuted patellar fracture fixation using modified cerclage wiring.

Methods

From February 2016 to April 2018, 38 cases of simple unilateral closed comminuted patellar fracture were treated by modified cerclage wiring. Among these cases, 16 patients were males and 22 were females, aged 23–68 years (average 40.4 ± 9.1 years). Comminuted patellar fractures were classified according to the AO/OTA classification: 10 cases were type 34-C2 (three fragments), 28 cases were type 34-C3 (more than three fragments). Postoperative complications including loosening of internal fixation, fragment re-displacement, nonunion, infection, breakage of internal fixation and traumatic osteoarthritis were assessed. The clinical results after operation were evaluated by the clinical grading scales of Böstman including range of movement, pain, work, atrophy, assistance in walking, effusion, giving way, and stair-climbing during follow-up.

Results

A total of 38 patients were followed up for 6–36 months (mean time 16.1 ± 5.8 months). The bone union radiographically occurred at approximately 2.5–3.5 months (mean time 2.92 ± 0.25 months). No postoperative complications, such as infection, dislocation, breakage of the implants, painful hardware, and post-traumatic osteoarthritis, were observed. According to the clinical grading scales of Böstman, satisfactory results were obtained, and the mean score at the final follow-up was 28.7 (range 20–30) points. Thirty-two patients (84.2%) with excellent results had a mean score of 29.5 ± 0.7 (range 28–30) points, and six patients (15.8%) with good results had a mean score of 24.5 ± 2.2 (range 20–27) points. The patients with excellent and good scores had active flexion of 130° (110–140).

Conclusions

Modified cerclage wiring can effectively treat comminuted patellar fracture and offers a new strategy resulting in satisfactory results without obvious complications.

Boyd Amputation Using the Tension Band Technique

Background

Amputation at the level of the hindfoot results in an equinus deformity from an imbalance of muscle-tendons acting across the ankle. Boyd’s reconstruction for hindfoot amputations is a well-known technique that retains the calcaneus and fuses it with the distal tibia at the ankle mortise. It provides an excellent weight-bearing stump and in most cases does not require an artificial limb but its use has been restricted because of the difficulty in obtaining high union rates in the tibiocalcaneal fusion.

Materials and methods

Five patients (four unilateral and one bilateral) underwent leg amputations from January 2012 to November 2013 using the Boyd technique for reconstructing the stump and were stabilized with a tension band. The study sample consisted of adult patients who had traumatic reasons for the amputation. Patients under 18 years old with a hindfoot that was inadequate for Boyd reconstruction (i.e., insufficient soft tissue coverage or no posterior tibial artery pulse) were excluded. One (case #2) had systemic comorbidities (e.g., hypertension, diabetes, chronic vascular insufficiency) as well as being a smoker. Three men and two women (mean age 39 years; range 21–61 years) were included. Three patients underwent amputation on the right side, one on the left side, and one bilaterally (case #5). All patients presented with Gustillo and Anderson IIIC open fractures. The mean time from lesion to amputation was 2.25 weeks (range 1–4 weeks). The mean follow-up duration was 16 (range 12–24) months. The post-surgery examination included a clinical examination and radiography. A 6 minute walk test (6 MWT) was performed on week 32 after the amputation. This study was carried out with the approval of our institution’s ethics committee. All patients provided a written informed consent form in accordance with the World Medical Association and the Declaration of Helsinki.

Results

All six stumps fused successfully. The 6 MWT results were comparable to those found in the literature for other lower limb amputees.

Conclusion

The tension band technique used as part of the Boyd amputation to achieve tibiocalcaneal fusion was effective in all five trauma patients. Sound fusion was achieved in all cases with the 6 MWT scores comparable to that in the literature. This technique should be considered an osteosynthesis option for the Boyd procedure.

Level of evidence

Level IV, retrospective study.

How to cite this article

Mongon MLD, Sposito AL, Nunes GMN, et al. Boyd Amputation Using the Tension Band Technique. Strategies Trauma Limb Reconstr 2019;14(2):102–105.

Outcomes of Intramedullary Nailing with Cerclage Wiring in Subtrochanteric Femoral Fractures

Aims

The aim of this study was to compare the outcomes of closed reduction against open reduction with cerclage wires in patients with subtrochanteric fractures treated with intramedullary nailing (IMN).

Materials and methods

We identified 141 patients who had an IMN over a 4-year period. They were classified into three groups based on fracture pattern and whether open or closed reduction was performed. Type I was a transverse fracture, type II, a spiral fracture with an intact posterior and medial wall in the proximal fragment, and a type III fracture without intact posterior or medial walls. The primary outcome measure was a revision surgery for implant failure. Secondary outcome measures were related to fracture reduction and radiological union scores of the hip (RUSH).

Results

There were 35 patients who had a type I fracture, 26 patients with a type II fracture, and 80 patients with a type III fracture. The mean follow-up was 7 months. Closed reduction in type III fractures was associated with a significantly increased risk of mechanical complications (p = 0.005) and unplanned returns to theatre for implant failure (p = 0.04) as compared to open reduction. Open reduction in type III fractures was associated with a significantly higher mean RUSH scores (p = 0.0006). There was no significant difference in mean operative time between open and closed reduction in type III fractures (p = 0.12).

Conclusion

We recommend open reduction with cerclage wiring in type III subtrochanteric fractures in order to reduce the risk of implant failure, nonunion, and need for further surgery.

How to cite this article

Mehta NJ, Goldsmith T, Lacey A, et al. Outcomes of Intramedullary Nailing with Cerclage Wiring in Subtrochanteric Femoral Fractures. Strategies Trauma Limb Reconstr 2019;14(1):29–33.

Fixation of the Various Coronal Plane Fracture Fragments, Including the Entire Coronoid Process, in Patients with Mayo Type IIB Olecranon Fractures - Four Methods for Fixation

BACKGROUND

We introduce several methods for fixation of unique Mayo type II olecranon fractures with the coronal plane fragment (CPF) including the entire coronoid process and report the radiological and clinical results through a case series.

MATERIALS AND METHODS

12 patients were operated using this method with a mean age of 44 years. CPFs were fixed with concurrent fixation by a locking plate screw for the olecranon in three patients (method 1), cerclage wiring in six patients (method 2), a mini plate in two patients (method 3), and a double-locking plate (method 4) in one patient. We accessed the fragment through an additional medial coronoid approach after identifying the olecranon fragment through a dorsal approach (methods 1-3). In method 4, the CPF was fixed through a dorsal approach between the comminuted metaphyseal fragments.

RESULTS

With the exception of one patient with delayed union, all patients had achieved union at 3-month followup. The mean flexion extension arc was 125°. The mean pronation/supination was 72.5°/71.7° (range, 60-80°/60-80°). The mean visual analog scale score for elbow pain was 0.92 (range, 0-2), and the mean Mayo Elbow Performance Score was 86.7 (range, 80-90). The mean Disabilities of the Arm, Shoulder, and Hand score was 10.2 (range, 4-14). There were no major complications.

CONCLUSION

A thorough preoperative understanding of the fragment patterns and preparation of tools for adequate reduction and fixation are necessary for satisfactory clinical and radiological outcomes. However, further comparative trials of conservative management versus surgery for CPF fixation, and any differences in outcomes according to the CPF fixation options, are required.

Medial malleolus fractures: A biomechanical comparison of tension band wiring fixation methods

BACKGROUND

This study compared the biomechanical properties of three different fixation methods of tension band wirings, used in the treatment of medial malleolus fractures. The first method used an innovative "handmade bent pin" for cerclage fixation. The second method used a U-shaped K-wire to attach the cerclage to the medial tibial cortex. These two novel fixation techniques were compared with the traditional tension band wiring technique which is fixated to the bone by a screw.

HYPOTHESIS

Novel fixation techniques of tension band wiring provide stable fixation.

MATERIAL AND METHODS

In this study 27 artificial bone models, which medial malleolus fractures were simulated on, were used. Using an electromechanical test device, the force required to pull out each implant was assessed and compared.

RESULTS

This study found that; while handmade bent pinning resulted averagely 840.25N (range: 647-1066±118.72) and U-shaped K-wire fixation was 381.71N (range: 176-651±150.2) pull out strength, traditional tension band wiring indicated 871.33N (range: 549-1008±137.74) pull out strength.

DISCUSSION

Handmade bent pinning method provide similar results with traditional tension band wiring. Therefore, in suitable cases, it may be an acceptable alternative to traditional tension band wiring techniques when treating malleolar fractures. Although the outcomes of U-shaped K-wire fixation indicated lower than other two groups, the outcomes were comparable with the literature. So while performing tension band wiring, both handmade fixation systems may be used in certain cases. For Orthopaedic surgeons, it is better to know and think about these alternative handmade pinning systems created from simple K-wires during the surgery if needed.

LEVEL OF EVIDENCE

IV, Biomechanical trial.

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

INTRODUCTION

Cerclage wiring for reduction of complex femoral shaft fractures can create iatrogenic vascular injury.

OBJECTIVE

To describe the anatomical relation of blood vessels to the femur and develop a technical guide for safe passage of cerclage wire.

MATERIALS AND METHODS

CT lower-limb angiographs (CTA) of 80 patients were reviewed and analysed to identify the superficial femoral artery (SFA) and the deep femoral artery (DFA) as well as the relation of those arteries to the femoral cortex. The total length of the femur was measured and divided into eight equal segments (seven levels). At each level, the medial half of the femur was divided into eight sectors labelled A through H and the position of the SFA and DFA was recorded. The shortest distance between the femoral cortex and the SFA and DFA at each level was measured. The data was analysed using STATA version 10.0.

RESULTS

The average total femoral length from the tip of greater trochanter to lateral joint line was 402.98 ± 26.16 cm. The average distances from the SFA to the femur (d1) for levels 1 through 7 were 37.20 ± 5.0, 32.09 ± 4.74, 27.13 ± 4.19, 27.71 ± 5.46, 23.71 ± 4.40, 13.63 ± 3.59 and 10.08 ± 3.09 mm, respectively. The average distances between the DFA and the femur (d2) for levels 1 through 3 were 26.70 ± 4.13, 14.76 ± 3.27 and 9.58 ± 3.79 mm, respectively. The position of the SFA is located in sectors B through E at levels 1-3 and in sectors E through H at levels 4-7 and the position of the DFA located in sectors B through F at levels 1-3.

CONCLUSION

Cerclage wiring should be started from the posterior intermuscular septum at the linea aspera. The safe area is the proximal half (midshaft) of the femur where the SFA and DFA lie at a safe distance from the femur. Between the midshaft and the distal 1/4, insertion of the passer must be done meticulously with the tip kept close to posteromedial cortex. Below the distal 1/4, the tip of the passer should be kept close to the posterior cortex to avoid injury to the SFA and the sciatic nerve.

Amputated limb by cerclage wire of femoral diaphyseal fracture: a case report

An entrapment of the femoral artery by cerclage wiring is a rare complication after spiral diaphyseal femoral fractures. We report the case of an 82-year-old female treated by an antegrade intramedullary nailing and multiple cable augmentation, which was then complicated by injury to the femoral artery that resulted in ipsilateral leg necrosis and amputation. The entrapment was caused by direct belting by the cable and resulted in a total obstruction of the femoral artery.

Biomechanical evaluation of periprosthetic refractures following distal femur locking plate fixation

INTRODUCTION

Distal femur fractures proximal to total knee femoral component constitutes the most prevalent type of periprosthetic fracture, and plate fixation treatment is associated with a 7.7% incidence of refracture proximal to the plate. The primary objective of this study was to compare proximal fixation techniques of a periprosthetic distal femur fracture plate in an osteoporotic bone model. The secondary objective was to determine the subsequent periprosthetic plate fracture pattern and/or complexity associated with each proximal plate fixation configuration.

MATERIALS AND METHODS

A segmental defect was created in 21 synthetic osteoporotic adult femurs 6 cm proximal to the distal femur and all specimens were stabilised with a 246 mm locking femur plate. Fixation in the most proximal hole was varied by use of either a cerclage cable, unicortical locking screw, or a bicortical locking screw. Specimens were tested to failure in simultaneous eccentric compression and torsion.

RESULTS

Proximal cerclage fixation demonstrated higher mean maximum axial force at failure (4142.67±178.71 N, p<0.001), stiffness (443.8±61.64 N/mm), and maximum torque (20.9±0.93 N m, p<0.001). Unicortical and bicortical screw refractures occurred at the screw, cerclage wire refractures occurred at the first proximal screw distal to the cerclage.

CONCLUSIONS

In periprosthetic distal femur fracture locking plate fixation, proximal hole stabilization with a cerclage wire tolerates significantly higher failure forces while distributing forces distal to the area within the plate fixation. Cerclage wiring may be an option in distal femur periprosthetic fractures to alleviate stress risers in vulnerable bone.

A novel technique of patella fracture fixation facilitating early mobilization and reducing re-operation rates

OBJECTIVE

Fractures of patella constitute 1% of all fractures. Various techniques have been described for internal fixation of patella fractures. Superiority of one technique over the other has long been debated. We reviewed a series of fifty-one patients with transverse or comminuted fractures of patella treated with a novel technique to assess if it had any advantages over the existing methods of fixation.

DESIGN

Retrospective.

SETTING

A tertiary care centre.

PATIENTS & METHODS

Fifty-one patients with patella fracture OTA 34C, with a mean age of 39 years (range 18-61) were treated with technique of cerclage and two tension bands at our institute. Forty-eight patients completed the study.

MAIN OUTCOME MEASUREMENTS

Range of Motion and evidence of radiological union were assessed at regular follow-ups.

RESULTS

Forty-four out of forty-eight patients had gained up-to 90 degrees of active flexion at the end of 1 week. Two patients (4.2%) developed superficial infection. All fractures had united at the end of 12 weeks. Five patients (10.3%) underwent a second surgery; four (8.3%) due to implant related complications. Malunion or non-union was not noted in any of the cases.

CONCLUSION

The advantages of the described method are early mobilization, elimination of k-wire related complications, and ease of use in comminuted fracture pattern as well and a lower reoperation rates as compared to the available literature. We strongly recommend its use in cases of displaced comminuted/transverse fractures of patella as an alternate method of treatment.

LEVEL OF EVIDENCE

Level III.