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

Abstract 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.

Download Full-text

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

Journal of Clinical Medicine ◽

10.3390/jcm10153331 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3331

Author(s):

Michalis Panteli ◽

James S. H. Vun ◽

Robert M. West ◽

Anthony Howard ◽

Ippokratis Pountos ◽

...

Keyword(s):

Risk Factors ◽

Staphylococcus Aureus ◽

Femoral Fractures ◽

Deep Infection ◽

P Value ◽

Superficial Infection ◽

Revision Operation ◽

Non Union ◽

Prolonged Length ◽

Micro Organisms

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

Download Full-text

Union rates and functional outcome of double plating of the femur: systematic review of the literature

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-021-03767-6 ◽

2021 ◽

Author(s):

M. F. Lodde ◽

M. J. Raschke ◽

J. Stolberg-Stolberg ◽

J. Everding ◽

S. Rosslenbroich ◽

...

Keyword(s):

Systematic Review ◽

Fracture Healing ◽

Functional Outcome ◽

Femoral Fractures ◽

Periprosthetic Fractures ◽

Level Of Evidence ◽

Distal Femoral Fractures ◽

Femur Fractures ◽

Meta Analyses ◽

Double Plating

Abstract Background The optimal treatment strategy for the surgical management of femur fractures and non-unions remains unknown. The aim of this study is to assess union rates, complications and outcome after femoral double plating. Treatment of shaft, distal, periprosthetic fractures and pathological proximal femur fractures as well as femoral non-unions with double plating were evaluated. Methods A systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was conducted. Published literature reporting on the treatment and clinical outcome of femoral fractures and non-unions with double plating was identified. In total, 24 studies with 436 cases of double plating, 64 cases of single plating, 84 cases of intramedullary nailing (IM), and 1 interfragmentary screw treatment met the inclusion criteria of this systematic review. The evaluated literature was published between 1991 and 2020. Results Double plating of femoral fractures achieved high healing rates and few complications were reported. It displayed significantly less intraoperative haemorrhage, shorter surgery time reduced risk of malunion in polytraumatised patients when compared to IM. Fracture healing rate of double-plating distal femoral fractures was 88.0%. However, there were no significant differences regarding fracture healing, complication or functional outcome when compared to single plating. Treatment of periprosthetic fractures with double plating displayed high healing rates (88.5%). Double plating of non-unions achieved excellent osseous union rates (98.5%). Conclusions The literature provides evidence for superior outcomes when using double plating in distal femoral fractures, periprosthetic fractures and femoral non-unions. Some evidence suggests that the use of double plating of femoral fractures in polytraumatised patients may be beneficial over other types of fracture fixation. Level of evidence IV.

Download Full-text

Trigen Intertan Nail in Unstable Peritrochanteric femur fractures in the Elderly -functional and radiological outcomes in 50 cases

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00079 ◽

2020 ◽

Vol 8 (5_suppl5) ◽

pp. 2325967120S0007

Author(s):

Sanjeev Patnaik ◽

Akash Panda

Keyword(s):

Femoral Fractures ◽

The Elderly ◽

Harris Hip Score ◽

Radiographic Evaluation ◽

Non Union ◽

Femur Fractures ◽

Modified Harris Hip Score ◽

Head Neck ◽

Intertan Nail

INTRODUCTION: Peritrochanteric femur fractures have increased significantly in recent decades and the trend continues, due to rising age of the population. Surgical treatment, in the form of rigid internal fixation and early mobilization is now the gold standard. One of the recent implant developments is the Trigen Intertan Nail (Smith & Nephew) for the treatment of peri-trochanteric femur fractures that uses 2 cephalocervical screws in an integrated mechanism allowing linear intra-operative compression and rotational 3-point stability of the head/neck fragment. AIMS & OBJECTIVE: To analyse the functional & radiological outcomes using TRIGEN INTERTAN nail for the treatment of peri-trochanteric femur fractures in the elderly population. DESIGN: Prospective study. METHODS: Between March 1, 2016, and March 31, 2019, 50 patients with an intertrochanteric femur fracture were treated with Trigen InterTan Nail (Smith-Nephew). All fractures were classified by OTA/AO Classification. All surviving patients were followed up for a minimum of 6 months post-operatively. Functional and radiographic evaluation were performed at 3 months & 6 months follow up using the modified Harris hip score. RESULTS: The age of the patients was 60-85 years. 2 patients died due to other co-morbidites, 3 did not come for follow up, leaving 45 patients available for final evaluation. The surgical time was 60-90 minutes. All fractures showed radiological union within 12-16 weeks . Radiographic analysis at healing revealed no loss of reduction, no uncontrolled collapse , no non-union, no femoral shaft fractures, and no implant failures. 2 cases had trochanteric split intra-operatively, requiring cerclage wiring, 1 case was poorly reduced and had varus malalignment. Modified Harris hip score was excellent in 20 patients, good in 10 cases, fair in 9 cases and poor in 1 case. CONCLUSIONS: The Trigen Intertan nail appears to be a reliable implant for the treatment of peri-trochanteric femoral fractures. Its design provides for stability against rotation and minimizes neck mal-unions (shortening) through linear intraoperative compression of the head/neck segment to the shaft. As a result of the minimal complication rate and improved clinical and radiological outcomes, this implant is now used as the standard implant for most unstable peri-trochanteric femur fractures at our institution.

Download Full-text

CASE STUDY OF TITANIUM ELASTIC NAIL FOR FRACTURES

International Medical Science Research Journal ◽

10.51594/imsrj.v1i3.64 ◽

2020 ◽

Vol 1 (3) ◽

pp. 50-60

Author(s):

Mohammad Sadiq ◽

Mohammad Alam

Keyword(s):

Plate Fixation ◽

Clavicle Fracture ◽

Operating Time ◽

Operative Management ◽

Clinical Results ◽

Deep Infection ◽

Implant Removal ◽

Superficial Infection ◽

Non Union ◽

Plate Group

Mostly, clavicle fracture is treated conservatively but because of higher rates of delayed union, non-union, symptomatic, malunion cosmetic deformity and other complications, there is increased used of operative management for clavicle fracture. In this regard, plating and intramedullary nailing are common surgical options. The operative technique is also found to be producing favorable results compare to the traditional method based on recent prospective randomized studies. In this study, the objective is to make a comparison between clinical results, operative method, and resulting complications proportion. The study was conducted on 66 patients who had OTA type B DMCFs and underwent surgical fixation with antegrade TENs and 1/3rd tubular plate. The study participants were divided in to two groups based on TENS and other with plate fixation with 1/3rd tubular plate. We conducted evaluation using constant-murley shoulder outcome and dash scores at 6, 12, weeks, 3, 6, and 12 months for determining outcomes. It was observed that among TENS group, there was easier implant removal and minimal complications, less blood loss, lesser operating time, with only complication of shortening of about 0.5 cm in fewer cases. In the other group which is plate group, no major complications were observed except minor one such as deep infection, superficial infection, hypertrophied scarring without pain, and decreased shoulder motion with no case of shortening. In terms of union and stability, no significant differences were found in both groups. Based on the result, it is suggested that TENS is more preferable since it involves fewer morbidity, better cosmetic results, and easier implant removal. Fixation with plate seems to be little more stable and its implant of choice is comminuted fracture.

Download Full-text

DYNAMIC HIP SCREW (DHS)

The Professional Medical Journal ◽

10.29309/tpmj/2016.23.01.800 ◽

2016 ◽

Vol 23 (01) ◽

pp. 076-080

Author(s):

Mehtab Pirwani ◽

Abbas Memon ◽

Shakeel Ahmed Memon

Keyword(s):

Deep Infection ◽

Lateral Approach ◽

Gender Ratio ◽

Superficial Infection ◽

Non Union ◽

Fracture Table ◽

Group A ◽

Hip Screw ◽

Comparative Results ◽

Group B

Objectives: To analyze the comparative results of dynamic DHS fixation in stableand the unstable intertrochanteric fractures at LUH. Study Design: Comparative study. Setting:Orthopedic unit I of LUH Jamshoro. Period: 26th May 2010 – 25th August 2011. Methodology:All 40 patients with femur intertrochanteric fracture were enlisted. All cases isolated in 2 groupsevery having 20 patients, group A stable fracture and group B unstable fractures. After completephysical examination, examinations and fracture arrangement evaluation, patients were readiedfor operation. Fracture table was used in each operation. Fracture reduction was initiallyattempted by close manipulation and was successful in 30 (75%) cases. Lateral approach forproximal femur was used in every case. All fractures, whether stable or unstable, were reducedanatomically without any type of osteotomy and then fixed with 135o dynamic hip screw.Results: Mean age was 62.8.2 years of the cases. Gender ratio was 3:1. According to modeof injury were found RTA in 21 (70%) patients. Postoperative complications were recorded as;superficial infection noted in 2 (5%) patients and there was no case of deep infection. Averagestay of hospital found 16.5 days in 17 (42.5%) patients belongs to stable group and 06 (15%)patients belong to unstable group. All (n=40) patients were pain free on their discharge fromhospital. In all (n=40) patients we achieved union and there was no case of delayed unionor non-union. We assessed functional outcome of our patients on the base of Stinchfield HipAssessment system. According to SHAS 28 (70%) patients were excellent, 05 (12.5%) patientswere good, 04 (10%) were fair and 03 (7.5) were poor. We had not found mortality in our patients.Conclusions: According to our conclusion DHS is the best implant for intertrochanteric fracturefixation. No matter; whether fracture is stable, unstable and fresh or old.

Download Full-text

Functional outcomes of reverse distal femoral locking plate in the extra capsular fractures of proximal femur

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20191046 ◽

2019 ◽

Vol 5 (3) ◽

pp. 417

Author(s):

Jaspreet Singh ◽

Harpal Singh Selhi ◽

Rahul Gupta ◽

Gurleen Kaur

Keyword(s):

Proximal Femur ◽

Functional Outcomes ◽

Locking Plate ◽

Femoral Fractures ◽

Delayed Union ◽

Bony Union ◽

Proximal Femoral Fractures ◽

Superficial Infection ◽

Non Union ◽

Wound Breakdown

Background: The optimal management of unstable proximal femoral fractures is controversial. In this prospective study, the functional outcomes of reverse distal femoral locking plate for the treatment of comminuted unstable proximal femoral fractures were assessed. Objectives were to study the functional outcomes of reverse locking plate in extra-capsular fractures of the proximal femur, with respect to quality of reduction, time to bony union, mobility achieved, complications of the procedure, secondary procedures performed (if any) and delayed complications like implant breakage, delayed union, non-union.Methods: 17 patients with unstable proximal femoral fractures were assessed and managed with reverse distal femur plates, and evaluated with X-ray, physical examination, Palmer and Parker mobility score.Results: Union was achieved in all the patients, with average time to union 6.43±1.18 months (range 3-12 months). There was one loosening of implant and wound breakdown, which was managed conservatively. One case of loosening of proximal screws was there, but the fracture united in 9 months with some varus angulation. Superficial infection occurred in one patient, which healed after debridement and IV antibiotics.Conclusions: Taking into consideration the simple surgical technique, good healing rate and minimum complications, it is strongly recommended to use reverse locked distal femoral plates for the management of proximal femoral fractures and further in lean patients, sum-muscular MIPPO should be attempted.

Download Full-text

Association Between Comorbid Depression and Rates of Postoperative Complications, Readmissions, and Revision Arthroscopic Procedures After Elective Hip Arthroscopy

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211036493 ◽

2021 ◽

Vol 9 (9) ◽

pp. 232596712110364

Author(s):

Ryan D. Freshman ◽

Madeleine Salesky ◽

Charles J. Cogan ◽

Drew A. Lansdown ◽

Alan L. Zhang

Keyword(s):

Cohort Study ◽

Postoperative Complications ◽

Hip Arthroscopy ◽

Knee Arthroscopy ◽

Hospital Readmissions ◽

Level Of Evidence ◽

Superficial Infection ◽

Depression Prevalence ◽

Femoroacetabular Impingement Syndrome ◽

Increased Risk

Background: Depression and related psychiatric diagnoses are common in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The effects of depression on postoperative complications, readmissions, and additional ipsilateral hip surgery are not well studied. Hypothesis: Patients with preoperative depression who undergo hip arthroscopy for FAIS would experience higher rates of 90-day postoperative complications and readmissions, with an increased risk of additional ipsilateral hip procedures, as compared with patients without depression. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study between 2010 and 2019 was performed using the Mariner/PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without preexisting depression who underwent hip arthroscopy for FAIS. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Patients undergoing shoulder or knee arthroscopy were also identified to compare lifetime preoperative depression prevalence amongst groups. Results: The lifetime preoperative depression prevalence was significantly higher in patients undergoing hip arthroscopy as compared with patients undergoing shoulder or knee arthroscopy (25.4% vs 22.2% vs 19.8%; P < .001). When compared with the patients without depression, patients with preoperative depression had higher rates of 90-day readmissions (2.4% vs 1.5%) and complications, including urinary tract infection (36.2% vs 28.9%), pneumonia (12.9% vs 9.1%), hematoma formation (3.1% vs 1.9%), acute kidney injury (4.0% vs 2.6%), deep venous thrombosis/pulmonary embolism (2.6% vs 1.7%), and superficial infection (4.9% vs 2.8%; P < .01 for all comparisons). Preoperative depression was associated with significantly higher odds of undergoing revision hip arthroscopy within 2 years (6.3% vs 2.4%; P < .001). Conclusion: Patients with preexisting depression experienced higher rates of 90-day postoperative complications and hospital readmissions after elective hip arthroscopy for FAIS and were more likely to undergo revision hip arthroscopy within 2 years of the index procedure.

Download Full-text

ANTEGRADE X RETROGRADE NAILING IN FEMORAL FRACTURES: A STUDY ON CONSOLIDATION AND INFECTION

Acta Ortopédica Brasileira ◽

10.1590/1413-785220192706218655 ◽

2019 ◽

Vol 27 (6) ◽

pp. 313-316

Author(s):

Jorge Rafael Durigan ◽

Ana Carolina da Silva ◽

Pedro Takata ◽

Caio Zamboni ◽

Claudio Santili ◽

...

Keyword(s):

Intramedullary Nailing ◽

Bone Healing ◽

Femoral Fractures ◽

Healing Time ◽

Retrograde Nailing ◽

University Hospitals ◽

Level Of Evidence ◽

Femur Fractures ◽

Significant Difference ◽

Retrospective Comparative Study

ABSTRACT Objective: Osteosynthesis with intramedullary nailing is considered the method of choice to treat diaphyseal femur fractures in adults. The objective of this retrospective study was to evaluate the bone healing time and incidence of infection in patients with diaphyseal femur fractures treated surgically with retrograde and antegrade intramedullary nailing. Methods: The medical records of 123 patients from two university hospitals dated 2011-2013 were evaluated, with 126 diaphyseal femur fractures having been found. The most frequent treatment was antegrade intramedullary nailing (51%), of which 38% involved reaming (n=25). Results: We found evidence of 92% healed fractures at 12 months postoperatively. Complications included chronic osteomyelitis in one patient and femoral neck fracture in another patient, both after reamed antegrade nailing. Pyoarthritis of the knee associated with osteomyelitis affected two patients after reamed retrograde nailing and one patient after unreamed retrograde nailing. Conclusion: We did not observe a significant difference in bone healing rates with the use of reamed or unreamed antegrade or retrograde nailing. Complications included the presence of infection with an incidence similar to that reported in the literature, and of particular significance, unrelated to the type of approach. Level of evidence III, Retrospective comparative study.

Download Full-text

Management of Complex Distal Femur Fractures: Comparative Study between Ilizarov External Fixation and Double Plating

QJM ◽

10.1093/qjmed/hcaa059.007 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

M F Thakeb ◽

A H Gooda ◽

T A Fayyad ◽

M A Elkersh ◽

E N Abourisha

Keyword(s):

Knee Society Score ◽

Distal Femur ◽

Weight Bearing ◽

Femoral Fractures ◽

Controlled Study ◽

Level Of Evidence ◽

Femur Fractures ◽

Randomized Clinical Study ◽

Significant Difference ◽

Double Plating

Abstract Background In this prospective randomized clinical study, we report results of management of type C2 and C3 distal femur fractures by Ilizarov external fixator in comparison with double plating through separate medial and lateral approaches with a mean of 42.8 ± 6.84 weeks follow-up. Patients and Methods In this study we managed 30 cases with highly comminuted distal femoral fractures AO classification type C2 or C3. Fifteen cases were surgically managed by Ilizarov technique and the other fifteen cases were surgically managed by double plating technique. We compare between both group as regard clinical, radiological results and rate of complications. Results while using Knee society score, the results are the following: In Ilizarov group: 7 cases (46.67%) are excellent, 4 cases (26.67%) are good, 3 cases (20.00%) had fair results while 1 case (6.67%) had poor results. In internal fixation group, 8 cases (53.33%) had excellent results, 3cases (20%) had good results, 2 cases (13.33%) had fair results while 2 cases (13.33%) had poor results. Conclusion In fixation of complex distal femur fracture, both Ilizarov and double plating methods had no significant difference in clinical outcome by knee society score and in rate of complications. Ilizarov allow earlier weight bearing and less blood loss while double plating gives better ROM of knee joint and rapid radiological healing. Level of Evidence Level I Randomized controlled study.

Download Full-text

Buried or unburied K-wires for lateral condyle elbow fractures

Annals of The Royal College of Surgeons of England ◽

10.1308/003588412x13171221592375 ◽

2012 ◽

Vol 94 (7) ◽

pp. 513-516 ◽

Cited By ~ 15

Author(s):

L McGonagle ◽

S Elamin ◽

DM Wright

Keyword(s):

Deep Infection ◽

Lateral Condyle ◽

Non Union ◽

Increased Risk ◽

Elbow Fractures ◽

Wire Fixation ◽

Superficial Wound ◽

Fracture Configuration ◽

K Wires ◽

Humeral Condyle

INTRODUCTION Lateral humeral condyle fractures typically require a longer period of internal fixation than other distal humeral fractures due to the increased risk of non-union. K-wires can be buried and left in situ until union or they can be left unburied and require removal after four weeks, with plaster immobilisation until union. There is no consensus as to whether wire burial is preferable or not. The aim of this study was to determine whether K-wire burial is associated with more complications than non-buried wires in treating lateral condyle fractures of the elbow. METHODS All patients with lateral humeral condyle fractures treated with K-wire fixation at our institution from May 2008 to August 2011 were included in the study. Fracture configuration, mode of reduction, wire burial and complications were assessed. RESULTS Sixty-seven patients (19 girls and 48 boys, mean age: 6.5 years, range: 1–17 years) were included in the study. All had closed injuries and were treated with open reduction and K-wire fixation. K-wires were buried in 55 patients. Thirteen cases of buried wires eroded through skin and were removed on average 45 days (range: 30–58 days) post-operatively. Of the wire erosion cases, three developed microbiologically proven infections, one of which was a deep infection. There were a further three superficial wound infections in the absence of wire erosion through the skin. There were complications in 2 of the 12 cases in the unburied wires group: 1 microbiologically proven superficial wire site infection and 1 wire backed out after 11 days, requiring refixation. CONCLUSIONS Wire erosion through the skin is the most common complication of K-wire burial. This may be due to the decrease in swelling after fracture fixation, making the wires more prominent under the skin. Skin integrity should be monitored closely if wires are buried.

Download Full-text