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.

Finite Element Analysis of Proximal Femoral Nail Anti-Rotation Blade Combined with Cerclage Wire Fixation for Osteoporotic Subtrochanteric Fracture

Osteoporosis is a type of systemic bone disease wherein the patient is highly vulnerable to bone fracture because of the decrease in bone density and quality, destruction of the bone microstructure, and an increase in the bone fragility. Most of the osteoporotic subtrochanteric fractures are unstable in nature, requiring the conservative treatment of a long-duration bed rest and traction; this condition is prone to complications resultant from extended bed rest, often leading to death. Presently, the preferred treatment is internal fixation, such as sliding hip screws, blade plates, locking compression plates, and femoral intramedullary nails [1-8]. Owing to its valuable biological properties, intramedullary nail can be used for the optimal fixation of subtrochanteric fractures [9-11]. Unless any contraindication exist, immediate tolerable weight-bearing activities may be allowed to patients with subtrochanteric femur fractures who have been treated with statically locked intramedullary nails [12]. Considering that the proximal femoral fracture occurs under the traction of the surrounding muscles, it is extremely challenging to perform precision reduction and fixation in the surgery. Inappropriate reduction and selection of internal fixation can easily lead to failure of internal fixation, resulting in complications such as lower limb shortening deformity, hip varus deformity, and nonunion of fracture. Presently, good outcomes have been reported with the use of PFNA combined with cerclage wire for the treatment of subtrochanteric fracture of the femur [13-15]. There are few studies to help decide whether PFNA should be combined with cerclage wire or used alone according the Seinsheimer classification of subtrochanteric fractures.

Augmented cerclage wire improves the fixation strength of a two-screw construct for humerus split type greater tuberosity fracture: a biomechanical study

Background Poor functional outcome can result from humeral greater tuberosity (GT) fracture if not treated appropriately. A two-screw construct is commonly used for the surgical treatment of such injury. However, loss of reduction is still a major concern after surgery. To improve the biomechanical strength of screw fixation in GT fractures, we made a simple modification of the two-screw construct by adding a cerclage wire to the two-screw construct. The purpose of this biomechanical study was to analyze the effect of this modification for the fixation of GT fractures. Materials and methods Sixteen fresh-frozen human cadaveric shoulders were used in this study. The fracture models were arbitrarily assigned to one of two fixation methods. Group A (n = 8) was fixed with two threaded cancellous screws with washers. In group B (n = 8), all screws were set using methods identical to group A, with the addition of a cerclage wire. Horizontal traction was applied via a stainless steel cable fixed directly to the myotendinous junction of the supraspinatus muscle. Displacement of the fracture fixation under a pulling force of 100 N/200 N and loading force to construct failure were measured. Results The mean displacements under 100 N and 200 N traction force were both significantly decreased in group B than in group A. (100 N: 1.06 ± 0.12 mm vs. 2.26 ± 0.24 mm, p < 0.001; 200 N: 2.21 ± 0.25 mm vs. 4.94 ± 0.30 mm, p < 0.001) Moreover, the failure load was significantly higher in group B compared with group A. (415 ± 52 N vs.335 ± 47 N, p = 0.01), Conclusions The current biomechanical cadaveric study demonstrated that the two-screw fixation construct augmented with a cerclage wire has higher mechanical performance than the conventional two-screw configuration for the fixation of humeral GT fractures. Trial registration Retrospectively registered.

Growth modulation of angular deformities with a novel constant force implant concept-preclinical results

Purpose Varus-valgus deformities in children and adolescents are often corrected by temporary hemi-epiphysiodesis, in which the physis is bridged by an implant to inhibit growth. With standard implant solutions, the acting forces cannot be regulated, rendering the correction difficult to control. Furthermore, the implant load steadily increases with ongoing growth potentially leading to implant-related failures. A novel implant concept was developed applying a controlled constant force to the physis, which carries the potential to avoid these complications. The study aim was to proof the concept in vivo by analyzing the effect of three distinct force levels on the creation of varus deformities. Methods The proposed implant is made of a conventional cerclage wire and features a twisted coil that unwinds with growth resulting in an implant-specific constant force level. The proximal medial tibial physes of 18 lambs were treated with the implant and assigned to three groups distinct by the force level of the implant (200 N, 120 N, 60 N). Results The treatment appeared safe without implant-related failures. Deformity creation was statistically different between the groups and yielded on average 10.6° (200 N), 4.8° (120 N) and 0.4° (60 N) over the treatment period. Modulation rates were 0.51°/mm (200 N), 0.23°/mm (120 N) and 0.05°/mm (60 N) and were constant throughout the treatment. Conclusion By means of the constant force concept, controlled growth modulation appeared feasible in this preclinical experiment. However, clinical trials are necessary to confirm whether the results are translatable to the human pathological situation.

Cerclage wire fixation of trochanteric osteotomies in complex hip revision: our experience and comparison with cable-plate fixation

Introduction: Osteotomy of the greater trochanter is a commonly used procedure in complex revision hip arthroplasty in order to achieve a wide exposure to the femoral stem and acetabular components. There is no clinical evidence in favour of a specific fixation method. The aim of this study was to compare cable-plate with figure-of-eight cerclage wire fixation in patients requiring a trochanteric “slide” osteotomy. Material and methods: In a retrospective study, 51 greater trochanteric “slide” osteotomies in complex acetabular revision arthroplasties were included. Patients were divided into 2 groups: 28 hips were fixed with 1 of 2 cable-plate systems (Dall-Miles staple, Stryker or Cable-Ready plate, Zimmer) and 23 with a figure-of-eight cerclage wire. Consolidation, osteolysis, migration of greater trochanter, bursitis of the trochanteric area, Trendelenburg gait and removal of osteosynthesis material were studied at 6 months follow-up. Results: Both groups showed good union rates. The lysis rate was similar with 32% in the cable-plate group versus 29% in the cerclage wire group ( p = 0.084). 43% of the hips with cable-plate and 22% of the cerclage wire had trochanteric migration ( p = 0.297). Pain at the greater trochanter was less frequent in the cerclage wire group (9%) as compared to the cable-plate group (43%) ( p = 0.007). Implant removal was more frequent in the cable-plate group (4 vs. 0 patients). Trendelenburg gait was found in 3 patients in the cerclage wire group as compared to 10 in the cable-plate group ( p = 0.054). Conclusions: The cerclage wiring had superior clinical outcomes with similar radiographic results. The authors recommend the use of figure-of-eight cerclage wire when fixing a greater trochanteric “slide” osteotomy in complex revision hip arthroplasty.

Case series and finite element analysis of PFNA combined with cerclage wire for treatment of subtrochanteric fracture of femur

Objective To retrospectively analyze the clinical efficacy of PFNA combined with a cerclage wire in the treatment of 52 patients with unstable subtrochanteric fracture of the femur and to analyze the biomechanical effect of ligature on a fracture model. Methods In this study, 52 patients with unstable subtrochanteric fractures were treated in our orthopedic trauma center from June 2013 to July 2018. The Seinsheimer type IV fracture model was established using the patient’s CT data, and the joint surface of the distal femoral condyle and the external condyle were restrained. The femoral head was used as the loading point, and a force of 500 N was applied vertically along the long axis of the femoral shaft. Results All 52 patients were followed up for 12 to 37 months, with an average of 18.07 ± 4.38 months. According to the Sanders hip function score, 28 cases were excellent (55–60 points), 22 cases were good (45–54 points), and 2 cases were poor (35–44 points), with an excellent and good rate of 96.15%. Postoperative deep vein thrombosis occurred in 3 cases, and fracture nonunion occurred in 1 case. No infection, loose fracture of internal fixation or hip varus deformity occurred. The finite element analysis indicated that the displacement of the whole model decreased slightly and the relative sliding of the fracture block decreased, but the maximum stress of the femur increased after the addition of the cerclage wire. Conclusion The treatment of unstable subtrochanteric fracture of the femur with PFNA combined with cerclage wire has the advantages of simple operation, satisfactory reduction of fracture, stable fixation, and good recovery of limb function. The finite element analysis suggested that the biomechanical strength fixation was enhanced after the addition of cerclage wire. However, the local stress concentration of the tie may increase the risk of failure.

Arthroscopic Reduction and Fixation by Cerclage Wire Loop for Tibial Spine Avulsion in Adults: Short-term Results

Background: Several arthroscopic techniques for the treatment of avulsion tibial spine fractures have been described in the literature. Purpose: To evaluate the outcomes of the arthroscopically assisted stainless steel wiring technique in the treatment of avulsed tibial spine in adults. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study involved 28 patients (28 knees), 16 to 42 years of age, with tibial spine avulsion fracture that was treated using arthroscopic reduction and cerclage wire fixation by a single surgeon between March 2015 and August 2018. The degrees of avulsion in these patients were type II (n = 12), type III (n = 10), and type IV fractures (n = 6). Clinical assessment included International Knee Documentation Committee (IKDC) objective score (which noted swelling), range of knee movement, Tegner activity scale, Lachman test, and pivot-shift test compared with the normal opposite knee. Results: The mean follow-up period was 24.1 months (range, 18-30 months). The mean IKDC score was 93.7 (range, 88.5-98.9); the IKDC score was normal in 22 patients and nearly normal in 6 patients. The Lachman test was grade 1 in 25 patients and grade 2 in 3 patients, whereas the pivot-shift test was grade 0 in 26 patients and grade 1 in 2 patients. All patients achieved their preinjury Tegner activity levels. Radiological assessment showed healing in all patients within a mean of 12 weeks after surgery. Conclusion: The outcomes of all patients were satisfactory; fixation by cerclage wiring permitted reduction of tibial spine fragment anatomically to its fracture bed, provided stable fixation in displaced tibial spine avulsion, and allowed for early rehabilitation and weightbearing because of stable fixation.

Intraarticular Migration of Broken Patella Cerclage and Figure-of-Eight Wire

BACKGROUND: Breakage of the wire commonly follows the procedure performed for displaced patellar fractures; nevertheless, there have not been many reports about wire fragment migration. To the best of our knowledge, there were only six documented cases of wire fragment intraarticular translocation. CASE REPORT: A 47-year-old male patient, with a history of patella fracture 3 years ago, was treated with cerclage and figure-of-eight wiring, presented with severe restriction of knee movements for the past 4 weeks. X-ray and fluoroscopy examination showed cerclage wire had broken at multiple sites with one broken piece migrated posterior intraarticularly. This case is unique due to the size of the migrated broken cerclage wire, which was about only length 1.5 cm and diameter 1.25 mm attached to posterior lateral condyle which prevented its further migration; otherwise, it could damage neurovascular structures. This intraarticular piece of wire was removed successfully with fluoroscopy support. CONCLUSION: Increased time-lapse from the initial surgery, the comminution of the fragment fracture, wire shape and size, and the incorrect placement of wire are the risk factors of intraarticular migration. We should educate the patient about the risks of hardware failure and possible migration with all patients receiving bone fixation with wires, and we can offer elective hardware removal as an option.