Outcomes of cerclage wiring to manage intra-operative femoral fracture occurring during cementless hemiarthroplasty in older patients with femoral neck fractures

Outcomes of cerclage wiring for intraoperative calcar fractures in cementless hemiarthroplasty in older patients with femoral neck fractures

BACKGROUND

Cementless hip hemiarthroplasty is one of the options for the treatment of osteoporotic femoral neck fractures. Intraoperative periprosthetic femoral calcar fractures sometimes occur during the surgery, and the use of cerclage wiring to maintain the position and stability of the femoral stem and prevent the progression of the fracture. This study examines the outcomes of cerclage wiring to treat intraoperative periprosthetic calcar fractures in cementless hip hemiarthroplasty in osteoporotic femoral neck fractures.

MATERIALS AND METHODS

A retrospective review of femoral neck fractures treated with cementless hemiarthroplasty was conducted. Twenty-one calcar fractures that underwent cerclage wiring were compared with a demographically similar control group of 21 patients without intraoperative fractures. Radiological parameters, including proximal femoral morphology and stem subsidence, and Harris Hip score were evaluated for clinical outcomes.

RESULTS

A tapered wedge-shaped type cementless stem was used in all of the cases. The most common femur types were Dorr B in both groups. The average stem subsidence of wires applied below a lesser trochanter was less than above (p = 0.905). The fracture group had a mean HHS of 83.85 ± 6.62, and the control group had a mean HHS of 88.00 ± 5.76 (p = 0.067).

CONCLUSIONS

Using cerclage wiring in treating intraoperative periprosthetic femoral calcar fractures provides adequate fixation for the stability of the femoral stem either above or below the lesser trochanter.

Comparison of clinical efficacy between femoral neck system and cannulated screw in Pauwels type III femoral neck fracture: A meta-analysis

BACKGROUND

In recent years, the femoral neck system (FNS) has become increasingly widely used for Pauwels type III femoral neck fractures.

OBJECTIVE

We performed a meta-analysis to investigate the safety and efficacy of FNS and the mainstream internal fixation method, cannulated screw (CS), in the treatment of Pauwels type III femoral neck fractures.

METHODS

We systematically searched all research studies from PubMed, Embase, Web of Science, Cochrane, WANFANG, and the Chinese Academic Journal Full-Text Database (CNKI) from 2018 to July 2024 and conducted data extraction. The study was conducted on July 26, 2024. We used the PRISMA guidelines to assess the quality of the results of all included studies. In addition, we searched for references to relevant articles. After completing the literature search, we performed a manual literature screening to obtain studies that met the inclusion criteria. The outcomes were Harris Hip Score, operation duration, intraoperative blood loss, hospital stay, healing time, and postoperative complications.

RESULTS

This meta-analysis ultimately included nine studies (n = 524) and conducted quality evaluations. All nine articles were retrospective cohort studies. The study exhibited statistically significant variations between the FNS and CS groups in relation to total complications (95% confidence interval (CI)= [0.11, 0.40], odds ratio (OR) = 0.21, P < 0.001), Harris Hip Score (95%CI = [2.14, 3.65], mean difference (MD) = 2.89, P < 0.001), Femoral head necrosis (95%CI = [0.17, 0.86], OR = 0.38, P = 0.02), Internal fixation failure (95%CI = [0.06, 0.50], OR = 0.17, P = 0.001), Medium femoral neck shortening (95%CI = [0.17, 0.53], OR = 0.30, P < 0.001), intraoperative blood loss (95%CI = [11.57, 26.80], MD = 19.19, P < 0.001), Operation duration (95%CI = [-15.20, -2.17], MD = -8.69, P = 0.009), and healing time (95%CI = [-1.30, -0.32], MD = -0.81, P = 0.001).

CONCLUSION

This meta-analysis showed that in Pauwels type III femoral neck fractures, the femoral neck system has a shorter operative time, a lower rate of postoperative complications, a shorter healing time, less shortening of the femoral neck, and a higher Harris Hip Score compared with cannulated screws, but increases intraoperative blood loss. However, more clinical studies are needed to confirm our conclusions due to our small sample size and lack of randomized controlled trials.

Sciatic Nerve Entrapment from Cerclage Wiring in Intramedullary Nail Fixation

Cerclage wiring may be used to optimize the stability of intramedullary nail or plate fixations in comminuted proximal femoral fractures, periprosthetic fractures, and other selected cases. In this article, we presented a novel case of iatrogenic sciatic nerve entrapment from cerclage wiring used to supplement intramedullary nail fixation. We also illustrate and highlight the role of ultrasound in assessing the sciatic nerve to make a timely diagnosis.

What features of stem increase the risk of intraoperative femoral fracture during cementless primary hip arthroplasty?

INTRODUCTION

Cementless fixation has become increasingly popular in hip arthroplasty due to its shorter operation time, easier technique, biologic fixation, and avoidance of bone cement implantation syndrome compared to cemented fixation. However, intraoperative periprosthetic femoral fracture (IOPFx) is a disconcerting complication during cementless hip arthroplasty. Our purpose was to identify the features of cementless stem that increase the risk of IOPFx during primary hip arthroplasty.

MATERIALS AND METHODS

We retrospectively reviewed all 4806 hip arthroplasties that was performed in a single institution from May 2003 to December 2020. Age at the index arthroplasty, sex, body mass index, physical status, ambulatory function, side of the operation, operational history, cause of the index arthroplasty, type of arthroplasty, surgical approach, surgeon, implant information, and events during the operation were investigated. The shoulder geometry and length of stem were also reviewed. The event of interest was narrowed down to IOPFx among various records of intraoperative events.

RESULTS

We found IOPFx of 2.6% among all the hips operated with cementless stem. In the multivariable analysis, female (OR = 1.52), childhood hip disease (OR = 2.30), stove-pipe femur (OR = 2.43), combined approach (OR = 2.60), and standard length of stem (OR = 1.59) were found to be significant risk factors of IOPFx.

CONCLUSIONS

In conclusion, a stem with a standard length is significantly associated with risk of IOPFx compared to a shortened stem. These findings highlight the importance of careful consideration in terms of the risk of IOPFx when standard length cementless stem is chosen.

Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis

Background

Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA.

Methods

We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study.

Results

The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF.

Conclusions

The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Cerclage performance analysis - a biomechanical comparison of different techniques and materials

BACKGROUND

Wire cerclages play a fundamental role in fracture fixation. With an increasing variety of designs being commercially available the question arises which cerclage should be used. This study investigates the biomechanical properties of metallic and non-metallic cerclages and their different application-types. Furthermore, potential influence of muscular interposition between bone and cerclage constructs was tested.

METHODS

Samples of the following four different cerclage types were tested on 3D printed models of human humeri as well as on human cadaveric humeri with and without muscular interposition: Titanium Cable Cerclage (CC), Steel Wire Cerclage (SWC), Suture Tape (ST), Suture Tape Cerclage (STC) with both single- (sSTC) and double-loop application (dSTC). A preinstalled self-locking mechanism secured by the provided tensioner in the STCs being the main difference to the STs. Cyclic loading was performed to 1 kN and then linearly to a maximum load of 3 kN. Statistical analysis was performed using either one-way ANOVA and post-hoc Tukey or Kruskal-Wallis and post-hoc Dunn test depending on normalization of data (p < 0.05).

RESULTS

Whilst all cerclage options could withstand high loads during failure testing, only within the CC and dSTC group, all samples reached the maximal testing load of 3000 N without any failure. The SWC reached 2977.5 ± 63.6 N, the ST 1970.8 ± 145.9 N, and the sSTC 1617.0 ± 341.6 N on average. Neither muscular interposition nor bone quality showed to have a negative influence on the biomechanical properties of the cerclage constructs, presenting no significant differences.

CONCLUSION

All tested cerclage constructs produce reliable stability but differ in their resulting compression forces, in a simplified fracture model. Therefore, non-metallic cerclage alternatives can provide similar stability with less compression and stiffness to metallic cable constructs, but they may offer several advantages and could possibly provide future benefits. Especially, by offering more elasticity without losing overall stability, may offer a biologic benefit. Installing any cerclage constructs should be performed carefully, especially if poor bone quality is present, as the tightening process leads to high forces on the construct.

Effects of Seamless Operating Room Nursing Combined with Multistyle Health Education on the Psychological State, Rehabilitation Quality, and Nursing Satisfaction in Patients with Internal Fixation of Femoral Fracture

Objective. To explore the effects of seamless operating room nursing combined with multistyle health education on the psychological state, rehabilitation quality, and nursing satisfaction in patients with internal fixation of femoral fracture. Methods. Eighty patients who received internal fixation of femoral fracture in our hospital (November 2020–November 2021) were chosen as the research objects, and their clinical data were retrospectively analyzed. They were divided into experimental group and control group according to the sequence of hospital admission. In perioperative period, the control group received routine nursing measures and the experimental group received seamless operating room nursing combined with multistyle health education. The patients’ psychological state, rehabilitation quality, and nursing satisfaction after intervention were compared between the two groups. Results. Compared with the control group, the experimental group achieved remarkably lower score of Profile of Mood States (POMS) after nursing ( $p$  < 0.001). The experimental group had much higher cognitive level scores, Harris hip score (HHS), Functional Independence Measure (FIM) score, and nursing satisfaction score in comparison with the control group ( $p$  < 0.05). In perioperative period, the experimental group had much lower total incidence of complications in comparison with the control group ( $p$  < 0.05). Conclusion. Seamless operating room nursing combined with multistyle health education, as an effective measure to improve the rehabilitation quality of the patients with internal fixation of femoral fracture, has better effects on improving the patients’ psychological state and reducing complications in perioperative period in comparison with the routine nursing intervention. Further studies are conducive to providing a better solution for the patients with internal fixation of femoral fracture.

Application of Multimode Health Education Combined with Humanistic Care in Pain Management of Patients with Femoral Fracture and Its Influence on VAS Score

Objective

To explore the application of multimode health education combined with humanistic care in pain management of patients with femoral fracture and its influence on VAS score.

Methods

A total of 120 patients with femoral fracture admitted in our hospital (May 2017–May 2021) were selected as the research objects. The patients who received routine health education were included into the routine group, and the patients who received multimode health education combined with humanistic care were included into the combined group, with 60 cases in each group. The pain management effect of the two groups was compared after nursing intervention.

Results

No significant difference was found in age, BMI, fracture sites, gender, education degree, and residence between the two groups (P > 0.05). The awareness rate of health knowledge of the combined group was as high as 93.33%, which was obviously higher than that of the routine group (P < 0.05). Compared with the routine group, excellent rates of sitting durability and joint range of motion in the combined group were obviously higher (P < 0.05), and poor rates of sitting durability and joint range of motion in the combined group were obviously lower (P < 0.05). Compared with the routine group, VAS scores of the combined group at 1 d, 2 d, and 3 d after admission and at 1 d, 2 d, and 3 d after surgery were remarkably lower (P < 0.05). Compared with the routine group, compliance of exercise, medical waist belt using, and working posture of the combined group 1 week, 1 month, and 6 months after surgery was obviously higher (P < 0.05). Compared with the routine group, the scores of Rasmussen and Johner-Wruhs of the combined group 6 months after surgery were conspicuously higher (P < 0.05).

Conclusion

The application of multimode health education combined with humanistic care in pain management of patients with femoral fracture can effectively relieve pain, improve the awareness rate of health knowledge, promote the recovery of lower limb function, and enhance the prognosis of quality of life for patients.

Medial femoral plate with cannulated screw for Pauwels type III femoral neck fracture: A meta-analysis

BACKGROUND

Femoral neck fractures often occur in the elderly, which usually results in hip pain.

OBJECTIVE

The purpose of this study was to evaluate the difference in the treatment of Pauwels type III femoral neck fractures with medial femoral support plate combined with cannulated screws and cannulated screws alone.

METHODS

PubMed, ScienceDirect, China Academic Journals Full-text Database (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), Embase and Cochrane Library were used to collect clinical controlled trials of the medial femoral support plate combined with hollow screw internal fixation and simple hollow screw internal fixation for Pauwels type III femoral neck fracture.

RESULTS

Seven articles (n= 409 cases) were evaluated for quality and included in this meta-analysis. Four hundred and nine patients with Pauwels type III femoral neck fractures were included: 202 in the experimental group and 207 in the control group. The results showed that, compared with simple hollow screw internal fixation, the medial femoral support plate combined with hollow screw internal fixation has a longer operation time (MD= 23.05, 95% CI= 13.86-32.24), and more intraoperative blood loss (MD= 91.55, 95% CI= 50.72-132.39), shorter healing time (MD=-1.48, 95% CI (-1.71, -1.26)), lower incidence of complications (RR= 0.34, 95% CI= 0.19-0.61), lower VAS score (MD=-1.28, 95% CI (-1.83, -0.72)), and higher Harris score (MD= 8.49, 95% CI (4.15, 12.83)).

CONCLUSION

Medial femoral plate combined with cannulated screw for Pauwels type III femoral neck fracture can shorten healing time, reduce postoperative complications, and improve the postoperative Harris score.

Outcomes of Cerclage Cabling for Intraoperative Calcar Cracks in Cementless Total Hip Arthroplasty Using Broach-Only, Tapered Wedge Stems

BACKGROUND

Intraoperative femoral fractures are well-known but often overlooked complications in total hip arthroplasty (THA). We examined outcomes of cerclage cabling for intraoperative calcar cracks in THA with cementless tapered wedge stems.

METHODS

In total, 4928 primary THAs were performed using broach-only, tapered wedge stems between January 2007 and November 2017 in a single institution. Of these, we identified 71 intraoperative calcar cracks (69 patients) managed by 2-mm cerclage cables. Clinical outcomes, amount of stem subsidence, and implant survivorship of the calcar crack group (68 THAs) were compared with those of the matched control group (68 THAs) without intraoperative fractures. Multivariate analysis was performed to identify potential risk factors for stem subsidence >3 mm.

RESULTS

The mean stem subsidence was greater in the calcar crack group (2.0 vs 1.2 mm, P = .021), whereas revision-free survivorships of THA were similar between groups at 6 years (98.5% vs 98.4%; log-rank, P = .987). In the calcar crack group, a Dorr type C femur and the absence of cabling proximal to the lesser trochanter (LT) were identified as independent risk factors for stem subsidence >3 mm. For the subgroup with 42 calcar cracks managed by a single cable applied proximal to the LT, revision-free survivorship of THA was 100% at 6 years. There was no complete radiolucency to indicate aseptic stem loosening in either group.

CONCLUSION

The application of a single cable proximal to the LT of the femur for intraoperative calcar cracks demonstrated 100% revision-free survivorship with lower stem subsidence in THA with tapered wedge stems.

A quantitative biomechanical study of positive buttress techniques for femoral neck fractures: a finite element analysis

Background:

Refractory femoral neck fractures cannot be anatomically reduced by closed traction reduction which may affect fracture healing. We evaluated the biomechanical effects of positive, negative, and anatomic reduction of various degrees of displacement in Pauwels I femoral neck fractures by a finite element analysis.

Methods:

Five reduction models of Pauwels type I femoral neck fracture were established using the Mimics 17.0 (Materialize, Leuven, Belgia) and Hypermesh 12.0 (Altair Engineering, Troy, MI, USA). According to the degree of fracture displacement, there were three models of positive support, an anatomic reduction model, and a negative 2 mm reduction model. Finite element analysis was conducted using the ABAQUS 6.9 software (Simulia, Suresnes, France). The von Mises stress distribution and the stress peak of internal fixation in different models, the displacement between fracture blocks, and the principal strain of the femoral neck cancellous bone model were recorded under the axial stress of 2100 N.

Results:

The peak von Mises stress on screw of each model was located at the thread of the screw tip. The peak von Mises stress was the lowest at the tip of the anatomic reduction model screw (261.2 MPa). In the positive 4 mm model, the von Mises stress peak was the highest (916.1 MPa). The anatomic reduction model showed the minimum displacement (0.388 mm) between fracture blocks. The maximum displacement was noted in the positive 4 mm model (0.838 mm). The displacement in the positive 3 mm model (0.721 mm) was smaller than that in the negative 2 mm model (0.786 mm). Among the five models, the strain area of the femoral neck cancellous bone was mainly concentrated around the screw hole, and the area around the screw hole could be easily cut.

Conclusions:

Compared with negative buttress for femoral neck fracture, positive buttress can provide better biomechanical stability. In Pauwel type I fracture of femoral neck, the range of positive buttress should be controlled below 3 mm as far as possible.