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Khanna A, MacInnis BR, Cross WW, Andrew Sems S, Tangtiphaiboontana J, Hidden KA, Yuan BJ. Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3097-3101. [PMID: 39186097 DOI: 10.1007/s00590-024-04035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/24/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. METHODS A retrospective review was conducted of patients > 50 years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. RESULTS Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0 years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8 weeks, p = 0.005). CONCLUSION Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50 years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. LEVEL OF EVIDENCE : Level III, Retrospective Comparative Study.
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Affiliation(s)
- Ankur Khanna
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
| | - Bailey R MacInnis
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - S Andrew Sems
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | | | - Krystin A Hidden
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
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Rehme-Röhrl J, Brand A, Dolt A, Grünewald D, Hoffmann R, Stuby F, Schweigkofler U, von Rüden C. Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion. J Clin Med 2024; 13:3591. [PMID: 38930120 PMCID: PMC11205226 DOI: 10.3390/jcm13123591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/01/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.
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Affiliation(s)
- Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Annika Dolt
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Dag Grünewald
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Fabian Stuby
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt, 60389 Frankfurt, Germany
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
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El-Alfy B, Abououf A, Darweash A, Fawzy S. The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases. INTERNATIONAL ORTHOPAEDICS 2024; 48:1105-1111. [PMID: 38227010 PMCID: PMC10933179 DOI: 10.1007/s00264-023-06085-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/26/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries. METHODS Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities. RESULTS The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results. CONCLUSION Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.
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Affiliation(s)
- Barakat El-Alfy
- Department of Orthopaedic Surgery, Mansoura University Hospital, Mansoura University, Mansoura, 7650001, Egypt
| | - Alaa Abououf
- Department of Orthopaedic Surgery, Faculty of Medicine, Aswan University, New Aswan City, 81528, Egypt.
| | - Ahmed Darweash
- Department of Orthopaedic Surgery, Faculty of Medicine, Suez University, PO Box 43221, Suez, Egypt
| | - Salam Fawzy
- Department of Orthopaedic Surgery, Mansoura University Hospital, Mansoura University, Mansoura, 7650001, Egypt
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Hinz N, Stacenko K, Lutz C, Schulz AP, Wendlandt R. Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis. Injury 2023; 54:111009. [PMID: 37643944 DOI: 10.1016/j.injury.2023.111009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface. MATERIALS AND METHODS In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model. RESULTS Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa). CONCLUSIONS Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.
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Affiliation(s)
- Nico Hinz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Trauma Hospital Hamburg, Bergedorfer Strasse 10, Hamburg 21033, Germany.
| | - Katrin Stacenko
- Swemac Innovation (Germany) GmbH, Faulmannweg 5, Kiel 24148, Germany
| | - Christian Lutz
- Swemac Innovation (Germany) GmbH, Faulmannweg 5, Kiel 24148, Germany
| | - Arndt-Peter Schulz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Trauma Hospital Hamburg, Bergedorfer Strasse 10, Hamburg 21033, Germany; Medical Faculty, Universität zu Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany
| | - Robert Wendlandt
- Medical Faculty, Universität zu Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany; Clinic for Orthopedics and Trauma Surgery, Laboratory for Biomechanics, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, Lübeck 23538, Germany
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Abstract
SUMMARY Pertrochanteric nonunion management is a technically challenging problem. When repair is undertaken rather than conversion arthroplasty, successful treatment revolves around accurate deformity correction, preservation of vascularity, and stable durable fixation. The decision to use an extramedullary or intramedullary implant should be influenced by nonunion-specific characteristics and patient-related conditions. Failure to understand these nuances when selecting an implant strategy often results in treatment failure. The primary purpose of this article was to discuss these variables and delineate when an intramedullary implant should be considered for treatment of a pertrochanteric nonunion. The secondary purpose was to describe the author's preferred surgical technique for implant-driven deformity correction and compression when choosing an intramedullary nail.
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Affiliation(s)
- Michael Githens
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
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The role of an augmentative plating in the management of femoral subtrochanteric nonunion. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04767-4. [PMID: 36624207 DOI: 10.1007/s00402-023-04767-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation. MATERIALS AND METHODS Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months. RESULTS Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed. CONCLUSIONS Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.
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van Trikt CH, Donders JCE, Klinger CE, Wellman DS, Helfet DL, Kloen P. Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age. BMC Geriatr 2022; 22:985. [PMID: 36539691 PMCID: PMC9764700 DOI: 10.1186/s12877-022-03670-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients. METHODS We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations. RESULTS We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications. CONCLUSIONS Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Clinton H. van Trikt
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Johanna C. E. Donders
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Craig E. Klinger
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - David S. Wellman
- grid.260917.b0000 0001 0728 151XOrthopaedic Trauma Service, Westchester Medical Center, New York Medical College, Valhalla, NY USA
| | - David L. Helfet
- grid.5386.8000000041936877XOrthopaedic Trauma Service, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY USA
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Egol KA, Walden T, Gabor J, Leucht P, Konda SR. Hip-preserving surgery for nonunion about the hip. Arch Orthop Trauma Surg 2022; 142:1451-1457. [PMID: 33635401 DOI: 10.1007/s00402-021-03820-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Nonunions about the hip occur as a result of femoral neck, intertrochanteric, and certain subtrochanteric fractures. Treatment of a hip fracture nonunion allows for the choice between hip preservation or arthroplasty. The goal of this study was to examine outcomes of hip-preservation nonunion surgery METHODS: Patients who underwent hip preservation for a fracture nonunion of the femoral neck, intertrochanteric and subtrochanteric region to 1 cm below the lesser trochanter over a 10-year period were identified in our nonunion registry. Patients were followed for a minimum of 1 year. Functional outcomes were recorded at follow-up visits. For comparison regarding surgical and hospital outcomes, a group of 23 patients who underwent conversion total hip arthroplasties (cTHA) at the same academic medical center was reviewed. Quality measures such as length of stay, reoperation, and complications were collected. All statistics analysis utilized IBM SPSS 25 (Armonk, NY) RESULTS: Thirty patients who underwent 30 hip-preserving nonunion surgeries were analyzed and compared with 23 cTHA patients. Twenty-nine nonunions went on to heal (average time to union 6.3 months). There was improvement in functional outcome scores for the hip preservation group between baseline and latest follow-up (p < 0.001). Reoperation was required in five patients (17%), including four failed to heal and required a second repair to gain union and one failure that was converted to THA rather than attempt a second nonunion repair. Hip preservation failures were older than those that healed with the index treatment (p = 0.11). There was no significant difference in hospital length of stay, complication rate, or need for reoperation when compared to cTHA group. CONCLUSION Hip-preserving surgery is an option that should be considered for patients with nonunion of fractures about the hip. The rates of complications (20.3 vs 17.3%) and reoperation (16.7 vs 17.3%) were equivalent to conversion THA. Excellent outcomes can be achieved in terms of radiographic union and function with hip preservation.
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Affiliation(s)
- Kenneth A Egol
- NYU Langone Orthopedic Hospital, New York, NY, USA. .,Jamaica Hospital Medical Center, New York, NY, USA.
| | | | | | | | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, New York, NY, USA.,Jamaica Hospital Medical Center, New York, NY, USA
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Yoon YC, Park KC, Oh CW, Kim JW, Kim JW, Park KH, Kim TS, Song HK, Abdel Baki SW. Intramedullary nailing of subtrochanteric fractures in elderly patients: Comparative study of helical blade cephalomedullary nail versus reconstruction nail. Injury 2022; 53:1477-1483. [PMID: 35120730 DOI: 10.1016/j.injury.2022.01.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing (IMN), which is a common method for treating subtrochanteric fractures, is conducted as cephalomedullary (CMN) or reconstruction (RCN) nailing. Numerous studies have reported the effectiveness of CMN, which requires a shorter surgery time and provides stronger fixation strength with blade-type devices. However, the radiographic and clinical outcomes of the use of CMN and RCN in elderly patients aged ≥65 years have not been compared yet. This study aimed to investigate whether CMN offers superior outcomes over RCN in the treatment of subtrochanteric fractures in elderly patients. MATERIALS AND METHODS This retrospective study included 60 elderly patients (17 men and 43 women; mean age: 74.9 years) diagnosed with subtrochanteric fractures and treated with IMN with helical blade CMN (CMN group: 30 patients) or RCN (RCN group: 30 patients) between January 2013 and December 2018 with at least 1 year of follow-up period. Radiologic outcomes were evaluated based on the postoperative state of alignment and the achievement and timing of bony union at the final follow-up. Clinical outcomes were evaluated using the Merle d'Aubigné-Postel score. Radiologic and clinical outcomes in the two groups were compared and analyzed, and the occurrence of complications was examined. RESULTS The difference in malalignment between the two groups was not significant; however, the RCN group achieved more effective reduction. At the final follow-up, bony union was achieved within 18.9 weeks, on average, in 28 patients in the CMN group and within 21.6 weeks, on average, in 27 patients in the RCN group. Twenty patients in the CMN group and 26 in the RCN group showed good or better results according to the Merle d'Aubigné-Postel score. No significant differences were found for any of the parameters. CONCLUSIONS In the treatment of difficult subtrochanteric fractures in elderly patients, RCN can provide excellent reduction and strong fixation similar to CMN and can result in outstanding clinical and radiologic outcomes.
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Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Republic of Korea
| | - Ki-Chul Park
- Department of Orthopedic Surgery, School of Medicine, Hanyang University Guri Hospital, Guri-si, Gyeonggi-do Province, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Chung-gu, Daegu, Republic of Korea.
| | - Joon-Woo Kim
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Chung-gu, Daegu, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeong-Hyeon Park
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Chung-gu, Daegu, Republic of Korea
| | - Tae-Seong Kim
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Chung-gu, Daegu, Republic of Korea
| | - Hyung Keun Song
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon-si, Gyeonggi-do Province, Republic of Korea
| | - Sharkawy Wagih Abdel Baki
- Department of Orthopaedic Surgery, Aswan University Hospital, Aswan University Faculty of Medicine, Aswan, Egypt
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Vicenti G, Solarino G, Bizzoca D, Simone F, Maccagnano G, Zavattini G, Ottaviani G, Carrozzo M, Buono C, Zaccari D, Moretti B. Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series. BMC Musculoskelet Disord 2022; 22:1067. [PMID: 35227245 PMCID: PMC8886749 DOI: 10.1186/s12891-022-05089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions. METHODS Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire. RESULTS From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery. CONCLUSIONS This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.
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Affiliation(s)
- Giovanni Vicenti
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Giuseppe Solarino
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Davide Bizzoca
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy.
- University of Bari "Aldo Moro, PhD course in Public Health, Clinical Medicine, and Oncology, Piazza Giulio Cesare 11, 70100, Bari, Italy.
| | - Filippo Simone
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | | | - Giacomo Zavattini
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Guglielmo Ottaviani
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Massimiliano Carrozzo
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Claudio Buono
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Domenico Zaccari
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro", AOU Consorziale Policlinico, Orthopaedic & Trauma Unit, Bari, Italy
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Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients. J Orthop Trauma 2021; 35:619-625. [PMID: 34596060 DOI: 10.1097/bot.0000000000002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. DESIGN Longitudinal observational cohort study. SETTING Academic Level 1 trauma center. PATIENTS/PARTICIPANTS One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018. INTERVENTION Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion. RESULTS Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures. CONCLUSIONS The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion. LEVEL OF EVIDENCE Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.
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Richardson P, Panteli M, Giannoudis PV. Exchange nailing and medial wall reconstruction following implant failure in a subtrochanteric femoral fracture. Trauma Case Rep 2021; 36:100555. [PMID: 34841032 PMCID: PMC8605424 DOI: 10.1016/j.tcr.2021.100555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 10/29/2022] Open
Abstract
Failure of fixation of subtrochanteric fractures has been reported in as high as 20% of cases. Several associations have been suggested to contribute to failed fixation. Discontinuity of the medial wall/column is considered to be one of the most significant risk factors for non-union and subsequent implant failure, especially if this defect is not addressed during the revision surgery. We present a case of failed fixation of a subtrochanteric fracture in an 86-year-old female where revision surgery paid special attention to restoring the medial wall continuity via bone grafting resulting in satisfactory union of the fracture. We advocate the necessity of reconstructing the medial column in similar cases in order to enhance healing and restore the biomechanical support of the subtrochanteric region.
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Affiliation(s)
- Philippa Richardson
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter V. Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
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13
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Kang SJ, Bao FL, Huang DS, Jiang T, Hu YM, Li JM, Liu T. Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures. Orthop Surg 2021; 13:1899-1911. [PMID: 34435729 PMCID: PMC8523774 DOI: 10.1111/os.13144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail. METHOD From February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self-made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double-stranded steel wire was introduced into a self-made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x-rayed front and side fractures before and after surgery and the maximum displacement and formation of the three-dimensional CT-scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery. RESULT A total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X-ray and three-dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair. CONCLUSION For refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.
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Affiliation(s)
- Shi-Jie Kang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Fei-Long Bao
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Dong-Sheng Huang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Tao Jiang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Yi-Ming Hu
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Jian-Min Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Tao Liu
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
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DeRogatis MJ, Kanakamedala AC, Egol KA. Management of Subtrochanteric Femoral Fracture Nonunions. JBJS Rev 2021; 8:e1900143. [PMID: 33006463 DOI: 10.2106/jbjs.rvw.19.00143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.
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Affiliation(s)
- Michael J DeRogatis
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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15
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Poller (blocking) screw with intramedullary femoral nailing for subtrochanteric femoral non-unions: clinical outcome and review of concepts. Eur J Trauma Emerg Surg 2021; 48:1295-1306. [PMID: 33835188 DOI: 10.1007/s00068-021-01651-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Surgery to treat nonunion resulted from malalignment is challenging since correction and bone union should be achieved simultaneously. To report the clinical outcomes achieved through reconstruction of sub-trochanteric femoral fractures by femoral nailing using a poller screw and to review the current concepts. MATERIALS AND METHODS Fourteen patients (11 men and 3 women; mean age 56.4 years) who were diagnosed with non-union of subtrochanteric femoral fractures and who underwent intramedullary nailing with blocking screws between August 2013 and March 2019, with at least 1 year follow-up, were analyzed retrospectively. The preoperative and postoperative Centrum-Collum-Diaphyseal angle and anterior angulation angle were measured. Bone union time, position and number of poller screws used, and complications were analyzed. Functional assessment was performed by evaluating the Harris hip score. The related literature was searched, and 14 clinical studies on the treatment of sub-trochanteric non-union were analyzed. RESULTS Bone union was achieved in 12/14 cases (85.7%) at the final follow-up within a mean of 6.52 (3-12) months. Bone union was also achieved in two patients lacking bone union at the final follow-up through bone grafting and augmented plating. No cases developed complications, including infection and bone necrosis, and the varus deformity and anterior angulation significantly improved from a preoperative mean of 12.4° and 9.4° to postoperative mean 3.8° and 2.4°, respectively. The mean Harris hip score at the final follow-up was 87.07 (73-98) points. Analysis of published literature revealed high rates of bone union (78-100%) through various fixation methods. CONCLUSION Correction with blocking screws and rigid fixation with intramedullary nailing to treat sub-trochanteric-non-union-caused malalignment can yield good clinical and radiological outcomes.
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Management of Refractory Aseptic Subtrochanteric Non-union by Dual Plating. Indian J Orthop 2021; 55:636-645. [PMID: 33995867 PMCID: PMC8081806 DOI: 10.1007/s43465-020-00318-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Subtrochanteric fractures are challenging to treat because of their anatomical and biomechanical behaviours. Non-unions of this region become much more difficult to treat because of the previous surgical scar, fibrosis, mal-reduction, presence of an implant, compromised soft tissue, and osseous vascularity, bone-mass loss etc. The aim is to provide a stable mechanical environment by PF-LCP, augmented by LCP (dual plating) where biology can work uneventfully. Biology is re-initiated by decortication (shingling) and autologous cancellous bone graft. METHODS Twelve cases of failed aseptic subtrochanteric non-union either with intact or broken implant were included in this study in a period of 3 years from August 2016 to July 2019. The interposing fibrous tissue resected in patients with mal-aligned fragments. The mechanical stabilization is achieved by orthogonal dual plating. PF-LCP on lateral and 4.5 mm LCP anteriorly, decortication, and cancellous graft applied before applying for the anterior plate. Patients were encouraged for a toe-touch walk with walking-frame from 3rd post-operative day. Functional outcomes were assessed using Parker Mobility Score (PMS). RESULTS All fractures united in 7 ± 1.53 months. ROM at the knee remained unchanged but improved at the hip after revision surgery. Average PMS improved to 7.58 from pre-revision 1.75 validating the efficacy of this protocol. CONCLUSION Adequate stability by dual-plate construct and re-initiation of cellular and biochemical processes by decortication and cancellous bone-graft reunited ununited subtrochanteric fractures. This particular combination of plates and decortication has not been employed earlier as per our review of the literature. AIM To offer a new paradigm for the management of surgically failed subtrochanteric non-unions.
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17
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Shin WC, Jang JH, Moon NH, Jun SB. Is open bone graft always necessary when treating aseptic subtrochanteric nonunion with a reamed intramedullary nail? BMC Musculoskelet Disord 2021; 22:145. [PMID: 33648481 PMCID: PMC7923340 DOI: 10.1186/s12891-021-04016-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/25/2021] [Indexed: 11/30/2022] Open
Abstract
Background This study aimed to compare the radiological results between closed nailing without bone graft (BG) and open nailing with BG for aseptic subtrochanteric nonunion and to determine when an open procedure with BG should be considered. Methods In this retrospective study, we investigated patients who underwent surgical intervention for subtrochanteric nonunion between January 2008 and March 2018 in two institutions. Patients with infection, large bone defect, pathologic fracture, open fracture, previous surgery using plate, and follow-up of less than 1 year were excluded. We compared the demographic details and radiological results between patients who underwent the open procedure with BG (BG group) and the closed procedure without BG (non-BG group) as a historical control, and risk factors for the failure of revision surgery were evaluated. Results Thirty-seven patients met the criteria and were divided into the following two groups: the BG group (n=19) who underwent open nailing with BG and the non-BG group (n=18) who underwent closed reamed nailing without BG. The mean degrees of correction of varus and flexion deformity were significantly different (p=0.001, respectively), 6.2° and 2.9° in the BG group and 4.1° and 0.6° in the non-BG group, respectively. Bony union was observed in 17 cases (89.5%) in an average of 7.4 months in the BG group and in 16 cases (88.9%) in 7.6 months in the non-BG group, with no significant differences. The factors that were significantly associated with failure of revision were atypical fracture, two or more previous surgeries, and varus and sagittal anterior angulation. Conclusions The radiological results of closed reamed nailing without BG for subtrochanteric nonunion were satisfactory. In the effort of percutaneous realignment, gap reduction, and intramedullary reaming, the radiological results of closed nailing without BG were not different from those of open nailing with BG; therefore, closed procedure without BG may be an acceptable option in appropriately selected patients.
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Affiliation(s)
- Won Chul Shin
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Trauma Center, Bio-medical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea.
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Se Bin Jun
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Evaluation and management of atypical femoral fractures: an update of current knowledge. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:825-840. [PMID: 33590316 DOI: 10.1007/s00590-021-02896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.
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19
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Baltes T, van der Veen A, Blankevoort L, Donders J, Kloen P. Locking plate constructs in subtrochanteric fixation: a biomechanical comparison of LCP screws and AO-nuts. J Clin Orthop Trauma 2020; 16:1-6. [PMID: 33717935 PMCID: PMC7919968 DOI: 10.1016/j.jcot.2020.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/30/2020] [Accepted: 12/26/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Various studies have reported the use of the 95-degree condylar blade plate in the treatment of a subtrochanteric fracture or non-union. However, the holding power of standard screws in the metaphyseal and diaphyseal area is often diminished due to osteopenia. The alternative in this area is the use of locking plates, Schühlis or AO-nuts. With the latter two, non-locking screws in the blade plate can be converted to a fixed angle fixation. The objective of this study was to compare the stiffness and strength of the AO-nut augmented 95-degree condylar blade plate construct with that of a locking plate construct. In addition, a clinical series of eight patients treated with the AO-nut augmented 95-degree condylar blade plate construct is presented. METHODS Single screw-plate constructs of a 5.0 mm locking screw/locking compression plate (LCP) and a 4.5 mm non-locking screw/4.5 mm dynamic compression plate (DCP), converted to a fixed-angle screw construct using AO-nuts, were tested by cantilever bending. During loading, force and displacement were recorded, from which the bending stiffness (N/mm) and the yield strength (N) were determined. Secondarily, all patients that underwent surgical treatment for subtrochanteric fracture, malunion or non-union by the senior author using this technique, underwent chart review. RESULTS The stiffness of the locking screws was about four times higher compared to the AO-nut augmented construct. The yield strength was 2.3 times higher for the locking screw construct. In none of the eight patients treated with the fixed-angle blade plate, failure of the AO-nut augmented construct occurred. CONCLUSIONS Although the stiffness and strength of the AO-nut augmented construct is less than of the locking screw, excellent clinical outcomes can be achieved utilizing this construct.
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Affiliation(s)
- T.P.A. Baltes
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Corresponding author. Department of Orthopaedic Surgery, PO Box 22660, Amsterdam, 1100 DD, the Netherlands.
| | - A.J. van der Veen
- Department of Physics and Medical Technology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - L. Blankevoort
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - J.C.E. Donders
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - P. Kloen
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Kalia A, Singh J, Garg S, Singh R. Proximal Femoral Non-unions with Implant In Situ Treated by Revision Osteosynthesis: A Real Challenge. J Orthop Case Rep 2020; 10:80-84. [PMID: 34169023 PMCID: PMC8046450 DOI: 10.13107/jocr.2020.v10.i09.1912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Proximal femur fractures non-union with implant failure creates a nightmare for both the surgeon and the patient. Meticulous surgical planning and the correct choice of the implant are essential to achieve success in the revision surgery. Materials and Methods: Eleven patients with ununited proximal femur fractures including both intertrochanteric and subtrochanteric fractures who had a failed previous implant were included in the study. Femoral neck nonunions and infected nonunions were excluded from the study. One patient was lost to follow-up. Results: One patient was lost to follow-up and out of the remaining ten patients, six were males and four were females. Mean age was 62.2 years (35–74). Union was achieved with mean union time of 10.1 months (9–14). Mean surgical time was 105 min (90–125) and mean blood loss during surgery was 600 ml (350–850). Mean time of revision surgery after the primary index surgery was 20 months (15–30). Mean duration of follow-up was 12.9 months (12-16). Conclusion: Revision osteosynthesis in proximal femoral nonunions with implant failure is a real test of surgeons expertise because of the many factors going against like osteoporosis, distorted proximal femur anatomy due to the already present implant resulting in poor bone stock availability. Judicious and appropriate selection of implants is an impeccable factor for fracture union and positive outcome.
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Affiliation(s)
- Anoop Kalia
- Department of Orthopaedics, Max Super Speciality Hospital, Mohali, Punjab. India
| | - Jagdeep Singh
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. India
| | - Sorabh Garg
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. India
| | - Rajdeep Singh
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. India
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Benz D, Tarrant SM, Balogh ZJ. Proximal femur fracture non-union with or without implant failure: A revision technique with clinical outcomes. Injury 2020; 51:1925-1930. [PMID: 32513448 DOI: 10.1016/j.injury.2020.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/17/2020] [Accepted: 05/11/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This manuscript presents a revision surgical technique with clinical outcomes for the management of inter and subtrochanteric femur fracture non-union with or without implant failure. METHODS Between January 2010 and January 2019, consecutive patients presenting with inter and subtrochanteric femur fracture non-union and/or implant failure managed with exchange intramedullary nailing, LCP augmentation and biological supplementation were identified. Patient demographics and perioperative data was recorded. RESULTS 13 patients with 10 intertrochanteric and 3 subtrochanteric femur fractures were identified. Revision was performed for implant failure in 8 (62%) patients and non-union in 5 (38%) patients. Fracture union occurred in all patients at an average of 9 months post revision. CONCLUSIONS Exchange intramedullary nailing, with LCP augmentation and biological supplementation is an effective technique to restore anatomy, maintain function and facilitate immediate weight bearing while providing a fixation construct able to withstand the often extended time periods required to achieve fracture union.
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Affiliation(s)
- Daniel Benz
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia
| | - Seth M Tarrant
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, Australia.
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Tucker WA, Birt MC, Heddings AA, Horton GA. The Effect of Postoperative Nonsteroidal Anti-inflammatory Drugs on Nonunion Rates in Long Bone Fractures. Orthopedics 2020; 43:221-227. [PMID: 32379334 DOI: 10.3928/01477447-20200428-06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 03/03/2020] [Indexed: 02/03/2023]
Abstract
The association of nonsteroidal anti-inflammatory drugs (NSAIDs) with non-union in long bone fractures has been controversial. The purpose of this study was to evaluate whether NSAID exposure results in increased risk of non-union in operatively treated long bone fractures. The authors used International Classification of Diseases and Current Procedural Terminology codes to identify patients under a single-payer private insurance with operatively treated humeral shaft, tibial shaft, and subtrochanteric femur fractures from a large database. Patients were divided into cohorts based on NSAID use in the immediate postoperative period, and nonunion rates were compared. A cost analysis and a multivariate analysis were performed. Between 2007 and 2016, a total of 5310 tibial shaft, 3947 humeral shaft, and 8432 subtrochanteric femur fractures underwent operative fixation. Patients used NSAIDs in the first 90 days postoperatively in 900 tibial shaft, 694 humeral shaft, and 967 subtrochanteric femur fractures. In these patients, nonunion rates were 18.8%, 17.4%, and 10.4%, respectively. When no NSAIDs were used, the rates were 11.4%, 10.1%, and 4.6% for each fracture type, respectively (P<.05). Among patients taking NSAIDs, subtrochanteric femur fractures had a 2.4 times higher risk of nonunion and humeral shaft and tibial shaft fractures both had a 1.7 times higher risk of nonunion (P<.05). Multivariate analysis showed NSAID use to be an independent risk factor in all 3 types. Cost analysis showed a great increase in economic burden (P<.05). This study indicated that NSAID exposure was associated with fracture nonunion. [Orthopedics. 2020;43(4):221-227.].
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The utility of the angled blade plate in hip fracture nonunion treatment: A report of three cases and review of the literature. OTA Int 2019; 2:e041. [PMID: 33937669 PMCID: PMC7997124 DOI: 10.1097/oi9.0000000000000041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 06/04/2019] [Indexed: 01/05/2023]
Abstract
Objectives: We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions. Design: Retrospective, case series. Setting: Tertiary academic hospital. Patients/Participants: Three. Intervention: We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP. Main outcome measurements: Radiographic union and clinical outcome. Results: All three patients achieved radiographic union, and were ambulating without pain at final follow-up. Conclusions: The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.
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Mukherjee P, Brattgjerd JE, Niratisairak S, Nilssen JR, Strømsøe K, Steen H. The stabilising effect by a novel cable cerclage configuration in long cephalomedullary nailing of subtrochanteric fractures with a posteromedial wedge. Clin Biomech (Bristol, Avon) 2019; 68:1-7. [PMID: 31125925 DOI: 10.1016/j.clinbiomech.2019.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clinical studies suggest that an adjunctive cerclage in intramedullary nailing of subtrochanteric fractures improves the outcome. Despite this, to what extent various cerclage configurations influences the fixation strength, remains undocumented. We tested the hypothesis that the stability of subtrochanteric fractures with a posteromedial wedge treated with long cephalomedullary nail varies with cerclage configuration. METHODS 40 composite femurs with a subtrochanteric osteotomy including a posteromedial-wedge were locked by cephalomedullary nailing (T2 recon, Stryker) and divided into 4 groups. In Group-A no cerclage was applied. The Group-B received a lateral tension-band (cerclage cable with crimp, Depuy-Synthes). Without any fixation, the wedge-component was removed in these groups. The Group-C was fixed with a cerclage encircling the wedge-component, while in the Group-D a novel figure-of-8 cerclage stabilised the wedge-component. Each femur was tested quasi-static in a material-testing-machine for stiffness calculation, first horizontally to simulate seated-position and then vertically to simulate standing-position. Finally, cyclic testing was performed in the upright-posture to measure deformation over time. FINDINGS In Group-D the mean stiffness in the sitting-position was 6.4, 5.8 and 3.1 times higher than the Groups-A, B and C, respectively, and correspondingly 2.0, 2.1 and 1.7 times higher in the standing-position (p < 0.05). Over time, Group-D demonstrated less mean deformation than tension-band (p = 0.05), while the deformation was not significantly different from the other groups. INTERPRETATION Additional use of cerclage enhances the stability of intramedullary nailed subtrochanteric fractures, and use of the figure-of-8 cerclage configuration, compressing the entire posteromedial-buttress, is the superior technique.
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Affiliation(s)
- Pavel Mukherjee
- Biomechanics Lab, Division of Orthopaedic Surgery, Oslo University Hospital, 4950 Nydalen, 0424 Oslo, Norway; Department of Orthopaedic Surgery, North Norwegian University Hospital, St. Olavs Gata 70, 9406 Harstad, Norway.
| | - Jan Egil Brattgjerd
- Biomechanics Lab, Division of Orthopaedic Surgery, Oslo University Hospital, 4950 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 1171 Blindern, 0318 Oslo, Norway
| | - Sanyalak Niratisairak
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 1171 Blindern, 0318 Oslo, Norway
| | - Jan Rune Nilssen
- Norwegian Defense Research Establishment, Kjeller, Instituttvn 20, NO-2007 Kjeller, Norway
| | - Knut Strømsøe
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 1171 Blindern, 0318 Oslo, Norway
| | - Harald Steen
- Biomechanics Lab, Division of Orthopaedic Surgery, Oslo University Hospital, 4950 Nydalen, 0424 Oslo, Norway
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Bifocal treatment for peri-articular femoral nonunions: A retrospective case series review. OTA Int 2019; 2:e023. [PMID: 33937658 PMCID: PMC7997152 DOI: 10.1097/oi9.0000000000000023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022]
Abstract
Aim This is a retrospective review of complex periarticular femoral nonunions where bone loss from comminution at original fracture, subsequent infection or lysis was identified and treated by radical excision, internal fixation, and concurrent femoral lengthening from a different level. Material and Method Sixteen patients with a mean age of 41 years were treated. There were 6 infected nonunions. Ten nonunions were located in the distal femur and the remaining proximal. Case notes and radiograph review were used to determine fracture union, lengthening achieved, and complications. Patient outcome was assessed using the SF-12, Tegner-Lysholm Knee Score, and Oxford Hip Score. Results Fracture union was achieved in all patients. The mean lengthening performed was 51 mm (range 30-80) with a fixator time averaging 39 weeks (range 17-80). The bone healing index was 1.9 months/cm. All but 2 patients were restored to within 5 mm of opposite leg length; 1 patient subsequently underwent contralateral limb shortening. The SF-12 had a mean Physical Health Composite Score of 40.0 (22.4-52.9) and a mean Mental Health Composite Score of 49 (30.7-62.0). The Oxford Hip Score was scored at a mean of 39 (21-47) and the Tegner-Lysholm score had a mean of 71 (36-94). There were 3 cases of fracture/deformity from the lengthened bone column (regenerate) and 2 patients required a quadricepsplasty for knee stiffness that was present prior to the treatment for the nonunion. Conclusion Bifocal treatment of complex periarticular femoral nonunions offers a single solution for dealing with bone loss, nonunion, and instability. The method is safe and reliable but has, as with all methods involving distraction osteogenesis, a significant complication rate. Despite this caution, the patients' outcomes were satisfactory.
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Abstract
BACKGROUND The treatment of subtrochanteric fracture nonunion is challenging. Although revision with either an intramedullary or extramedullary device had been advocated with acceptable results, complications that require secondary procedures still arise. The use of an intramedullary device with augmentation plate fixation is a well-known approach for femoral or tibial diaphyseal nonunion. However, this approach has not previously been reported for subtrochanteric fracture nonunion. MATERIALS AND METHODS A series of 21 cases of subtrochanteric fracture nonunion treated with an intramedullary device in combination with augmentation side plating were collected and retrospectively reviewed after an average of 18 months of followup. Fourteen patients with a prior well-fixed intramedullary device were treated with side plating and bone grafting. Seven patients underwent revision nailing in addition to side plating and bone grafting. RESULTS All fractures united well without major complication. The average time to union was 7.1 months. CONCLUSION The use of an intramedullary device with augmentation plate fixation is a reliable and decisive procedure for treating subtrochanteric fracture nonunion that produces satisfactory results with a low complication rate.
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Affiliation(s)
- Yu Cheng Lo
- Department of Orthopaedics Surgery, Changhua Christian Hospital, Changhua, Taiwan,Address for correspondence: Dr. Yu Cheng Lo, Department of Orthopaedics Surgery, Changhua Christian Hospital, No. 135, Nanhsiao Street, Changhua 500, Taiwan. E-mail:
| | - Yu Ping Su
- Department of Orthopaedics and Traumatology, Veterans General Hospital, Taipei, Taiwan
| | - Cheng Pu Hsieh
- Department of Orthopaedics Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun Hsiung Huang
- Department of Orthopaedics Surgery, Changhua Christian Hospital, Changhua, Taiwan
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Lotzien S, Rausch V, Schildhauer TA, Gessmann J. "Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw". BMC Musculoskelet Disord 2018; 19:448. [PMID: 30577781 PMCID: PMC6303875 DOI: 10.1186/s12891-018-2372-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications. METHODS We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating. RESULTS Between 2002 and 2017, we identified 40 patients with a mean age of 65.4 years (range 34-91 years) who met the inclusion criteria. At a mean follow-up period of 26.3 months (range 6-173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63 months (± 12.4 months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery. CONCLUSIONS The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.
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Affiliation(s)
- Sebastian Lotzien
- BG University Hospital Bergmannsheil, Bochum, Germany
- Department of General and Trauma Surgery, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | | | | | - Jan Gessmann
- BG University Hospital Bergmannsheil, Bochum, Germany
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Prins J, Donders JCE, Helfet DL, Wellman DS, Klinger CE, Redko M, Kloen P. Periprosthetic femoral nonunions treated with internal fixation and bone grafting. Injury 2018; 49:2295-2301. [PMID: 30366829 DOI: 10.1016/j.injury.2018.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/13/2018] [Accepted: 10/15/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Periprosthetic femoral nonunions (PPFN) have a reported incidence of 3-9%. Literature on PPFN management is scarce. The study aim was to review combined results of two academic teaching hospitals using comparable PPFN treatment strategies. MATERIALS AND METHODS A retrospective review was conducted of all patients treated for a PPFN between February 2005 and December 2016. All patients treated with internal fixation for a PPFN with complete clinical and radiological follow-up until healing were included. Nineteen patients were identified (mean age 71.2 years, range 49-87). Treatment consisted of failed hardware removal, debridement, reduction, and rigid internal fixation with or without bone graft. For revision PPFN surgery, use of dual-plating and bone graft augmentation was common. RESULTS Eighteen of 19 patients (94.7%) progressed to osseous union. One patient was converted to a total femoral prosthesis. No patients were lost to follow-up. All were ambulatory at last follow-up and mean follow-up was 39.8 months. Fourteen patients (73.7%) united after our index nonunion surgery at mean 9.8 months. Five patients (26.3%) required revision surgery after our index nonunion treatment and in 4 of these cases union was achieved at mean 18.0 months. CONCLUSIONS Our results suggest debridement, revision of fixation and liberal use of bone grafting can lead to reliable healing in the majority of PPFNs. For those PPFNs that do not heal following initial treatment, good healing potential persists with an additional procedure. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Jonne Prins
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Johanna C E Donders
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - David L Helfet
- Orthopaedic Trauma Service, Center for Hip Preservation, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, United States.
| | - David S Wellman
- Orthopaedic Trauma Service, Center for Hip Preservation, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, United States
| | - Craig E Klinger
- Orthopaedic Trauma Service, Center for Hip Preservation, Hospital for Special Surgery and New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, United States
| | - Mariya Redko
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, United States
| | - Peter Kloen
- Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Kim SM, Rhyu KH, Lim SJ. Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate. Bone Joint J 2018; 100-B:1511-1517. [PMID: 30418051 DOI: 10.1302/0301-620x.100b11.bjj-2018-0306.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. PATIENTS AND METHODS Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale. RESULTS In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group. CONCLUSION The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.
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Affiliation(s)
- S M Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University School of Medicine, Seoul, South Korea
| | - K H Rhyu
- Department of Orthopedic Surgery, Kyung Hee University Hospital, College of Medicine, Kyung-Hee University, Seoul, South Korea
| | - S J Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Kilinc BE, Oc Y, Kara A, Erturer RE. The effect of the cerclage wire in the treatment of subtrochanteric femur fracture with the long proximal femoral nail: A review of 52 cases. Int J Surg 2018; 56:250-255. [PMID: 29960077 DOI: 10.1016/j.ijsu.2018.06.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/30/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION To present the effect of the cerclage fixation, which was performed for the purpose of preserving the alignment obtained by open reduction, on the long-term clinical and radiological results of subtrochanteric fractures. MATERIALS AND METHODS The inclusion criterias were at least 2 years of follow-up, no severe cognitive impairment, and to be able to walk independently prior to fracture. Patients with transverse or short oblique subtrochanteric hip fractures (AO/OTA class 32-A3.1), patients underwent previous femoral or hip operation for the same side and those with segmental fractures, bilateral fractures and pathological fractures were not included in the study. The clinical and radiological results of the patients were evaluated. The clinical evaluations were performed with Palmer and Parker Mobility Score (PPM), Lower Extremity Functional Score (LEFS), visual analogue score (VAS) and return to pre-injury activity status. The elapsed time between the trauma and the surgery date, the duration of surgery the estimated amount of bleeding, and the length of hospital stay of patients were assessed. RESULTS Thirty-two of the 52 patients were female and 20 were male. The mean age of females was 77.80 ± 9.75 years and the mean age of the males was 79.18 ± 6.50 years. The mean follow-up period of the patients was 62.25 ± 34.68 months. The mean time until the patients' surgery was 6.18 ± 3.32 days. The mean duration of surgery was 52.6 ± 13.8 min. The mean amount of bleeding was 176 ± 90 ml. The mean length of patients' hospital stay was 6.2 ± 3.2 days. The postoperative mean duration of union was found to be 3.8 ± 1.6 months. The mean value of varus/valgus angulation in coronal plane measurements was 0.52°. No complication was observed in any patient during the cerclage application. The mean number of wire was 1.3. LEFS difference was statistically significant. PPM decline was not statistically significant. CONCLUSION Open reduction and the use of cerclage did not produce a negative effect in terms of fracture union. The generation of medial support by anatomical reduction of the fracture prevents the implant failure and provide a basis for union.
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Affiliation(s)
| | - Yunus Oc
- Sisli Hamidiye Etfal Training and Research Hospital, Halaskargazi Cad., Etfal Sk, 34371, Şişli, İstanbul, Turkey.
| | - Adnan Kara
- Medipol University Medical Faculty, Göztepe Mahallesi, Metin Sk. No:4, 34214, Bağcılar, İstanbul, Turkey.
| | - Ramazan Erden Erturer
- İstinye University Medical Faculty, Esenkent Mahallesi, Süleyman Demirel Cd, 34510, Esenyurt, İstanbul, Turkey.
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Provisional Plating of Subtrochanteric Femur Fractures Before Intramedullary Nailing in the Lateral Decubitus Position. J Orthop Trauma 2018; 32:e151-e156. [PMID: 29065038 DOI: 10.1097/bot.0000000000001044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Subtrochanteric femur fractures remain a challenge for surgeons to obtain and maintain adequate reduction and stable fixation. For this reason, multiple techniques have been described, but we are unaware of a detailed contemporary description of the combination of provisional plating before intramedullary fixation in the lateral decubitus position. We present our technique as it was used from 2011 to 2015 to treat 22 fractures and how it compared clinically to the other 48 subtrochanteric femur fractures treated during that period. The clinical and radiographic outcomes for all fractures were evaluated. The operative time was shorter when no open reduction was used but open cases showed no significant difference when using a provisional plate. Those patients treated with provisional plating were shown to have higher blood loss values and longer operative times, but when looking at the outcomes, the rate of malunion, which was defined as >5 degrees of angulation on postoperative radiographs, was significantly lower at 0% in the provision plating in the lateral decubitus position subset compared with the remaining subtrochanteric fractures, 27.7% (P = 0.013). As the quality of reduction and stability of fixation are the most significant factors in determining outcomes of subtrochanteric femur fractures, this study shows that this technique is a valuable tool in an orthopaedist's armamentarium and present it as such.
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Tucker A, Warnock M, McDonald S, Cusick L, Foster AP. Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:511-520. [PMID: 29043506 DOI: 10.1007/s00590-017-2059-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 10/08/2017] [Indexed: 12/29/2022]
Abstract
Cephalomedullary nail (CMN) failure is a rare entity following hip fracture treatment. However, it poses significant challenges for revision surgery, both mechanically and biologically. Nail failure rates have been reported at < 2%; however, no published studies have reported revision surgery procedures and their respective outcomes. We present a regional experience, with outcomes, of the revision options. We identified 20 fatigued CMNs that underwent four different revision procedures. Mean age was 73 ± 15.24 years, with a 3:1 female preponderance, and a median ASA grade of 3. Post-operative CMN radiographs demonstrated a significant number of fractures were fixed in varus, with reductions in neck-shaft angles post-operatively. A "poor" quality of reduction resulted in significantly earlier nail failure, compared to "adequate" and "good" (p = 0.027). Tip-Apex Distance (TAD) mean was 23.2 ± 8.3 mm, and an adequate TAD with three-point fixation was seen in only 35% of cases. Mean time to failure was 401.0 ± 237.2 days, with mean age at failure of 74.0 ± 14.8 years. Options after failure included revision CMN nail, proximal femoral locking plate (PFLP), long-stem or restoration arthroplasty, or femoral endoprosthesis. Barthel Functional Index scores showed no significant difference at 3 and 12 months post-operatively, nor any difference between treatment groups. Mean 12-month mortality was 30%, akin to a primary hip fracture mortality risk according to NICE guidelines. Mortality rates were lowest in revision nails. Subsequent revision rates were higher in the PFLP group. There is no reported evidence on the best surgical technique for managing the failed CMN, with no clear functional benefit in the options above. Good surgical technique at the time of primary CMN surgery is critical in minimising fatigue failure. After revision, overall mortality rates were equivalent to reported primary hip fracture mortality rates. Further multicentre evaluations are required to assess which technique convey the best functional outcomes without compromising 12-month mortality rates.
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Affiliation(s)
- Adam Tucker
- Altnagelvin Area Hospital, Glenshane Road, Londonderry, BT47 6SB, Northern Ireland, UK.
| | - Michael Warnock
- Altnagelvin Area Hospital, Glenshane Road, Londonderry, BT47 6SB, Northern Ireland, UK
| | - Sinead McDonald
- Fracture Outcomes and Research Department, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Laurence Cusick
- Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Andrew P Foster
- Altnagelvin Area Hospital, Glenshane Road, Londonderry, BT47 6SB, Northern Ireland, UK
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Dumbre Patil SS, Karkamkar SS, Dumbre Patil VS, Patil SS, Ranaware AS. Author's reply. Indian J Orthop 2017; 51:348-349. [PMID: 28566792 PMCID: PMC5439326 DOI: 10.4103/ortho.ijortho_435_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Sampat S Dumbre Patil
- Department of Orthopaedics, Noble Hospital, Pune, Maharashtra, India,Address for correspondence: Dr. Sampat S Dumbre Patil, Department of Orthopaedics, Noble Hospital, 153, Magarpatta City Road, Hadapsar, Pune - 411 013, Maharashtra, India. E-mail:
| | | | | | - Shailesh S Patil
- Department of Orthopaedics, Noble Hospital, Pune, Maharashtra, India
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Lin SJ, Huang KC, Chuang PY, Lee CY, Huang TW, Lee MS, Hsu RWW. The outcome of unstable proximal femoral fracture treated with reverse LISS plates. Injury 2016; 47:2161-2168. [PMID: 27435361 DOI: 10.1016/j.injury.2016.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/16/2016] [Accepted: 07/07/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Russel-Taylor type 2B fractures compromised the trochanteric region and medial buttress of proximal femur. This fracture pattern limits the choice of implants and raises the risk of adverse outcomes. We aimed to (i) determine the outcome of Russel-Taylor type 2B fractures treated using reverse less invasive stabilization system plates (LISS-DF) and to (ii) learn what factors affected outcomes after osteosynthesis with reverse LISS plates. DESIGN A retrospective study SETTING: The study was conducted at a Level III trauma center in Taiwan. METHODS Twenty-five consecutive patients presenting with a Russel-Taylor type 2B fracture were enrolled. All cases were treated with reverse LISS plates. A Modified Radiographic Union Scale for Femur (RUSF), Radiographic parameters, functional scores, and complications were assessed. RESULTS Union occurred in 21 cases at an average of 18.8 weeks. The average immediate postoperative neck-shaft angle was 130° (range: 122-135°) compared with 139° (range: 135-141°, p=0.05) on the contralateral side. Two cases had complications of proximal screws cutting out and two cases had broken implants. Finally, all 4 cases required repeated surgeries (16%). Malunion occurred in 4 patients and early mechanical failure (proximal screws cut out) occurred in 2. There was a significant difference in the purchase index of the proximal screws between cases with redisplacement and those without (26.4mm and 98.6mm, p=0.01). CONCLUSIONS The use of reverse LISS plate appeared to be an alternative procedure for the specific pattern in the present study. We recommend using this reverse locking plate to treat unstable proximal femoral fractures with meticulous techniques of placing plates. Adequate purchase of the proximal locking screws might decrease the risks of complications.
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Affiliation(s)
- Shih-Jie Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Change Gung University, Taoyuan, Taiwan
| | - Po-Yao Chuang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chien-Yin Lee
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsan-Wen Huang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Change Gung University, Taoyuan, Taiwan.
| | - Mel S Lee
- Change Gung University, Taoyuan, Taiwan; Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan.
| | - Robert Wen-Wei Hsu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Change Gung University, Taoyuan, Taiwan
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35
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Clinical outcome of conventional versus biological fixation of subtrochanteric fractures by proximal femoral locked plate. Injury 2016; 47:1309-17. [PMID: 27015752 DOI: 10.1016/j.injury.2016.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 02/25/2016] [Accepted: 03/09/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical fixation is the standard management of the subtrochanteric fractures. Proximal femoral locked plating (PF-LCP) provides a strong construct for fixation with a high success rate. However, some studies reported implant failure due to loss of the postero-medial bone support and recommended an anatomical reduction. Other studies reported excellent to good results with indirect (biological) fixation without anatomical reduction. In this study, we reviewed the short-term clinical results of PF-LCP fixation for subtrochanteric fractures using both conventional and biological fixation. MATERIALS AND METHODS Forty six patients (34 males and 12 females) with comminuted subtrochanteric fractures were included aged between 18 and 74 (mean 44.3 years). They were treated in a single-blind random manner by either conventional (open, direct) or biological (indirect) reduction method and internal fixation with PF-LCP. Intra-operative variables including; duration of surgery, blood loss, fluoroscopy time and any complications were recorded. Post-operative differences including; duration of healing, implant failure, complications and the final clinical outcome by Harris Hip Score (HHS) were documented. RESULTS 44 cases continued to the final follow-up (23 of the open fixation group and 21 of the biological fixation group). Patients of open group demonstrated greater blood loss (756±151 vs. 260±39ml; P<0.0001), longer operative times (129±16.9 vs. 91±8min; P<0.0001) and incisions (s) length (20.4±3 vs. 13.4±1cm; P<0.0001). More patients needed blood transfusion in open group (11 patients vs. six in closed group; P<0.0001). Patients of biological group demonstrated longer fluoroscopy time (80.9±7.3 vs. 47.2±5.8sec.; P<0.0001). For each group, one case of implant failure was recorded. Low patient compliance was a detrimental factor for the implant failure in both cases. No much difference was demonstrated for the healing rate (open group; 18.3±3.7 vs. biological group16.5±4 weeks; P<0.058) and for the functional outcome (open group; excellent/good: 54%/37%, biological group; excellent/good: 57%/33%; P=0.766). CONCLUSION PF-LCP provided a strong construct for fixation of the comminuted subtrochanteric fractures either by open or biological techniques. Low patient compliance is an influential factor for implant failure in both types.
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Dumbre Patil SS, Karkamkar SS, Patil VSD, Patil SS, Ranaware AS. Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures. Indian J Orthop 2016; 50:374-8. [PMID: 27512218 PMCID: PMC4964769 DOI: 10.4103/0019-5413.185598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND When primary fixation of proximal femoral fractures with implants fails, revision osteosynthesis may be challenging. Tracts of previous implants and remaining insufficient bone stock in the proximal femur pose unique problems for the treatment. Intramedullary implants like proximal femoral nail (PFN) or surface implants like Dynamic Condylar Screw (DCS) are few of the described implants for revision surgery. There is no evidence in the literature to choose one implant over the other. We used the reverse distal femur locking compression plate (LCP) of the contralateral side in such cases undergoing revision surgery. This implant has multiple options of fixation in proximal femur and its curvature along the length matches the anterior bow of the femur. We aimed to evaluate the efficacy of this implant in salvage situations. MATERIALS AND METHODS Twenty patients of failed primary proximal femoral fractures who underwent revision surgery with reverse distal femoral locking plate from February 2009 to November 2012 were included in this retrospective study. There were 18 subtrochanteric fractures and two ipsilateral femoral neck and shaft fractures, which exhibited delayed union or nonunion. The study included 14 males and six females. The mean patient age was 43.6 years (range 22-65 years) and mean followup period was 52.1 months (range 27-72 months). Delayed union was considered when clinical and radiological signs of union failed to progress at the end of four months from initial surgery. RESULTS All fractures exhibited union without any complications. Union was assessed clinically and radiologically. One case of ipsilateral femoral neck and shaft fracture required bone grafting at the second stage for delayed union of the femoral shaft fracture. CONCLUSIONS Reverse distal femoral LCP of the contralateral side can be used as a salvage option for failed fixation of proximal femoral fractures exhibiting nonunion.
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Affiliation(s)
- Sampat S Dumbre Patil
- Department of Orthopaedics, Noble Hospital, Hadapsar, Pune, Maharashtra, India,Address for correspondence: Dr. Sampat S Dumbre Patil, Department of Orthopaedics, Noble Hospital, 153, Magarpatta City Road, Hadapsar, Pune - 411 013, Maharashtra, India. E-mail:
| | - Sachin S Karkamkar
- Department of Orthopaedics, Noble Hospital, Hadapsar, Pune, Maharashtra, India
| | | | - Shailesh S Patil
- Department of Orthopaedics, Noble Hospital, Hadapsar, Pune, Maharashtra, India
| | - Abhijeet S Ranaware
- Department of Orthopaedics, Noble Hospital, Hadapsar, Pune, Maharashtra, India
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Brinker MR, O'Connor DP. Management of Aseptic Tibial and Femoral Diaphyseal Nonunions Without Bony Defects. Orthop Clin North Am 2016; 47:67-75. [PMID: 26614922 DOI: 10.1016/j.ocl.2015.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
An evidence-based description of aseptic tibial and femoral diaphyseal nonunions without segmental defects is based on a systematic search of MEDLINE. Aseptic nonunion of the femoral or tibial diaphysis without segmental defects and with an in situ nail, treated with reamed exchange nailing or augmentative plating and bone grafting, has consistently high union rates. Aseptic nonunion without segmental defects and with in situ plate and screw fixation is best managed with revision plate and screw fixation and autogenous bone graft. Various techniques and methods of biological stimulation have relatively high union rates.
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Affiliation(s)
- Mark R Brinker
- Fondren Orthopedic Group LLP, Texas Orthopedic Hospital, 7401 South Main Street, Houston, TX 77030, USA; Department of Orthopaedic Surgery, The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | - Daniel P O'Connor
- Department of Health and Human Performance, University of Houston, 3855 Holman GAR104, Houston, TX 77204-6015, USA.
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Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them. Injury 2015; 46 Suppl 5:S3-11. [PMID: 26298022 DOI: 10.1016/j.injury.2015.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, Leeds LS7 4SA, UK
| | - Raul Castillo
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK
| | - Nikolaos K Kanakaris
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, Leeds LS7 4SA, UK.
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Vaishya R, Agarwal AK, Gupta N, Vijay V. Reversed distal femoral locking plate for failed proximal femoral nail with non-union of proximal femoral fractures. INTERNATIONAL ORTHOPAEDICS 2015; 40:1709-1715. [DOI: 10.1007/s00264-015-3002-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/14/2015] [Indexed: 11/28/2022]
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A Biomechanical Comparison of Two Intramedullary Implants for Subtrochanteric Fracture in Two Healing Stages: A Finite Element Analysis. Appl Bionics Biomech 2015; 2015:475261. [PMID: 27019584 PMCID: PMC4745424 DOI: 10.1155/2015/475261] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 02/13/2015] [Indexed: 11/23/2022] Open
Abstract
Background. The biomechanical effect of two implants, namely, proximal femoral nail antirotation for Asia (PFNA-II) and Expert Asian Femoral Nail (A2FN), for treating subtrochanteric fracture during healing stages, is still unclear. Methods. A 3D finite element model of an intact femur was constructed and validated. The fractured and postoperative models were accordingly produced. The postoperative models were loaded with the peak joint forces during gait for the soft and hard callus stages. The effects of stress distribution on the implants, femoral head and callus, and the deformation of the proximal femur were examined. Results. Both implants showed similar biomechanical effect in two healing stages. As the healing duration increased, the von Mises stress of two implants and the tensile stress of the femoral head decreased, whereas the compressive stress of the femoral head increased. However, the PFNA-II operation resulted in higher stress on the implant, lower stress on the proximal femur, and lower compressive stress and higher tensile stress on the callus than A2FN operation. Conclusions. The A2FN implant may provide a biomechanically superior construct for subtrochanteric fracture healing. However, the upper screw of the A2FN implant may be more likely to be loose in the healing process.
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Four pins assisted reduction of complex segmental femoral fractures: a technique for closed reduction. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2014; 34:912-916. [PMID: 25480590 DOI: 10.1007/s11596-014-1373-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 10/30/2014] [Indexed: 10/24/2022]
Abstract
Complex segmental femoral fractures are usually not amenable to closed reduction. The purpose of this study was to evaluate a series of patients who had undergone four pins assisted reduction and intramedullary nail fixation to determine the therapeutic effect of this closed reduction technique. Between December 2010 and January 2013, 15 consecutive patients with segmental femoral fractures were treated with four pins assisted reduction at our hospital. The patient was placed in a supine position on a radiolucent fracture table and a gentle traction was attempted on the limb. Usually, the proximal fracture segment exhibited the typical deformity of flexion, external rotation, and abduction, the middle segment exhibited adduction and distal fracture segment exhibited flexion. Four Schanz pins were placed percutaneously to fix one cortex and did not penetrate into the medullary cavity, and the "T" sharp handles were fixed on the Schanz pins. The fragments were then reduced by reversing the deforming forces for segmental fractures by two assistants. And then, the reduction could be easily achieved and intramedullary nail fixation was performed. Radiographs were evaluated for the quality of the reduction and fracture union. Closed reduction was achieved in all patients using the four pins technology. All 15 fractures united uneventfully. No patient had a rotational malunion or limb length discrepancy at the time of the last follow-up. Thirteen of the fifteen (86.7%) patients had anatomic reduction and two of them (13.3%) had minor varus alignment of 3° and 5°. Knee stiffness was observed in 2 patients and no implant failure was observed. Surgical treatment of complex segmental femoral fractures with four pins assisted reduction and intramedullary nail fixation techniques can result in excellent reductions and a high union rate.
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Issack PS. Bisphosphonate-Associated Subtrochanteric Femoral Fracture with Profound Proximal Cortical Thickening and Canal Narrowing Requiring Blade-Plate Fixation: A Report of Two Cases. JBJS Case Connect 2014; 4:e87. [PMID: 29252446 DOI: 10.2106/jbjs.cc.n.00026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul S Issack
- Department of Orthopaedic Surgery, New York-Presbyterian/Lower Manhattan Hospital, 170 William Street, New York, NY 10038.
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Kloen P, Nützinger J. Waking up the healing potential of the bone:subtrochanteric non-union in femoral dysplasia successfully treated after 40 years of pain and disability. BMJ Case Rep 2013; 2013:bcr-2012-007469. [PMID: 23291811 DOI: 10.1136/bcr-2012-007469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe a successful valgus osteotomy for a subtrochanteric non-union in a dysplastic femur that had not healed in 40 years despite many earlier attempts. The optimisation of biology and biomechanics in the subtrochanteric area shows that even in a longstanding and complex deformity around the hip salvage is possible.
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Affiliation(s)
- P Kloen
- Department of Orthopaedic Surgery, AMC, Amsterdam, The Netherlands.
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Giannoudis PV, Ahmad MA, Mineo GV, Tosounidis TI, Calori GM, Kanakaris NK. Subtrochanteric fracture non-unions with implant failure managed with the "Diamond" concept. Injury 2013; 44 Suppl 1:S76-81. [PMID: 23351877 DOI: 10.1016/s0020-1383(13)70017-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clinical problem. This study assessed the clinical outcome of patients treated according to the principles of the "Diamond" concept. METHODS Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union in the setting of metalwork failure (broken cephalomedullary reconstruction nail), and treated in a single tertiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures were excluded. The revision strategy was based on the "Diamond concept"; optimisation of the mechanical and the biological environment (implantation of growth factor (rhBMP-7), scaffold (RIA bone graft from contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The minimum follow up was 26 months (16-48). RESULTS Fourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with initial breakage of the distal locking screws followed by nail breakage at the lag screw level. The intraoperative examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases, with an average of 5.2 degrees (0-11). The average time to distal locking screw failure was 4.4 months (2-8.5) and nail failure was 6.5 months (4-10). The time to union after the revision surgery was 6.8 months (5-12). Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism, one myocardial infarction, one below the knee deep vein thrombosis and one blade plate failure that required further revision with double plating and grafting. CONCLUSION Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures. Distal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis, a single stage procedure based on the "Diamond concept" that simultaneously optimizes the mechanical and biological environment is a successful method for managing complex subtrochanteric atrophic non-unions with failed metalwork.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.
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Auxiliary locking plate improves fracture stability and healing in intertrochanteric fractures fixated by intramedullary nail. Clin Biomech (Bristol, Avon) 2012; 27:1006-10. [PMID: 22884619 DOI: 10.1016/j.clinbiomech.2012.07.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 05/21/2012] [Accepted: 07/17/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intertrochanteric fractures present a significant management challenge due to their low inherent stability. The objective of this study was to determine whether an auxiliary locking plate decreases interfragmentary motions and improves fracture healing in intertrochanteric fractures treated by intramedullary nail. METHODS Biomechanical tests and a clinical retrospective study in intertrochanteric to subtrochanteric nonunions were performed. Six synthetic femurs were osteotomized intertrochanterically and fixated with a long gamma nail and an additional locking compression plate. Mechanical tests were conducted that simulated the hip joint force during gait cycle. Following the initial test, the locking compression plate (LCP) was removed from each specimen and the test was repeated. Interfragmentary motions, strains on implants and osteosynthesis stiffness were determined. For the clinical part of the study, 13 intertrochanteric to subtrochanteric nonunions were treated with revisional long gamma nail and additional locking compression plate. Complications and time to union were determined. FINDINGS Biomechanically, interfragmentary rotation was 48% smaller (P=0.047) and interfragmentary shear movement was 42% smaller (P=0.007) with locking compression plate. Strains on the nail decreased by 20-27% (P<0.027) and the osteosynthesis stiffness increased by 23% (P=0.005) with locking compression plate. Clinically, fracture healing was achieved in eleven out of 13 patients after 9.0months (range 4 to 22months). INTERPRETATION The findings of our study indicate that auxiliary locked plating considerably improves biomechanical performance and results in successful healing of unstable intertrochanteric to subtrochanteric femur fractures.
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Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17 consecutive cases over 2 years. Injury 2011; 42:1317-21. [PMID: 21497812 DOI: 10.1016/j.injury.2011.03.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 02/13/2011] [Accepted: 03/15/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND The conflict between the anatomist and biologist surgeons is exemplified by the debate about subtrochanteric hip fractures. Closed intramedullary nailing is biologically friendly but may result in prolonged procedures and malunion. By contrast, accurate anatomical open reduction may disturb the biological composition of the fracture environment. METHODS There were 17 patients at our institution over a 2-year period whose long oblique subtrochanteric fractures would not reduce perfectly in an anatomical fashion using closed methods. All these patients had their fractures treated identically using a new policy at our unit. This strategy involved reduction of the fracture through an open approach, and then employing cerclage cables to stabilise the fracture in an anatomical position before finally inserting a cephalomedullary nail. These patients were retrospectively reviewed at an average of 18 months postoperatively, to assess their progressive functional and radiological outcome up to that point. RESULTS One patient had nonunion and required a secondary procedure. One patient died 8 days postoperatively from a medical complication. The remaining 15 healed within 6 months and all returned to independent living. CONCLUSIONS The results demonstrate that judicious use of cerclage cables to augment fixation of subtrochanteric femur fractures does not have a deleterious effect on healing. One should endeavour, however, to minimise the number of cables used. The basic science literature underpinning our approach to these unstable fractures is also discussed.
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Adult proximal humerus locking plate for the treatment of a pediatric subtrochanteric femoral nonunion: a case report. J Orthop Trauma 2011; 25:e63-7. [PMID: 21577158 DOI: 10.1097/bot.0b013e3181f8d9c3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Nonunions of pediatric subtrochanteric femur fractures are exceedingly rare and have to date not been reported in the literature. We present the case of an 11-year-old boy who developed such a nonunion after open reduction internal fixation using a pediatric locked proximal femur plate. Using an adult proximal humerus locking plate, adequate proximal fixation of the nonunion was obtained. Furthermore, previously placed distal screw holes were safely bridged and the biomechanical environment around the nonunion site improved. Uneventful healing was possible with the use of adjuvant bone grafting. No short- or midterm complications occurred. Although other implants can certainly be adapted to a use different than that of its original design, the present case suggests that adult proximal humerus locking plates may be a safe option for revision surgery of the proximal pediatric femur.
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Tzioupis C, Panteliadis P, Gamie Z, Tsiridis E. Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report. J Med Case Rep 2011; 5:87. [PMID: 21362192 PMCID: PMC3055835 DOI: 10.1186/1752-1947-5-87] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 03/01/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Femoral subtrochanteric fractures are commonly treated using intramedullary devices. Failure of the implant and subsequent nonunion is still an issue, however, and limited evidence exists regarding the most appropriate treatment. CASE PRESENTATION We report the case of an 80-year-old Caucasian woman with a subtrochanteric fracture originally treated using a trochanteric gamma nail which failed, resulting in a nonunion and fracture of its proximal end. The nonunion was revised with the removal of the broken trochanteric gamma nail, application of a condylar blade plate, ipsilateral Reamer/Irrigator/Aspirator autografting, recombinant human bone morphogenetic protein-7 and injectable hydroxyapatite cement. The fracture united fully at ten months following revision surgery, with no signs of femoral head avascular necrosis at 18-month follow-up. CONCLUSION The essential requirements for success when revising a nonunited fracture are to provide anatomical reduction, mechanical stability, bone defect augmentation and biological stimulation to achieve healing. Current advances in molecular biology, such as recombinant human bone morphogenetic protein-7, and biotechnology such as the Reamer/Irrigator/Aspirator system and hydroxyapatite injectable cement can improve patient outcomes over the use of our traditional revision techniques.
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Affiliation(s)
- Christopher Tzioupis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Pavlos Panteliadis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Zakareya Gamie
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Eleftherios Tsiridis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
- Academic Orthopaedic Unit, Faculty of Medicine, Aristotle University of Thessaloniki 541 24, Greece
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A Biomechanical Analysis of Locking Plate Fixation With Minimally Invasive Plate Osteosynthesis in a Subtrochanteric Fracture Model. ACTA ACUST UNITED AC 2011; 70:E19-23. [DOI: 10.1097/ta.0b013e3181d40418] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Managing bone deficiency and nonunions of the proximal femur. Orthop Clin North Am 2010; 41:105-18; table of contents. [PMID: 19931059 DOI: 10.1016/j.ocl.2009.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Revision surgery of the proximal femur with bone loss secondary to failed cephalomedullary nails is problematic and becoming more prevalent as their use grows. This article presents a technique of deformity correction, bone graft techniques that reconstitute residual defects, and definitive fixation using load-sharing devices that provide immediate stability for bone healing and early rehabilitation. Preoperative planning and the potential advantages and disadvantages of newer fixed-angled plates versus established implants are discussed. With proper planning, surgical execution with proved techniques, augmented by the addition of newer graft harvesting techniques, anatomic restoration, and bone reconstitution with healing, has invariably been the result.
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