Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.

Treatment for subtrochanteric fracture and subsequent nonunion in an adult patient with osteopetrosis:A case report and review of the literature

BACKGROUND As a congenital metabolic bone disease caused by defective osteoclastic resorption of immature bone,osteopetrosis is characterized by diffused sclerosis of bones,brittle bones,easy fracturing,narrow medullary canals,and a weak fracture healing ability.At present,clear standards and principles for the treatment of fractures in patients with osteopetrosis are lacking.Non-operative treatment can prevent fracture hematoma and preserve the blood supply to the bone fragments,while being associated with frequent failures and higher mortality rates.Meanwhile,closed reduction and internal fixation with intramedullary nail(CRIF+IMN)approaches can also protect blood supply to the fracture site.However,IMN cannot be used for the vast majority of patients with osteopetrosis due to the narrowing of medullary canals.Thus,open reduction and internal fixation with plate remains the most appropriate surgical method for treating fractures in patients with osteopetrosis,but this approach is complicated by the lack of intramedullary hematopoiesis in such patients.Fracture healing primarily depends on the blood supply to the external periosteum.Open reduction can also easily destroy the periosteum and cause delayed fracture healing or even nonunion;however,CRIF may be the most practical approach.As a result,it would be prudent to solve the difficulty of drilling during the operation and the problem of postoperative nonunion.CASE SUMMARY In 2018,we treated an adult patient with osteopetrosis presenting with a subtrochanteric fracture.The fracture was fixed using a femoral locking compression plate.Because of delayed consolidation,at 12 mo postoperatively the patient was further treated with platelet-rich plasma(PRP)combined with radial extracorporeal shock wave therapy(rESWT).Antero-posterior and lateral radiographs obtained at the latest follow-up(10 mo)showed that the callus had grown at the original fracture site,and the medial fracture line almost disappeared.CONCLUSION Osteosynthesis remains the first choice of treatment approach for fractures in patients with osteopetrosis,especially peritrochanteric fractures.Preoperative preparation is necessary to avoid risks such as drill bit breakage and iatrogenic fracture during the operation.Moreover,fractures in a patient with osteopetrosis present with a high risk of delayed union and nonunion,which can be potentially cured with PRP+rESWT.

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

Purpose:Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages.However,no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment.This study is performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures.Methods:Patients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed.The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group.The patients'clinical data,including the operative time,intraoperative blood loss,hospital stay,reoperation rate,fracture union time,and Harris hip score,were compared between these 2 groups.Categorical variables were compared using Chi-square or Fisher's exact test.Continuous variables with normal distribution were presented as mean±standard deviation and analyzed with Student's t-test.Nonnormally distributed variables were expressed as median(Q_(1),Q_(3))and assessed using the Mann-Whitney test.A p<0.05 was considered significant.Results:In total,69 patients were included in the study(35 patients in the non-cerclage group and 34 patients in the cerclage group).The baseline data of the 2 groups were comparable.There were no significant difference in the length of hospital stay(z=-0.391,p=0.696),operative time(z=-1.289,p=0.197),or intraoperative blood loss(z=-1.321,p=0.186).However,compared with non-cerclage group,the fracture union time was shorter(z=-5.587,p<0.001),the rate of nonunion was lower(χ^(2)=6.030,p=0.03),the anatomical reduction rate was higher(χ^(2)=5.449,p=0.03),and the Harris hip score was higher(z=-2.99,p=0.003)in the cerclage group,all with statistically significant differences.Conclusions:Intramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures.This technique can improve the reduction effect,increase the stability of fracture fixation,shorten the fracture union time,reduce the occurrence of nonunion,and contribute to the recovery of hip joint function.

Subtrochanteric femur fracture treated by intramedullary fixation

Purpose： To discuss surgical technique, operative efficacy and clinical outcome of intramedullary fixation in the treatment of subtrochanteric femur fractures. Methods： From February 2011 to February 2013, 76 cases of subtrochanteric femur fractures were treated by intramedullary fixation in our hospital, including 53 males and 23 females, with the age range of 37 -72 years （mean 53.5 years）. According to Seinsheimer classification, there were 2 cases of type I, 7 type Ⅱ, 15 type Ⅲ, 23 type IV and 29 type V. Firstly, all patients underwent closed reduction with the guidance of C-arm fluoroscopy in a traction table. Two cases of type I and 3 cases of type Ill fractures had ideal closed reduction followed by internal fixation. The others needed additional limited open reduction. Radiographic examination was used to evaluate callus formation and fracture healing in postoperative 1, 3, 6 and 12 months follow-up. Functional recovery was evaluated by Harris Hip Scoring （HHS） system. Results： Patients were followed up for 6-12 months. All fractures were healed except one patient with delayed union. The average bone union time was 4.5 months. According to HHS system, 65 cases were considered as excellent in functional recovery, 8 good, 2 fair and 1 poor. The proportion of the patients with excellent and good recovery was 96.05%. Conclusion： Intramedullary fixation is feasible for the treatment of subtrochanteric femur fracture. The accuracy of intraoperative reduction and surgical skill are important for the clinical outcome and the patients＇ prognosis.

Comparison of extramedullary and intramedullary devices for treatment of subtrochanteric femoral fractures at tertiary level center

Objective： The treatment of subtrochanteric fractures is challenging and treatment modalities and implants are constantly evolving. This study attempts to revisit and compare extramedullary vs. intramedullary devices in relatively young population. Methods： Thirty patients with subtrochanteric fractures were enrolled and treated with extramedullary or intramedullary devices and follow-up continued one year for clinico-radiological assessment. Results： The mean age of patients was 37,53 years. Most were males between 21-40 years. The dominant mode of injury was traffic accidents （66%）. Fractures were classified according to Russell-Taylor classification. Forty percent were Russell-Taylor type IA, 37% type IB and 23% type IIA. Average time to surgery was 3.6 days from the time of admission to hospital. Mean duration of surgery was 45 minutes for intramedullary device （group A） and 105 minutes for extramedullary device （group B）. Average blood loss was 100 ml in group A and 200 ml in group B. Mean duration of radiation exposure was 130 seconds and 140 seconds for groups A and B, while average duration of hospital stay was 12 days and 16 days respectively. Excellent results were seen in 47% of cases in group A and 33% of cases in group B. Conclusion： Intramedullary device is a reliable implant for subtrochanteric fractures. It has high rates of union with minimal soft-tissue damage. Intramedullary fixation has biological and biomechanical advantages, but surgery is technically demanding. Gradual learning and patience is needed to make this method truly rewarding.

Lateral cortex blowout during PFNA blade insertion in a subtrochanteric fracture - Should bone quality determine the type of nail used？

Subtrochanteric fractures pose a therapeutic challenge to the surgeons. With the advent of proximal femoral nails, most of the cases are treated with nailing. Newer nails like proximal femoral nail antirotation （PFNA） require the blade to be directly hammered into the bone compared to older nails where the screws are drilled and tapped before insertion. We report one such case in a middle aged female that had intraoperative lateral cortex blowout during PFNA blade insertion in a sclerotic bone. This occurrence to the best of our knowledge is unreported in literature. It is therefore imperative to consider the quality of bone before a decision is made on the implant chosen.

Role of percutaneous cerclage wire in the management of subtrochanteric fractures treated with intramedullary nails

Purpose： Cerclage wire application has emerged as a potential therapeutic adjunct to intramedullary nailing for subtrochanteric fractures. But its popularity is plagued by the concern of possible negative effect on fracture zone biology. This study was intended to analyze the clinico-radiological outcome and complications associated with cerclage wire application. Methods： Retrospective analysis was performed on all the subtrochanteric fractures operated with intramedullary nailing between January 2012 and January 2016. After exclusion, 48 patients were available with an average follow-up of 20.8 months. Long oblique, spiral, spiral wedge or comminuted fracture configurations with butterfly fragments were particularly considered for cerclage wire appli- cation, which was employed by percutaneous cerclage passer in 21 patients. Assessment was done in terms of operation time, blood loss, quality of reduction, neck-shaft angle, follow-up redisplacement, union time, complications, and final functional evaluation by Merle d＇Aubigne＇-Postel score. Results： Average operation time and blood loss were significantly higher in cerclage group （p 〈 0.05）. However, cerclage use substantially improved quality of reduction in terms of maximum cortical displacement （p = 0.003） and fracture angulation （p - 0.045）; anatomical reduction was achieved in 95.23% of cases as compared to 74.07% without cerclage. Union time was shorter, although not statis- tically different （p - 0.208）, in cerclage group. Four patients in non-cerclage group developed non-union, 2 of them had nail breakage. No infection or any other implant related complications were reported with cerclage use. Conclusion： Minimally-invasive cerclage wire application has proved to be beneficial for anatomical reconstruction in difficult subtrochanteric fractures, whenever applicable, without any harmful effect on fracture biology.

Two Different Total Hip Arthroplasties for Hartofilakidis Type C1 Developmental Dysplasia of Hip in Adults

Background： Total hip arthroplasty （THA） in developmental dysplasia of the hip （DDH） is more complex than the normal hip, with large replacement risks and many complications.Although nonosteotomy THA is convenient to perform, femoral osteotomy shortening can avoid blood vessel and nerve traction injuries.This study aimed to compare osteotomy THA with nonosteotomy to determine reasonable options for operative management of DDH.Methods： Data on 48 DDH patients who underwent THA were analyzed retrospectively.The patients were divided into two groups： Group A 29 cases （nonosteotomy）, and group B 19 cases （osteotomy）.Harris and Western Ontario and McMaster Universities Osteoarthritis Index （WOMAC） scores, limb length discrepancy （LLD）, radiological data on the hip, and claudication were evaluated.Data were analyzed by using paired-sample Student＆#39;s t-test, independent-sample Student＆#39;s t-test, and Pearson＆#39;s Chi-square test;the test level was α =0.05.Results： Postoperative Harris （90.7 ＆#177; 5.1） and WOMAC scores （88.0 ＆#177; 10.6） were significantly improved compared with preoperative Harris （44.8 ＆#177; 5.7） and WOMAC scores （42.0 ＆#177; 5.3） in group A （P 〈 0.05）.Postoperative Harris （90.4 ＆#177; 2.8） and WOMAC scores （88.2 ＆#177; 5.9） were significantly improved compared with preoperative Harris （44.4 ＆#177; 4.2） and WOMAC scores （43.2 ＆#177; 4.3） in group B （P 〈 0.05）.One case of dislocation occurred in group A;after closed reduction, dislocation did not recur.In group A, 2 patients developed cutaneous branch injury of the femoral nerve, which spontaneously recovered without treatment.Postoperative LLD 〉2 cm was seen in one case in group A and five cases in group B.Postoperative claudication showed no significant difference between the two groups （P 〉 0.05）.No patients developed infection;postoperative X-rays showed that the location of the prosthesis was satisfactory, and the surrounding bone was not dissolved.Conclusions： THA is effective and safe for DDH.For unilateral high dislocation DDH patients with limb lengthening ≤4 cm and good tissue conditions, THA without femoral osteotomy may be considered.