Importance of firm isthmic fixation in high-energy induced subtrochanteric fracture of the femur: retrospective observational study in a level I trauma center.
European journal of trauma and emergency surgery : official publication of the European Trauma Society
INTRODUCTION:This study aimed to report the surgical outcomes in patients with high-energy induced subtrochanteric fracture and determine the risk factors for nonunion using statistical analysis. METHODS:This study evaluated 88 patients with high-energy induced subtrochanteric fractures who underwent surgeries with indirect reduction technique and intramedullary nailing between March 2015 and December 2020. Outcome measures, including union time and nonunion incidence, were assessed by radiologic evaluation. Multiple logistic regression analyses were performed to identify the risk factors for nonunion, using age, sex, injury severity score, body mass index, preoperative mobility score, implant, and isthmic fixation as covariates. RESULTS:Five nonunions and two delayed unions were identified. The average union time was 17.4 weeks. Multiple logistic regression analyses showed that poor isthmic fixation was the only risk factor for nonunion (odds ratio 15.294, 95% confidence interval 1.603-145.894, P value 0.018). Out of five nonunion cases, four were confirmed as hypertrophic, and one was confirmed as atrophic. CONCLUSION:Although surgical treatment using an indirect reduction technique and intramedullary nailing showed good outcomes, hypertrophic nonunion due to distal instability could occur if a firm fixation at the level of the isthmus cannot be achieved. LEVEL OF EVIDENCE:Level III, retrospective cohort study.
10.1007/s00068-021-01709-w
Subtrochanteric femur nonunion - Chasing the elusive an analysis of two techniques to achieve union: Nail-plate fixation and plate-structural fibula graft fixation.
Injury
INTRODUCTION:The subtrochanteric region is known for its unique biomechanical properties that contribute to challenges in fracture reduction. To ensure optimal fracture healing, achieving robust mechanical stability is essential. There are very few studies in the literature describing the treatment of subtrochanteric fracture nonunion. PURPOSE:To analyze the outcomes of two techniques of revision fixation of nonunion in subtrochanteric femur fracture, namely, nail-plate fixation and plate-structural fibula graft fixation. METHODS:This was a retrospective analysis of subtrochanteric femur nonunion between January 2011 and December 2019. The demographic details, details of the index surgery, details of the revision surgery and the time to final union were collected. The nonunion was divided based on the level of the fracture into high subtrochanteric and low subtrochanteric. Two revision techniques were used: plate-structural fibula graft for high subtrochanteric and nail-plate construct for low subtrochanteric femur fractures RESULTS: Out of the 54 patients that were included, there was malalignment in 53.70 %, medial comminution in 46.3 %, distraction at the fracture site in 44.4 %, lateral trochanteric wall break in 37.03 % and implant failure in 70.37 % of the patients. There were 20 high subtrochanteric and 34 low subtrochanteric fractures. Union was achieved in 53 patients (98.14 %). The mean LEFS score was 71.4 in the nail-plate group and 66.2 in the plate-structural fibula graft group (p 0.003). CONCLUSION:The treatment of subtrochanteric femur fracture nonunion can be a daunting task. The goal is to correct the varus and restore the medial support which will prevent the occurrence of collapse and another failure. We were able to achieve this with both the nail-plate and the plate- structural fibula graft revision methods.
10.1016/j.injury.2024.111462
Nonunion of fractures of the subtrochanteric region of the femur.
Haidukewych George J,Berry Daniel J
Clinical orthopaedics and related research
There are no large clinical series to guide the clinician treating a subtrochanteric nonunion. Deformity, bone loss from previous hardware, and the high stresses in the subtrochanteric region all pose challenges to achieving successful bony union with reoperation. The purpose of this study was to retrospectively review a consecutive series of patients treated with reoperation using contemporary techniques for subtrochanteric nonunion. Between 1992 and 2002, 23 patients with a mean age of 55 years (range, 16-88 years) with 23 subtrochanteric nonunions were treated with additional attempts to achieve union. Two patients were lost to followup. The remaining 21 patients were followed up for a mean of 12 months (range, 6-39 months). Implants used for revision internal fixation were as follows: eight patients were treated with a cephalomedullary nail, seven patients were treated with a standard antegrade femoral nail, five patients were treated with a 95 degree angled blade plate, one patient was treated with a sliding hip screw, one patient was treated with a 95 degree dynamic condylar screw, and one patient was treated with dual large fragment plates. Eighteen of 23 patients had bone grafting: eight had autograft, six had allograft, and both were used in three patients. One patient had free vascularized fibular transfer. Twenty of 21 nonunions healed (95%). At last followup, all patients with healed fractures had no or minimal pain. All were ambulatory. There were no intraoperative complications. There was one postoperative complication (4%), an adynamic ileus that was treated medically. Revision internal fixation and selected bone grafting for subtrochanteric nonunion led to a high rate of fracture union and functional improvement. Intramedullary devices with fixation into the femoral head and neck and fixed angled devices were effective in achieving stable fixation of the proximal bony fragment.
10.1097/00003086-200402000-00030
Functional Outcome of Subtrochanteric Femoral Fracture Fixation by Intramedullary Interlocking Surgical Implant Generation Network Nail.
Mymensingh medical journal : MMJ
Subtrochanteric femoral fractures are one of the common fractures encountered in today's Orthopaedic practice. High stress leads implant failure and produce varus collapse. From the perspective of biomechanics, intramedullary fixation has unique advantage which can better distribute stress and acting load-sharing implants. Biomechanically proximal wide canal and short segment provide less optimal fixation by conventional intramedullary nails. Intramedullary nail by Surgical Implant Generation Network (SIGN) has proximal interlocking that gain purchase through femoral neck and provide improved stability for proximal part. The aim of this study was to evaluate the functional outcome of subtrochanteric fractures fixation by intramedullary interlocking SIGN nail. This prospective study was conducted from July 2016 to June 2018 at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) through non randomized purposive sampling. Total 31 patients, aged above 18 years irrespective of sex with closed subtrochanteric fractures were included. Patients with pathological fracture, multiple injuries were excluded from the study. The mean age of the patients was 42.61±19.59 years with range 18-80 years. Most common fractures were Seinsheimer type III (51.6%) and average follows up 42.39 weeks (24-48 weeks). Union rate 93.55% with delayed union 6.45% and no nonunion. Functionally most of patient started early partial (77.42%) and full (64.52%) weight bearing with 61.29% have full knee ROM and 83.9% without limb shortening. Maximum patients regained walking (83.87%) and squatting (90.32%) and return to preinjury state (80.65%) of activities. Evaluation of outcome by Modified Harris Hip Score showed excellent (70.97%), good (22.58%), fair (3.23%) and poor (3.23%) thus satisfactory outcome were 93.55%. This study concludes that intramedullary interlocking SIGN nail is a safe and reliable implant for the treatment of subtrochanteric fractures with excellent functional outcome.
The role of an augmentative plating in the management of femoral subtrochanteric nonunion.
Archives of orthopaedic and trauma surgery
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.
10.1007/s00402-023-04767-4
Subtrochanteric fracture treatment: a retrospective study of 46 patients.
Li Fan,Sang Weilin,Wang Qiugen,Huang Jianhua,Lu Haimin
Medical principles and practice : international journal of the Kuwait University, Health Science Centre
OBJECTIVE:To investigate whether or not reconstruction of the medial cortex in subtrochanteric fracture can reduce the risks of internal fixation failure, fracture malunion, and nonunion. SUBJECTS AND METHODS:Between 2005 and 2008, 46 patients with subtrochanteric fracture were treated with intramedullary nailing and followed up. The average age was 42 years. According to the Seinsheimer classification, 26 patients were type IIIA, 7 were type IIIB, 11 were type IV and 2 were type V. Medial cortex alignment was achieved under traction in 40 cases. In 5 cases, the medial fractures were too far away and we used minimally invasive open reduction with wire or titanium cable cerclage. In 1 case of type IIIA subtrochanteric fracture, the displaced medial fracture was not reconstructed and was fixed with a long Gamma nail. We reviewed all patients' radiographs before and after treatment to evaluate bone healing. RESULTS:The 46 patients were followed up for an average of 24.3 months. Bone union was achieved within an average of 18.7 weeks in 45 cases. One case, a type IIIA fracture nonunion with displaced medial fracture, was not reconstructed. Instead, we used a free fibular transplantation on the medial side and fracture union was achieved 6 months after revision surgery. CONCLUSIONS:In reconstructing the medial cortex in subtrochanteric fracture treatment, continuity and integrity are important. They can reduce the failure of internal fixation and the incidence of nonunion.
10.1159/000329787
Management of Subtrochanteric Femoral Fracture Nonunions.
DeRogatis Michael J,Kanakamedala Ajay C,Egol Kenneth A
JBJS reviews
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.
10.2106/JBJS.RVW.19.00143
Risk factors for nonunion after intramedullary nailing of subtrochanteric femoral fractures.
Krappinger Dietmar,Wolf Bernhard,Dammerer Dietmar,Thaler Martin,Schwendinger Peter,Lindtner Richard A
Archives of orthopaedic and trauma surgery
INTRODUCTION:Nonunion is a common complication after intramedullary nailing of subtrochanteric femoral fractures. A more detailed knowledge, particularly of avoidable risk factors for subtrochanteric fracture nonunion, is thus desired to develop strategies for reducing nonunion rates. The aim of the present study therefore was to analyse a wide range of parameters as potential risk factors for nonunion after intramedullary nailing of subtrochanteric fractures. MATERIALS AND METHODS:Seventy-four patients who sustained a subtrochanteric fracture and were treated by femoral intramedullary nailing at a single level 1 trauma centre within a 6-year period were included in this study. A total of 15 patient-related, fracture-related, surgery-related, mechanical and biological parameters were analysed as potential risk factors for nonunion. Furthermore, the accuracy of each of these parameters to predict nonunion was calculated. RESULTS:Nonunion occurred in 17 of 74 patients (23.0%). Of the 15 potential risk factors analysed, only 3 were found to have a significant effect on the nonunion rate (p < 0.05): postoperative varus malalignment, postoperative lack of medial cortical support and autodynamisation of the nail within the first 12 weeks post-surgery. Accuracy of each of these 3 parameters to predict nonunion was > 0.70. Furthermore, the nonunion rate significantly increased with the number of risk factors (no risk factor: 2.9%, one risk factor: 23.8%, two risk factors: 52.9%, and three risk factors: 100% [Chi-square test, p = 0.001)]. CONCLUSIONS:Our study indicates that intraoperative correction of varus malalignment and restoration of the medial cortical support are the most critical factors to prevent nonunion after intramedullary nailing of subtrochanteric femoral fractures. In addition, autodynamisation of the nail within the first 3 months post-surgery is a strong predictor for failure and should result in revision surgery.
10.1007/s00402-019-03131-9