Abstract
Introduction
Subtrochanteric fractures are more difficult to treat than other proximal femoral fractures. The aim of this study was to report the outcomes for patients with subtrochanteric fractures treated using a cephalomedullary nail following open reduction and cerclage wiring versus closed reduction alone, regarding health-related quality of life (HRQoL) and social function.
Materials and methods
We performed a prospective cohort study including patients aged 60 years or older suffering fragility subtrochanteric fractures of the femur treated with cephalomedullary nails, with a minimum 2-year follow-up. We defined two treatment groups: one treated with closed reduction manoeuvres (60 patients), and another treated with open reduction and cerclage wiring (30 patients). The outcomes were mortality, orthopaedic complications (reoperation and no-union), social function (Jensen Index), and HRQoL (EQ-5D index score).
Results
There were no differences regarding sex, age, side affected, type of implant, anaesthetic risk, 1-year mortality, and orthopaedic complications. Surgical time was longer in the cerclage wire group, but length of stay was 2 days shorter for the cerclage group and reduction was better. Patients treated with cerclage wiring had significantly better EQ-ED at 12 months (0.66 ± 0.22 points vs. 0.78 ± 0.15 points); and social status at 12 and 18 months (2.77 ± 1.00 points vs. 2.10 ± 1.22 points).
Conclusions
Better reduction is achieved when using cerclage wires for fragility subtrochanteric fractures. These fractures had a negative effect on quality of life and social function, but better outcomes were observed in the cerclage group.
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References
Lundy DW (2007) Subtrochanteric femoral fractures. J Am Acad Orthop Surg 15:663–671
Bedi A, Le Toan T (2004) Subtrochanteric femur fractures. Orthop Clin North Am 35:473–483. doi:10.1016/j.ocl.2004.05.006
Shukla S, Johnston P, Ahmad MA et al (2007) Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails. Injury 38:1286–1293. doi:10.1016/j.injury.2007.05.013
Barquet A, Francescoli L, Rienzi D, López L (2000) Intertrochanteric-subtrochanteric fractures: treatment with the long Gamma nail. J Orthop Trauma 14:324–328
Afsari A, Liporace F, Lindvall E et al (2010) Clamp-assisted reduction of high subtrochanteric fractures of the femur: surgical technique. J Bone Joint Surg Am 92(Suppl 1 Pt 2):217–225. doi:10.2106/JBJS.J.00158
Nieves JW, Bilezikian JP, Lane JM et al (2010) Fragility fractures of the hip and femur: incidence and patient characteristics. Osteoporos Int 21:399–408. doi:10.1007/s00198-009-0962-6
Haidukewych GJ, Berry DJ (2004) Nonunion of fractures of the subtrochanteric region of the femur. Clin Orthop 419:185–188
Kuzyk PRT, Bhandari M, McKee MD et al (2009) Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma 23:465–470. doi:10.1097/BOT.0b013e3181acfdfd
Liu P, Wu X, Shi H et al (2015) Intramedullary versus extramedullary fixation in the management of subtrochanteric femur fractures: a meta-analysis. Clin Interv Aging 10:803–811. doi:10.2147/CIA.S82119
Matre K, Havelin LI, Gjertsen J-E et al (2013) Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury 44:735–742. doi:10.1016/j.injury.2012.12.010
Barquet A, Mayora G, Fregeiro J et al (2004) The treatment of subtrochanteric nonunions with the long gamma nail: twenty-six patients with a minimum 2-year follow-up. J Orthop Trauma 18:346–353
Giannoudis PV, Ahmad MA, Mineo GV et al (2013) Subtrochanteric fracture non-unions with implant failure managed with the “Diamond” concept. Injury 44(Suppl 1):S76–S81. doi:10.1016/S0020-1383(13)70017-2
Ekström W, Németh G, Samnegård E et al (2009) Quality of life after a subtrochanteric fracture: a prospective cohort study on 87 elderly patients. Injury 40:371–376. doi:10.1016/j.injury.2008.09.010
Miedel R, Törnkvist H, Ponzer S et al (2011) Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail. J Orthop Trauma 25:208–213. doi:10.1097/BOT.0b013e3181eaaf52
Robinson CM, Houshian S, Khan LAK (2005) Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am 87:2217–2226. doi:10.2106/JBJS.D.02898
Yoon Y-C, Jha A, Oh C-W et al (2014) The pointed clamp reduction technique for spiral subtrochanteric fractures: a technical note. Injury 45:1000–1005. doi:10.1016/j.injury.2014.01.007
Afsari A, Liporace F, Lindvall E et al (2009) Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am 91:1913–1918. doi:10.2106/JBJS.H.01563
Tomás J, Teixidor J, Batalla L et al (2013) Subtrochanteric fractures: treatment with cerclage wire and long intramedullary nail. J Orthop Trauma 27:e157–e160. doi:10.1097/BOT.0b013e31826fc03f
Mingo-Robinet J, Torres-Torres M, Moreno-Barrero M et al (2015) Minimally invasive clamp-assisted reduction and cephalomedullary nailing without cerclage cables for subtrochanteric femur fractures in the elderly: surgical technique and results. Injury 46:1036–1041. doi:10.1016/j.injury.2015.01.019
Kennedy MT, Mitra A, Hierlihy TG et al (2011) Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17 consecutive cases over 2 years. Injury 42:1317–1321. doi:10.1016/j.injury.2011.03.023
Ban I, Birkelund L, Palm H et al (2012) Circumferential wires as a supplement to intramedullary nailing in unstable trochanteric hip fractures: 4 reoperations in 60 patients followed for 1 year. Acta Orthop 83:240–243. doi:10.3109/17453674.2012.665329
Riehl JT, Widmaier JC (2009) Techniques of obtaining and maintaining reduction during nailing of femur fractures. Orthopedics 32:581. doi:10.3928/01477447-20090624-17
Yoon RS, Donegan DJ, Liporace FA (2015) Reducing subtrochanteric femur fractures: tips and tricks, do’s and don’ts. J Orthop Trauma 29(Suppl 4):S28–S33. doi:10.1097/BOT.0000000000000287
Kim J-W, Park K-C, Oh J-K et al (2014) Percutaneous cerclage wiring followed by intramedullary nailing for subtrochanteric femoral fractures: a technical note with clinical results. Arch Orthop Trauma Surg 134:1227–1235. doi:10.1007/s00402-014-2023-7
Hoskins W, Bingham R, Joseph S et al (2015) Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome. Injury 46:1992–1995. doi:10.1016/j.injury.2015.07.001
Persiani P, Noia G, de Cristo C et al (2015) A study of 44 patients with subtrochanteric fractures treated using long nail and cerclage cables. Musculoskelet Surg 99:225–230. doi:10.1007/s12306-015-0385-9
Li F, Sang W, Wang Q et al (2011) Subtrochanteric fracture treatment: a retrospective study of 46 patients. Med Princ Pract 20:519–524. doi:10.1159/000329787
Müller T, Topp T, Kühne CA et al (2011) The benefit of wire cerclage stabilisation of the medial hinge in intramedullary nailing for the treatment of subtrochanteric femoral fractures: a biomechanical study. Int Orthop 35:1237–1243. doi:10.1007/s00264-010-1204-4
Charnley J (1961) The closed treatment of common fractures. Cambridge University, Cambridge
Malik MHA, Harwood P, Diggle P, Khan SA (2004) Factors affecting rates of infection and nonunion in intramedullary nailing. J Bone Joint Surg Br 86:556–560
Harrop JS, Styliaras JC, Ooi YC et al (2012) Contributing factors to surgical site infections. J Am Acad Orthop Surg 20:94–101. doi:10.5435/JAAOS-20-02-094
Perren SM (2002) Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 84:1093–1110
Apivatthakakul T, Phaliphot J, Leuvitoonvechkit S (2013) Percutaneous cerclage wiring, does it disrupt femoral blood supply? A cadaveric injection study. Injury 44:168–174. doi:10.1016/j.injury.2012.10.016
Tidermark J, Bergström G, Svensson O et al (2003) Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 12:1069–1079
Jensen JS (1984) Determining factors for the mortality following hip fractures. Injury 15:411–414
Marsh JL, Slongo TF, Agel J et al (2007) Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 21:S1–S133
Seinsheimer F (1978) Subtrochanteric fractures of the femur. J Bone Joint Surg Am 60:300–306
Baumgaertner MR, Curtin SL, Lindskog DM (1998) Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop 348:87–94
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM (1995) The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 77:1058–1064
Corrales LA, Morshed S, Bhandari M, Miclau T (2008) Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am 90:1862–1868. doi:10.2106/JBJS.G.01580
Bhandari M, Fong K, Sprague S et al (2012) Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am 94:e1091–e1096. doi:10.2106/JBJS.K.01344
Mehta V, Finn HA (2005) Femoral artery and vein injury after cerclage wiring of the femur: a case report. J Arthroplasty 20:811–814. doi:10.1016/j.arth.2004.12.050
Aleto T, Ritter MA, Berend ME (2008) Case report: superficial femoral artery injury resulting from cerclage wiring during revision THA. Clin Orthop 466:749–753. doi:10.1007/s11999-007-0109-z
Walters SJ, Brazier JE (2005) Comparison of the minimally important difference for two health state utility measures: EQ-5D and SF-6D. Qual Life Res Int 14:1523–1532
Larsen K, Hansen TB, Søballe K (2008) Hip arthroplasty patients benefit from accelerated perioperative care and rehabilitation: a quasi-experimental study of 98 patients. Acta Orthop 79:624–630. doi:10.1080/17453670810016632
Desteli EE, İmren Y, Erdoğan M, Aydagün Ö (2015) Quality of life following treatment of trochanteric fractures with proximal femoral nail versus cementless bipolar hemiarthroplasty in elderly. Clin Investig Med 38:E63–E72
Incavo SJ, Difazio F, Wilder D (1990) Strength of cerclage fixation systems: a biomechanical study. Clin Biomech 5:236–238. doi:10.1016/0268-0033(90)90007-S
Lenz M, Perren SM, Richards RG et al (2013) Biomechanical performance of different cable and wire cerclage configurations. Int Orthop 37:125–130. doi:10.1007/s00264-012-1702-7
Bhandari M, Guyatt GH, Swiontkowski MF et al (2002) A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma 16:562–566
Guyver PM, McCarthy MJH, Jain NPM et al (2014) Is there any purpose in classifying subtrochanteric fractures? The reproducibility of four classification systems. Eur J Orthop Surg Traumatol 24:513–518. doi:10.1007/s00590-011-0780-3
Loizou CL, McNamara I, Ahmed K et al (2010) Classification of subtrochanteric femoral fractures. Injury 41:739–745. doi:10.1016/j.injury.2010.02.018
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All individuals included in this study gave informed consent for both methods of treatment prior to surgery.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Codesido, P., Mejía, A., Riego, J. et al. Subtrochanteric fractures in elderly people treated with intramedullary fixation: quality of life and complications following open reduction and cerclage wiring versus closed reduction. Arch Orthop Trauma Surg 137, 1077–1085 (2017). https://doi.org/10.1007/s00402-017-2722-y
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DOI: https://doi.org/10.1007/s00402-017-2722-y