Management of Refractory Aseptic Subtrochanteric Non-union by Dual Plating

BackgroundSubtrochanteric 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.MethodsTwelve 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).ResultsAll 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.ConclusionAdequate 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.AimTo offer a new paradigm for the management of surgically failed subtrochanteric non-unions.     

股骨近端锁定加压钢板治疗老年股骨粗隆间骨折的护理

目的探讨老年股骨粗隆间骨折的护理措施。方法术前给予心理疏导,术后注意观察患者的病情变化、刀口引流管,并予正确的体位和安全护理措施;减少严格卧床时间,尽早功能锻炼,预防下肢静脉血栓等并发症的发生。结果 36例患者术后随访6~12个月,平均8.5个月,按Sanders评分标准,优32例,良3例,差1例(1例因高血压脑病于术后5个月死亡),总优良率为94.6%。结论缩短了患者严格卧床时间,所有患者未出现明显并发症,安全可靠,有效提高了老年患者的生活质量,治疗和护理效果满意。     

Evaluation of proximal femoral locking plate in unstable extracapsular proximal femoral fractures: Surgical technique & mid term follow up results

Background

Stable trochanteric femur fractures can be treated successfully with conventional implants such as sliding hip screw, cephalomedullary nails, angular blade plates. However comminuted and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment of complex, comminuted proximal femoral fractures.

Method

We reviewed 30 patients with unstable inter or subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average operative time was 80 min. Patients were followed up for a period of 3 years (June 2010–June 2013). Patients were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-shaft angle), limb shortening, and hardware failure.

Result

All patients showed signs of union at an average of 9 weeks (8–10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5.

Conclusion

PF-LCP represents a feasible alternative for treatment of unstable inter- or subtrochanteric fractures.     

Clinical outcome of conventional versus biological fixation of subtrochanteric fractures by proximal femoral locked plate

IntroductionSurgical 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 methodsForty 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.Results44 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 ± 39 ml; P < 0.0001), longer operative times (129 ± 16.9 vs. 91 ± 8 min; P < 0.0001) and incisions (s) length (20.4 ± 3 vs. 13.4 ± 1 cm; 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 ± 5.8 sec.; 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).ConclusionPF-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.     

PF-LCP与PFNA治疗高龄股骨粗隆间骨折Evans III-V型临床对比研究

目的 探讨PF-LCP与PFNA治疗高龄股骨粗隆间骨折Evans III-V型临床疗效及安全性差异。方法 研究对象选取我院2012年4月~2015年4月收治Evans III-V型高龄股骨粗隆间骨折共110例,以随机区组法分为A组（55例）和B组（55例）,分别采用PF-LCP与PFNA术式治疗;比较两组患者围手术期临床指标水平、术后随访髋关节Harris评分及术后并发症发生率等。结果 B组患者手术时间和术中失血量均显著优于A组,差异具有显著性意义（P<0.05）;两组患者骨折愈合时间和住院时间比较差异无统计学意义（P>0.05）;B组患者术后随访Harris评分显著高于A组,差异具有显著性意义（P<0.05）;B组患者术后并发症发生率显著低于A组,差异具有显著性意义（P<0.05）。结论 PFNA治疗高龄股骨粗隆间骨折Evans III-V型可有效缩短手术时间,减少术中创伤,改善术后髋关节功能,且有助于降低术后并发症发生风险,价值优于PF-LCP。