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Open Access 01-12-2019 | Fracture Healing | Research article

Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success

Published in: BMC Musculoskeletal Disorders | Issue 1/2019

Abstract

Background

Subtrochanteric femur fractures (SFF) are uncommon, but have a high complication rate concerning non-union and mechanical complications. There is ongoing discussion about risk factors for delayed fracture healing after SFF. The purpose of this study was to evaluate potential risk factors for delayed fracture healing after SFF.

Methods

This retrospective radio-morphometric case control study compares 61 patients after SFF in two groups (uncomplicated healing within 6 months postoperatively vs. delayed union) concerning radiographical properties. The patients were analyzed concerning the following parameter: Quality of the reduction according to Baumgaertner, CCD-angle, Tip-Apex Distance, leg-length shortening and fracture healing according to the RUSH Score.

Results

The mean RUSH-Score at 6 months postoperatively was 21.32(±4.57). At that point of time, only 29/61 fractures were radiographically fully consolidated (timely fracture healing) and 32 patients were rated as delayed union. The total revision rate was 9/61 (14.7%), whereof four patients required revision for symptomatic non-union of the SFF. The results of the radio-morphometric measurement showed a significant difference between both groups concerning the degree of reduction measured according to Baumgaertner (p = 0.022). The postoperative ipsilateral CCD-angle was different between the two groups (p = 0.019). After 12 months postoperatively, 48/61 (78.6%) of fractures were rated healed without any further intervention.

Conclusions

Delayed union after SFF occurs frequently. In our patient population, the quality of reduction and the postoperative CCD-angle were the key factors to avoid delayed union.

Level of evidence

Level III, Therapeutic study.

Trial registration

Clinical Trial Registry University of Regensburg Z-2018-1074-1. Registered 04. Aug 2018. https://studienanmeldung.zks-regensburg.de

Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS. Introduction: fracture and dislocation classification Compendium-2018: international comprehensive classification of fractures and dislocations committee. J Orthop Trauma. 2018;32(Suppl 1):S1–S10. https://doi.org/10.1097/BOT.0000000000001063.CrossRefPubMed

Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg Am. 1978;60(3):300–6.CrossRefPubMed

Marsh D. Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. 1998;(355 Suppl):S22–30. https://doi.org/10.1097/00003086-199810001-00004.CrossRef

Forward DP, Doro CJ, O'Toole RV, Kim H, Floyd JC, Sciadini MF, Turen CH, Hsieh AH, Nascone JW. A biomechanical comparison of a locking plate, a nail, and a 95 degrees angled blade plate for fixation of subtrochanteric femoral fractures. J Orthop Trauma. 2012;26(6):334–40. https://doi.org/10.1097/BOT.0b013e3182254ea3.CrossRefPubMed

Hoskins W, Bingham R, Joseph S, Liew D, Love D, Bucknill A, Oppy A, Griffin X. Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome. Injury. 2015;46(10):1992–5. https://doi.org/10.1016/j.injury.2015.07.001.CrossRefPubMed

Kim KK, Won Y, Smith DH, Lee GS, Lee HY. Clinical results of complex subtrochanteric femoral fractures with long Cephalomedullary hip nail. Hip & pelvis. 2017;29(2):113–9. https://doi.org/10.5371/hp.2017.29.2.113.CrossRef

Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15(11):663–71.CrossRefPubMed

Lunsjo K, Ceder L, Tidermark J, Hamberg P, Larsson BE, Ragnarsson B, Knebel RW, Allvin I, Hjalmars K, Norberg S, Fornander P, Hauggaard A, Stigsson L. Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems. Acta Orthop Scand. 1999;70(5):459–66.CrossRefPubMed

Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. 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. 2013;44(6):735–42. https://doi.org/10.1016/j.injury.2012.12.010.CrossRefPubMed

10.

Panteli M, Mauffrey C, Giannoudis PV. Subtrochanteric fractures: issues and challenges. Injury. 2017;48(10):2023–6. https://doi.org/10.1016/j.injury.2017.09.001.CrossRefPubMed

11.

Riehl JT, Koval KJ, Langford JR, Munro MW, Kupiszewski SJ, Haidukewych GJ. Intramedullary nailing of subtrochanteric fractures--does malreduction matter? Bull Hosp Joint Dis. 2014;72(2):159–63.

12.

Shukla S, Johnston P, Ahmad MA, Wynn-Jones H, Patel AD, Walton NP. Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails. Injury. 2007;38(11):1286–93. https://doi.org/10.1016/j.injury.2007.05.013.CrossRefPubMed

13.

Wang PC, Ren D, Song CH, Zhou B. Surgical technique for subtrochanteric fracture of femur. Orthop Surg. 2016;8(4):516–8. https://doi.org/10.1111/os.12291.CrossRefPubMed

14.

Yoon RS, Donegan DJ, Liporace FA. Reducing subtrochanteric femur fractures: tips and tricks, do's and don'ts. J Orthop Trauma. 2015;29(Suppl 4):S28–33. https://doi.org/10.1097/BOT.0000000000000287.CrossRefPubMed

15.

Zhou ZB, Chen S, Gao YS, Sun YQ, Zhang CQ, Jiang Y. Subtrochanteric femur fracture treated by intramedullary fixation. Chin J Traumatol. 2015;18(6):336–41.CrossRefPubMed

16.

Codesido P, Mejia A, Riego J, Ojeda-Thies C. 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. 2017;137(8):1077–85. https://doi.org/10.1007/s00402-017-2722-y.CrossRefPubMed

17.

Ekstrom W, Nemeth G, Samnegard E, Dalen N, Tidermark J. Quality of life after a subtrochanteric fracture: a prospective cohort study on 87 elderly patients. Injury. 2009;40(4):371–6. https://doi.org/10.1016/j.injury.2008.09.010.CrossRefPubMed

18.

Miedel R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail. J Orthop Trauma. 2011;25(4):208–13. https://doi.org/10.1097/BOT.0b013e3181eaaf52.CrossRefPubMed

19.

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. https://doi.org/10.1016/S0020-1383(13)70017-2.CrossRefPubMed

20.

Kang SH, Han SK, Kim YS, Kim MJ. Treatment of subtrochanteric nonunion of the femur: whether to leave or to exchange the previous hardware. Acta Orthop Traumatol Turc. 2013;47(2):91–5.CrossRefPubMed

21.

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(1):448. https://doi.org/10.1186/s12891-018-2372-4.CrossRefPubMedPubMedCentral

22.

Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord. 2018;19(1):369. https://doi.org/10.1186/s12891-018-2276-3.CrossRefPubMedPubMedCentral

23.

Bhandari M, Fong K, Sprague S, Williams D, Petrisor B. 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. 2012;94(15):e1091–6. https://doi.org/10.2106/JBJS.K.01344.CrossRefPubMed

24.

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058–64.CrossRefPubMed

25.

Cho JW, Oh CW, Leung F, Park KC, Wong MK, Kwek E, Kim HJ, Oh JK. Healing of atypical subtrochanteric femur fractures after Cephalomedullary nailing: which factors predict union? J Orthop Trauma. 2017;31(3):138–45. https://doi.org/10.1097/BOT.0000000000000743.CrossRefPubMed

26.

Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010;34(5):719–22. https://doi.org/10.1007/s00264-009-0837-7.CrossRefPubMed

27.

Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PR. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J. 2014;96-B(8):1029–34. https://doi.org/10.1302/0301-620X.96B8.33644.CrossRefPubMed

28.

Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959;41-A:1399–408.CrossRefPubMed

29.

Muller T, Topp T, Kuhne CA, Gebhart G, Ruchholtz S, Zettl R. 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. 2011;35(8):1237–43. https://doi.org/10.1007/s00264-010-1204-4.CrossRefPubMedPubMedCentral

30.

Mahomed N, Harrington I, Kellam J, Maistrelli G, Hearn T, Vroemen J. Biomechanical analysis of the gamma nail and sliding hip screw. Clin Orthop Relat Res. 1994;304:280–8.

31.

Frank T, Osterhoff G, Sprague S, Garibaldi A, Bhandari M, Slobogean GP, Investigators F. The radiographic union score for hip (RUSH) identifies radiographic nonunion of femoral neck fractures. Clin Orthop Relat Res. 2016;474(6):1396–404. https://doi.org/10.1007/s11999-015-4680-4.CrossRefPubMedPubMedCentral

32.

Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52(3):457–67.CrossRefPubMed

33.

Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009;23(9):628–33. https://doi.org/10.1097/BOT.0b013e3181b04835.CrossRefPubMed

34.

Mingo-Robinet J, Torres-Torres M, Moreno-Barrero M, Alonso JA, Garcia-Gonzalez S. Minimally invasive clamp-assisted reduction and cephalomedullary nailing without cerclage cables for subtrochanteric femur fractures in the elderly: surgical technique and results. Injury. 2015;46(6):1036–41. https://doi.org/10.1016/j.injury.2015.01.019.CrossRefPubMed

Title: Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success
Publication date: 01-12-2019
Keyword: Fracture Healing
Published in: BMC Musculoskeletal Disorders / Issue 1/2019
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-019-2775-x

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Trial registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Trial registration

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