Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
European Journal of Trauma and Emergency Surgery
Published in: European Journal of Trauma and Emergency Surgery 3/2022

Open Access 26-11-2021 | Original Article

Management of subtrochanteric femur fractures: is open reduction associated with poor outcomes?

Authors: Michalis Panteli, James Shen Hwa Vun, Robert Michael West, Anthony John Howard, Ippokratis Pountos, Peter Vasilios Giannoudis

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2022

Login to get access

Abstract

Purpose

The aim of this study was to identify factors associated with the need for open reduction in subtrochanteric femoral fractures and investigate the effect of cerclage wiring compared to open reduction alone, on the development of complications, especially infection and non-union.

Methods

All consecutive patients with a fracture involving the subtrochanteric region were retrospectively identified, over an 8-year period. Data documented and analysed included patient demographics, fracture characteristics, patient comorbidities, time to fracture union and development of complications.

Results

A total of 512 patients met the inclusion criteria (523 fractures). Open reduction was performed in 48% (247) of the fractures. Following matching and regression analysis, we identified diaphyseal extension of the fracture to be associated with an open reduction (OR: 2.30; 95% CI 1.45–3.65; p < 0.001). Open reduction was also associated with an increased risk of superficial infection (OR: 7.88; 95% CI 1.63–38.16; p = 0.010), transfusion within 48 h following surgery (OR: 2.44; 95% CI 1.96–4.87; p < 0.001) and a prolonged surgical time (OR: 3.09; 95% CI 1.96–4.87; p < 0.001). The risk of non-union, deep infection and overall mortality was not increased with open reduction. The use of cerclage wires [50 out of 201 fractures (24.9%) treated with an open reduction] to achieve anatomical reduction as compared to open reduction alone significantly reduced the risk of non-union (OR: 0.20; 95% CI 0.06–0.74; p = 0.015).

Conclusion

Open reduction of subtrochanteric fractures is not associated with an increased risk of deep infection and non-union, even though it is associated with an increased risk of superficial infection, prolonged surgical time and transfusion. The use of cerclage wire is associated with reduced risk of non-union with little evidence of an increase in complications.

Level of evidence

III.
Literature
1.
Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res. 1992;1992:231–6.
2.
Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am. 2015;46:21–35.PubMedCrossRef
3.
Krappinger D, Wolf B, Dammerer D, Thaler M, Schwendinger P, Lindtner RA. Risk factors for nonunion after intramedullary nailing of subtrochanteric femoral fractures. Arch Orthop Trauma Surg. 2019;139:769–77.PubMedPubMedCentralCrossRef
4.
Russell TATJ. Subtrochanteric fractures of the femur. Philadelphia: WB Saunders; 1992. p. 1485–524.
5.
Panteli M, Mauffrey C, Giannoudis PV. Subtrochanteric fractures: issues and challenges. Injury. 2017;48:2023–6.PubMedCrossRef
6.
Loizou CL, McNamara I, Ahmed K, Pryor GA, Parker MJ. Classification of subtrochanteric femoral fractures. Injury. 2010;41:739–45.PubMedCrossRef
7.
8.
GJ. Haidukewych JL (2010) Subtrochanteric fractures Rockwood and Green’s fractures in adults: Lippincott Williams & Wilkins, Philadelphia, p 1641–1654
9.
Santolini E, Goumenos SD, Giannoudi M, Sanguineti F, Stella M, Giannoudis PV. Femoral and tibial blood supply: a trigger for non-union? Injury. 2014;45:1665–73.PubMedCrossRef
10.
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;44:735–42.PubMedCrossRef
11.
Kim JW, Park KC, Oh JK, Oh CW, Yoon YC, Chang HW. Percutaneous cerclage wiring followed by intramedullary nailing for subtrochanteric femoral fractures: a technical note with clinical results. Arch Orthop Trauma Surg. 2014;134:1227–35.PubMedCrossRef
12.
Apivatthakakul T, Phaliphot J, Leuvitoonvechkit S. Percutaneous cerclage wiring, does it disrupt femoral blood supply? A cadaveric injection study. Injury. 2013;44:168–74.PubMedCrossRef
13.
Persiani P, Noia G, de Cristo C, Graci J, Gurzi MD, Villani C. A study of 44 patients with subtrochanteric fractures treated using long nail and cerclage cables. Musculoskelet Surg. 2015;99:225–30.PubMedCrossRef
14.
Malik MH, Harwood P, Diggle P, Khan SA. Factors affecting rates of infection and nonunion in intramedullary nailing. J Bone Jt Surg Br Vol. 2004;86:556–60.CrossRef
15.
Tang P, Gates C, Hawes J, Vogt M, Prayson MJ. Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures? J Orthop Trauma. 2006;20:317–22.PubMedCrossRef
16.
Imerci A, Aydogan NH, Tosun K. Evaluation of inter- and intra-observer reliability of current classification systems for subtrochanteric femoral fractures. Eur J Orthop Surg Traumatol. 2018;28:499–502.PubMedCrossRef
17.
Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer Science & Business Media; 2012.
18.
19.
Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224:59–74.PubMedCrossRef
20.
R Foundation for Statistical Computing V, Austria R: A language and environment for statistical computing.
21.
22.
Hoskins W, Bingham R, Joseph S, Liew D, Love D, Bucknill A, et al. Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome. Injury. 2015;46:1992–5.PubMedCrossRef
23.
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.PubMedCrossRef
24.
25.
26.
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;137:1077–85.PubMedCrossRef
27.
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;38:1286–93.PubMedCrossRef
28.
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;46:1036–41.PubMedCrossRef
29.
Perren SM, Fernandez Dell’Oca A, Lenz M, Windolf M. Cerclage, evolution and potential of a Cinderella technology. An overview with reference to periprosthetic fractures. Acta Chir Orthop Traumatol Cech. 2011;78:190–9.PubMed
30.
Nather A, Ong H, Aziz Z (2005) Structure of bone. bone grafts and bone substitutes: basic science and clinical applications. World Scientific Publishing Company; 2005. p 3–17.
31.
Pazzaglia UE, Congiu T, Raspanti M, Ranchetti F, Quacci D. Anatomy of the intracortical canal system: scanning electron microscopy study in rabbit femur. Clin Orthop Relat Res. 2009;467:2446–56.PubMedPubMedCentralCrossRef
32.
Lenz M, Perren SM, Gueorguiev B, Richards RG, Krause F, Fernandez Dell’Oca A, et al. Underneath the cerclage: an ex vivo study on the cerclage-bone interface mechanics. Arch Orthop Trauma Surg. 2012;132:1467–72.PubMedCrossRef
33.
Lenz M, Perren SM, Richards RG, Muckley T, Hofmann GO, Gueorguiev B, et al. Biomechanical performance of different cable and wire cerclage configurations. Int Orthop. 2013;37:125–30.PubMedCrossRef
34.
Forch S, Sandriesser S, Fenwick A, Mayr E. Impairment of the blood supply by cerclages: myth or reality?: An overview of the experimental study situation. Unfallchirurg. 2021;124:231–40.PubMedCrossRef
35.
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;35:1237–43.PubMedPubMedCentralCrossRef
36.
Yoon BH, Lee YK, Kim SC, Kim SH, Ha YC, Koo KH. Epidemiology of proximal femoral fractures in South Korea. Arch Osteoporos. 2013;8:157.PubMedCrossRef
37.
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;19:369.PubMedPubMedCentralCrossRef
38.
Howard A, Giannoudis PV. Proximal femoral fractures: issues and challenges. Injury. 2012;43:1975–7.PubMedCrossRef
39.
Kilinc BE, Oc Y, Kara A, Erturer RE. The effect of the cerclage wire in the treatment of subtrochanteric femur fracture with the long proximal femoral nail: a review of 52 cases. Int J Surg (London, England). 2018;56:250–5.CrossRef
40.
Trikha V, Das S, Agrawal P, Arkesh M, Kumar Dhaka S. Role of percutaneous cerclage wire in the management of subtrochanteric fractures treated with intramedullary nails. Chin J Traumatol. 2018;21:42–9.PubMedPubMedCentralCrossRef
Metadata
Title
Management of subtrochanteric femur fractures: is open reduction associated with poor outcomes?
Authors
Michalis Panteli
James Shen Hwa Vun
Robert Michael West
Anthony John Howard
Ippokratis Pountos
Peter Vasilios Giannoudis
Publication date
26-11-2021
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Trauma and Emergency Surgery / Issue 3/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-021-01834-6

Other articles of this Issue 3/2022

European Journal of Trauma and Emergency Surgery 3/2022 Go to the issue

Original Article

Short-term outcome of isolated lateral malleolar fracture treatment is independent of hospital trauma volume or teaching status: a nationwide retrospective cohort study

Original Article

Local application reduces number of needed EPC for beneficial effects on wound healing compared to systemic treatment in mice

Original Article

The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery

Original Article

Functional outcomes of internal fixation of scapula fractures due to high-velocity gunshot injuries

Review Article

Efficacy of tracheal tube introducers and stylets for endotracheal intubation in the prehospital setting: a systematic review and meta-analysis

Original Article

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk