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“Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochanteric fractures
Journal Pre-proof “Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures Arvind Kumar, Dushyant Chouhan, Amit Narang, Rizwan Khan, Samarth Mittal PII:
S0976-5662(20)30001-1
DOI:
https://doi.org/10.1016/j.jcot.2020.01.001
Reference:
JCOT 955
To appear in:
Journal of Clinical Orthopaedics and Trauma
Received Date: 14 November 2019 Revised Date:
1 January 2020
Accepted Date: 2 January 2020
Please cite this article as: Kumar A, Chouhan D, Narang A, Khan R, Mittal S, “Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020
TITLE - “Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures
Authors in order (with academic degrees) Arvind Kumar1, Dushyant Chouhan2 , Amit Narang3 , Rizwan Khan4, Samarth Mittal5 1. Dr. Arvind Kumar (MBBS, MS) Assistant Professor Department of Orthopaedics Hamdard Institute of Medical Sciences and Research New Delhi - 110062 (India) [email protected] 2. Dr. Dushyant Chouhan (MBBS, MS) Senior Resident department of Orthopedics, Lady Hardinge Medical College, New Delhi [email protected] 3. Dr. Amit Narang (MBBS, MS) Senior Resident department of Orthopedics, Lady Hardinge Medical College, New Delhi [email protected] 4. Dr. Rizwan Khan (MBBS, DO)
Senior Resident Department of Orthopaedics Hamdard Institute of Medical Sciences and Research New Delhi - 110062 (India) [email protected] 5. Dr. Samarth Mittal (MBBS, MS)(corresponding author) Assistant Professor of Orthopaedics JPN Apex Trauma Centre All India Institute of Medical Sciences Ansari Nagar, New Delhi - 110029 (India) [email protected]
*Corresponding Author : Dr. Samarth Mittal Assistant Professor of Orthopedics, JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS) New Delhi, India Email: [email protected] Mobile number : +91 9013562489
Conflict of interests: None Funding: None
“Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures Abstract Reverse oblique peritrochanteric fractures are unstable injuries. They have an inherent tendency of lateral wall opening and varus displacement.Cephalomedullary nails are the preferred implants for fixation of these fractures. Standard techniques and a medial entry point may not always be helpful in correcting alignment, resulting in persisting varus malreduction. A simple technique using a Lowman clamp and a conventional 3.5 mm plate has been described to prevent lateral wall opening and indirectly, the varus malreduction.
Keywords: Lateral wall; peritrochanteric fractures; reverse oblique; technique; varus malreduction
Introduction
Peri-trochanteric femoral fractures can present in diverse forms, varying from a simple AO type 31A Injury to complex AO type 31C injury. For simple injuries the reduction is simple and they can often be fixed using a standard sliding hip screw or a cephalomedullary nail. The other fractures are preferably fixed with cephalomedullary nails[1]. Among the complex AO type 31C injuries, the reverse oblique fractures are often difficult to manage because of their inherent tendency to displace owing to the unstable fracture- pattern and muscle forces around the fracture[2]. Even with the use of correct nailing techniques, preventing varus malreduction or lateral opening of the fracture is often unavoidable[3,4]. Open techniques can be helpful in maintaining reduction while the canal is prepared for the nail, but once the cephalomedullary nail is completely inserted inside the proximal fragment, a tendency of the lateral opening of fracture or varus malreduction always remains. Even the techniques for the prevention of this malreduction that have been described in the past, have not been able to completely fix this issue with a residual varus displacement still appreciable their radiographs[5]. Adding even a subtle varus to a proximal femur fracture, especially in elder patients with already osteoporotic bone is itself a major risk factor for failure of fixation[6]. Thus, either an anatomical alignment or slightly valgus alignment is preferred to prevent the varus collapse and failure of fixation. Among the described techniques for preventing varus malreduction of the proximal fragment, the first is related to the entry point and direction for the proximal reaming[5]. The entry point should be made medial to the tip of the greater trochanter and proximal reaming is done towards a slightly lateral direction distally. Other techniques depend upon the intraoperative use of clamps to maintain reduction which is understandable considering the basic principles of fracture
fixation. However, once the angulated part of the nail enters the proximal fragment, the clamps often fail to stabilize the reduction that was maintained prior to the nail insertion. The intramedullary track created during reaming should exactly match with the shape of the nail with the fracture in a reduced position. Any mismatch between these would result in fracture displacement. The soft cancellous bone in the proximal femur may tolerate a minor mismatch but that would vary from patient to patient. We describe a simple technique using a Lowman clamp and a conventional 3.5mm plate for stabilization of reverse oblique fractures in anatomical position or in a slightly valgus position, as per the requirement, with reduction maintained during all steps from the preliminary reduction to the final fixation of the proximal cephalomedullary and distal interlocking screw.
Technique (figures 1 and 2 )
The patient is positioned supine on a fracture table. The limbs are positioned as per the convenience of the operating surgeon. The longitudinal traction assembly is maintained on the fractured limb while the opposite limb is flexed and abducted. After standard painting and draping a lateral longitudinal incision is created centred over the fracture site. After subcutaneous dissection, Tensor Fascia Lata is split in the direction of the incision. The Vastus Lateralis is dissected off from the posterolateral intermuscular septum and retracted anteriorly providing a clear exposure of the lateral femoral cortex. The fracture site is identified and prepared as per the requirement of the fracture. Marginal freshening of the fracture is required for nonunion and late presenting cases. Without any periosteal damage, the terminal spike of the proximal fragment is identified and covered temporarily with a conventional 3.5mm plate. The length of the plate
depends upon the requirement of the valgus that needs to be induced at the fracture. For fractures requiring extra valgus, the proximal end of the plate should span the trochanteric flare up to the vastus ridge. For the restoration of the lateral wall continuity that would indirectly restore the medial wall continuity as well, a small plate with one or two holes proximal and distal to the spike of the reverse oblique fragment would be sufficient. The plate should be slightly on the anterior half than the posterior half on the proximal fragment to avoid interference with the cephalomedullary screw track. Once the plate is positioned well, a Lowman clamp is placed centered over the fracture zone with its two medial limbs sliding over the medial cortex of the proximal femur and single lateral limb covering the already placed plate and indirectly, the lateral cortex. The clamp is gradually tightened grasping the whole fracture and plate assembly like a claw-grip. With tightening, the lateral fracture angulation tends to reduce to take up the shape of the plate covering it. When a larger spanning plate, extending up to the trochanteric flare is used, a further tightening after the restoration of the lateral will result in a more inward push to the proximal fragment resulting in a valgus alignment. A single or double unicortical screws can be used to prevent anteroposterior displacement of the plate, if required. Once the appropriate alignment has been achieved, appropriate remaining using a medial entry point and a slightly medial to lateral direction from proximal to distal is kept for reaming using the proximal reamer. The proximal reamer is advanced to a slightly lower level than the level of the lesser trochanter. This would allow additional room for the angulation of the nail without adding stress on the fracture. Conventional reaming is then continued and the cephalomedullary nail is inserted. The clamp need not be removed at any stage until the insertion of all the nail screws both proximally as well as distally. The clamp can be slightly loosened to reposition the plate if interfering with the
proximal cephalomedullary screw track but needs to be retightened after repositioning. Once the proximal screw is inserted, the nail still has a scope of play inside the medullary canal and therefore the clamp and plate assembly should not be removed until the distal locking is done. The fracture remains stable after both cephalomedullary and distal screws are inserted as they would prevent the nail motion within the osseous canal. After this, the clamp and plate assembly can be removed without compromising the fracture reduction. The wound is closed in layers after thorough lavage and dressed. Figures 1 and 2 demonstrate the stepwise application of the described technique. In our institute, we have been using this technique in all reverse oblique fractures to address the opening and varus displacement of the lateral cortex (Figure 3). In simple reverse oblique fractures with a single fracture line, the clamp often suffices in maintaining the reduction during canal preparation and nail insertion. However, in fractures with wide fracture zone and comminution, the lateral limb of the clamp remains insufficient to effectively buttress all fragments of the lateral wall along the same plane and the fracture tends to open up laterally whenever a reamer or the final nail is inserted, creating an undesirable track inside the proximal femur. The addition of plate to the lateral limb of the clamp increases the area of the effective buttress of the clamp, proximally as well as distally. This prevents the lateral opening of the fracture during the passage of various instruments through the proximal femoral canal. By the time of submission of this technique, a total of twelve cases, managed using this technique in reverse oblique peritrochnateric fractures had a minimum follow-up of three months. Radiological union was achieved in all of them within four months postoperatively (Figure 3). No wound or soft tissue related complications were noted.
Discussion
Reverse oblique fractures of the peritrochanteric region are difficult fractures to reduce[2]. Poor reduction, especially the alignment of the lateral wall is a major risk factor for the fixation failure and varus malreduction in these fractures[6]. The complication rate is very low with a good reduction and alignment of the lateral wall[1,3,4,6]. While a good reduction quality in reverse oblique fractures has always been stressed upon, the techniques for prevention of lateral wall displacement during the reaming of the femoral canal and intramedullary nail insertion are sparse. The most important technique that has been widely advocated for the prevention of the varus malreduction is the medial entry point for the guidewire insertion prior to reaming[5]. However, this technique may not be always successful and a subtle opening of the lateral wall may still persist. With open techniques, the assistant can hold the fracture in a reduced position while canal reaming is done, but again minor displacements of the fracture as the reamer crosses the fracture zone can result in a mismatch between desired nail track and the created one. This will result in the opening of the lateral wall that is difficult to control once the nail has been inserted. Our technique is a simple technique that utilizes two readily available devices in the operating room, a Lowman clamp, and a conventional 3.5mm plate. The clamp and plate assembly grasps a major circumference of the fracture zone, and the lateral wall takes up the shape of the plate when the camp is tightened. This assembly prevents opening up of the lateral wall and maltracking of the reamer inside the proximal femur. Thus, a desirable intramedullary track for insertion of the nail is created which prevents fracture displacement when the final intramedullary nail is inserted. Still, the construct remains flexible until all the proximal and
distal screws have been inserted and therefore, the assembly should not be disturbed prior to final screw insertion. Following the insertion of proximal and distal screws, the construct becomes a rigid one and the clamp-plate assembly can be removed. In summary, this technique allows stable reduction of the reverse oblique fractures of peritrochanteric region which remains static throughout the various steps of cephalomedullary nailing. As the fracture alignment is restored, this technique reduces the risk of implant failure and varus malreduction in reverse oblique fractures of peritrochanteric region.
References: 1. Radaideh AM, Qudah HA, Audat ZA, Jahmani RA, Yousef IR, Saleh AAA. Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures. J Clin Med. 2018;7(4):78. Published 2018 Apr 12. doi:10.3390/jcm7040078 2. Haidukewych G., Israel A., Berry D. Reverse obliquity fractures of the intertrochanteric region of the femur. J. Bone Jt. Surg. Am. 2001;38:643–650. doi: 10.2106/00004623200105000-00001. 3. Okcu G, Ozkayin N, Okta C, Topcu I, Aktuglu K. Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail?. Clin Orthop Relat Res. 2013;471(9):2768–2775. doi:10.1007/s11999-013-2948-0 4. Ozkan K, Eceviz E, Unay K, Tasyikan L, Akman B, Eren A. Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail. Int Orthop. 2011;35(4):595–598. doi:10.1007/s00264-010-1002-z
5. Westacott DJ, Bhattacharaya S. A simple technique to help avoid varus malreduction of reverse oblique proximal femoral fractures. Ann R Coll Surg Engl. 2013;95(1):74. doi:10.1308/003588413X13511609957056b 6. Hao, Y., Zhang, Z., Zhou, F., Ji, H., Tian, Y., Guo, Y., … Hou, G. (2019). Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA). Journal of Orthopaedic Surgery and Research, 14(1). doi:10.1186/s13018-019-1414-4
Figure legends:
Figure 1. a) a reverse oblique fracture has a tendency of varus displacement and opening up of the lateral wall, b) a conventional 3.5mm plate is placed over the lateral aspect of the fracture, c) a Lowman clamp is used to grasp the fracture and plate assembly between its medial and lateral limbs, d) With tightening of the Lowman clamp, the lateral cortex gets buttressed by the plate and gets realigned, e) the plate and clamp assembly prevents the opening up of the lateral as the proximal angulation of the cephalomedullary nail can disturb the fracture reduction when traversed.
Figure 2. Stepwise fluoroscopic images showing application of the described technique a non union of reverse oblique peritrochanteric fracture. a) The fracture has a varus opening of the lateral wall. b) A 3.5mm plate is placed over the fracture on lateral aspect. c) A Lowman clamp is directed to grasp the fracture and the plate assembly. Once the Lowman clamp is tightened, the lateral wall gets reduced. d) Serial reaming can be done without disturbing the fracture reduction.
e) The reduction is maintained when the nail is inserted. f) The cephalomedullary guidewire is inserted while the reduction remains maintained. g) Once the cephalomedullary screw is inserted, it will prevent the further displacement of the proximal fragment. h) The AP projection after removal of the clamp and plate assembly showing a well maintained reduction. i) The lateral projection of the proximal femur showing a well maintained reduction. Figure 3. Preoperative (a) and postoperative (b) AP radiographs of a complex reverse oblique peritrochanteric fracture treated with a cephalomedullary nail in that the lateral wall was reduced using the described “clamp and plate” technique. Radiological signs of callus formation and fracture healing are evident in a two months post operative radiograph (c).
S0976-5662(20)30001-1
DOI:
https://doi.org/10.1016/j.jcot.2020.01.001
Reference:
JCOT 955
To appear in:
Journal of Clinical Orthopaedics and Trauma
Received Date: 14 November 2019 Revised Date:
1 January 2020
Accepted Date: 2 January 2020
Please cite this article as: Kumar A, Chouhan D, Narang A, Khan R, Mittal S, “Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020
TITLE - “Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures
Authors in order (with academic degrees) Arvind Kumar1, Dushyant Chouhan2 , Amit Narang3 , Rizwan Khan4, Samarth Mittal5 1. Dr. Arvind Kumar (MBBS, MS) Assistant Professor Department of Orthopaedics Hamdard Institute of Medical Sciences and Research New Delhi - 110062 (India) [email protected] 2. Dr. Dushyant Chouhan (MBBS, MS) Senior Resident department of Orthopedics, Lady Hardinge Medical College, New Delhi [email protected] 3. Dr. Amit Narang (MBBS, MS) Senior Resident department of Orthopedics, Lady Hardinge Medical College, New Delhi [email protected] 4. Dr. Rizwan Khan (MBBS, DO)
Senior Resident Department of Orthopaedics Hamdard Institute of Medical Sciences and Research New Delhi - 110062 (India) [email protected] 5. Dr. Samarth Mittal (MBBS, MS)(corresponding author) Assistant Professor of Orthopaedics JPN Apex Trauma Centre All India Institute of Medical Sciences Ansari Nagar, New Delhi - 110029 (India) [email protected]
*Corresponding Author : Dr. Samarth Mittal Assistant Professor of Orthopedics, JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS) New Delhi, India Email: [email protected] Mobile number : +91 9013562489
Conflict of interests: None Funding: None
“Clamp and plate” - A simple technique for prevention of varus malreduction in reverse oblique peritrochnateric fractures Abstract Reverse oblique peritrochanteric fractures are unstable injuries. They have an inherent tendency of lateral wall opening and varus displacement.Cephalomedullary nails are the preferred implants for fixation of these fractures. Standard techniques and a medial entry point may not always be helpful in correcting alignment, resulting in persisting varus malreduction. A simple technique using a Lowman clamp and a conventional 3.5 mm plate has been described to prevent lateral wall opening and indirectly, the varus malreduction.
Keywords: Lateral wall; peritrochanteric fractures; reverse oblique; technique; varus malreduction
Introduction
Peri-trochanteric femoral fractures can present in diverse forms, varying from a simple AO type 31A Injury to complex AO type 31C injury. For simple injuries the reduction is simple and they can often be fixed using a standard sliding hip screw or a cephalomedullary nail. The other fractures are preferably fixed with cephalomedullary nails[1]. Among the complex AO type 31C injuries, the reverse oblique fractures are often difficult to manage because of their inherent tendency to displace owing to the unstable fracture- pattern and muscle forces around the fracture[2]. Even with the use of correct nailing techniques, preventing varus malreduction or lateral opening of the fracture is often unavoidable[3,4]. Open techniques can be helpful in maintaining reduction while the canal is prepared for the nail, but once the cephalomedullary nail is completely inserted inside the proximal fragment, a tendency of the lateral opening of fracture or varus malreduction always remains. Even the techniques for the prevention of this malreduction that have been described in the past, have not been able to completely fix this issue with a residual varus displacement still appreciable their radiographs[5]. Adding even a subtle varus to a proximal femur fracture, especially in elder patients with already osteoporotic bone is itself a major risk factor for failure of fixation[6]. Thus, either an anatomical alignment or slightly valgus alignment is preferred to prevent the varus collapse and failure of fixation. Among the described techniques for preventing varus malreduction of the proximal fragment, the first is related to the entry point and direction for the proximal reaming[5]. The entry point should be made medial to the tip of the greater trochanter and proximal reaming is done towards a slightly lateral direction distally. Other techniques depend upon the intraoperative use of clamps to maintain reduction which is understandable considering the basic principles of fracture
fixation. However, once the angulated part of the nail enters the proximal fragment, the clamps often fail to stabilize the reduction that was maintained prior to the nail insertion. The intramedullary track created during reaming should exactly match with the shape of the nail with the fracture in a reduced position. Any mismatch between these would result in fracture displacement. The soft cancellous bone in the proximal femur may tolerate a minor mismatch but that would vary from patient to patient. We describe a simple technique using a Lowman clamp and a conventional 3.5mm plate for stabilization of reverse oblique fractures in anatomical position or in a slightly valgus position, as per the requirement, with reduction maintained during all steps from the preliminary reduction to the final fixation of the proximal cephalomedullary and distal interlocking screw.
Technique (figures 1 and 2 )
The patient is positioned supine on a fracture table. The limbs are positioned as per the convenience of the operating surgeon. The longitudinal traction assembly is maintained on the fractured limb while the opposite limb is flexed and abducted. After standard painting and draping a lateral longitudinal incision is created centred over the fracture site. After subcutaneous dissection, Tensor Fascia Lata is split in the direction of the incision. The Vastus Lateralis is dissected off from the posterolateral intermuscular septum and retracted anteriorly providing a clear exposure of the lateral femoral cortex. The fracture site is identified and prepared as per the requirement of the fracture. Marginal freshening of the fracture is required for nonunion and late presenting cases. Without any periosteal damage, the terminal spike of the proximal fragment is identified and covered temporarily with a conventional 3.5mm plate. The length of the plate
depends upon the requirement of the valgus that needs to be induced at the fracture. For fractures requiring extra valgus, the proximal end of the plate should span the trochanteric flare up to the vastus ridge. For the restoration of the lateral wall continuity that would indirectly restore the medial wall continuity as well, a small plate with one or two holes proximal and distal to the spike of the reverse oblique fragment would be sufficient. The plate should be slightly on the anterior half than the posterior half on the proximal fragment to avoid interference with the cephalomedullary screw track. Once the plate is positioned well, a Lowman clamp is placed centered over the fracture zone with its two medial limbs sliding over the medial cortex of the proximal femur and single lateral limb covering the already placed plate and indirectly, the lateral cortex. The clamp is gradually tightened grasping the whole fracture and plate assembly like a claw-grip. With tightening, the lateral fracture angulation tends to reduce to take up the shape of the plate covering it. When a larger spanning plate, extending up to the trochanteric flare is used, a further tightening after the restoration of the lateral will result in a more inward push to the proximal fragment resulting in a valgus alignment. A single or double unicortical screws can be used to prevent anteroposterior displacement of the plate, if required. Once the appropriate alignment has been achieved, appropriate remaining using a medial entry point and a slightly medial to lateral direction from proximal to distal is kept for reaming using the proximal reamer. The proximal reamer is advanced to a slightly lower level than the level of the lesser trochanter. This would allow additional room for the angulation of the nail without adding stress on the fracture. Conventional reaming is then continued and the cephalomedullary nail is inserted. The clamp need not be removed at any stage until the insertion of all the nail screws both proximally as well as distally. The clamp can be slightly loosened to reposition the plate if interfering with the
proximal cephalomedullary screw track but needs to be retightened after repositioning. Once the proximal screw is inserted, the nail still has a scope of play inside the medullary canal and therefore the clamp and plate assembly should not be removed until the distal locking is done. The fracture remains stable after both cephalomedullary and distal screws are inserted as they would prevent the nail motion within the osseous canal. After this, the clamp and plate assembly can be removed without compromising the fracture reduction. The wound is closed in layers after thorough lavage and dressed. Figures 1 and 2 demonstrate the stepwise application of the described technique. In our institute, we have been using this technique in all reverse oblique fractures to address the opening and varus displacement of the lateral cortex (Figure 3). In simple reverse oblique fractures with a single fracture line, the clamp often suffices in maintaining the reduction during canal preparation and nail insertion. However, in fractures with wide fracture zone and comminution, the lateral limb of the clamp remains insufficient to effectively buttress all fragments of the lateral wall along the same plane and the fracture tends to open up laterally whenever a reamer or the final nail is inserted, creating an undesirable track inside the proximal femur. The addition of plate to the lateral limb of the clamp increases the area of the effective buttress of the clamp, proximally as well as distally. This prevents the lateral opening of the fracture during the passage of various instruments through the proximal femoral canal. By the time of submission of this technique, a total of twelve cases, managed using this technique in reverse oblique peritrochnateric fractures had a minimum follow-up of three months. Radiological union was achieved in all of them within four months postoperatively (Figure 3). No wound or soft tissue related complications were noted.
Discussion
Reverse oblique fractures of the peritrochanteric region are difficult fractures to reduce[2]. Poor reduction, especially the alignment of the lateral wall is a major risk factor for the fixation failure and varus malreduction in these fractures[6]. The complication rate is very low with a good reduction and alignment of the lateral wall[1,3,4,6]. While a good reduction quality in reverse oblique fractures has always been stressed upon, the techniques for prevention of lateral wall displacement during the reaming of the femoral canal and intramedullary nail insertion are sparse. The most important technique that has been widely advocated for the prevention of the varus malreduction is the medial entry point for the guidewire insertion prior to reaming[5]. However, this technique may not be always successful and a subtle opening of the lateral wall may still persist. With open techniques, the assistant can hold the fracture in a reduced position while canal reaming is done, but again minor displacements of the fracture as the reamer crosses the fracture zone can result in a mismatch between desired nail track and the created one. This will result in the opening of the lateral wall that is difficult to control once the nail has been inserted. Our technique is a simple technique that utilizes two readily available devices in the operating room, a Lowman clamp, and a conventional 3.5mm plate. The clamp and plate assembly grasps a major circumference of the fracture zone, and the lateral wall takes up the shape of the plate when the camp is tightened. This assembly prevents opening up of the lateral wall and maltracking of the reamer inside the proximal femur. Thus, a desirable intramedullary track for insertion of the nail is created which prevents fracture displacement when the final intramedullary nail is inserted. Still, the construct remains flexible until all the proximal and
distal screws have been inserted and therefore, the assembly should not be disturbed prior to final screw insertion. Following the insertion of proximal and distal screws, the construct becomes a rigid one and the clamp-plate assembly can be removed. In summary, this technique allows stable reduction of the reverse oblique fractures of peritrochanteric region which remains static throughout the various steps of cephalomedullary nailing. As the fracture alignment is restored, this technique reduces the risk of implant failure and varus malreduction in reverse oblique fractures of peritrochanteric region.
References: 1. Radaideh AM, Qudah HA, Audat ZA, Jahmani RA, Yousef IR, Saleh AAA. Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures. J Clin Med. 2018;7(4):78. Published 2018 Apr 12. doi:10.3390/jcm7040078 2. Haidukewych G., Israel A., Berry D. Reverse obliquity fractures of the intertrochanteric region of the femur. J. Bone Jt. Surg. Am. 2001;38:643–650. doi: 10.2106/00004623200105000-00001. 3. Okcu G, Ozkayin N, Okta C, Topcu I, Aktuglu K. Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail?. Clin Orthop Relat Res. 2013;471(9):2768–2775. doi:10.1007/s11999-013-2948-0 4. Ozkan K, Eceviz E, Unay K, Tasyikan L, Akman B, Eren A. Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail. Int Orthop. 2011;35(4):595–598. doi:10.1007/s00264-010-1002-z
5. Westacott DJ, Bhattacharaya S. A simple technique to help avoid varus malreduction of reverse oblique proximal femoral fractures. Ann R Coll Surg Engl. 2013;95(1):74. doi:10.1308/003588413X13511609957056b 6. Hao, Y., Zhang, Z., Zhou, F., Ji, H., Tian, Y., Guo, Y., … Hou, G. (2019). Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA). Journal of Orthopaedic Surgery and Research, 14(1). doi:10.1186/s13018-019-1414-4
Figure legends:
Figure 1. a) a reverse oblique fracture has a tendency of varus displacement and opening up of the lateral wall, b) a conventional 3.5mm plate is placed over the lateral aspect of the fracture, c) a Lowman clamp is used to grasp the fracture and plate assembly between its medial and lateral limbs, d) With tightening of the Lowman clamp, the lateral cortex gets buttressed by the plate and gets realigned, e) the plate and clamp assembly prevents the opening up of the lateral as the proximal angulation of the cephalomedullary nail can disturb the fracture reduction when traversed.
Figure 2. Stepwise fluoroscopic images showing application of the described technique a non union of reverse oblique peritrochanteric fracture. a) The fracture has a varus opening of the lateral wall. b) A 3.5mm plate is placed over the fracture on lateral aspect. c) A Lowman clamp is directed to grasp the fracture and the plate assembly. Once the Lowman clamp is tightened, the lateral wall gets reduced. d) Serial reaming can be done without disturbing the fracture reduction.
e) The reduction is maintained when the nail is inserted. f) The cephalomedullary guidewire is inserted while the reduction remains maintained. g) Once the cephalomedullary screw is inserted, it will prevent the further displacement of the proximal fragment. h) The AP projection after removal of the clamp and plate assembly showing a well maintained reduction. i) The lateral projection of the proximal femur showing a well maintained reduction. Figure 3. Preoperative (a) and postoperative (b) AP radiographs of a complex reverse oblique peritrochanteric fracture treated with a cephalomedullary nail in that the lateral wall was reduced using the described “clamp and plate” technique. Radiological signs of callus formation and fracture healing are evident in a two months post operative radiograph (c).