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Functional outcome of biological condylar blade plating of subtrochanteric fractures
J Orthop Sci (2012) 17:567–573 DOI 10.1007/s00776-012-0244-6
ORIGINAL ARTICLE
Functional outcome of biological condylar blade plating of subtrochanteric fractures P. R. J. V. C. Boopalan • Thilak S. Jepegnanam Manasseh Nithyananth • K. Venkatesh • Vinoo M. Cherian
•
Received: 17 August 2011 / Accepted: 14 May 2012 / Published online: 9 June 2012 Ó The Japanese Orthopaedic Association 2012
Abstract Background The aim of this study was to review highenergy subtrochanteric fractures treated biologically with the 95° angled blade plate, to assess the time to union and return to work, and to perform a functional evaluation using the traumatic hip rating scale. Patients and methods This study is a retrospective review of 22 patients with 23 fractures. Twenty-one patients (96 %) with 22 fractures were available for analysis. The average age was 33 years (range 18–47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients. Seven patients had other associated injuries. 32B2.1 (40 %) was the commonest fracture pattern according to the OTA classification. Results The average follow-up period was 29 months (range 12–49). The mean time to fracture healing was 16 weeks (range 12–32). All patients returned to their prefracture occupation (100 %). Eighteen patients (86 %) healed without any additional surgery. The outcome according to the hip rating scale was excellent in ten
Preliminary results of this study were presented at the SICOT 2008 Triennial World Congress in Hong Kong. P. R. J. V. C. Boopalan (&) T. S. Jepegnanam Department of Orthopaedics Unit III, Christian Medical College, Vellore 632004, Tamil Nadu, India e-mail: [email protected] M. Nithyananth K. Venkatesh V. M. Cherian Department of Orthopaedics Unit I, Christian Medical College, Vellore 632004, Tamil Nadu, India
patients and good in eleven patients. Two patients (9 %) required additional surgery. Conclusions Biological fixation of subtrochanteric fractures using 95° CBP results in a high union rate with low morbidity and good functional outcome.
Introduction Subtrochanteric fractures in young adults usually occur due to high-energy trauma. The fracture is often comminuted and displaced, and there is extensive soft-tissue injury. They have a high incidence of nonunion and implant failure [1]. The complications occur due to decreased vascularity and the predominant cortical bone of the subtrochanteric region. Apart from the complex fracture pattern in this region, the fragments are also subject to multiple deforming forces. The choice in regards to fixation is between intramedullary and extramedullary devices. Although intramedullary fixation is biomechanically superior to extramedullary fixation, it has similar rates of complications to conventional plating [2–4]. Trochanteric and piriformis fossa comminution can displace the fracture fragments during nailing. An abducted proximal fragment can result in residual varus deformity after nailing. Similarly, conventional plating results in devascularization of comminuted fracture fragments and nonunion [5]. Recently, biological fixation with extramedullary devices has resulted in successful healing of subtrochanteric fractures [6, 7]. The utilization of 95° condylar blade plates in such a fracture has been proven to give good results in the past, provided that devitalization of the fracture fragments was avoided [8]. Since most studies have focused on fracture union and have not assessed functional recovery following treatment
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with extramedullary devices, the study described in this paper was undertaken to review high-energy subtrochanteric fractures that were treated biologically with the 95° angled condylar blade plate (CBP). The time to union, return to work, functional evaluation using the traumatic hip rating scale, and complications were assessed.
Patients and methods A retrospective review of 22 consecutive patients who presented to the authors (all of whom had 7–15 years of surgical experience) with high-velocity subtrochanteric fractures from January 2004 to December 2007, and were treated by performing biological fixation with the 95° blade plate, was performed. All of the patients gave their informed consent prior to being included into the study, and the local ethics committee authorized the study. Patients treated for pathological fractures and patients who had suffered low-energy fractures due to domestic falls were excluded. There were 22 patients with 23
fractures. One patient died three months after injury due to unrelated causes. Thus, 21 patients (96 %) with 22 fractures were available for analysis (Table 1). The average age was 33 years (range 18–47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients, followed by fall from a height in eight patients and fall from a moving vehicle in two patients. Seven patients had associated injuries. 32B2.1 (40 %) was the commonest fracture pattern according to the OTA classification. Surgeries were performed on a fracture table and utilized an image intensifier, as described earlier [9]. The guide pin was used to guide the seating chisel. Care was taken to insert the blade just below the intersection of the trabeculae in the head and also to keep the muscle covering the fracture fragments between proximal and distal fixation. The lesser trochanter was lagged to restore medial cortical continuity whenever possible. A tensioning device was not used for reduction. The comminution was reduced
Table 1 Patient profile Case no.
Age
Sex
Mode of injury
OTA classification
Side
Follow-up in months
Union in months
Hip rating score
Result
Other injuries, comorbidity
1
28
M
Fall from height
32-B2.1
L
49
3
60
Excellent
2
24
M
Fall from height
32-B1.1
R
44
3
50
Good
3
24
F
Fall from height
32-A3.1
R
36
4
58
Excellent
4
46
F
MVA
32-C1.1
L
34
6
53
Good
Multiple rib fractures, Rt sternoclavicular dislocation, Lt knee hemarthrosis
5
42
M
Fall from height
32-C1.1
L
37
3
53
Good
L proximal humerus fracture
6
47
F
Fall from height
32-B2.1
R
27
3
53
Good
7
47
M
Fall from moving bus
32-B2.1
R
14
4
47
Good
8
22
M
Fall from top of van
32-A3.1
R
20
4
58
Excellent
9
23
M
MVA
32-C3.1
R
20
8
50
Good
10
25
M
MVA
32-B2.1
R
28
4
60
Excellent
11
30
M
MVA
32-B3.1
L
24
4
60
Excellent
Intraperitoneal bladder rupture, open book pelvic injury
12
38
M
MVA
32-B2.1
R
48
6
54
Good
Zygoma fracture
13 14
18 27
M M
MVA MVA
32-B3.1 32-B2.1
R R,L
36 40
3 6
54 52,52
Good Good
Lt AE amputation Rt acetabulum fracture, open book pelvic injury
15
36
M
Fall from height
32-C2.1
L
12
3
58
Excellent
16
39
M
MVA
32-B2.1
R
31
8
60
Excellent
17
35
M
Fall from height
32-B3.1
R
18
3
58
Excellent
18
45
M
MVA
32-A2.1
R
36
4
58
Excellent
19
38
F
MVA
32-B3.1
R
25
3
54
Good
20 21
33 35
M M
MVA Fall from height
32-B2.1 32-C1.1
R R
25 12
3 3
52 56
Good Excellent
123
Lt femur basicervical fracture, straddle fracture pelvis
Biological femur condylar blade plating
569
Table 2 Traumatic hip rating scale
Table 2 continued
No. of points
No. of points
Criteria
Pain 0
Constant; unbearable; patient uses strong medication frequently
2
Constant but bearable; patient uses strong medication occasionally Little or none at rest; with activities; patient uses salicylates frequently
4 6
When starting, then better, or after a certain activity; patient uses salicylates occasionally
Criteria
6
Muscle power, fair to good; arc of flexion as much as 90°; fair lateral and rotatory movement
8
Muscle power, good or normal; arc of flexion more than 90°; good lateral and rotatory movement
10
Muscle power, normal; motion, normal or near normal
Daily activities Shoes and socks
8
Occasional and slight
10
None
0
Unable
0
Bedridden
3 5
With difficulty With ease
2
Uses a wheelchair; transfer activities with walker
0
Unable
4
Markedly restricted
3
One at a time
Uses no support, housebound
4
With railing
Uses one support, can walk less than one block
5
Normal
Walking (gait)
Uses bilateral support, can walk short distances 6
Stairs
Radiographic evaluation
Moderately restricted
0
Nonunion/plate failure/secondary arthritis
Uses no support, can walk less than one block
2
Delayed union
Uses one support, can walk up to five blocks
4
Uses bilateral support, unrestricted 8
Mildly restricted
6
Uses no support, limps 10
Uses one support, no limp Unrestricted
Varus greater than 5° but less than 10° Shortening greater than 1 cm but less than 2.5 cm
8
Varus less than 5° Shortening less than 1 cm
Uses no support, no appreciable limp 10
Function
Varus greater than 10° Shortening greater than 2.5 cm
Anatomic reduction
Total score
Retired preinjury 0
Completely dependent and confined
55–60 (excellent)
2
Partially dependent
45–54 (good)
4
Independent; can do limited housework, limited shopping
\35 (fail)
6
Can do most housework; shops freely; can do desk-type work
8
Very little restriction; can work on feet
10
Normal activities
Employed preinjury 0
Unemployed/retired secondary to injury
2
Part-time/light duty
4
Changed jobs secondary to injury
6
Altered job description somewhat
8
Returned to work with some disability
10
Returned to full work
Motion-muscle power 0
Ankylosis with deformity
2
Ankylosis with good functional position
4
Muscle power, poor to fair; flexion less than 60°; restricted lateral and rotatory movement
35–44 (poor)
with a long reduction hook from proximal and distal without disturbing the intervening soft tissue envelope, and the length and rotations were adjusted by the traction table. In two patients, the skin was incised only over the greater trochanter and distally over the lower end of the plate. A shorter blade was used in these patients. In another patient with bilateral subtrochanteric fractures and an unstable pelvic fracture, the surgery was performed on a radiolucent table. In patients with isolated subtrochanteric fractures, an average of 420 ml of blood were transfused (range 0–1000). Postoperative care started with passive knee mobilization and static quadriceps exercises on the first postoperative day. Patients were allowed to toe touch and
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570
walk with crutches. This was continued until bridging callus was visible on the plain radiograph (usually around six weeks). Weight bearing was progressive thereafter. The fracture was deemed united if there was at least three cortices healing and no sign of the fracture line in AP and lateral radiographs. All patients were followed up until fracture healing was observed, and then subsequently asked if they would participate in a further follow-up to evaluate function using the traumatic hip rating scale [10]. The traumatic hip scale rating assesses pain, walking distance and aid, return to preinjury occupation, muscle power and range of motion at hip, radiographic evaluation, and the ability to perform stair climbing and wear shoes and socks. According to the traumatic hip rating scale, a score of 55–60 is excellent, 45–54 is good, 35–44 is poor, and less than 35 is failure (Table 2). The average follow-up period was 29 months (range 12–49). At the one-year follow-up, the time to union, return to work, and complications were studied by two authors who were involved in the care of patients, and a functional evaluation was performed using the traumatic hip rating scale.
P. R. J. V. C. Boopalan et al.
the hip rating scale was excellent in ten patients and good in eleven patients (Figs. 1, 2, 3, 4). Complications One patient (case no. 3) had a deep wound infection with an Aerococcus species, which meant that the wound had to
Results The mean time to fracture healing was 16 weeks (range 12–32). Eighteen patients (86 %) healed without any additional surgeries (Table 1). All patients returned to their prefracture occupation (100 %). The outcome according to
Fig. 2 Final follow-up at 27 months with a good functional outcome (case no. 4)
Fig. 1 AP radiograph of a 46-year-old lady (case no. 4) with a 32C11 Lt femur fracture
Fig. 3 AP radiograph of a 35-year-old man (case no. 22) with a 32C1-1 Rt femur fracture
123
Biological femur condylar blade plating
571
be washed out and antibiotics applied for wound healing (Table 3). This patient’s fracture healed in 16 weeks. One other patient (case no. 20) developed grade 2 heterotopic ossification, which did not affect outcome. Two patients (9 %) required additional surgeries. One patient (case no. 9) had late revision surgery with intramedullary nail and bone grafting for varus malreduction after implant failure (Figs. 5, 6). This patient was operated on with two small incisions and a shorter than usual blade plate. The second patient (case no. 16) underwent revision surgery for a varus reduction of [5° at index surgery. He had revision surgery before failure with a blade plate device soon after index surgery. The average time to union in these two patients was six months (range 4–8). The final
Fig. 4 AP radiograph at final follow-up with excellent outcome (case no. 22)
functional outcome in these patients was excellent in one and good in one.
Discussion Subtrochanteric fractures constitute 7–34 % of all femur fractures [11]. In young patients, they are usually due to high-velocity injuries, and result in comminuted and unstable fracture patterns. Both intramedullary and extramedullary implants are used to treat subtrochanteric fractures, but there is still no consensus on the best implant. A recent systematic review has confirmed that, and the authors of the review have concluded that future studies should differentiate between high-energy and low-energy injuries when assessing the superiority of intramedullary versus extramedullary devices [12]. The most commonly used intramedullary implants for subtrochanteric fractures are cephalomedullary nails. Nails have the advantage of reamed debris, which aid with fracture healing. The disadvantages, however, include a possible loss of endosteal and periosteal blood supply. Nails can cause a trochanteric split when the fracture extends to the pyriform fossa, resulting in varus [13]. Reaming the canal produces fat emboli that can alter the patient’s oxygenation adversely. In obese patients, abduction of the proximal fragment makes it difficult to gain a good entry over the trochanter, and can result in lateralized or medial penetration of the guide wire and reamer. Large lateral and medial wall fractures require open reduction with intramedullary devices [14]. In a large series of subtrochanteric fractures, long gamma nail had a complication rate of 19 % [15]. Most nails have a mismatch with the Asian femoral curvature, and can cause iatrogenic fracture and anterior cortex impingement [16]. Although earlier studies of extramedullary fixation vary widely, biological plate fixation has the advantage of preserving the endosteal and periosteal supply and can be performed with comparable disruption of the soft tissue envelope to nails [17]. Preserving the femoral nutrient and perforating arteries enables faster mineralization of callus
Table 3 Cases with complications Case no
Age
Sex
Mode of injury
OTA classification
Side
Follow-up in months
Union in months
Hip rating score
Result
Complications
3
24
F
Fall from height
32-A3.1
R
36
4
58
Excellent
Wound infection
9
23
M
MVA
32-C3.1
R
20
8
50
Good
Revised to cephalomedullary nail and bone grafting
16
39
M
MVA
32-B2.1
R
31
8
60
Excellent
20
33
M
MVA
32-B2.1
R
25
3
52
Good
Revision to condylar blade plate for varus angulation Grade 2 heterotopic ossification
123
572
Fig. 5 AP radiograph of a 23-year-old man (case no. 9) with a 32C31 Rt femur fracture with a bent blade plate and varus deformity
Fig. 6 Final follow-up at 20 months after revision to reconstruction nail and good outcome (case no. 9)
[18, 19]. Comminuted fragments can be percutaneously reduced to the plate, improving the elastic stability for fracture healing. Vaidya et al. [20] reported 100 % fracture
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P. R. J. V. C. Boopalan et al.
healing with biological dynamic condylar screw (DCS) fixation. DCS has the advantage of submuscular plate sliding, but the loss of bone stock from the femoral head and neck during insertion can make subsequent surgeries due to failure difficult. Condylar blade plate is still unpopular although it is a standard option for subtrochanteric fractures. This is reflected in the sparse literature on it recently, and in the predominance of reports on it from experienced surgeons [7, 9, 21]. This may be because the surgery has a steep learning curve and blade plate insertion has to be precise in all three planes. Previous reports have not reported on functional outcome, in spite of good union rates [7, 9, 21, 22]. In this series, a functional assessment was performed for all patients. CBP was preferred, based on patient characteristics (young age, high-velocity injuries, and good bone quality) and fracture geometry (loss of medial cortical continuity or lateral wall comminution). It has the advantage of providing rigid fixation in the head and neck with better rotational stability, and does not allow lateral wall collapse. This study highlights certain pitfalls in the surgical technique that should be avoided to improve outcome. Careful preoperative planning, minimal dissection of medial side structures, and adequate reduction and stability have all been emphasized before. We emphasize the following points. Before the guide wire and chisel is inserted, either the proximal femur should be manipulated to correct the deformity of the proximal fragment, or the image intensifier (II) must be positioned in such a way that it compensates for the deformity of the proximal fragment, providing a true anteroposterior view. In this series, two patients had reoperations for varus malreductions. This has also been reported in case series by surgeons of vast experience [9]. Though subtrochanteric fractures have been fixed with two incisions, this necessitates the use of a shorter blade length [8]. The length of the blade and the length of the plate are inversely related (i.e., if a long plate is necessary, the blade length should be reduced). In this way, the plate can be introduced submuscularly and turned 180° to be inserted into the precut path in the bone (Fig. 7). Varus angulation of the distal limb also eases this step. Comminuted medial fragments and the lesser trochanter are lagged to achieve medial cortical continuity for medial support. This series shows a good outcome for high-velocity subtrochanteric fractures treated with the blade plate. The study results may be closer to those obtained in routine clinical practice in most centers. The advantages of this study are that it is an observational case series in which 96 % of the patients were followed up and analyzed. The results of this study reflect the importance of having multiple surgeons follow the same surgical principle, whereas
Biological femur condylar blade plating
Fig. 7 Intraoperative picture shows submuscular insertion of the condylar blade plate. Arrow points to the blade facing outwards during submuscular sliding, before it gets turned 180° to be inserted into the precut path in the bone
in most published studies it is the outcome of a single surgeon. The disadvantage is that it is a retrospective analysis. In conclusion, biological fixation of subtrochanteric fractures with 95° CBP is technically demanding but can provide good functional outcome. Conflict of interest The authors do not have any conflict of interest. None of the authors received any payment or consideration from any source for the conduct of this study.
References 1. Bergman GD, Winquist RA, Mayo KA, Hansen ST Jr. Subtrochanteric fracture of the femur. Fixation using the Zickel nail. J Bone Joint Surg Am. 1987;69:1032–40. 2. Brien WW, Wiss DA, Becker V Jr, Lehman T. Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail. J Orthop Trauma. 1991;5:458–64. 3. Fielding JW, Cochran GV, Zickel RE. Biomechanical characteristics and surgical management of subtrochanteric fractures. Orthop Clin North Am. 1974;5:629–50. 4. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2008:CD000093. 5. Nungu KS, Olerud C, Rehnberg L. Treatment of subtrochanteric fractures with the AO dynamic condylar screw. Injury. 1993;24: 90–2. 6. Rohilla R, Singh R, Magu NK, Siwach RC, Sangwan SS. Miniincision dynamic condylar screw fixation for comminuted subtrochanteric hip fractures. J Orthop Surg (Hong Kong). 2008;16: 150–5.
573 7. Siebenrock KA, Muller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury. 1998;29(Suppl 3):C7–15. 8. Kesemenli C, Subasi M, Necmioglu S, Kapukaya A. Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation. Injury. 2002;33:691–9. 9. Yoo MC, Cho YJ, Kim KI, Khairuddin M, Chun YS. Treatment of unstable peritrochanteric femoral fractures using a 95 degrees angled blade plate. J Orthop Trauma. 2005;19:687–92. 10. Sanders R, Regazzoni P. Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma. 1989;3:206–13. 11. Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am. 2004;35:473–83. 12. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010:CD000093. 13. Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN)—a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand. 2003;74:53–8. 14. Jiang LS, Shen L, Dai LY. Intramedullary fixation of subtrochanteric fractures with long proximal femoral nail or long gamma nail: technical notes and preliminary results. Ann Acad Med Singapore. 2007;36:821–6. 15. van Doorn R, Stapert JW. The long gamma nail in the treatment of 329 subtrochanteric fractures with major extension into the femoral shaft. Eur J Surg. 2000;166:240–6. 16. Hwang JH, Oh JK, Han SH, Shon WY, Oh CW. Mismatch between PFNa and medullary canal causing difficulty in nailing of the pertrochanteric fractures. Arch Orthop Trauma Surg. 2008;128:1443–6. 17. Lee PC, Hsieh PH, Yu SW, Shiao CW, Kao HK, Wu CC. Biologic plating versus intramedullary nailing for comminuted subtrochanteric fractures in young adults: a prospective, randomized study of 66 cases. J Trauma. 2007;63:1283–91. 18. Baumgaertel F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury. 1998;29(Suppl 3):C3–6. 19. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury. 1997; 28(Suppl 1):A7–12. 20. Vaidya SV, Dholakia DB, Chatterjee A. The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture. Injury. 2003;34:123–8. 21. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989:122–30. 22. Vanderschot P, Vanderspeeten K, Verheyen L, Broos P. A review on 161 subtrochanteric fractures—risk-factors influencing outcome: age, fracture pattern and fracture level. Unfallchirurg. 1995;98:265–71.
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ORIGINAL ARTICLE
Functional outcome of biological condylar blade plating of subtrochanteric fractures P. R. J. V. C. Boopalan • Thilak S. Jepegnanam Manasseh Nithyananth • K. Venkatesh • Vinoo M. Cherian
•
Received: 17 August 2011 / Accepted: 14 May 2012 / Published online: 9 June 2012 Ó The Japanese Orthopaedic Association 2012
Abstract Background The aim of this study was to review highenergy subtrochanteric fractures treated biologically with the 95° angled blade plate, to assess the time to union and return to work, and to perform a functional evaluation using the traumatic hip rating scale. Patients and methods This study is a retrospective review of 22 patients with 23 fractures. Twenty-one patients (96 %) with 22 fractures were available for analysis. The average age was 33 years (range 18–47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients. Seven patients had other associated injuries. 32B2.1 (40 %) was the commonest fracture pattern according to the OTA classification. Results The average follow-up period was 29 months (range 12–49). The mean time to fracture healing was 16 weeks (range 12–32). All patients returned to their prefracture occupation (100 %). Eighteen patients (86 %) healed without any additional surgery. The outcome according to the hip rating scale was excellent in ten
Preliminary results of this study were presented at the SICOT 2008 Triennial World Congress in Hong Kong. P. R. J. V. C. Boopalan (&) T. S. Jepegnanam Department of Orthopaedics Unit III, Christian Medical College, Vellore 632004, Tamil Nadu, India e-mail: [email protected] M. Nithyananth K. Venkatesh V. M. Cherian Department of Orthopaedics Unit I, Christian Medical College, Vellore 632004, Tamil Nadu, India
patients and good in eleven patients. Two patients (9 %) required additional surgery. Conclusions Biological fixation of subtrochanteric fractures using 95° CBP results in a high union rate with low morbidity and good functional outcome.
Introduction Subtrochanteric fractures in young adults usually occur due to high-energy trauma. The fracture is often comminuted and displaced, and there is extensive soft-tissue injury. They have a high incidence of nonunion and implant failure [1]. The complications occur due to decreased vascularity and the predominant cortical bone of the subtrochanteric region. Apart from the complex fracture pattern in this region, the fragments are also subject to multiple deforming forces. The choice in regards to fixation is between intramedullary and extramedullary devices. Although intramedullary fixation is biomechanically superior to extramedullary fixation, it has similar rates of complications to conventional plating [2–4]. Trochanteric and piriformis fossa comminution can displace the fracture fragments during nailing. An abducted proximal fragment can result in residual varus deformity after nailing. Similarly, conventional plating results in devascularization of comminuted fracture fragments and nonunion [5]. Recently, biological fixation with extramedullary devices has resulted in successful healing of subtrochanteric fractures [6, 7]. The utilization of 95° condylar blade plates in such a fracture has been proven to give good results in the past, provided that devitalization of the fracture fragments was avoided [8]. Since most studies have focused on fracture union and have not assessed functional recovery following treatment
123
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P. R. J. V. C. Boopalan et al.
with extramedullary devices, the study described in this paper was undertaken to review high-energy subtrochanteric fractures that were treated biologically with the 95° angled condylar blade plate (CBP). The time to union, return to work, functional evaluation using the traumatic hip rating scale, and complications were assessed.
Patients and methods A retrospective review of 22 consecutive patients who presented to the authors (all of whom had 7–15 years of surgical experience) with high-velocity subtrochanteric fractures from January 2004 to December 2007, and were treated by performing biological fixation with the 95° blade plate, was performed. All of the patients gave their informed consent prior to being included into the study, and the local ethics committee authorized the study. Patients treated for pathological fractures and patients who had suffered low-energy fractures due to domestic falls were excluded. There were 22 patients with 23
fractures. One patient died three months after injury due to unrelated causes. Thus, 21 patients (96 %) with 22 fractures were available for analysis (Table 1). The average age was 33 years (range 18–47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients, followed by fall from a height in eight patients and fall from a moving vehicle in two patients. Seven patients had associated injuries. 32B2.1 (40 %) was the commonest fracture pattern according to the OTA classification. Surgeries were performed on a fracture table and utilized an image intensifier, as described earlier [9]. The guide pin was used to guide the seating chisel. Care was taken to insert the blade just below the intersection of the trabeculae in the head and also to keep the muscle covering the fracture fragments between proximal and distal fixation. The lesser trochanter was lagged to restore medial cortical continuity whenever possible. A tensioning device was not used for reduction. The comminution was reduced
Table 1 Patient profile Case no.
Age
Sex
Mode of injury
OTA classification
Side
Follow-up in months
Union in months
Hip rating score
Result
Other injuries, comorbidity
1
28
M
Fall from height
32-B2.1
L
49
3
60
Excellent
2
24
M
Fall from height
32-B1.1
R
44
3
50
Good
3
24
F
Fall from height
32-A3.1
R
36
4
58
Excellent
4
46
F
MVA
32-C1.1
L
34
6
53
Good
Multiple rib fractures, Rt sternoclavicular dislocation, Lt knee hemarthrosis
5
42
M
Fall from height
32-C1.1
L
37
3
53
Good
L proximal humerus fracture
6
47
F
Fall from height
32-B2.1
R
27
3
53
Good
7
47
M
Fall from moving bus
32-B2.1
R
14
4
47
Good
8
22
M
Fall from top of van
32-A3.1
R
20
4
58
Excellent
9
23
M
MVA
32-C3.1
R
20
8
50
Good
10
25
M
MVA
32-B2.1
R
28
4
60
Excellent
11
30
M
MVA
32-B3.1
L
24
4
60
Excellent
Intraperitoneal bladder rupture, open book pelvic injury
12
38
M
MVA
32-B2.1
R
48
6
54
Good
Zygoma fracture
13 14
18 27
M M
MVA MVA
32-B3.1 32-B2.1
R R,L
36 40
3 6
54 52,52
Good Good
Lt AE amputation Rt acetabulum fracture, open book pelvic injury
15
36
M
Fall from height
32-C2.1
L
12
3
58
Excellent
16
39
M
MVA
32-B2.1
R
31
8
60
Excellent
17
35
M
Fall from height
32-B3.1
R
18
3
58
Excellent
18
45
M
MVA
32-A2.1
R
36
4
58
Excellent
19
38
F
MVA
32-B3.1
R
25
3
54
Good
20 21
33 35
M M
MVA Fall from height
32-B2.1 32-C1.1
R R
25 12
3 3
52 56
Good Excellent
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Lt femur basicervical fracture, straddle fracture pelvis
Biological femur condylar blade plating
569
Table 2 Traumatic hip rating scale
Table 2 continued
No. of points
No. of points
Criteria
Pain 0
Constant; unbearable; patient uses strong medication frequently
2
Constant but bearable; patient uses strong medication occasionally Little or none at rest; with activities; patient uses salicylates frequently
4 6
When starting, then better, or after a certain activity; patient uses salicylates occasionally
Criteria
6
Muscle power, fair to good; arc of flexion as much as 90°; fair lateral and rotatory movement
8
Muscle power, good or normal; arc of flexion more than 90°; good lateral and rotatory movement
10
Muscle power, normal; motion, normal or near normal
Daily activities Shoes and socks
8
Occasional and slight
10
None
0
Unable
0
Bedridden
3 5
With difficulty With ease
2
Uses a wheelchair; transfer activities with walker
0
Unable
4
Markedly restricted
3
One at a time
Uses no support, housebound
4
With railing
Uses one support, can walk less than one block
5
Normal
Walking (gait)
Uses bilateral support, can walk short distances 6
Stairs
Radiographic evaluation
Moderately restricted
0
Nonunion/plate failure/secondary arthritis
Uses no support, can walk less than one block
2
Delayed union
Uses one support, can walk up to five blocks
4
Uses bilateral support, unrestricted 8
Mildly restricted
6
Uses no support, limps 10
Uses one support, no limp Unrestricted
Varus greater than 5° but less than 10° Shortening greater than 1 cm but less than 2.5 cm
8
Varus less than 5° Shortening less than 1 cm
Uses no support, no appreciable limp 10
Function
Varus greater than 10° Shortening greater than 2.5 cm
Anatomic reduction
Total score
Retired preinjury 0
Completely dependent and confined
55–60 (excellent)
2
Partially dependent
45–54 (good)
4
Independent; can do limited housework, limited shopping
\35 (fail)
6
Can do most housework; shops freely; can do desk-type work
8
Very little restriction; can work on feet
10
Normal activities
Employed preinjury 0
Unemployed/retired secondary to injury
2
Part-time/light duty
4
Changed jobs secondary to injury
6
Altered job description somewhat
8
Returned to work with some disability
10
Returned to full work
Motion-muscle power 0
Ankylosis with deformity
2
Ankylosis with good functional position
4
Muscle power, poor to fair; flexion less than 60°; restricted lateral and rotatory movement
35–44 (poor)
with a long reduction hook from proximal and distal without disturbing the intervening soft tissue envelope, and the length and rotations were adjusted by the traction table. In two patients, the skin was incised only over the greater trochanter and distally over the lower end of the plate. A shorter blade was used in these patients. In another patient with bilateral subtrochanteric fractures and an unstable pelvic fracture, the surgery was performed on a radiolucent table. In patients with isolated subtrochanteric fractures, an average of 420 ml of blood were transfused (range 0–1000). Postoperative care started with passive knee mobilization and static quadriceps exercises on the first postoperative day. Patients were allowed to toe touch and
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570
walk with crutches. This was continued until bridging callus was visible on the plain radiograph (usually around six weeks). Weight bearing was progressive thereafter. The fracture was deemed united if there was at least three cortices healing and no sign of the fracture line in AP and lateral radiographs. All patients were followed up until fracture healing was observed, and then subsequently asked if they would participate in a further follow-up to evaluate function using the traumatic hip rating scale [10]. The traumatic hip scale rating assesses pain, walking distance and aid, return to preinjury occupation, muscle power and range of motion at hip, radiographic evaluation, and the ability to perform stair climbing and wear shoes and socks. According to the traumatic hip rating scale, a score of 55–60 is excellent, 45–54 is good, 35–44 is poor, and less than 35 is failure (Table 2). The average follow-up period was 29 months (range 12–49). At the one-year follow-up, the time to union, return to work, and complications were studied by two authors who were involved in the care of patients, and a functional evaluation was performed using the traumatic hip rating scale.
P. R. J. V. C. Boopalan et al.
the hip rating scale was excellent in ten patients and good in eleven patients (Figs. 1, 2, 3, 4). Complications One patient (case no. 3) had a deep wound infection with an Aerococcus species, which meant that the wound had to
Results The mean time to fracture healing was 16 weeks (range 12–32). Eighteen patients (86 %) healed without any additional surgeries (Table 1). All patients returned to their prefracture occupation (100 %). The outcome according to
Fig. 2 Final follow-up at 27 months with a good functional outcome (case no. 4)
Fig. 1 AP radiograph of a 46-year-old lady (case no. 4) with a 32C11 Lt femur fracture
Fig. 3 AP radiograph of a 35-year-old man (case no. 22) with a 32C1-1 Rt femur fracture
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Biological femur condylar blade plating
571
be washed out and antibiotics applied for wound healing (Table 3). This patient’s fracture healed in 16 weeks. One other patient (case no. 20) developed grade 2 heterotopic ossification, which did not affect outcome. Two patients (9 %) required additional surgeries. One patient (case no. 9) had late revision surgery with intramedullary nail and bone grafting for varus malreduction after implant failure (Figs. 5, 6). This patient was operated on with two small incisions and a shorter than usual blade plate. The second patient (case no. 16) underwent revision surgery for a varus reduction of [5° at index surgery. He had revision surgery before failure with a blade plate device soon after index surgery. The average time to union in these two patients was six months (range 4–8). The final
Fig. 4 AP radiograph at final follow-up with excellent outcome (case no. 22)
functional outcome in these patients was excellent in one and good in one.
Discussion Subtrochanteric fractures constitute 7–34 % of all femur fractures [11]. In young patients, they are usually due to high-velocity injuries, and result in comminuted and unstable fracture patterns. Both intramedullary and extramedullary implants are used to treat subtrochanteric fractures, but there is still no consensus on the best implant. A recent systematic review has confirmed that, and the authors of the review have concluded that future studies should differentiate between high-energy and low-energy injuries when assessing the superiority of intramedullary versus extramedullary devices [12]. The most commonly used intramedullary implants for subtrochanteric fractures are cephalomedullary nails. Nails have the advantage of reamed debris, which aid with fracture healing. The disadvantages, however, include a possible loss of endosteal and periosteal blood supply. Nails can cause a trochanteric split when the fracture extends to the pyriform fossa, resulting in varus [13]. Reaming the canal produces fat emboli that can alter the patient’s oxygenation adversely. In obese patients, abduction of the proximal fragment makes it difficult to gain a good entry over the trochanter, and can result in lateralized or medial penetration of the guide wire and reamer. Large lateral and medial wall fractures require open reduction with intramedullary devices [14]. In a large series of subtrochanteric fractures, long gamma nail had a complication rate of 19 % [15]. Most nails have a mismatch with the Asian femoral curvature, and can cause iatrogenic fracture and anterior cortex impingement [16]. Although earlier studies of extramedullary fixation vary widely, biological plate fixation has the advantage of preserving the endosteal and periosteal supply and can be performed with comparable disruption of the soft tissue envelope to nails [17]. Preserving the femoral nutrient and perforating arteries enables faster mineralization of callus
Table 3 Cases with complications Case no
Age
Sex
Mode of injury
OTA classification
Side
Follow-up in months
Union in months
Hip rating score
Result
Complications
3
24
F
Fall from height
32-A3.1
R
36
4
58
Excellent
Wound infection
9
23
M
MVA
32-C3.1
R
20
8
50
Good
Revised to cephalomedullary nail and bone grafting
16
39
M
MVA
32-B2.1
R
31
8
60
Excellent
20
33
M
MVA
32-B2.1
R
25
3
52
Good
Revision to condylar blade plate for varus angulation Grade 2 heterotopic ossification
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572
Fig. 5 AP radiograph of a 23-year-old man (case no. 9) with a 32C31 Rt femur fracture with a bent blade plate and varus deformity
Fig. 6 Final follow-up at 20 months after revision to reconstruction nail and good outcome (case no. 9)
[18, 19]. Comminuted fragments can be percutaneously reduced to the plate, improving the elastic stability for fracture healing. Vaidya et al. [20] reported 100 % fracture
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P. R. J. V. C. Boopalan et al.
healing with biological dynamic condylar screw (DCS) fixation. DCS has the advantage of submuscular plate sliding, but the loss of bone stock from the femoral head and neck during insertion can make subsequent surgeries due to failure difficult. Condylar blade plate is still unpopular although it is a standard option for subtrochanteric fractures. This is reflected in the sparse literature on it recently, and in the predominance of reports on it from experienced surgeons [7, 9, 21]. This may be because the surgery has a steep learning curve and blade plate insertion has to be precise in all three planes. Previous reports have not reported on functional outcome, in spite of good union rates [7, 9, 21, 22]. In this series, a functional assessment was performed for all patients. CBP was preferred, based on patient characteristics (young age, high-velocity injuries, and good bone quality) and fracture geometry (loss of medial cortical continuity or lateral wall comminution). It has the advantage of providing rigid fixation in the head and neck with better rotational stability, and does not allow lateral wall collapse. This study highlights certain pitfalls in the surgical technique that should be avoided to improve outcome. Careful preoperative planning, minimal dissection of medial side structures, and adequate reduction and stability have all been emphasized before. We emphasize the following points. Before the guide wire and chisel is inserted, either the proximal femur should be manipulated to correct the deformity of the proximal fragment, or the image intensifier (II) must be positioned in such a way that it compensates for the deformity of the proximal fragment, providing a true anteroposterior view. In this series, two patients had reoperations for varus malreductions. This has also been reported in case series by surgeons of vast experience [9]. Though subtrochanteric fractures have been fixed with two incisions, this necessitates the use of a shorter blade length [8]. The length of the blade and the length of the plate are inversely related (i.e., if a long plate is necessary, the blade length should be reduced). In this way, the plate can be introduced submuscularly and turned 180° to be inserted into the precut path in the bone (Fig. 7). Varus angulation of the distal limb also eases this step. Comminuted medial fragments and the lesser trochanter are lagged to achieve medial cortical continuity for medial support. This series shows a good outcome for high-velocity subtrochanteric fractures treated with the blade plate. The study results may be closer to those obtained in routine clinical practice in most centers. The advantages of this study are that it is an observational case series in which 96 % of the patients were followed up and analyzed. The results of this study reflect the importance of having multiple surgeons follow the same surgical principle, whereas
Biological femur condylar blade plating
Fig. 7 Intraoperative picture shows submuscular insertion of the condylar blade plate. Arrow points to the blade facing outwards during submuscular sliding, before it gets turned 180° to be inserted into the precut path in the bone
in most published studies it is the outcome of a single surgeon. The disadvantage is that it is a retrospective analysis. In conclusion, biological fixation of subtrochanteric fractures with 95° CBP is technically demanding but can provide good functional outcome. Conflict of interest The authors do not have any conflict of interest. None of the authors received any payment or consideration from any source for the conduct of this study.
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