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Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures
Journal Pre-proof
Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures Keong-Hwan Kim , Youngsik Yoon , Eic Ju Lim PII: DOI: Reference:
S0020-1383(20)30052-8 https://doi.org/10.1016/j.injury.2020.01.027 JINJ 8537
To appear in:
Injury
Accepted date:
21 January 2020
Please cite this article as: Keong-Hwan Kim , Youngsik Yoon , Eic Ju Lim , Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.01.027
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 Published by Elsevier Ltd.
Percutaneous
acetabular anchoring
pin-assisted
cephalomedullary
nailing
for
subtrochanteric and unstable intertrochanteric fractures
Keong-Hwan Kim, MD1 ; Youngsik Yoon, MD1; Eic Ju Lim, MD2
1
Department of Orthopaedic Surgery, Kangwon National University Hospital, Baengnyeong-
ro 156, Chuncheon-Si, Gangwon-Do 24289, Republic of Korea 2
Department of Orthopaedic Surgery, Guro Hospital, Korea University Medical Center, 148,
Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea
Corresponding Author: Keong-Hwan Kim
Department of Orthopaedic Surgery, Kangwon National University Hospital, Baengnyeongro 156, Chuncheon-Si, Gangwon-Do 24289, Republic of Korea Tel: +82-33-258-2000 Fax: +82-33-258-2149 E-mail: [email protected]
Abstract It is important to maintain acceptable reduction and make suitable entry when performing cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures; however, this is often challenging due to deforming forces or the unstable nature of the fracture itself. Several percutaneous reduction techniques for fractures have been introduced, but, in some cases, a loss of reduction during the nailing procedure is experienced. To prevent this problem, it is important to keep the proximal fragment stable for the entire nailing procedure. The present study reports favourable outcomes for cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures when percutaneous acetabular anchoring pin is used to maintain the proximal fragment stably in the reduced position.
Keywords: intertrochanteric fracture, subtrochanteric fracture, anchoring pin, cephalomedullary nailing
Introduction Cephalomedullary nailing has superior clinical and biomechanical results over other surgical methods used for subtrochanteric and unstable intertrochanteric fractures [1,2]; however, the procedure is technically demanding. In particular, it is difficult to maintain reduction due to deforming forces caused by hip abductors, hip flexors and short external rotators in subtrochanteric fractures [3]. Several authors have reported the necessity of open reduction for favourable reduction and surgical outcomes [4,5]. However, there are disadvantages to these techniques that can be detrimental in terms of the biology around the fracture due to additional soft tissue injury [6]. In this study, we introduced cases of percutaneous acetabular anchoring pin-assisted cephalomedullary nailing, which minimise the damage to the soft tissue around the fracture and can be easily performed whilst maintaining the proximal fragment stably in the reduced position.
Patients and Methods The present study was conducted after receiving approval for retrospectively reviewing the medical records and radiographic images of cases from the Institutional Review Board of our institute. Of 116 consecutive patients who underwent cephalomedullary nailing for intertrochanteric (108 patients) or subtrochanteric (8 patients) fracture from March 2018 to June 2019, we retrospectively reviewed 15 patients using the percutaneous acetabular anchoring pin technique.
Surgical technique and the evaluation of reduction status Under general or spinal anaesthesia, the patient was positioned on the fracture table. First, we attempted closed reduction by manipulation of the distal limb using traction and rotation. In cases where it was difficult to obtain acceptable reduction by these manoeuvres, we performed several percutaneous reduction techniques using instruments such as pins, haemostatic forceps and bone hooks [7-12]. However, in several cases it was challenging to maintain acceptable reduction due to deforming forces or the unstable nature of the fracture. We performed percutaneous reduction techniques twice on the femoral side maximally. In cases of failure to maintain fracture reduction in a maximum of two attempts, we fixed the proximal fragment stably in the reduced position with the acetabulum using an anchoring pin. We used a Steinmann pin of 2-mm diameter as the anchoring pin, and pin insertion was performed under fluoroscopic guidance. Initially, we manually placed the tip of the anchoring pin on the anterosuperior ridge between the femoral head and neck whilst maintaining the proximal fragment stably in the reduced position. Anatomical reduction was attempted, and, in exceptional cases, when the proximal fragment tended to move into the distal fragment in unstable intertrochanteric fractures, the proximal fragment was intentionally reduced outward [13]. Then, the anchoring pin was inserted into the subchondral bone of the anterosuperior ridge by tapping the pin using a hammer, followed by inserting it toward the anteroinferior wall of the acetabulum using a power drill. When the anchoring pin touched the inner acetabular wall, it was possible to feel resistance; at this point, we inserted the pin into subchondral hard bone for anchorage to the acetabular wall (Fig. 1). Once the proximal fragment was stably fixed by the anchoring pin, we could make a proper entry point and insert the nail easily (Figs. 2, 3). We created an entry point for the nail on the tip of the greater trochanter, followed by nail insertion using the usual technique.
We evaluated the reduction status using immediate postoperative radiographs. In cases of intertrochanteric fractures, the neck–shaft angle and anteromedial cortex were evaluated. The reduction in both the medial cortex and the anterior cortex were evaluated using Chang’s and Tsukada’s methods, respectively [13,14]. In cases of subtrochanteric fracture, the neck–shaft angle and angulation on the fracture sites were evaluated.
Results Of the total of 15 cases, 5 cases were of subtrochanteric fractures (1 male, 4 females) and 10 were of unstable intertrochanteric fractures (4 males, 6 females). Except for one case of intertrochanteric fracture and one case of subtrochanteric fracture due to motor vehicle injury in young patients, all cases were due to low-energy injury in elderly patients. The mean operation time was 60.5 min (range 40–95 min) for intertrochanteric fractures and 108 min (range 80–120 min) for subtrochanteric fractures. In cases of intertrochanteric fractures, there was no postoperative reduction status in the form of the proximal fragment engaged into the distal fragment in both anteroposterior and translateral views. No lateral nail entry point was noted in cases of subtrochanteric fractures (Table 1). No acute complications (such as vascular or nerve injury associated with the anchoring pin procedure) occurred during surgery.
Discussion Several minimally invasive techniques have been reported for the reduction of subtrochanteric and unstable intertrochanteric fractures [7-10]. Also, several authors have
reported provisional pin fixation for intertrochanteric fractures, and this technique is efficient in difficult cases [11,12]. However, we have experienced technical difficulties to maintain the reduction status in limited cases such as highly unstable intertrochanteric fractures with limited bone-to-bone contact in the anteromedial cortex whilst even using these techniques. In these cases, loss of reduction of the proximal fragment was usually the main problem. Therefore, we devised the anchoring pin technique to maintain the proximal fragment stably in the reduced position. We believe that an anchoring pin warrants more stable maintenance of the proximal fragment during nailing because the pin is in contact with three subchondral areas, i.e. two areas of the femoral head and one of the acetabular inner wall. In cases of subtrochanteric fractures, favourable outcomes have been reported using cerclage on the fracture site [15-17]. Although the cerclage technique may be useful in subtrochanteric fractures, this is technically difficult in atypical femoral fractures with short oblique or transverse configurations. Adverse effects have also been reported involving additional soft tissue injury around the fracture site [6]. Care is required when the fracture site is exposed for open reduction or is directly manipulated when using cerclage; however, when using percutaneous acetabular anchoring pin-assisted cephalomedullary nailing, this problem is eliminated because the fracture is not directly exposed or manipulated. When performing cephalomedullary nailing in proximal femoral fractures, it is important to make an appropriate entry point for nail insertion to obtain acceptable reduction and alignment [18,19]. Varus malreduction caused by nail insertion at the lateral starting point increases the risk of implant failure and nonunion [4]. However, it is difficult to create an appropriate entry portal due to deforming forces and to maintain reduction status in subtrochanteric and unstable intertrochanteric fractures. Our technique is suitable for solving these problems because entry can be made whilst maintaining the proximal fragment stably in
the reduced position. In the present study, all cases showed favourable postoperative reduction and alignment. It is important to insert the anchoring pin using the appropriate path and target point. In this procedure, the anchoring pin is directed through the anterior part of the femoral head to the anteroinferior subchondral bone of the inner acetabulum (Fig. 1). This position does not disturb the lag screw insertion. Care should be taken to avoid injury to the neurovascular structure or inner pelvic structure, which may occur if the anchoring pin deviates to the wrong path or if the anchoring pin is inserted too far into the inner pelvic wall. To prevent these injuries, the path of the anchoring pin was monitored under fluoroscopic guidance, and tactile sense was carefully monitored on the basis of a thorough understanding of pelvic anatomy when the pin was in contact with hard areas such as the femoral head and neck junction or inner acetabular wall.
Conclusion Cephalomedullary nailing assisted with percutaneous acetabular anchoring pin may be a useful and effective alternative to achieve favourable postoperative reduction and alignment in subtrochanteric and unstable intertrochanteric fractures.
References [1]
Forward DP, Doro CJ, O'Toole RV, Kim H, Floyd JC, Sciadini MF, et al. 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;26:334-40.
[2]
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.
[3]
Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am 2004;35:473-83.
[4]
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.
[5]
Beingessner DM, Scolaro JA, Orec RJ, Nork SE, Barei DP. Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases. Injury 2013;44:1910-5.
[6]
Schaser KD, Zhang L, Haas NP, Mittlmeier T, Duda G, Bail HJ. Temporal profile of microvascular disturbances in rat tibial periosteum following closed soft tissue trauma.
Langenbecks Arch Surg 2003;388:323-30. [7]
Pape HC, Tarkin IS. Intraoperative reduction techniques for difficult femoral fractures. J
Orthop Trauma 2009;23:S6-11. [8]
Park J, Yang KH. Correction of malalignment in proximal femoral nailing--Reduction technique of displaced proximal fragment. Injury 2010;41:634-8.
[9]
Yoon YC, Jha A, Oh CW, Durai SK, Kim YW, Kim JH, et al. The pointed clamp reduction technique for spiral subtrochanteric fractures: a technical note. Injury 2014;45:1000-5.
[10]
Lim SW, Shon OJ. Steinmann pin assisted reduction of subtrochanteric femoral fracture. J
Korean Fract Soc 2015;28:17-22. [11]
Cho JW, Kim HJ, Kim J, Cho WT, Jeong CD, Oh JK. Provisional pin fixation can maintain reduction in A3 intertrochanteric fractures. Arch Orthop Trauma Surg 2016;136:945-55.
[12]
Jain MJ, Mavani KJ, Patel D. Role of Provisional Fixation of Fracture Fragments By Steinmann-Pin and Technical Tips in Proximal Femoral Nailing for Intertrochanteric Fracture. J Clin Diagn Res 2017;11:RC01-RC5.
[13]
Chang SM, Zhang YQ, Ma Z, Li Q, Dargel J, Eysel P. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg 2015;135:811-8.
[14]
Tsukada S, Okumura G, Matsueda M. Postoperative stability on lateral radiographs in the surgical
treatment
of
pertrochanteric
hip
fractures.
Arch
Orthop
Trauma Surg
2012;132:839-46. [15]
Kennedy MT, Mitra A, Hierlihy TG, Harty JA, Reidy D, Dolan M. Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17
consecutive cases over 2 years. Injury 2011;42:1317-21. [16]
Tomas J, Teixidor J, Batalla L, Pacha D, Cortina J. Subtrochanteric fractures: treatment with cerclage wire and long intramedullary nail. J Orthop Trauma 2013;27:e157-60.
[17]
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.
[18]
Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 2005;19:681-6.
[19]
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg
Am 2009;91:712-9.
Legends
Figure 1 The simulation of the acetabular anchoring pin technique on a pelvic sawbone model shows that the pin is inserted into the anteroinferior acetabular wall through the anterior part of the femoral head (a, b). The anteroinferior acetabular wall (marked by the dotted area) is the target area to anchor the pin (c).
Figure 2 A 61-year-old woman experienced an atypical femoral fracture in the subtrochanteric area following a fall (a). The proximal fragment was de-rotated using a pin inserted into the proximal fragment as a joystick, and the anchoring pin was inserted with the proximal fragment maintained in the reduced position (b). Nail insertion was performed while
maintaining the anchoring pin in the insertion position (c). Postoperative simple radiographs show good reduction and alignment (d, e).
Figure 3 An 82-year-old woman had an intertrochanteric fracture following a fall (a, b). The fracture was reduced using a haemostatic forceps and a pin as a joystick (white arrow). The proximal fragment was fixed with an anchoring pin (white arrow head), followed by guide pin (black arrow head) insertion for the nail entry from the greater trochanter (c). Postoperative simple radiographs show good reduction and alignment (d, e).
Table 1. Classification and postoperative radiographic evaluation Patient AO/OTA N–S Age Sex No. classification angle (C) 1 31 M 31A2.3 128 2 82 F 31A3.1 130 3 94 F 31A3.1 140 4 85 F 31A3.3 133 5 84 F 31A3.3 127 6 81 F 31A3.3 130 7 72 M 31A3.3 132 8 71 F 31A3.3 134 9 92 M 31A3.3 152* 10 85 M 31A3.3 136 11 61 F 32A2a 128 12 78 F 32A2a 124 13 82 F 32A3a 126 14 77 F 32A3a 130 15 24 M 32B3a 130 N–S neck–shaft, C contralateral, AP anteroposterior
N–S angle 130 135 129 128 129 128 131 134 127 134 135 127 126 130 134
Medical cortex NP NP PMCS NP NP NP NP NP PMCS NP
Anterior cortex ADPF ADPF R R ADPF ADPF R PDPF R ADPF
Nail entry
Angulation*** (AP view)
Angulation*** (Translateral view)
Medial** GT GT Medial** Medial**
0 0 0 0 0
4, anterior 0 4, anterior 0 0
NP neutral position, PMCS positive medial cortical support, ADPF anteriorly displaced proximal fragment, R reduced, PDPF posteriorly displaced proximal fragment, GT tip of the greater trochanter [13,14] * The contralateral hip has dysplastic feature. ** Entry point for the nail, slightly medial to the tip of the greater trochanter to avoid varus malalignment. ***Angulations on fracture sites were measured using the lateral cortex and anterior cortex in the anteroposterior and translateral views, respectively.
Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures Keong-Hwan Kim , Youngsik Yoon , Eic Ju Lim PII: DOI: Reference:
S0020-1383(20)30052-8 https://doi.org/10.1016/j.injury.2020.01.027 JINJ 8537
To appear in:
Injury
Accepted date:
21 January 2020
Please cite this article as: Keong-Hwan Kim , Youngsik Yoon , Eic Ju Lim , Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.01.027
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 Published by Elsevier Ltd.
Percutaneous
acetabular anchoring
pin-assisted
cephalomedullary
nailing
for
subtrochanteric and unstable intertrochanteric fractures
Keong-Hwan Kim, MD1 ; Youngsik Yoon, MD1; Eic Ju Lim, MD2
1
Department of Orthopaedic Surgery, Kangwon National University Hospital, Baengnyeong-
ro 156, Chuncheon-Si, Gangwon-Do 24289, Republic of Korea 2
Department of Orthopaedic Surgery, Guro Hospital, Korea University Medical Center, 148,
Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea
Corresponding Author: Keong-Hwan Kim
Department of Orthopaedic Surgery, Kangwon National University Hospital, Baengnyeongro 156, Chuncheon-Si, Gangwon-Do 24289, Republic of Korea Tel: +82-33-258-2000 Fax: +82-33-258-2149 E-mail: [email protected]
Abstract It is important to maintain acceptable reduction and make suitable entry when performing cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures; however, this is often challenging due to deforming forces or the unstable nature of the fracture itself. Several percutaneous reduction techniques for fractures have been introduced, but, in some cases, a loss of reduction during the nailing procedure is experienced. To prevent this problem, it is important to keep the proximal fragment stable for the entire nailing procedure. The present study reports favourable outcomes for cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures when percutaneous acetabular anchoring pin is used to maintain the proximal fragment stably in the reduced position.
Keywords: intertrochanteric fracture, subtrochanteric fracture, anchoring pin, cephalomedullary nailing
Introduction Cephalomedullary nailing has superior clinical and biomechanical results over other surgical methods used for subtrochanteric and unstable intertrochanteric fractures [1,2]; however, the procedure is technically demanding. In particular, it is difficult to maintain reduction due to deforming forces caused by hip abductors, hip flexors and short external rotators in subtrochanteric fractures [3]. Several authors have reported the necessity of open reduction for favourable reduction and surgical outcomes [4,5]. However, there are disadvantages to these techniques that can be detrimental in terms of the biology around the fracture due to additional soft tissue injury [6]. In this study, we introduced cases of percutaneous acetabular anchoring pin-assisted cephalomedullary nailing, which minimise the damage to the soft tissue around the fracture and can be easily performed whilst maintaining the proximal fragment stably in the reduced position.
Patients and Methods The present study was conducted after receiving approval for retrospectively reviewing the medical records and radiographic images of cases from the Institutional Review Board of our institute. Of 116 consecutive patients who underwent cephalomedullary nailing for intertrochanteric (108 patients) or subtrochanteric (8 patients) fracture from March 2018 to June 2019, we retrospectively reviewed 15 patients using the percutaneous acetabular anchoring pin technique.
Surgical technique and the evaluation of reduction status Under general or spinal anaesthesia, the patient was positioned on the fracture table. First, we attempted closed reduction by manipulation of the distal limb using traction and rotation. In cases where it was difficult to obtain acceptable reduction by these manoeuvres, we performed several percutaneous reduction techniques using instruments such as pins, haemostatic forceps and bone hooks [7-12]. However, in several cases it was challenging to maintain acceptable reduction due to deforming forces or the unstable nature of the fracture. We performed percutaneous reduction techniques twice on the femoral side maximally. In cases of failure to maintain fracture reduction in a maximum of two attempts, we fixed the proximal fragment stably in the reduced position with the acetabulum using an anchoring pin. We used a Steinmann pin of 2-mm diameter as the anchoring pin, and pin insertion was performed under fluoroscopic guidance. Initially, we manually placed the tip of the anchoring pin on the anterosuperior ridge between the femoral head and neck whilst maintaining the proximal fragment stably in the reduced position. Anatomical reduction was attempted, and, in exceptional cases, when the proximal fragment tended to move into the distal fragment in unstable intertrochanteric fractures, the proximal fragment was intentionally reduced outward [13]. Then, the anchoring pin was inserted into the subchondral bone of the anterosuperior ridge by tapping the pin using a hammer, followed by inserting it toward the anteroinferior wall of the acetabulum using a power drill. When the anchoring pin touched the inner acetabular wall, it was possible to feel resistance; at this point, we inserted the pin into subchondral hard bone for anchorage to the acetabular wall (Fig. 1). Once the proximal fragment was stably fixed by the anchoring pin, we could make a proper entry point and insert the nail easily (Figs. 2, 3). We created an entry point for the nail on the tip of the greater trochanter, followed by nail insertion using the usual technique.
We evaluated the reduction status using immediate postoperative radiographs. In cases of intertrochanteric fractures, the neck–shaft angle and anteromedial cortex were evaluated. The reduction in both the medial cortex and the anterior cortex were evaluated using Chang’s and Tsukada’s methods, respectively [13,14]. In cases of subtrochanteric fracture, the neck–shaft angle and angulation on the fracture sites were evaluated.
Results Of the total of 15 cases, 5 cases were of subtrochanteric fractures (1 male, 4 females) and 10 were of unstable intertrochanteric fractures (4 males, 6 females). Except for one case of intertrochanteric fracture and one case of subtrochanteric fracture due to motor vehicle injury in young patients, all cases were due to low-energy injury in elderly patients. The mean operation time was 60.5 min (range 40–95 min) for intertrochanteric fractures and 108 min (range 80–120 min) for subtrochanteric fractures. In cases of intertrochanteric fractures, there was no postoperative reduction status in the form of the proximal fragment engaged into the distal fragment in both anteroposterior and translateral views. No lateral nail entry point was noted in cases of subtrochanteric fractures (Table 1). No acute complications (such as vascular or nerve injury associated with the anchoring pin procedure) occurred during surgery.
Discussion Several minimally invasive techniques have been reported for the reduction of subtrochanteric and unstable intertrochanteric fractures [7-10]. Also, several authors have
reported provisional pin fixation for intertrochanteric fractures, and this technique is efficient in difficult cases [11,12]. However, we have experienced technical difficulties to maintain the reduction status in limited cases such as highly unstable intertrochanteric fractures with limited bone-to-bone contact in the anteromedial cortex whilst even using these techniques. In these cases, loss of reduction of the proximal fragment was usually the main problem. Therefore, we devised the anchoring pin technique to maintain the proximal fragment stably in the reduced position. We believe that an anchoring pin warrants more stable maintenance of the proximal fragment during nailing because the pin is in contact with three subchondral areas, i.e. two areas of the femoral head and one of the acetabular inner wall. In cases of subtrochanteric fractures, favourable outcomes have been reported using cerclage on the fracture site [15-17]. Although the cerclage technique may be useful in subtrochanteric fractures, this is technically difficult in atypical femoral fractures with short oblique or transverse configurations. Adverse effects have also been reported involving additional soft tissue injury around the fracture site [6]. Care is required when the fracture site is exposed for open reduction or is directly manipulated when using cerclage; however, when using percutaneous acetabular anchoring pin-assisted cephalomedullary nailing, this problem is eliminated because the fracture is not directly exposed or manipulated. When performing cephalomedullary nailing in proximal femoral fractures, it is important to make an appropriate entry point for nail insertion to obtain acceptable reduction and alignment [18,19]. Varus malreduction caused by nail insertion at the lateral starting point increases the risk of implant failure and nonunion [4]. However, it is difficult to create an appropriate entry portal due to deforming forces and to maintain reduction status in subtrochanteric and unstable intertrochanteric fractures. Our technique is suitable for solving these problems because entry can be made whilst maintaining the proximal fragment stably in
the reduced position. In the present study, all cases showed favourable postoperative reduction and alignment. It is important to insert the anchoring pin using the appropriate path and target point. In this procedure, the anchoring pin is directed through the anterior part of the femoral head to the anteroinferior subchondral bone of the inner acetabulum (Fig. 1). This position does not disturb the lag screw insertion. Care should be taken to avoid injury to the neurovascular structure or inner pelvic structure, which may occur if the anchoring pin deviates to the wrong path or if the anchoring pin is inserted too far into the inner pelvic wall. To prevent these injuries, the path of the anchoring pin was monitored under fluoroscopic guidance, and tactile sense was carefully monitored on the basis of a thorough understanding of pelvic anatomy when the pin was in contact with hard areas such as the femoral head and neck junction or inner acetabular wall.
Conclusion Cephalomedullary nailing assisted with percutaneous acetabular anchoring pin may be a useful and effective alternative to achieve favourable postoperative reduction and alignment in subtrochanteric and unstable intertrochanteric fractures.
References [1]
Forward DP, Doro CJ, O'Toole RV, Kim H, Floyd JC, Sciadini MF, et al. 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;26:334-40.
[2]
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.
[3]
Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am 2004;35:473-83.
[4]
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.
[5]
Beingessner DM, Scolaro JA, Orec RJ, Nork SE, Barei DP. Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases. Injury 2013;44:1910-5.
[6]
Schaser KD, Zhang L, Haas NP, Mittlmeier T, Duda G, Bail HJ. Temporal profile of microvascular disturbances in rat tibial periosteum following closed soft tissue trauma.
Langenbecks Arch Surg 2003;388:323-30. [7]
Pape HC, Tarkin IS. Intraoperative reduction techniques for difficult femoral fractures. J
Orthop Trauma 2009;23:S6-11. [8]
Park J, Yang KH. Correction of malalignment in proximal femoral nailing--Reduction technique of displaced proximal fragment. Injury 2010;41:634-8.
[9]
Yoon YC, Jha A, Oh CW, Durai SK, Kim YW, Kim JH, et al. The pointed clamp reduction technique for spiral subtrochanteric fractures: a technical note. Injury 2014;45:1000-5.
[10]
Lim SW, Shon OJ. Steinmann pin assisted reduction of subtrochanteric femoral fracture. J
Korean Fract Soc 2015;28:17-22. [11]
Cho JW, Kim HJ, Kim J, Cho WT, Jeong CD, Oh JK. Provisional pin fixation can maintain reduction in A3 intertrochanteric fractures. Arch Orthop Trauma Surg 2016;136:945-55.
[12]
Jain MJ, Mavani KJ, Patel D. Role of Provisional Fixation of Fracture Fragments By Steinmann-Pin and Technical Tips in Proximal Femoral Nailing for Intertrochanteric Fracture. J Clin Diagn Res 2017;11:RC01-RC5.
[13]
Chang SM, Zhang YQ, Ma Z, Li Q, Dargel J, Eysel P. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg 2015;135:811-8.
[14]
Tsukada S, Okumura G, Matsueda M. Postoperative stability on lateral radiographs in the surgical
treatment
of
pertrochanteric
hip
fractures.
Arch
Orthop
Trauma Surg
2012;132:839-46. [15]
Kennedy MT, Mitra A, Hierlihy TG, Harty JA, Reidy D, Dolan M. Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17
consecutive cases over 2 years. Injury 2011;42:1317-21. [16]
Tomas J, Teixidor J, Batalla L, Pacha D, Cortina J. Subtrochanteric fractures: treatment with cerclage wire and long intramedullary nail. J Orthop Trauma 2013;27:e157-60.
[17]
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.
[18]
Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma 2005;19:681-6.
[19]
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg
Am 2009;91:712-9.
Legends
Figure 1 The simulation of the acetabular anchoring pin technique on a pelvic sawbone model shows that the pin is inserted into the anteroinferior acetabular wall through the anterior part of the femoral head (a, b). The anteroinferior acetabular wall (marked by the dotted area) is the target area to anchor the pin (c).
Figure 2 A 61-year-old woman experienced an atypical femoral fracture in the subtrochanteric area following a fall (a). The proximal fragment was de-rotated using a pin inserted into the proximal fragment as a joystick, and the anchoring pin was inserted with the proximal fragment maintained in the reduced position (b). Nail insertion was performed while
maintaining the anchoring pin in the insertion position (c). Postoperative simple radiographs show good reduction and alignment (d, e).
Figure 3 An 82-year-old woman had an intertrochanteric fracture following a fall (a, b). The fracture was reduced using a haemostatic forceps and a pin as a joystick (white arrow). The proximal fragment was fixed with an anchoring pin (white arrow head), followed by guide pin (black arrow head) insertion for the nail entry from the greater trochanter (c). Postoperative simple radiographs show good reduction and alignment (d, e).
Table 1. Classification and postoperative radiographic evaluation Patient AO/OTA N–S Age Sex No. classification angle (C) 1 31 M 31A2.3 128 2 82 F 31A3.1 130 3 94 F 31A3.1 140 4 85 F 31A3.3 133 5 84 F 31A3.3 127 6 81 F 31A3.3 130 7 72 M 31A3.3 132 8 71 F 31A3.3 134 9 92 M 31A3.3 152* 10 85 M 31A3.3 136 11 61 F 32A2a 128 12 78 F 32A2a 124 13 82 F 32A3a 126 14 77 F 32A3a 130 15 24 M 32B3a 130 N–S neck–shaft, C contralateral, AP anteroposterior
N–S angle 130 135 129 128 129 128 131 134 127 134 135 127 126 130 134
Medical cortex NP NP PMCS NP NP NP NP NP PMCS NP
Anterior cortex ADPF ADPF R R ADPF ADPF R PDPF R ADPF
Nail entry
Angulation*** (AP view)
Angulation*** (Translateral view)
Medial** GT GT Medial** Medial**
0 0 0 0 0
4, anterior 0 4, anterior 0 0
NP neutral position, PMCS positive medial cortical support, ADPF anteriorly displaced proximal fragment, R reduced, PDPF posteriorly displaced proximal fragment, GT tip of the greater trochanter [13,14] * The contralateral hip has dysplastic feature. ** Entry point for the nail, slightly medial to the tip of the greater trochanter to avoid varus malalignment. ***Angulations on fracture sites were measured using the lateral cortex and anterior cortex in the anteroposterior and translateral views, respectively.