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Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report
Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report R. Pascarella, S. Cerbasi* , A. Maresca, P. Sangiovanni, R. Fantasia Section of Orthopaedics and Trauma Surgery, Ospedali Riuniti, Ancona, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 July 2018 Received in revised form 20 November 2018 Accepted 23 November 2018
This case report describes the management and therapeutic solution for the treatment of subtrochanteric non-union in a patient with hip arthrodesis. Two techniques can be used in the treatment of these non-unions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union. We report an unusual case of a patient who started her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Satisfactory outcomes were finally obtained. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union. © 2018 Elsevier Ltd. All rights reserved.
Keywords: Subtrochanteric non-union Hip arthrodesis Intramedullary fixation Plate fixation Bone grafting Case report
Introduction Subtrochanteric fractures are associated with a variable incidence of non-union. This condition usually follows a surgical treatment with failure of fixation because this femoral area is subjected to concentrated biomechanical stress [1–5]. Development of subtrochanteric non-union depends on the method and type of fixation used. For extramedullary devices, rates of 4–13% have been reported [2]. Zubairi [6] revealed a high failure rate (26%) with proximal femur locking compression plates (PF-LCP). The lowest rates are seen with intramedullary fixation [1] although rates as high as 10% have been described [2]. The main causes of failed consolidation can be traced back to the interruption of the medial cortex of the femur, to comminution of the fracture and consequent loss of bone substance, to an imperfect reduction, to an incorrect surgical treatment or to particular biomechanical conditions of the hip [1–8]. Two techniques can be used in the treatment of these nonunions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union [1,4,7,9]. We report a case of a patient who started
* Corresponding author at: Section of Orthopaedic & Trauma Surgery, Ospedali Riuniti di Ancona, Via Conca 71, 60030, Ancona, Italy. E-mail address: [email protected] (S. Cerbasi). https://doi.org/10.1016/j.injury.2018.11.036 0020-1383/© 2018 Elsevier Ltd. All rights reserved.
her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union. This clinical case illustrates the importance of carefully assessing patient anatomical conditions to optimize the surgical strategies and the adequate timing of the treatment. In our report we have complied with the SCARE guideline [10]. Case report The patient’s clinical history – long, complex and at times resembling a novel’s plot – begun in 1958, when, aged 18, she suffered from septic arthritis of the right hip. The prescribed therapy was antibiotics and bed rest for a year. However, the recurrence of the infection led doctors to suggest a hip arthrodesis. In the operating room, the doctor that was performing surgery suffered a massive heart attack during operation, and in falling on the floor lifeless he cut the patient’s femoral artery with the knife. The woman underwent the surgical repair of the artery lesion and, since she was haemorrhaging and no other blood was available, was treated with a blood transfusion from another surgeon who was in the operating room. The following day the hip arthrodesis procedure was completed with the placement of a screw (Fig. 1). During the following five years, the patient suffered from recurrent abscesses in the right hip region, which were treated with bed rest, plaster casts and antibiotics. Due to the persistence of the infection
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
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Fig. 1. Pelvis with an artrodhesis of the right hip.
and the screw’s exposure, it was decided to surgically remove it. While everything was being prepared to move the patient on to the operating table, the woman fell on the floor and suffered a right hip pertrochanteric fracture, as well as a coccyx one. The screw of the arthrodesis surgery was removed, and an osteosynthesis of the femoral fracture was performed with plate (Fig. 2). The patient was in good health for nearly 35 years until, in March 2000, she fell again – this time while getting off a car – and suffered a right proximal femur fracture below the plate (Fig. 3). So it was carried out another operation to remove the old plate and perform a new osteosynthesis with 13 holes diaphisary platem (Fig. 4). In the following months, due to the fracture’s failed ossification, the woman underwent three procedures of autologous bone grafting, taking the bone from her iliac crest. However, all the surgeries were unsuccessful. In September 2000, six months after the osteosynthesis, the plate broke (Fig. 5). The patient was again operated: the plate was removed and a Long Gamma nail was implanted (Fig. 6), first locked but dynamised after few months to
facilitate healing. After 10 months, the nail failed as well, and the non-union appeared again. We first had the patient in our care in September 2001, aged 61. The X-rays showed an atrophic nonunion and a broken nail at the level of the fracture’s surrounding area (Fig. 7). The general conditions were good, and there were no signs of infection. The woman underwent a nail removal surgery: the proximal fragment was removed from the greater trochanter, while the distal fragment was removed straight from the fracture. Then we carried out a non-union site resection until bone bloody and internal fixation with a compression plate and an omoplastic cortical bone graft in the opposite side (Fig. 8). Surgery was performed on the 11 September 2001, during the terrorist attack on the Twin Towers in New York. After a period of two months without weight bearing, the patient started walking with a progressive granting load on the right. Non-union is consolidated after 6 months about. Healing was based on the assessment of X-ray at each of the four cortices visible
Fig. 2. During removal of the hip artrodhesis screw, the patient full down from the surgical table and had a pertrochanteric fracture treated with plate. The picture show the fracture consolidation.
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R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Fig. 4. Open reduction and internal fixation with long plate. Three other surgical operation to put autoplastic bone graft from iliac crest.
Fig. 3. a–b) Fracture of proximal femur under the previous plate happened when the patient get off the car.
on AP and LL projections. The follow-up clinical and X-ray is 15 years. The patient walks free and X-rays shows a complete consolidation with partial bone resorption of graft (Fig. 9). Satisfaction, ability to work and pain with treatment received were evaluated, using an analog centesimal scale (VAS). The reported level of satisfaction was 90/100, ability to work 70/100 and pain with a value of 10/100 respectively. Another index used to evaluate the final outcome was Short-Form 36 Health Survey (SF36) [11,12], a generic questionnaire on health status comprising 36 questions that measure eight health domain scales (physical function, role physical, bodily pain, general health, vitality, social
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
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Fig. 5. Rupture of the plate after 6 months.
functioning, role emotional, and mental health). In Table 1 is showed good results of patient compared with her age and sexmatched norms. Discussion Fig. 6. Plate removal, reaming and intramedullary nail with cephalic screw.
Subtrochanteric femur non-unions are difficult to treat because of the anatomical peculiarities of the subtrochnateric area, the previous surgical treatment carried out and phenotype of the host, being an elderly patient with poor generalised health state [4,7,13]. Smoke, vascular problems, hormonal imbalances or altered electrolytic balances may be some of biological contributory causes, but the main cause of failure is usually an osteosynthesis not suited to stabilize the fracture for healing [1,4,6,7,13–16]. Intramedullary and extramedullary devices are used for treatment of acute subtrochanteric fractures, and also proved to be successful implants for revision internal fixation for subtrochanteric nonunions [7]. The treatment of these lesions is also linked to the type of nonunion (hypertrophic or atrophic) and to the treatment used before [1,4,9,13].
If the non-union is hypertrophic and the fracture was treated with a nail, the technique involves the removal of the intramedullary implant, reaming that produces osteoinductive material and a new bigger nail compared to previous one [1,4,9,13,17,18]. A standard nail can be used or when the level of non union is close to the trochanteric region, it is safer to use a long cephalomedullary nail. The cephalic screw usually gives the necessary stability for healing [17–19]. If need to be do an open surgery, for the presence of a plate or a broken nail to removed, or for an atrophic non-union, it is better to do an internal fixation with plate [1,4,7,9,20,21].
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R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Fig. 8. Broken nail removal, resection of non-union focus, compression plate and cortical bone graft.
Fig. 7. Rupture of nail after 10 months.
When the non-union is stiff is not necessary to open the focus but simply do an internal fixation with compression plate. If the non-union is atrophic bone bleeding edges are established, after removal of previous implant, it needs a focus resection until bone bloody, getting two surfaces matching, and then apply a compression plate. The insertion of an homologous cortical bone graft, applied on the medial side and stabilized with the screws of the plate, usually guarantees a good biomechanical situation and helps the healing of the lesion [4,7,9].The cortical bone graft “protects” the medial cortex of the femur from torsional and varus forces and allows greater keeping to screws in an often
osteoporotic bone. Several Authors emphasized the importance of reconstituting the medial cortex [2,5,22]. The graft also has a biological function demonstrated by osteointegration and the gradual reduction of the same in the parts not load after 6–8 months [4]. Some Authors indicate the use of autoplastic marrow bone graft in the non-union focus. Certainly the autoplastic graft determines a biological stimulus but sometimes it is not sufficient to healing if the implant not guarantee the stability required, as is in fact happened in the case descripted [13,23]. Cortical and marrow freeze-dried or irradiated bone graft do not guarantee to our opinion a good biomechanical stability and an adequate biological push [13,23].
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
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Fig. 9. Non-union healed after 6 months. Follow up after 7 years with a complete consolidation and osteointegration of graft.
A “locked joint” determinates an altered distribution of forces and weight to the next joints, which have more easily early arthrosis, axial deviations and fractures [24]. In the case presented, the presence of a “locking hip” influenced the recurrence of nonunion since all mechanical stress and forces were acting on fracture focus, impeding recovery [24–26]. If the medial cortex is comminuted or there is bone loss, that area shows a least resistance and then determinates the failure of the implant. This is the principal reason to use, in case of subtrochanteric non-union, a cortical bone graft to create a mechanical and biological support. In our case the cortical bone protected the medial region of the femur, ensuring optimum stability of the screws and allowing the "Silence mechanical" necessary for healing. Type of the fracture, general
and anatomical conditions of the patient should influenced the choice of surgical technique and, consequently, the type of healing for a satisfactory result. Conflict of interest statement The authors declare that they have no conflict of interest related to the publication of this manuscript. Ethics This Work submitted to Injury is comply with the principles laid down in the Declaration of Helsinki. The manuscript has been
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R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Table 1 In Table 1 is showed good results of patient compared with her age and sex-matched norms.
PF = Physical function; RP = Role Physical; BP = Bodily Pain; GH = General Healt; VT = Vitality; SF = Social Function; RE = Role Emotional; MH = Mental Health.
approved by the appropriate ethical committees related to the institution in which it was performed and that subject gave informed consent to the work. References [1] Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am 2015;46:21–35. [2] Craig NJ, Maffulli N. Subtrochanteric fractures: current management options. Disabil Rehabil 2005;27:1181–90. [3] Choi JY, Sung YB, Yoo JH, Chung SJ. Factors affecting time to bony union of femoral subtrochanteric fractures treated with intramedullary devices. Hip Pelvis 2014;26:107–13. [4] Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am 2004;35:473–83. [5] Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res 1992;283:231–6. [6] Zubairi A, Rashid RH, Zahid M, Hashmi PM, Noordin S. Proximal Femur locking for subtrochanteric femur fractures: factors associated with failure. Open Orthopaedic J. 2017;11:1058–65. [7] Haidukewych GJ, Berry DJ. Nonunion of fractures of the subtrochanteric region of the femur. Clin Orthop Relat Res 2004;419:185–8. [8] Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma 2009;23:465–70. [9] Gelalis ID, Politis AN, Arnaoutoglou CM, Korompilias AV, Pakos EE, Vekris MD, et al. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury 2012;43:980–8. [10] Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP, et al. The SCARE statement: consensus-based surgical case report guidelines. Int J Surg 2016;34:180–6. [11] Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. conceptual framework and item selection. Med Care 1992;30:473–83. [12] Apolone G, Mosconi P. The italian SF-36 health survey: translation, validation and norming. J Clin Epidemiol 1998;51:1025–36.
[13] Johnson EE. Acute lenthening of shortened lower extremities after malunion or nonunion of a fracture. J Bone J Surg 1994;76/A:379–89. [14] Taitsman LA, Lynch JR, Agel J, Barei DP, Nork SE. Risk factors for femoral nonunion after femoral shaft fracture. J Trauma 2009;67(6):1389–92. [15] Sims SH. Subtrochanteric femur fractures. Orthop Clin North Am 2002;33:113–26. [16] Zickel RE. Nonunions of fractures of the proximal & distal thirds of the shaft of the femur. Instr Course Lect 1988;33:173–9. [17] McLaren AC, Blokker CP. Locked intramedullary fixation for metaphiseal malunion and nonunion. Clin Orthop 1991;265:253–60. [18] Webb LX, Winquist RA, Hansell ST. Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft. Clin Orthop 1986;212:133–41. [19] Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the Gamma Nail and the dynamic hip screw. J Bone J Surg 1991;73B:330–4. [20] Ueng SW, Chao EK, Lee SS, Shih CH. Augmentative plate fixation for the management of femoral non union after intramedullary nailing. J Trauma 1997;43:640–4. [21] Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma 1998;45(October):747–52. [22] Vander Griend RA. The effect of internal fixation on the healing of large allografts. J Bone J Surg 1994;76/A:657–63. [23] Goldberg VM, Stevenson S, Shaffer JW: Bone and cartilage allografts: biology and clinical applications. Biology of autografts and allografts. Friedlander Ed., Park Ridge. American Academy of Orthopaedic Surgeons. [24] Lustig S, Vaz G, Guyen O, Tayot O, Chavane H, Bejui-Hugues J, et al. Total hip arthroplasty after hip arthrodesis performed for septic arthritis. Rev Chir Orthop Reparatrice Appar Mot 2007;93(December):828–35. [25] Brien WW, Golz RJ, Kunschner SH, Brien EW, Wiss DA. Hip joint arthrodesis utilizing anterior compression plate fixation. J Arthroplasty 1994;9 (April):171–6. [26] Matta JM, Siebenrock KA, Gautier E, Mehne D, Ganz R. Hip fusion through an anterior approach with the use of a ventral plate. Clin Orthop Relat Res 1997;337(April):129–39.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report R. Pascarella, S. Cerbasi* , A. Maresca, P. Sangiovanni, R. Fantasia Section of Orthopaedics and Trauma Surgery, Ospedali Riuniti, Ancona, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 July 2018 Received in revised form 20 November 2018 Accepted 23 November 2018
This case report describes the management and therapeutic solution for the treatment of subtrochanteric non-union in a patient with hip arthrodesis. Two techniques can be used in the treatment of these non-unions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union. We report an unusual case of a patient who started her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Satisfactory outcomes were finally obtained. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union. © 2018 Elsevier Ltd. All rights reserved.
Keywords: Subtrochanteric non-union Hip arthrodesis Intramedullary fixation Plate fixation Bone grafting Case report
Introduction Subtrochanteric fractures are associated with a variable incidence of non-union. This condition usually follows a surgical treatment with failure of fixation because this femoral area is subjected to concentrated biomechanical stress [1–5]. Development of subtrochanteric non-union depends on the method and type of fixation used. For extramedullary devices, rates of 4–13% have been reported [2]. Zubairi [6] revealed a high failure rate (26%) with proximal femur locking compression plates (PF-LCP). The lowest rates are seen with intramedullary fixation [1] although rates as high as 10% have been described [2]. The main causes of failed consolidation can be traced back to the interruption of the medial cortex of the femur, to comminution of the fracture and consequent loss of bone substance, to an imperfect reduction, to an incorrect surgical treatment or to particular biomechanical conditions of the hip [1–8]. Two techniques can be used in the treatment of these nonunions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union [1,4,7,9]. We report a case of a patient who started
* Corresponding author at: Section of Orthopaedic & Trauma Surgery, Ospedali Riuniti di Ancona, Via Conca 71, 60030, Ancona, Italy. E-mail address: [email protected] (S. Cerbasi). https://doi.org/10.1016/j.injury.2018.11.036 0020-1383/© 2018 Elsevier Ltd. All rights reserved.
her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union. This clinical case illustrates the importance of carefully assessing patient anatomical conditions to optimize the surgical strategies and the adequate timing of the treatment. In our report we have complied with the SCARE guideline [10]. Case report The patient’s clinical history – long, complex and at times resembling a novel’s plot – begun in 1958, when, aged 18, she suffered from septic arthritis of the right hip. The prescribed therapy was antibiotics and bed rest for a year. However, the recurrence of the infection led doctors to suggest a hip arthrodesis. In the operating room, the doctor that was performing surgery suffered a massive heart attack during operation, and in falling on the floor lifeless he cut the patient’s femoral artery with the knife. The woman underwent the surgical repair of the artery lesion and, since she was haemorrhaging and no other blood was available, was treated with a blood transfusion from another surgeon who was in the operating room. The following day the hip arthrodesis procedure was completed with the placement of a screw (Fig. 1). During the following five years, the patient suffered from recurrent abscesses in the right hip region, which were treated with bed rest, plaster casts and antibiotics. Due to the persistence of the infection
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
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Fig. 1. Pelvis with an artrodhesis of the right hip.
and the screw’s exposure, it was decided to surgically remove it. While everything was being prepared to move the patient on to the operating table, the woman fell on the floor and suffered a right hip pertrochanteric fracture, as well as a coccyx one. The screw of the arthrodesis surgery was removed, and an osteosynthesis of the femoral fracture was performed with plate (Fig. 2). The patient was in good health for nearly 35 years until, in March 2000, she fell again – this time while getting off a car – and suffered a right proximal femur fracture below the plate (Fig. 3). So it was carried out another operation to remove the old plate and perform a new osteosynthesis with 13 holes diaphisary platem (Fig. 4). In the following months, due to the fracture’s failed ossification, the woman underwent three procedures of autologous bone grafting, taking the bone from her iliac crest. However, all the surgeries were unsuccessful. In September 2000, six months after the osteosynthesis, the plate broke (Fig. 5). The patient was again operated: the plate was removed and a Long Gamma nail was implanted (Fig. 6), first locked but dynamised after few months to
facilitate healing. After 10 months, the nail failed as well, and the non-union appeared again. We first had the patient in our care in September 2001, aged 61. The X-rays showed an atrophic nonunion and a broken nail at the level of the fracture’s surrounding area (Fig. 7). The general conditions were good, and there were no signs of infection. The woman underwent a nail removal surgery: the proximal fragment was removed from the greater trochanter, while the distal fragment was removed straight from the fracture. Then we carried out a non-union site resection until bone bloody and internal fixation with a compression plate and an omoplastic cortical bone graft in the opposite side (Fig. 8). Surgery was performed on the 11 September 2001, during the terrorist attack on the Twin Towers in New York. After a period of two months without weight bearing, the patient started walking with a progressive granting load on the right. Non-union is consolidated after 6 months about. Healing was based on the assessment of X-ray at each of the four cortices visible
Fig. 2. During removal of the hip artrodhesis screw, the patient full down from the surgical table and had a pertrochanteric fracture treated with plate. The picture show the fracture consolidation.
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R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Fig. 4. Open reduction and internal fixation with long plate. Three other surgical operation to put autoplastic bone graft from iliac crest.
Fig. 3. a–b) Fracture of proximal femur under the previous plate happened when the patient get off the car.
on AP and LL projections. The follow-up clinical and X-ray is 15 years. The patient walks free and X-rays shows a complete consolidation with partial bone resorption of graft (Fig. 9). Satisfaction, ability to work and pain with treatment received were evaluated, using an analog centesimal scale (VAS). The reported level of satisfaction was 90/100, ability to work 70/100 and pain with a value of 10/100 respectively. Another index used to evaluate the final outcome was Short-Form 36 Health Survey (SF36) [11,12], a generic questionnaire on health status comprising 36 questions that measure eight health domain scales (physical function, role physical, bodily pain, general health, vitality, social
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
S5
Fig. 5. Rupture of the plate after 6 months.
functioning, role emotional, and mental health). In Table 1 is showed good results of patient compared with her age and sexmatched norms. Discussion Fig. 6. Plate removal, reaming and intramedullary nail with cephalic screw.
Subtrochanteric femur non-unions are difficult to treat because of the anatomical peculiarities of the subtrochnateric area, the previous surgical treatment carried out and phenotype of the host, being an elderly patient with poor generalised health state [4,7,13]. Smoke, vascular problems, hormonal imbalances or altered electrolytic balances may be some of biological contributory causes, but the main cause of failure is usually an osteosynthesis not suited to stabilize the fracture for healing [1,4,6,7,13–16]. Intramedullary and extramedullary devices are used for treatment of acute subtrochanteric fractures, and also proved to be successful implants for revision internal fixation for subtrochanteric nonunions [7]. The treatment of these lesions is also linked to the type of nonunion (hypertrophic or atrophic) and to the treatment used before [1,4,9,13].
If the non-union is hypertrophic and the fracture was treated with a nail, the technique involves the removal of the intramedullary implant, reaming that produces osteoinductive material and a new bigger nail compared to previous one [1,4,9,13,17,18]. A standard nail can be used or when the level of non union is close to the trochanteric region, it is safer to use a long cephalomedullary nail. The cephalic screw usually gives the necessary stability for healing [17–19]. If need to be do an open surgery, for the presence of a plate or a broken nail to removed, or for an atrophic non-union, it is better to do an internal fixation with plate [1,4,7,9,20,21].
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Fig. 8. Broken nail removal, resection of non-union focus, compression plate and cortical bone graft.
Fig. 7. Rupture of nail after 10 months.
When the non-union is stiff is not necessary to open the focus but simply do an internal fixation with compression plate. If the non-union is atrophic bone bleeding edges are established, after removal of previous implant, it needs a focus resection until bone bloody, getting two surfaces matching, and then apply a compression plate. The insertion of an homologous cortical bone graft, applied on the medial side and stabilized with the screws of the plate, usually guarantees a good biomechanical situation and helps the healing of the lesion [4,7,9].The cortical bone graft “protects” the medial cortex of the femur from torsional and varus forces and allows greater keeping to screws in an often
osteoporotic bone. Several Authors emphasized the importance of reconstituting the medial cortex [2,5,22]. The graft also has a biological function demonstrated by osteointegration and the gradual reduction of the same in the parts not load after 6–8 months [4]. Some Authors indicate the use of autoplastic marrow bone graft in the non-union focus. Certainly the autoplastic graft determines a biological stimulus but sometimes it is not sufficient to healing if the implant not guarantee the stability required, as is in fact happened in the case descripted [13,23]. Cortical and marrow freeze-dried or irradiated bone graft do not guarantee to our opinion a good biomechanical stability and an adequate biological push [13,23].
R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
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Fig. 9. Non-union healed after 6 months. Follow up after 7 years with a complete consolidation and osteointegration of graft.
A “locked joint” determinates an altered distribution of forces and weight to the next joints, which have more easily early arthrosis, axial deviations and fractures [24]. In the case presented, the presence of a “locking hip” influenced the recurrence of nonunion since all mechanical stress and forces were acting on fracture focus, impeding recovery [24–26]. If the medial cortex is comminuted or there is bone loss, that area shows a least resistance and then determinates the failure of the implant. This is the principal reason to use, in case of subtrochanteric non-union, a cortical bone graft to create a mechanical and biological support. In our case the cortical bone protected the medial region of the femur, ensuring optimum stability of the screws and allowing the "Silence mechanical" necessary for healing. Type of the fracture, general
and anatomical conditions of the patient should influenced the choice of surgical technique and, consequently, the type of healing for a satisfactory result. Conflict of interest statement The authors declare that they have no conflict of interest related to the publication of this manuscript. Ethics This Work submitted to Injury is comply with the principles laid down in the Declaration of Helsinki. The manuscript has been
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R. Pascarella et al. / Injury, Int. J. Care Injured 49S4 (2018) S2–S8
Table 1 In Table 1 is showed good results of patient compared with her age and sex-matched norms.
PF = Physical function; RP = Role Physical; BP = Bodily Pain; GH = General Healt; VT = Vitality; SF = Social Function; RE = Role Emotional; MH = Mental Health.
approved by the appropriate ethical committees related to the institution in which it was performed and that subject gave informed consent to the work. References [1] Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am 2015;46:21–35. [2] Craig NJ, Maffulli N. Subtrochanteric fractures: current management options. Disabil Rehabil 2005;27:1181–90. [3] Choi JY, Sung YB, Yoo JH, Chung SJ. Factors affecting time to bony union of femoral subtrochanteric fractures treated with intramedullary devices. Hip Pelvis 2014;26:107–13. [4] Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am 2004;35:473–83. [5] Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res 1992;283:231–6. [6] Zubairi A, Rashid RH, Zahid M, Hashmi PM, Noordin S. Proximal Femur locking for subtrochanteric femur fractures: factors associated with failure. Open Orthopaedic J. 2017;11:1058–65. [7] Haidukewych GJ, Berry DJ. Nonunion of fractures of the subtrochanteric region of the femur. Clin Orthop Relat Res 2004;419:185–8. [8] Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma 2009;23:465–70. [9] Gelalis ID, Politis AN, Arnaoutoglou CM, Korompilias AV, Pakos EE, Vekris MD, et al. Diagnostic and treatment modalities in nonunions of the femoral shaft: a review. Injury 2012;43:980–8. [10] Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP, et al. The SCARE statement: consensus-based surgical case report guidelines. Int J Surg 2016;34:180–6. [11] Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. conceptual framework and item selection. Med Care 1992;30:473–83. [12] Apolone G, Mosconi P. The italian SF-36 health survey: translation, validation and norming. J Clin Epidemiol 1998;51:1025–36.
[13] Johnson EE. Acute lenthening of shortened lower extremities after malunion or nonunion of a fracture. J Bone J Surg 1994;76/A:379–89. [14] Taitsman LA, Lynch JR, Agel J, Barei DP, Nork SE. Risk factors for femoral nonunion after femoral shaft fracture. J Trauma 2009;67(6):1389–92. [15] Sims SH. Subtrochanteric femur fractures. Orthop Clin North Am 2002;33:113–26. [16] Zickel RE. Nonunions of fractures of the proximal & distal thirds of the shaft of the femur. Instr Course Lect 1988;33:173–9. [17] McLaren AC, Blokker CP. Locked intramedullary fixation for metaphiseal malunion and nonunion. Clin Orthop 1991;265:253–60. [18] Webb LX, Winquist RA, Hansell ST. Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft. Clin Orthop 1986;212:133–41. [19] Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the Gamma Nail and the dynamic hip screw. J Bone J Surg 1991;73B:330–4. [20] Ueng SW, Chao EK, Lee SS, Shih CH. Augmentative plate fixation for the management of femoral non union after intramedullary nailing. J Trauma 1997;43:640–4. [21] Ueng SW, Shih CH. Augmentative plate fixation for the management of femoral nonunion with broken interlocking nail. J Trauma 1998;45(October):747–52. [22] Vander Griend RA. The effect of internal fixation on the healing of large allografts. J Bone J Surg 1994;76/A:657–63. [23] Goldberg VM, Stevenson S, Shaffer JW: Bone and cartilage allografts: biology and clinical applications. Biology of autografts and allografts. Friedlander Ed., Park Ridge. American Academy of Orthopaedic Surgeons. [24] Lustig S, Vaz G, Guyen O, Tayot O, Chavane H, Bejui-Hugues J, et al. Total hip arthroplasty after hip arthrodesis performed for septic arthritis. Rev Chir Orthop Reparatrice Appar Mot 2007;93(December):828–35. [25] Brien WW, Golz RJ, Kunschner SH, Brien EW, Wiss DA. Hip joint arthrodesis utilizing anterior compression plate fixation. J Arthroplasty 1994;9 (April):171–6. [26] Matta JM, Siebenrock KA, Gautier E, Mehne D, Ganz R. Hip fusion through an anterior approach with the use of a ventral plate. Clin Orthop Relat Res 1997;337(April):129–39.