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Non Union Distal Femur Fracture: Causes and Management Options

January 10, 2016/in Jan - April 2016 | Volume 2 | Issue 1

Volume 2 | Issue 1 | Jan-April 2016 | Page 28-33|Puneet Maheshwari, Pramod Maheshwari Author: Puneet Maheshwari[1], Pramod Maheshwari[1] [1] Maheshwari Nursing Home, 163, Bhagat Singh Marg Dewas M.P. 455001, India Address of Correspondence Dr. Puneet Maheshwari Maheshwari Nursing Home, 163, Bhagat Singh Marg Dewas M.P. 455001, India Email: puneet1984@gmail.com Abstract Distal femur fractures are […]

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 21-24 | Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2] . Author: Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2]. [1]SRH Zentralklinikum Suhl, Medical Director,Albert-Schweitzer-Str. 2 ,98527 Suhl. [2]Klinikum St. Georg Leipzig, Delitzscher Str. 141, 04129 Leipzig. Address of Correspondence Dr Ralf Herbert Gahr Klinikum St. Georg […]

Non Union Distal Femur Fracture: Causes and Management Options

January 10, 2016/in Jan - April 2016 | Volume 2 | Issue 1

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

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Non Union Distal Femur Fracture: Causes and Management Options

January 10, 2016/in Jan - April 2016 | Volume 2 | Issue 1

Volume 2 | Issue 1 | Jan-April 2016 | Page 28-33|Puneet Maheshwari, Pramod Maheshwari

Author: Puneet Maheshwari[1], Pramod Maheshwari[1]

[1] Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India

Address of Correspondence
Dr. Puneet Maheshwari
Maheshwari Nursing Home, 163, Bhagat Singh Marg
Dewas M.P. 455001, India
Email: puneet1984@gmail.com

Abstract

Distal femur fractures are common but complex fractures and often are associated with complications. The cases of failure may be secondary to mechanical failure or biological failure. The current review offers overview of these complications and tips and tricks on how to manage these complications.
Keywords: Distal Femur Fractures, Complications, Surgical management

Introduction

Distal femoral fractures are a common orthopaedic problem in all age groups of patients with and incidence of about 37 per 100,000 person years.(1) Distal femoral fractures since a long time has been considered difficult to treat using traditional implants due to high failure rate and secondary varus collapse. (2)
Distal femoral fractures in young age group is most commonly due to high energy trauma while in older age group it is mostly associated with fall from height or walking along with osteoporosis of bones. Treatment of these fractures can be successfully done with variety of plates(3-6) and retrograde intramedullary nails(7-10).
Early studies of treating distal femoral fractures with locked plates reported excellent out come with non-union rates of 0-14% (mostly less than 6%) (4, 11-21).
However, with the recent data being analyzed and reported the non-union rates are now as high has 17-21% (11, 22, 23). This can be partially attributed to wider variety of fracture morphology and in patients prone for development of non-union.
Definition of Non-union
Non-union definition is based on three factors namely, duration of time since injury, characteristics of fracture on serial x-rays and lastly clinical parameters assessed by the treating surgeon.
Presently, US FDA defines non-union as fracture bone that has not completely healed in 9 months since injury and which has not shown any signs of healing over 3 consecutive months on serial x-rays.(24)
Multiple literatures indicates that optimal time for healing is in between 4 to 12 months, taking into account the type of bone fractured, nature of injury and quality of the soft tissues around the fractured bone. (25-33)
Along with these factors one more important factor is the physiologic capability of the individual in mounting a healing response.

Classification
Distal femur fractures (AO classification)
As per the AO classification the distal femur (33) can be classified in to 3 types namely extra-articular, partial articular and complete articular factures, which are further classified.
Distal femur fractures are:
Type 33A: extraarticular fracture
o A1: simple
o A2: metaphyseal wedge and/or fragmented wedge
o A3: metaphyseal complex
Type 33B: partial articular fracture
o B1: lateral condyle, sagittal
o B2: medial condyle, sagittal
o B3: frontal
Type 33C: complete articular fracture
o C1: articular simple, metaphyseal simple
o C2: articular simple, metaphyseal multifragmentary
o C3: articular multifragmentary

Weber and Cech have classified femoral non-union based on the viability or blood supply of the fracture into two broad groups viable and non-viable types. (24)
Viable type of non-union has an intact blood supply to the fracture area and thus body can mount a healing response to injury. Viable type is further divided into hypertrophic and oligo-trophic non-union.
Non-viable type of non-union is also called as atrophic or avascular non-union. The vascularity of the fracture area is absent and thus it cannot mount a healing response to injury. Type of non-union can be determined on plain x-ray in AP and lateral view or more accurately on bone scans.
Classification of non-union is important not just for documentation purposes but also for management point. In a viable non-union minimally invasive or non-invasive treatment can lead to union and thus saving the patient from another major surgical procedure.
These procedures would be give a questionable healing response in case of atrophic non-union and there the surgeon need to be more aggressive and has to plan a more extensive treatment.

Diagnosis and Evaluation
It is extremely important for the treating surgeon to timely diagnose, evaluate and document a non-union both for management as well as for legal purpose.
Diagnosis begins with a detailed history and examination of the patient and the affected limb. Patient-related risk factors like tobacco addiction, use of analgesics peripheral vascular disease, diabetes should be looked for and documented. Any clinical symptom that may point towards infection (occult/overt) like fever, malaise, night pain or history of wound healing problem should be elicited.
Physical examination should identify and document any deformity, pain over fracture area, soft tissue cover problems, increased local temperature, drainage, abnormal mobility, crepitation, and limb length discrepancy.
Radiological evaluation should be done with plain x-rays of the affected part in AP, lateral, and both oblique views (45 degrees internal and external views). In majority of patients this will get the accurate diagnosis of nonunion and its subtype. CT scan is a more accurate modality than plain x-rays in diagnosing the non-union.(34)
Infection should be cause in all cases of femoral non-union unless ruled out. Hence proper blood work-up is must which should include complete blood count, ESR and CRP. Deep tissue culture at the time of secondary surgery is the gold standard for diagnosis of infection. (35)

Causes and Risk factors
Main causes of distal femoral nonunion are
Inadequate fracture stabilization leading to motion at fracture site
Avascularity at the fracture ends – due to compound fractures, excessive stripping of soft tissue during surgery
Fracture gap
Infection
Patient related
Surgeon related

Inadequate fracture stabilization leads to micro and macro movements at the fracture site, which may result due to inadequate fixation at the time of primary surgery or due to implant failure.
Avascularity or diminished blood supply to the fracture end results due to compound injury (27), excessive stripping of soft tissue during surgery, comminuted fractures.(36) Decreased blood supply leads to a poor healing response and causes atrophic non-union.
Multiple literature supports that in fractures with significant comminution the soft tissue stripping is more and thus injuring the blood supply.(28)
Presence of gap at the fracture site either due to bone loss or during surgery (fracture fixed in distraction or debridement) also contribute to the occurrence of non-union.(29) Any gap present is usually bridged by the fracture callus, but when the body fails to bridge this gap non union results.
Infection can result as a complication of open injury or surgical treatment. Infection leads to formation of dead necrotic bone in the form of sequestrum, ingrowth of infected granulation tissue, osteolysis and motion at fracture site due to loosening of implant or implant failure.
Patient factors like age, smoking, tobacco use, chronic use of analgesics (NSAIDs), medical comorbidities and obesity to name a few can lead to non-union (22, 37).
Surgeon related factors include technical factors like plate length, screw density of plate, material of implant (titanium vs. stainless steel) and cortical reduction. Studies have shown that use of titanium implants significantly reduces the chances of non-union and thus need for a secondary surgical procedure (22).
In case of implant failure, the most important factor is the length of plate used. Shorter plates are prone to fail earlier than longer plates due to relatively lower fatigue properties because of mechanical disadvantage. Usually, a plate with 9 or more screws are is less liable to give away (37).

Treatment Options
Ultimate aim of the surgeon is to achieve osseous union without complications. Along with this it is important for the surgeon to correct any mal-alignment control infection if present, achieving sufficient muscle strength and rehabilitation.
Currently the accepted method of primary fixation of distal femur fractures is retrograde nail and lateral plating either lateral locked plates or fixed angle plates.

1.   Nail dynamisation
2.   Exchange nailing
3.   Plate osteosynthesis
4.   External fixation
5.   Adjuvant treatment options
a.   Electrical stimulation and ultrasound therapy
b.   Bone grafting
c.   Bone graft substitutes and biologic agents
d.   Bone marrow infiltration

Nail Dynamisation
Nail dynamisation is the term used when the statically locked nail is converted to a dynamically locked plate. This is accomplished by removal of screw/s adjacent to the dynamic hole of the nail.
Mechanism of healing with this technique is that it allows for a controlled axial instability of the bone and implant at the fracture site. This allows transfer of weight bearing forces to non-union site and promotes healing.(38)
Dynamisation is most effective when done at an early stage of non-union or delayed union as judged by serial radiographs. Optimal time for dynamisation is around 3-6 months of injury and primary treatment.(36)
Available literature suggests a success rate of about 50%. Nail dynamisation should be done is axially stable fractures like transverse or oblique fractures.
There are few complications associated with this technique namely shortening, implant failure. Thus a regular follow-up of the patients is a must.

Exchange Nailing
Exchange nailing refers to the surgical technique where an already present nail is removed and a larger diameter and stiffer nail is inserted after reaming. It is desirable that the second nail should be atleast 1-2mm larger than the earlier nail and the reaming should be done until the osseous chatter is heard.
This method provides both mechanical and biological stimulus for healing. A larger diameter and stiffer nail provides more mechanical stability along with increased working length of the implant thus decreasing the chances of implant failure. Biologically reaming causes deposition of fresh marrow material in the non-union site and stimulates periosteal reaction.(39) Union rates reported with this technique is variable with some studies showing union rates as high as 97%. (31, 32) Studies show that chances of non-union are more when reaming is not done.(40)

Plate Osteosynthesis
Plate osteosynthesis is the most common and gold standard treatment option in cases of distal femoral non-unions.(37) Plating offers increased mechanical stability to fracture specially in hypertrophic non-unions. Plate osteosynthesis (open reduction and internal fixation) provides an excellent opportunity of the surgeon to correct any associated deformities along with providing an excellent axial and torsional stability. Traditionally fixed angled 95 degree angled blade plate was used for distal femoral fractures, applied on the lateral aspect.(3, 41) The newer locked plates now available are the implant of choice in present scenario.(4, 5, 11-13, 15, 16, 18-20, 42, 43) With the use of compression holes excellent direct compression of the fracture site can be achieved.(44)
Few studies have reported union rates for distal femur non-unions with plate osteosynthesis around 91% to 100%.(45, 46) Even in case of poor bone stock and long standing non-unions the union rates are in range of 95 to 98% (31, 47)
This method of achieving union has its own risks and disadvantages. There is increased risk of infection, blood loss, increased tissue stripping, implant breakage, screw loosening etc. (6, 45, 47-50). Another disadvantage is that patients treated with plate osteosynthesis require strict immobilization for some duration, which may lead to joint stiffness and decreased range of motion of joints along with delay in starting rehabilitation.
Abdel-Aa et al (46) reported in their study that about 13% of patients treated with plate osteosynthesis for distal femoral non union required quadricepsplasty and knee arthrolysis within one year of surgery.
Another technique has been described in literature where both nail and plate are used simultaneously in achieving union. In this technique with an intramedullary implant in situ, a plate is fixed in compression mode at the fracture site. This method provides positive points of both the techniques in the form of early weight bearing, fracture fixed in direct compression thus chances of early union, improved torsional and rotational stability. If required bone grafting can also be done at same time to further increase the osteogenic potential and to fill up any bony defects if present. In studies using this method there has been a union rate of 100% within one year of surgery.(49, 51, 52)

External Fixation
Multiplanar (Ilizarov technique) and uniplanar external fixation for treatment of non-union of femur has been reported in literature with modest success (53, 54). Compression and distraction at non-union site has been demonstrated to show signs of healing(55). However, with the high complication rate (eg osteomyletitis, severe pain requiring opiod anagesics, septic arthritis, pin failure, joint stiffness etc.) use of external fixation for non-union healing is restricted to small number of patients. Along with this, the technical complexity and cost factor also restricts its use to tertiary level centres (54).

Adjuvant Treatment
These treatment options can be used as an isolated treatment option or as a supplementary treatment for achieving union.

Electrical Stimulation
Multiple studies show that mechanical forces, electrical forces, magnetic forces and ultrasound waves have variable level of effect on bone healing and growth (56-59). Electrical stimulation is thought to be effective non-invasive modality for promoting fracture healing and in treatment of non-unions.
Generation of electrical potentials around bone occurs when mechanical stress is applied(60, 61). Electronegative and electropositive potentials are generated with compression and tension respectively (62). It has been proven that in electronegative potential bone growth occurs and with electropositive potential bone is resorbed (63).
There are three techniques of electrical stimulation, namely, direct electric current, capacitive coupling and inductive coupling.
Direct electrical current is an invasive technique involving one or more cathode electrodes being implanted in the bone and an anode usually placed on the skin over the fracture site(64). In a case series by Brighton et al. (65) out of 168 fractures, 76% showed good bony union by 12 weeks of electrical stimulation therapy.
Capacitive coupling is a noninvasive technique where two electrodes are placed over the skin such that fracture site lies in between the electrodes. Here alternating current (AC) is used and an electric field is generated in and around the fracture site. It is a dose dependent technique whereby the greater electrical field leads to more osteoblastic cell response along with increased time of exposure leading to increased osteoblastic cell proliferation (66, 67).
Inductive coupling uses the principle of Pulsed Electromagnetic Field (PEMF) generation using specific device. The device is placed over the skin (non-invasive) over the fracture site. Passing current in the device generates the magnetic field. This magnetic field induces an electrical field, which leads to a bone healing response. This time-varying electrical field simulates normal response of osteoblastic cells to mechanical stimuli (68).

Bone Grafting, bone marrow aspirate and biologic agents

These procedures and materials can be used as an isolated or adjuvant treatment depending of the non-union type.
Autogenous bone grafts are considered gold standard for grafting procedures(69). Autologous bone grafting in past has got a bad review mainly due to donor site complications(70). With advances in harvesting techniques there is a renewed interest in this procedure(71-73).
Biologic agents like Bone Morphogenic Proteins (BMP) have been studied in detail both in animals and in humans and gives promising results.
Bone Morphogenic Proteins are part of the Transforming Growth Factor-Beta (TGF-B) superfamily and with a cascade sequence of events leads to bone healing via chondrogenesis, osteogenesis, angiogenesis and extracellular matrix remodeling (74). There are more than 20 BMP identified in humans. Studies in animals and in-vitro have shown BMP -2,4,6,7,9 have high osteogenic potential (75-78). Recombinant BMP-2 and 4 are in use clinically (74) but with questionable safety and efficacy profile(79-82).

Summary
Every surgically managed fracture is a race between bony union and implant/biological failure leading to non-union. Management of acute distal femur fracture with a nail or plate has good union rate or more than 90%. But when non-union occurs, it becomes a challenging task for the surgeon and patient both. It presents a significant mental, emotional and financial implication on the patient and his/her family.
Careful history taking and meticulous examination during routine follow-ups can help a surgeon to diagnose a delayed union or non-union in early stage and can modify the management as per the need to achieve bony union. Established non-union requires a well planned out management protocol to be decided before hand. Surgeon should decide the management plan (either non-invasive or invasive) on case-to-case basis to achieve union, correction of deformities. Surgeon should also take care of the patient modifiable risk factors like use of NSAIDs, smoking, medical co-morbidities and nutritional status of patient.

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How to Cite this article: Maheshwari P, Maheshwari P. Non Union Distal Femur Fracture: Causes and Management Options. Trauma International Jan-Apr 2016;1(2):28-33.

Dr. Pramod Maheshwari

Dr. Puneet Maheshwari

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How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 21-24 | Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2] .

Author: Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2].

[1]SRH Zentralklinikum Suhl, Medical Director,Albert-Schweitzer-Str. 2 ,98527 Suhl.
[2]Klinikum St. Georg Leipzig, Delitzscher Str. 141, 04129 Leipzig.

Address of Correspondence
Dr Ralf Herbert Gahr
Klinikum St. Georg Leipzig
Delitzscher Str. 141, 04129 Leipzig
Email: ralfgahr@sanktgeorg.de

Abstract

Background: Hip fractures belong to the most frequent fractures of elderly people. The treatment follows a specific algorithm that focuses on the medical as well as the social situation of these patients. Despite modern operative techniques and implants complications may occur. They may be distinguished into two groups: local complications and systemic complications
Especially local complications (cut out of the femoral head screw) are the reason for revision surgery. Surgery (“salvage procedures”) may only be performed after critical analysis of the local situation and individual planning of the revision procedure. This article outlines the tactical course of action in these cases.
Keywords: Hip fractures – complication – salvage procedure – therapeutic algorithm.

Introduction

Hip fractures are typical injuries of the elderly [1]. Recent studies prove that the incidence of these entities rises dramatically with increasing age [1]. In 2008 Lohmann et al. showed an incidence of 0.06 percent at an age between 60 and 64 years and an incidence of 1.3 percent at people at their eighties [2]. In other words: More than 90 percent of the patients are in their seventies and in addition more than 70 percent are females [3].
American authors assume, that the number of hip fractures will increase from 250,000 in the year 1990 up to 500,000 in 2040 [4]. In Germany the rate of hip fractures totals up to 90/100.000 inhabitants for all classes of age but is 966/100.000 for septuagenarians [5, 6]. Till 2050 the incidence is assumed to multiply by five [6].
In case of geriatric patients suffering from a hip fracture leads to a significant decrease of life expectancy accompanied by an increased medical risk and a number of social problems (for example accommodation in a retirement home) [7, 8]. Anglo-American analyses indicate an average reduction of life expectancy of 1.8 years or 25 percent of the remaining life span per patient [9]. The treatment of such injuries demands a specific algorithm that takes the local surgical problems and co-morbidities as well as social necessities into consideration. Highest goal of the surgical treatment is the early mobilization, prevention of secondary complications and the return to maximal autonomy. Hip fractures today are regularly treated by operative stabilization [10]. Nevertheless the ideal operative procedure is still discussed in the literature [11].
Even modern operative techniques and implants these procedures show adverse events or complications in 15 to 20 percent [12, 13]. Based on acuteness, topography and implant association they may be distinguished into the following groups [14]:
A. Acuteness
Early complication (within three months after surgery)
tactical surgical failure
technical surgical failure
local complication (like wound healing disturbance or infection)
systemic complications (like deep vein thrombosis)

Late complication (after more than three months postoperatively)
effect of poor bone biology (like delayed union or pseudarthrosis)
contracture

b.Topography
local complication (see above)
systemic complication (see above)

c. Implant association
implant associated complication (like cutout, peri-implant fracture or implant failure); (see below)
non implant associated complication

(Revision) Surgery: Planning and tactics
In reference to the special situation of aged patients one has to pay attention to two central factors no matter if one performs primary or revision surgery:
· short term operation
· full weight bearing possible after surgery
Thus the planning of surgery must be focused on the prevention of tactical and technical failures. Revision surgery necessary because of local complications may be divided into two groups:
· Implant (osteosynthesis) related procedures.
Planned implant replacement (for example progressive coxarthrosis that leads to removal of an intramedullary stabilization system in order to implant a total hip arthoplasty).
Enforced implant replacement based on local complications (salvage procedures)

Not implant related local surgery (like the relief of a local hematoma).
A strict separation between these two types of complications is not always possible in praxi. Based on the above named principles one has to keep in mind the following general standards [15]:
· On the part of the surgical procedure:
o full weight bearing possible after surgery
o stable implant fixation in osteoporotic bone
o preservation of the vascularization of the femoral neck and head
o simple operative technique

· On the part of the surgeon:
o profound knowledge of possible implants and surgical techniques
o mastery of the intramedullary and extramedullary surgical options as well as of arthroplasties
oclear Nevertheless the different studies still show different results indication for a specific implant.

Key-factor I: Preoperative analysis (Fig. 1 and 2)
Primary surgery as well as revision surgery demands a proper analysis of the local situation. The following questions have to be answered preoperatively [15]:
·Where is the problem localized (femoral head and/or femoral neck, trochanteric region, subtrochanteric)?
·Why did the complication occur?
·How may the problem be solved (reosteosynthesis versus (hemi) arthroplasty)?
·What is the correct implant?
·When is the optimal point in time for the operation?

Key-factor II: Osteosynthesis or arthroplasty (Fig. 3)?
In order to answer these questions the following factors are important:
Is the actual situation generally applicable to be treated with an osteosynthesis?
o from the part of the fracture
o from the part of the hip joint (i.e. presence of a significant symptomatic coxathrosis)
If the answer to this question is YES: Which technique will be performed?
o intramedullary stabilization
oextramedullary stabilization
If the answer to this question is NO: Which alternative technique should be performed (hemiarthroplasty, total arthroplasty) [16, 17, 18, 19]?

Stable fractures (AO/OTA 31-A1) present the classic indication for osteosynthesis. The cure rate is close to 100 percent [20]. These fractures mainly are stabilized by the use of a dynamic hip screw (DHS).
AO/OTA A31-A2 and –A3 are unstable fractures. The optimal treatment is still open to debate in the recent literature [16, 17]. Intramedullary stabilization is considered to be better in terms of biomechanical considerations [21]. Nevertheless osteosynthesis failure is estimated to be 56 percent [20].
The question whether to perform reosteosynthesis or switch to hip arthroplasty is elaborated just by few studies. The different studies show different results. Nevertheless Faldini 2002, Sinno 2007 and Giannotti 2013 and 2014 indicate, that elder patients suffering from those unstable pertrochanteric fractures benefit from treatment by cemented hemiarthoplasty. This leads to faster mobilization and lower mortality [16, 17, 18, 19]. According to D`Arrigo et al. the candidates for proximal femur replacement are patients with non-viable proximal femoral segments, destruction of the proximal femoral articular surface, advanced age and the absence of coxarthrosis [22]. Total arthroplasty may be taken into consideration in case of patients with additional severe coxarthrosis.
Switching from internal fixation to arthoplasty offers some special problems [22]:
· failed internal fixation (sometimes accompanied by broken screws) must be removed
· necessity of special instruments in order to remove the failed system
· compromised proximal femur with bone loss distal to the typical neck-resection level for hip arthroplasty

Key-factor III: Open or closed reduction (Table 1)?
The preoperative fracture analysis with a view to it`s reductive capacity based on the radiographic findings (X-ray, CT-scan) is an integral component as well for primary surgery as for revision surgery when reosteosynthesis seams to be possible. Open and closed reduction is the typical approach. Normally AO/OTA 31 fractures will be closed reduced. However between three and 17 percent are estimated to be applicative for closed reduction [23, 24, 25]. In their study Sharma et al. identified 4 general fracture situations, which are not applicative for closed reduction [25]:
· AO/OTA 31-A1 fractures where the proximal fragment is locked underneath the overridden and mediatized shaft fragment
· AO/OTA 31-A1 fractures with bisected lesser trochanter
· AO/OTA 31-A2 fractures with entrapment of the posteromedial fragment at the fracture site
· AO/OTA 31-A2 fractures with an anteriorly displaced proximal fragment and an underlying separate lesser trochanter
The mentioned AO/OTA 31-A1 fractures mainly occurred in younger, the AO/OTA 31-A2 fractures in older patients.

Implant related specification of typical complications of osteosynthesis
In case of planned (re-) osteosynthesis knowledge of the specific osteosynthesis related complications is vital in order to avoid local surgical complications. In general the complication rate is estimated to be three percent [26]. Sathiyakumar et al. distinguished five different treatment variant with significantly different typical implant related complications [9].
The complications mentioned below may occur after intramedullary stabilization as well as extramedullary stabilization of AO/OTA 31 fractures.

Particulars and choice of typical complications of extramedullary systems
The overall complication rate is estimated to be between 6.8 and 16.7 percent [27]. The rate of mechanical complications is estimated to be 2.8 percent [26].
Typical complications
· Cutout. Between three and 16.7 percent for dynamic hip screws [27, 28, 29].
· Z-effect. Mentioned below (intramedullary complications)
· Jamming of the lag screw. According to Simpson this is one of the main reasons for dynamic hip screw failure [30].
· Peri-implant fracture. Parker et al. found it in 0.1 percent in their 2010 study [27].
· Implant overload
· Implant dislocation

Particulars and choice of typical complications of intramedullary systems
The overall complication rate is estimated between 3.6 and 18 percent in the recent literature [26].
Typical complications
·Dislocation of the lesser trochanter
·Varus dislocation of the fracture
·Z-effect-A classical complication of two screw systems (like the proximal femoral nail). The repetitive axial loading of the implant combined with an unstable fracture fixation situation leads to toggling of the nail within the femoral canal [31]. This leads to medial migration of the nail. This mechanism is also described in the 2008 study of Weil et al. [32]. Nevertheless the precise etiology requires further clarification [33].
·Cutout. The Cochrane analysis of 2010 describes a rate of 3.4% for intramedullary implants [27]. The contemporary 2014 study of Greorgiannos evidences a rate between two and ten percent [34]. For intramedullary system as well as extramedullary ones the possibility of cutouts depends on the positioning of the lag or sliding screw in the proximal fragment [34]. As early as 1995 Baumgartner et al. described the so-called “tip-apex-distance” (TAD). This nowadays is accepted to be the central principle for the optimal positioning of the lag screw. It is determined intraoperative in the ap. and axial view fluoroscopy [35]. Kuzyk et al. showed in 2012 that the position of the lag screw next to the “Adam´s bow” in the ap. view and in the center of the proximal fragment in the axial view optimizes the biomechanical stability of the osteosynthesis [36]. In addition Nikoloski et al. could prove, that the original TAD rule should be modified depending on the used system, especially when “two screw systems” are used [37]. These authors distinguished two main types of cutout [37]:
o cephaled cutout
o axial cutout
· Knife effect
· Secondary screw dislocation
· Peri-implant fracture. Robinson et al. described an incidence of 18.74 fractures per 1000 person years in case of fractures treated with intramedullary systems [38]. The analysis of Parker et al. in 2010 showed an incidence of 2.6 percent [27]. By developing new designs of the intramedullary devices in the last decades the rate of these complication could be decreased dramatically.
· Implant failure

Discussion

Trochanteric femoral fractures comprise 50 percent of geriatric hip fractures. [39]. Although union rates as high as 100 percent have been reported after primary reduction and internal fixation with stable fractures ideal implants and optimal reduction failure rates over 50 percent are described in case of unstable fractures, suboptimal fracture fixation and poor bone quality [40]. Thus the correct individualized primary stabilization already presents a demanding problem. Appropriate management of failed primary osteosynthesis is even more challenging.
According to the recent literature the choice of treatment depends on the clear identification of the fracture type combined with the specific local situation [39]:
· AO/OTA classification of the fracture.
· radiographic analysis of the local bone structure
o presence or absence of osteoporosis
o presence or absence of extended bone loss
o presence or absence of significant coxarthrosis
When, based on the AO/OTA classification and the above-mentioned facts, the decision for internal (re-) fixation is made optimal reduction of the fracture fragments and positioning of the chosen implant is from central interest [35]. According to the recent literature implant failure generally seems to be the result of poor fracture reduction, mechanical stress, fracture instability or technical error [40] Although the optimal treatment for unstable fracture situations {AO/OTA 31-A2 and A3) are still discussed controversially in the last years a rising number of studies presents good results for arthroplasty as well for primary as for revision surgery [41,42]. Unfortunately there are only few comparative studies and even fewer prospective, random controlled ones which compare prosthetic hip replacement with the standard internal fixation in terms of primary and revision surgery [16]. In their 2014 study these authors come to the conclusion that there are no major differences between the treatment with hemi- or total arthroplasty but especially the elderly patients with severe osteoporosis or comminuted trochanteric fracture take significant profit from the treatment with hip arthroplasty compared to internal fixation [Giannotti]. According to Parker et al. in 2006 there are no significant differences between arthroplasty and internal fixation for mechanical complications, local wound complications, general complications and mortality at one year or long-term function [42].

Conclusion

· proximal hip fracture treatment is no trauma surgery for beginners
· local bone and fracture situation have to be clearly analyzed before taking one or the other surgical option into consideration
· primary stabilization as well as reoperations show specific pitfalls which may affect the outcome of any chosen treatment option significantly
· surgeons have to have profound knowledge about how to identify these pitfalls in order to avoid technical and tactical failure
especially in unstable fracture situations and in case of failed primary internal stabilization arthroplastic treatment should be a serious alternative.

References

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How to Cite this article: Tiemann A H H, Gahr R H. How to Avoid local Complications during primary and revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting. Trauma International July-Sep 2015;1(1):21-24.

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Non Union Distal Femur Fracture: Causes and Management Options

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

Non Union Distal Femur Fracture: Causes and Management Options

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

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Non Union Distal Femur Fracture: Causes and Management Options

Author: Puneet Maheshwari[1], Pramod Maheshwari[1]

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References

(Abstract) (Full Text HTML) (Download PDF)

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

Author: Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2].

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Introduction

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