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Non Union Distal Femur Fracture: Causes and Management Options

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. Pramod Maheshwari

Dr. Puneet Maheshwari

Dr. Puneet Maheshwari

 


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Complications Related to Intertrochanteric fractures

Vol 1 | Issue 1 | July – Sep 2015 | page: 25-30 | Vaibhav Bagaria[1], Farokh Wadia[2]


Author: Vaibhav Bagaria[1], Farokh Wadia[2].

[1] Department of Orthopedics, Sir HN Reliance Foundation Hospital,
Mumbai, India.

Address of Correspondence
Dr Vaibhav Bagaria
Department of Orthopedics, Sir HN Reliance Foundation Hospital, Mumbai, India.
Email: bagariavaibhav@gmail.com


Abstract

Intrertrochanteric fractures are not very prone for complications, however when complications do occur they are quite disabling and challenging. Major complications can be avoided by understanding the personality of the fracture and by choosing correct implant. Complications can be listed as implant cut out, non union, implant failure, peri implant fracture and general medical complications. In this review we present the current evidence related to complications of Intertrochanteric fracture and also certain guidelines to avoid these complications
Keywords: Intertrochanteric fractures, complications, failure


Introduction

Inter trochanteric fractures and their complications are some of the commonest conditions seen by an orthopedic surgeon in their clinical practice. While some of these complications are avoidable and by optimization of technique and resources the outcomes can be improved, there are others which are unavoidable in a given circumstances. Since these fractures typically occur in geriatric group and the patient is often frail and having comorbidities, complications in this groups leads to loss of functional independence, prolonged hospital stay with tremendous costs to the patients, family and the society. The outcome after Inter trochanteric fracture especially in the elderly is dependent on several factors and the best way to manage complications is to preempt them. The paradigm is shifting for intertrochanteric fractures globally. The older paradigm, in the 20th century, of quick surgery and just getting the fracture to heal is no longer acceptable for most patients who are expected to have an independent ambulatory capacity and dignified quality of life

A thorough understanding of the possible complications and why they happen is cornerstone of attempts in reducing them. This chapter focuses on how these complications can be classified, evaluated, prevented and managed in cases where in these happen. There are several ways in which these complications can be classified. One of the ways is to associate them with their cause and by doing this, one can help prevent them and formulate a strategy where in the cause and management is protocolized. The complications can be Fracture related; Related to choice of the implant; Routine operative and general complications.

Materials and Methods:
AFracture pattern Related:
Stable Inter trochanteric fractures do well with any kind of fixation. On the other hand the unstable patterns. Complication rates such as screw cut outs have been reported to be as high as 50% in cases of unstable IT fractures ( 1) There have been some recent insights with regard to fracture pattern which have drastically improved our understanding of intertrochanteric fractures. The following concepts are discussed:
Fracture classification
Lateral wall fractures
Rotational instability
Fracture reduction

Fracture classification:
Previously used classification system of Boyd & Griffiths had poor inter and intra-observer reliability and were used commonly to describe fracture patterns rather than predict outcomes. Evans classification subsequently advanced our understanding about stable and unstable fracture patterns. But the most commonly used classification currently is the AO/OTA classification, which classifies IT fractures into three types: 31A1, 31 A2 and 31A3 with increasing instability as the grade increases. However, more important would be to classify them into two categories: 31A1.1 to 31A2.1 and 31A2.2 to 31 A3.3. The reason for this distinction as highlighted by Palm et al and Gotfried et al, is the quality of the greater trochanter and potential for a lateral wall fracture while inserting the sliding screw leading to a potentially unstable situation post-operatively.Fig 1

Lateral wall fractures:
Lateral wall is defined as part of the femoral cortex distal to the vastus ridge. Several studies have found that an inter-trochanteric fracture with extension into the lateral wall either existing or produced during insertion of screw plate device, leads to an unstable situation that cannot be salvaged with a sliding compression screw plate device. The latter are often labeled as iatrogenic lateral wall fractures (ILWF).
The support from lateral femoral wall is the key to success in sliding screw plate device to allow controlled compression and collapse at the fracture site. When the lateral femoral wall is fractured, the fracture line is parallel to the sliding vector of the sliding hip screw, which, as in the reverse oblique intertrochanteric fracture, allows the trochanteric and femoral head and neck fragments to slide laterally and the shaft to slide medially. The fracture complex subsequently disintegrates, with a high risk of failure. Palm et al in their series of 214 patients, found that a lateral wall fracture increases the risk of re-operation about 8 times, due to technical failure when a sliding hip screw was used. The bottom line is if there is a lateral wall or a greater trochanter fracture, sliding hip screw device should not be used.Fig 2

Rotational stability:
Until recent times, rotational stability of femoral head has been more or less neglected. With sliding compression screw devices, with single screw in the femoral head, the femoral head has been shown to be rotationally unstable especially with collapse and erosion of the neck with eventual cut out of the implant. To overcome this issue, many of the recent implants have added an extra screw incorporated within the plate design such as the PCP or the hybrid proximal femoral plate as well as the Inter TAN (Trochanteric antegrade nail) nailing system.

Fracture reduction:
Conventional teaching suggests that intertrochanteric fractures are reduced in internal rotation on fracture table. However, studies by Bannister et al and May et al show that up to 23% of intertrochanteric fractures reduce in external rotation. Excessive internal rotation can cause fracture gapping posteriorly which adds to destabilizing the fracture which already has postero-medial comminution.
Another common error is to accept less than optimal reduction. The most common malreduction is a posteriorly sagging femur shaft with an anterior step off at the fracture site. This may not be reduced by closed means and Carr et al [2] have described an open reduction maneuver where the shaft is first pulled laterally with a bone hook around the shaft to disimpact the fracture and then using a lever to push the head and neck fragment posteriorly to align with the shaft. This simple reduction maneuver is important to achieve anteromedial stability so as to allow immediate mobilization without putting excessive load on the implant.Fig 3

Implant Choice and complications: Three chief categories of implant used for these fractures are sliding/ dynamic hip screw, Intramedullary nails and endo prosthesis.
Dynamic Hip Screw & Medoff Plate: Cochrane review by Parker et al ( 3) have demonstrated the superiority of sliding hips screw in the management of the extra capsular neck fractures. In the review the studies included twenty-two trials (3749 participants) that compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with increased risk of operative and later fracture of the femur and increased reoperation rate. There were no major differences between implants in wound infection, mortality or medical complications. Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group. Results for post-operative complications, mortality and functional outcomes were similar in both groups. Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) versus the SHS.
Intramedullary femoral nails: There has been an increase in the use of these devices in last decades up from 3% to 67% as observed by Anglen et al in their study (4).
They have a distinct advantage over DHS when it comes to unstable inter trochanteric fractures. They however do have a complication set of their own which includes iatrogenic femoral fractures; difficult initial reduction and persistent thigh pain due to stress concentration around nail tip, varus angulation and secondary risk of femoral fractures. The classical indication for nailing is in managing the unstable patterns that include reverse obliquity fractures, transtrochanteric fractures, fractures with a large posteromedial fragment implying loss of the calcar buttress, and fractures with subtrochanteric extension. The reason for favoring nails in tis cases is based on biomechanical fact that since a nail is located closer to the centre of gravity and force transmission, the lever arm is shorter and there is less stress on the implant. They can thus resist higher forces across the medial calcar than what a sliding hip screw can. Intramedullary placement also prevents shaft medialization, which may commonly happen with unstable fracture patterns.

While there are a variety of devices that can be included in this category, the two commonest devices used are Gamma nail (Stryker) and Proximal Femoral Nail ( AO Synthes). The Gamma Nail was introduced before the PFN, which in comparison to a GN had a longer length, had two proximal screws and had a smaller diameter and could thus be inserted un reamed. The addition of an additional anti rotation screw was thought to decrease the probability of screw cut outs. The study by Schipper et al however did not find any difference in the cut out rates. It was then hypothesized that the so-called ‘knife effect’ counterbalances any advantage that the derotation screw offers in preventing the cutouts. The ‘ knife effect’ or the ‘Z effect’ originally described by Werner et al refers to development of condition following fixation with PFN in which the superior smaller screw migrates medially and the distal larger screw migrates laterally. It is believed that the medial cortex communition and a varus reduction is a contributory factor in this phenomenon (5).

Chief Complications with IM Devices:

1. Fractures of femoral Shaft:
2. Failure of fixation
3. Complication Associated with Distal Locking
The recent Cocharane database review 2014 that compare the various different types of intramedullary nails suggest that there is insufficient data to clearly state whether there are any outcome difference with the use of different types of intramedullary devices. It also states that since there is a clear evidence of superiority of the sliding hip screw over the intramedullary nail in the management of extra capsular fracture, further studies on different designs of these nails should take a back seat and a comparative trial for any new design should be made against the clearly superior sliding hip screw [6].

Primary Endo Prosthesis: A certain section of orthopedic surgeons believe that the primary arthroplasty for these procedures may help in early mobilization and consequently reduce mortality and morbidity associated with prolonged immobilization especially pulmonary atelectasis pressure sores and venous thromboembolism. While this rationale may not be applied to all cases, there is a small set of fracture patterns and patient groups in which the arthroplasty can play a role. In most cases they are usually the salvage procedure after secondary complications of conventional fixations. Hassankhani et al (7) in their study of 80 patients found hemiarthroplasty as a superior alternative with reduced rates of complications and patients in elderly patients who had unstable intertrochanteric fractures.
The key techniques that need to be remembered specifically for these cases are 1. Ensuring that the prosthesis is inserted or sunk to a point on stem that has been marked explicitly before insertion. It is important that the lesser trochanter as the land mark may not be an option in many of these cases. This helps in reducing dislocations and ensuring limb length symmetry.
2. Use of cement in cases of wide medullary canal and appropriate precautions during cementing to be taken.
3. Reconstruction of lesser trochanter with cables after the prosthesis is fixed.
4. Greater Trochanter reconstruction with use of K wires, cannulated screw or using tension band principle.

If done well, the studies by Sancheti et al a has revealed that results are comparable to fracture fixation and the only complication is of bed sore [8].

Major complications following the intertrochanteric fracture fixation surgery are:
A. Implant cut-out
This still remains the commonest cause of failure of the implant-fracture construct. It is an accepted almost dogmatic mandate that the tip apex distance correlates directly with implant cut-out, with higher the TAD, the greater is the risk of cut-out. This applies definitely for the sliding hip screw and has been shown recently to apply for cephalomedullary devices too.

Key technical points in preventing Implant Related complications:

1.Use of Tip Apex distance (TAD)& Parker ratio: Baumgaertner et al [9,10] first described the concept of TAD. This is a useful indicator for an optimal screw placement spatially irrespective of whether a plate or a nail is used. It is considered one of the most important indicators of hardware placement in most studies done on the failure of devices. Conventional thinking propagated a slight posterior and inferior placement of screw based on the philosophy that it gives more area for the screw to cut out. However the studies have shown that this increases the TAD and can be actually detrimental. Based on the concept it is agreed that a screw placed as central and as deep without perforating the head (within 10 mm of subchondral bone) is the ideal placement. Numerically speaking trauma surgeons should aim for the TAD of around 20 mm, generally the cases with TAD less than 25 mm have good outcomes.

Parker Ratio:
This is a mathematical measurement of screw placement within the femoral head and is a ratio of AB to AC multiplied by 100 in both AP and Lateral view. Parker in his original series of 225 patients with screw cutout in 25 found that on the AP view the average ratio was 45 for union and 58 for cut-out and it was 45 for union and 36 for cut-out on the lateral view.

Tip apex distance may not be valid for all types of implants. The proximal femoral nail antirotation (PFNA) is unique with a helical blade proximally that is impacted in the cancellous bone of the femoral head instead of using a standard lag screw. While this allows a better purchase in the femoral head and provides rotational stability, they have also been associated with increased cut out albeit for a different reason. Nikoloski et al [11]found that the tip apex distance of less than 20 mm for these devices was found to be associated with a higher incidence of blade cut out due to penetration of the subchondral bone of the femoral head
2. Assessment of the lateral wall: If there is a lateral wall fracture then the choice of implants becomes crucial. These fractures could either be reverse obliquity inter trochanteric fractures or trochanteric fractures. In these fracture the medialization of the femoral shaft with a lateral migration of proximal fragment occurs. If these occur there is a high chance of mal reduction, non union and screw cut out. Intramedullary devices in these cases are most suitable. Sliding hip screw when used must be either a ‘medoff plate’ or in conjunction with trochanteric stabilization plate or in some cases locking plates.
3.Entry Point: A good entry point for trochanteric nails is slightly medial to the tip of the greater trochanter. This helps prevents varus angulation. It is also important that while reaming the proximal part the reamers are well inside the proximal part past the entry point so as not to enlarge the entry point laterally.
4. Respecting the femoral Bow: One of the commonest complications of intramedullary nail is the iatrogenic fracture created during the nail insertion. It is important to be aware of the femoral bow, to check fluroscopically if the nail is hitting against the anterior cortex and not to hammer the nail especially in the osteoporotic patients.
5. Avoiding Varus Angulation: Any varus angulation increase the lever arm, increasing the stress on the implant predisposing it to failure. A good way to judge this intra operatively is to look at relative positions of tip of the GT and the centre of femoral head. For a good alignment they should be co planar. If the GT tip is higher than the centre of femoral head, it is a varus reduction and vice versa if the tip is higher. In most cases use of 130 degree nail and sliding screw is appropriate but can vary from person to person.
6. Avoiding Fracture distraction: This is especially true with the use of nails in which it is not uncommon to see malrotation and distraction. If the device is fixed in a distracted position, there is insufficient osseous contact and some of the load that would have been normally borne by this contact is entirely borne by the device and places it in vulnerable position prone to fatigue failures. The nail tends to break at its weakest point, which is the largest apertures for the screw in the nail. To avoid distraction, it is important to release traction before locking and also confirming the same on image intensifier.

B. Non Union:
Non-union is very rare after inter-trochanteric fractures and has been reported in 1% of older population. The reasons for non-union are poorly understood as the fracture affects metaphyseal bone with huge cancellous surfaces. The speculated reasons include delayed treatment, unfavorable fracture pattern, poor bone quality, and suboptimal internal fixation. While salvage total hip replacement is the treatment of choice for elderly patients with non-union, the technique is more difficult and often special design implant such as calcar replacement prosthesis, extended neck stem or long stem implant is required. Haidukewych et al [12] described good results in a series of 60 patients with failed intertrochanteric fractures that underwent revision to total hip replacement or bipolar hemiarthroplasty. A total of five reoperations were performed: two patients had a revision, one had a rewiring procedure because of trochanteric avulsion, one had late removal of trochanteric hardware, and one had debridement of fat necrosis. One patient had two dislocations, both of which were treated with closed reduction. They reported a survival rate of 100% at 5 yrs and 89% at 10 years.
In younger patients, revision fracture fixation should be attempted. Dhammi et al [13] have reported a 100% union rate in 18 patients at a mean follow-up of 5.6 months with excision of pseudarthrosis, freshening of bone edges, stable fixation with a 135 degree DHS, valgization and bone grafting. Similarly Vidyadhara et al reported lateral closing wedge osteotomy with DHS fixation that resulted in union, with improvement in Harris hip scores from 34 to 89 in seven patients.

C. Implant Failure
Breakage of cephalomedullary implant is a rare but serious complication and has been reported to have an incidence of 2.9% in a series of 453 patients by Von Ruden et al. [14]In this series, the breakage occurred on an average of 6 months post-operatively. In majority, the cause was delayed or non-union due to insufficient initial reduction of the fracture.

D. Complication Associated with Cement Augmentation: While in the traditional method of fixations the failure in intertrochanteric fractures was commonly secondary to the screw cut out, in the cement-augmented group, this is relatively rare. In a study by Wu et al [15] of the 321 patients who under went Cemented augmented DHS fixation for their inter trochanteric fractures, no patient has a lag screw cut out. Six patients had delayed or non union with side plate failures, with three screw breakages, one plate breakage and one patient had infection and avascular necrosis each. The procedure related complications in this study was around 8.9%

E. Peri-implant fracture

Dorr has classified proximal femur based on morphology into three types:
Type A femur has a small metaphysis, thick cortex and high narrowed isthmus.
Type B femur has a wider metaphysis, thinner cortex and a tapering but wider isthmus
Type C femur has wide metaphysis, thin cortex and straight/varus curvature of diaphysis with wide isthmus.

There is a significantly higher risk of peri-prosthetic fracture in Type C femurs, especially intra-operative perforation with the use of long cephalomedullary device in a varus curvature femur.
Peri-prosthetic fractures are otherwise common around the distal interlocking screw of a cephalomedullary device. Marmor et al [16] in a biomechanical study of eighteen synthetic femora compared stiffness and load to failure of three nail lengths (short, extended short and long) and found that the axial stiffness was significantly higher for short nails compared to long nail design whereas extended short nail exhibited a significantly higher failure load than short nail constructs. All peri-prosthetic fractures occurred around the distal interlocking screw irrespective of nail length.

Intra Operative Complications:
Breakage of the guide wire
Perforation of the femoral head
Convergence of the guide wires
Intraoperative conversion to other method of fixation secondary to propagation of the fracture line,
F. General Operative & Medical Complications: Since majority of these fractures occur in elderly patients who have co morbidities and age related issue, the medical complications in pre and peri operative period is a major concern. It has been reported that there is 20% mortality in perioperative period in the patient who have had unstable fractures.

Venous Thrombo Embolism (VTE): Venous thrombo embolism which includes both deep vein thrombosis and pulmonary embolism is a relatively common occurrence after hip fracture surgery (17). There are various rates of incidence with significant variations depending upon the co morbidities, pre operative risk factors, and even the racial composition. In view of the preventable nature of the disease, routine pharmacologic thromboprophylaxis is recommended by many consensus groups. Although there is still controversy about the role of universal thrombo prophylaxis, there is large body of evidence that unequivocally suggests that the thrombo prophylaxis should be given to patients who were immobile for greater than 72 hours before the surgery, those who had obesity, history of malignancy and in those whom the surgery lasted more than 72 hours (18).

Blood Loss: Since majority of these fracture occur in the geriatric age group, it is very important that the blood loss be monitored and appropriately replinshed after the surgery. In many cases a pre operative transfusion to build up the hemoglobin is also required. Various studies have tried to quantify the amount of surgical blood loss that occur with various techniques. In one of the larger studies by Zhang et al [19] in which they calculated the obvious and hidden blood loss in 216 cases of inter trochanteric fracture treated by PFN and 168 cases treated by DHS, they found that PFN group had a mean loss of 48.9 +/- 2.8 ml during the procedure, an obvious blood loss of 62.3 +/- 3.8 ml and a hidden blood loss of 385 +/- 6.2 ml. In contrast the blood loss intra operatively during DHS fixation was 124.9 +/- 7.8 ml, the obvious blood loss was 73.9 +/- 4.7 ml and the hidden blood loss was 243.4 +/- 6.3 ml.

Osteoporosis associated complications: One of the commonest cause of both the intertrochanteric fracture and also its complication post surgical fixation is the presence of osteoporosis. In a study done by Bonnaire et al (20) the incidence of the screw cut outs have been linked directly to the presence of osteoporosis and decreased bone density at the bone trabeculae.

Compliance: It is very important that appropriate post surgery policy is formulated with regards to rehabilitation, weight bearing and regaining the bone strength.

Associated fractures: While treating intertrochanteric fractures it is also important to rule out any associated injuries. They may be associated with distal radius fracture and vertebral body collapses. Apart from a thorough initial assessment it is also important to take adequate precaution while positioning the patients.

Other Co morbidities: As mentioned previously many Neurovascular Damage: While the incidence of many major neuro vascular problem following the interrochanteric fracture fiation is rare, yet there may be complications related to in appropriate padding and issues with incorrect traction. There have been case reports of profunda femoris artery damage that needed vascular intervention ( Ref)

Wound Infections – Superficial and Deep: As is with any surgery there can be wound infection. This may be related to patient factors and general immunity of the patient, factors related to operating environment and also the duration of the surgery. It is important to distinguish between a superficial and deep infection. While local wound dressing and antibiotics may treat the superficial infection, a deeper infection may require repeated washouts, antibiotic beads and occasionally implant removal.

Hematoma formation: Many of the patients who suffer from this type of fracture are on anti coagulants. In view of the high incidence of the VTE in these surgery, many of these patients are also thromboprophylaxysed, increasing the chances of hematoma formation post operatively. It is thus important to ensure that a meticulous hemostasis is obtained intra operatively and local wound inspection is diligently maintained to pick up any early signs of development of a local hematoma.

Other general complications:
Pneumonia
Anesthesia Related complications:
Bed Sores
Cardiovascular
Genitourinary
Psychiatric

Check list and strategy to avoiding Complication in case of extracapsular neck femur fracture:
While as an orthopedic surgeon, there are several factors that we cannot control like patient co morbidties, the quality of bone, the patient compliance, we can still minimize the complications by following a systematic protocol and following basic principles which include choosing the appropriate fixation device for the fracture pattern, identifying those fracture that are likely to be troublesome, perform accurate reduction and implanting the correct device at the same time being aware of the overall implant cost. The key points in the whole process are:
Thorough Pre operative evaluation
Preoperative Optimization – medical and Surgical
Risk Categorization for VTE and thrombo-prophylaxis
Preoperative Planning – fracture classification and treatment strategy
Inventory planning and Implant ordering
Good initial reduction
Choosing the right Implant
Overcome the intraoperative problems
Soft tissue management & Wound Care
Formulating a rehabilitation strategy
Patient Education and focusing on compliance
Building on the bone mass and preventing further fractures.


References

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How to Cite this article: Bagaria V, Wadia F. Complications Related to Intertrochanteric fractures. Trauma International July-Sep 2015;1(1):25-30

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