Scholarly article on topic 'Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures'

Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures Academic research paper on "Clinical medicine"

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{"Femoral fractures" / "Bone plates" / "Fracture fixation"}

Abstract of research paper on Clinical medicine, author of scientific article — Paritosh Gogna, Reetadyuti Mukhopadhyay, Amanpreet Singh, Ashish Devgan, Sahil Arora, et al.

Abstract Purpose Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise placement under image intensifier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image intensifiers is not available. Keeping this in mind we designed this study to identify if contralateral reversed distal femoral locking plate can be used successfully without the use of image intensifier. Methods Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range 19–47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal fixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean follow-up period of 3.2 years (range 2–4.6 years) using the Harris hip score. Results Twenty-one fractures united with the primary procedure, with a mean time of consolidation being 11 weeks (range, 9–16 weeks). One patient developed superficial suture line infection, which resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate. Repeat surgery with reversed distal femoral locking compression plate was performed along with bone grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting. The mean Harris hip score at the time of final follow-up was 90.63 (range 82–97). Conclusion The reversed contralateral distal femoral plate is a biomechanically sound implant, which when used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows results comparable to those achieved by using other extramedullary implants as well as intramedullary devices. The added advantage of this implant is its usability in the absence of an image intensifier.

Academic research paper on topic "Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures"

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ELSEVIER journal homepage: http://www.elsevier.com/locate/CJTEE

Original article

Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures

Paritosh Gogna, Reetadyuti Mukhopadhyay*, Amanpreet Singh, Ashish Devgan, Sahil Arora, Amit Batra, Sushil Kumar Yadav

Department of Orthopaedics and Rehabilitation, Pt BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

ARTICLE INFO ABSTRACT

Purpose: Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise placement under image intensifier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image intensifiers is not available. Keeping this in mind we designed this study to identify if contralateral reversed distal femoral locking plate can be used successfully without the use of image intensifier. Methods: Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range 19—47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal fixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean follow-up period of 3.2 years (range 2—4.6 years) using the Harris hip score.

Results: Twenty-one fractures united with the primary procedure, with a mean time of consolidation being 11 weeks (range, 9—16 weeks). One patient developed superficial suture line infection, which resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate. Repeat surgery with reversed distal femoral locking compression plate was performed along with bone grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting. The mean Harris hip score at the time of final follow-up was 90.63 (range 82—97). Conclusion: The reversed contralateral distal femoral plate is a biomechanically sound implant, which when used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows results comparable to those achieved by using other extramedullary implants as well as intramedullary devices. The added advantage of this implant is its usability in the absence of an image intensifier.

© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents lists available at ScienceDirect

Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Article history:

Received 15 December 2014

Received in revised form

12 March 2015

Accepted 24 March 2015

Available online 14 November 2015

Keywords: Femoral fractures Bone plates Fracture fixation

1. Introduction

The Subtrochanteric region of the femur is a high stress zone making treatment of fractures in this area a challenging job.1 High energy trauma is the major culprit causing subtrochanteric fractures in young adults. The fixation demands an implant that provides a suitable environment for fracture healing, in addition to providing stability.2,3 The tug of war between intramedullary and

* Corresponding author. Tel.: +91 9818875814. E-mail addresses: reetya_m@hotmail.com, reetadyutim@gmail.com (R. Mukhopadhyay).

Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.

extramedullary devices seem never ending. Although the intra-medullary fixation seems to be the current treatment of choice, it is not without pitfalls.4 It does provide a good bending stiffness, however the torsional control that it provides is poor; thus not an ideal implant for the spiral fractures that are often seen in this region.5 Patients with an intramedullary device also complain of significant insertion site pain. They also have abductor weakness and impingement to a certain extent.6 The endosteal blood supply is also hampered to a great extent.7 The use of an intramedullary device is further challenged by a fracture extending to the inter-trochanteric region. In addition, intramedullary fixation is a more tasking surgery, demanding greater amount of skill as compared to extra-medullary stabilization.8

Various extramedullary devices have also been developed and used over time for fixing subtrochanteric fractures. The angled

http://dx.doi.org/10.1016/j.cjtee.2015.n.002

1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Table 1

Clinical details of patients.

Case Sex Age Classification Follow-up(year) Full weight bearing(week) Harris hip score Complication Secondary procedure

1 M 19 A1 2 12 91

2 M 33 B2 2.1 13 95

3 F 28 B3 2.2 11 89

4 M 45 C1 2.4 16 94

5 M 24 B2 2.4 91 Nonunion Grafting at 1 year

6 M 25 A3 2.5 90 Nonunion Grafting at 1 year 3 months

7 M 27 C1 2.6 12 86

8 F 35 B3 2.7 16 97

9 M 24 A1 2.7 12 93

10 M 26 A3 2.8 15 92

11 M 33 B3 3 14 93

12 F 20 B1 3.2 9 90

13 M 27 B2 3.2 95 Implant breakage Refixation along with grafting

14 M 29 C1 3.4 10 94 Superficial infection

15 M 26 B3 3.4 9 97

16 F 19 B1 3.7 10 90

17 M 20 B3 3.8 12 83

18 F 21 A3 3.8 14 92

19 M 27 B3 3.9 13 89

20 M 27 C2 3.9 9 82

21 M 42 A3 4 10 84

22 F 24 B3 4.3 11 86

23 M 47 A3 4.4 12 88

24 M 23 C2 4.6 12 94 1 cm shortening

Mean 28 12 90.625

blade plate and the dynamic condylar screw being the ones that have been most widely used in this area.3 These extramedullary devices when used through a minimally invasive technique, put in the submuscular zone; preserve both the periosteal and endosteal blood supply in addition to providing stability and an environment apt for fracture healing.9 We intend to present a reversed contralateral distal femoral locking compression plate (DFLCP) as an biomechanically sound alternative extramedullary devise for

fixation of subtrochanteric fractures in adults at centers where an image intensifier is not available at the facility.

2. Material and methods

We treated 24 consecutive patients (18 men and 6 women), with subtrochanteric fractures of the femur at our center using reversed DFLCP. The mean age of the patients was 28 years (range 19—47

Fig. 1. (a) Preoperative radiographs of a 24 years old male with type A1 subtrochanteric fracture of the femur. (b) Postoperative radiographs of the same patient. (c) Radiographs at final follow-up showing consolidation of the fracture.

years) and the mean follow-up period was 3.2 years (range 2—4.6 years, Table 1). Exclusion criteria were patients with open injuries, pathological fractures, ipsilateral distal femoral fractures, ipsilateral neck or inter-trochanteric fractures and associated pelvic injury. All patients were put on skeletal traction till surgery. The mean time between presentation and surgery was 1.2 days (range 0—3 days). According to AO classification, 6 fractures were type A (two A1, and four A3), 12 were type B (two B1, three B2, and seven B3), and five were type C (three C1 and two C2). All fractures were open reduced, with care to minimally damage the soft tissue cover. Skin incision was made beginning at the greater trochanter and extending along the shaft. Fascia was incised along the skin incision. The fracture was exposed and reduced under vision, and a plate of appropriate length was placed with its proximal end at the trochanteric ridge. Post fixation alignment was acceptable as the cases were reduced under direct vision taking care about the length and rotation. We did not denude the bone; only the fracture site was exposed to attain direct anatomical reduction. Being a locking plate, it did not require any periosteal stripping. For the purpose of fixation in the proximal femur, the target was to drive long screws up to the femoral calcar in two rows of locking screws through the proximal expanded part of the locking plate and 6—8 cortices purchased in the distal fracture fragment. In 14 patients, in view of the spiral configuration of the fracture, it was fixed with inter-fragmentary screws and neutralized with a plate. After fixation, we moved the

hip joint through the complete range of motion and checked the stability. All wounds were closed over drain, which was removed 24 h after surgery. Physiotherapy in the form of static quadriceps exercises, ankle pump and active toe movements were encouraged immediately after operation. Supervised physiotherapy in the form of knee bending and nonweight-bearing walking was initiated as soon as the pain subsided, usually on the third postoperative day. Patients were reviewed at 2 weeks for suture removal, thereafter fortnightly for 2 months, and then at monthly interval for 6 months for clinic-radiological evaluation and complications if any; thereafter, clinical assessment was made at 6 monthly intervals. Functional outcome was assessed using the Harris hip score. Union was defined as bridging of three of the four cortices and disappearance of fracture line on the plain radiographs for a patient who was able to bear full weight. Nonunion was defined as a fracture that did not heal within 9 months.

3. Results

We were able to attain a union rate of 87.5% with the primary procedure (Figs. 1—3), with a mean time to full weight bearing being 12 weeks (range 9—16 weeks). The average operative time was 45 min with just one incidence of postoperative infection. There was a single case of limb length discrepancy of 1 cm, which was well compensated by the patient. One patient had superficial

Fig. 2. (a) Preoperative radiographs of a 27 years old male with type C1 subtrochanteric fracture of the femur. (b) Fracture was reduced and fixed using Lag screws, and reverse DFLCP was applied as a neutralization plate.

suture line infection, which resolved with a ten-day course of an oral antibiotic. We did not observe any implant back out though one patient presented with a broken plate due to domestic fall three weeks after surgery. Repeat surgery with reversed DFLCP was performed along with bone grafting and the fracture united. In the rest of the 2 cases, bone grafting of the fracture site was performed with cortico-cancellous graft harvested from ipsilateral iliac crest at 1 year and 1 year 3 months respectively, which resulted in union. The functional outcome of the patients was evaluated as per Harris hip score. The mean Harris hip score at one-year follow-up was 90.63 (range 82-97).

4. Discussion

The DFLCP has long been used in distal fractures of the femur with good long-term results.10 It is a biomechanically sound implant to be used in the subtrochanteric region as well. The shape of a reversed contralateral distal femoral plate fits well with the contour of the greater trochanter and the shaft of the plate fits well with the anterolateral curve of the femur. The use of locking screws further leaves a gap between the bone and the implant thus preserving the periosteal bold supply of the bone.3 The placement of the proximal end of the plate at the trochanteric ridge ensures at least one row of screws in the femoral calcar. Also, it was observed even if the most proximal screw went into the neck. It, being of a locking nature ensured sufficient hold. We achieved a union rate of 87.5% in our study group further confirming the bio-mechanically sound principle of this technique. Our union rate was comparable to that achieved by Siebenrock et al.11

Pakuts12 compared intramedullary devices with extramedullary implants for fixation of unstable intertrochanteric fractures. He observed that the mean time to union was 10 weeks when he used an intramedullary device (Gamma nail) as against 15 weeks in the group of patients treated with dynamic condylar screw. They concluded that extramedulary devices result in early ambulation; however we were able to achieve union in a mean time period of 11

weeks, which is comparable to the Gamma Nail group in their series. Use of locking plate as an internal fixator reduces the plate contact area thus preserving the vascularity and enhances healing; the chances of osteoporosis at the plate bone interface is also reduced.13 Thus, using an extra-medullary implant with minimal soft tissue stripping we can achieve a quick callus formation and good union rate thus allowing our patients an early rehabilitation and weight bearing comparable to that by an intramedullary fixation.14

Of the various extramedullary devices available for fixation of a fracture in this region, the angled blade plate and the dynamic condylar screw are the ones most widely used.3 Although the angled blade achieves good results particularly in comminuted fractures, its use is technically demanding requiring a tri-planar orientation.15 The use of the dynamic condylar screw also requires significant level of skill and an image intensifier.7

Rohilla et al16 using a mini incision technique of dynamic condylar screw fixation achieved results comparable to ours. They showed union at a mean interval of 16 weeks post surgery with full weight bearing at a mean of 11 weeks post surgery. Although Rantanen et al17 reported higher complication rates with the use of intra-medullary devices and higher rates of refracture and fixation failure put against extramedullary devices, intramedullary devices seem to be the implant of choice at most centers for sub-trochanteric fracture fixation today, with reports suggesting better postoperative restoration of walking ability. The recovery after intramedullary nailing may be faster and better with less complication because of its biomechanical benefit with central buttress and a shortened lever arm.18

The use of the reversed contralateral distal femoral plate is however a good option by surgeons working at centers without access to an image intensifier; with results comparable to that achieved by other modes of fixation, be it intramedullary or extramedullary. Ouyang et al19 using the reverse less invasive stabilization system plates showed complete union in all his 26 elderly patients with subtrochanteric femur fractures. He also observed

that his results were comparable to those attained by intra-medullary fixation. Gogna et al20 have used proximal humerus locking plate for fixation of paediatric subtrochanteric fractures and attained a 100% union rate at a mean of 8.75 weeks (range 6—14 weeks) thus, supporting the fact that locking periarticular plates are a viable option for fixation of subtrochanteric fractures.

Using this method, one needs to reduce the fracture under vision, ensuring that the distal expanded part of the plate falls just short of the trochanteric tip, as the target is no longer to insert a hip screw, visualization with an image intensifier in not required. The reason why we chose DFLCP rather than any other plates in our series is that it is readily available and familiar, provides multiple options for screw fixation in the proximal part of the fracture, it adheres closely to the anatomy of the proximal femur and the implant is cheaper compared with the LISS. With contralateral reversed DFLCP, the surgeon is able to insert at least two rows of long screws up to the femoral calcar providing enough stability. The initial mid-term result of our series is quite encouraging.

Our study has its own set of limitations. It is a small series with different configurations of subtrochanteric fractures. The follow-up period is short and there is lack of a control group. However, the strength of the study is that it is a single institutional study with cases treated by the same team of surgeons. The findings of our study show that reversed contralateral DFLCP, when used for fixation of the subtrochanteric fractures shows results comparable to those achieved by using other extra-medullary implants as well as intramedullary devices. The added advantages of this implant are its familiarity by the surgeons and usability in the absence of an image intensifier.

References

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hierarchical nonlinear hyperelastic finite element analysis. Biomed Eng Online. 2012;11:23.

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