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Chin J Traumatol
Chin J Traumatol
Chinese Journal of Traumatology
1008-1275
1008-1275
Elsevier

S1008-1275(24)00038-5
10.1016/j.cjtee.2024.03.011
Original Article
Intramedullary nailing for irreducible spiral subtrochanteric fractures: A comparison of cerclage and non-cerclage wiring
Guo Yan-Hui a
Song Zhan-Lin a
Zheng Hua-Yong b
Gao Jie b
Lin Yi-Yun b
Liu Zhi a
Li Lian-Hua 15901170726@163.com
b⁎
a Department of Orthopedics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, 100048, China
b Department of Orthopedics, The Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, 100048, China
⁎ Corresponding author. 15901170726@163.com
01 4 2024
9 2024
01 4 2024
27 5 305310
14 6 2023
9 1 2024
27 2 2024
© 2024 Production and hosting by Elsevier B.V. on behalf of Chinese Medical Association.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages. However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment. This study is performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures.

Methods

Patients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed. The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group. The patients' clinical data, including the operative time, intraoperative blood loss, hospital stay, reoperation rate, fracture union time, and Harris hip score, were compared between these 2 groups. Categorical variables were compared using Chi-square or Fisher's exact test. Continuous variables with normal distribution were presented as mean ± standard deviation and analyzed with Student's t-test. Non-normally distributed variables were expressed as median (Q1, Q3) and assessed using the Mann-Whitney test. A p < 0.05 was considered significant.

Results

In total, 69 patients were included in the study (35 patients in the non-cerclage group and 34 patients in the cerclage group). The baseline data of the 2 groups were comparable. There were no significant difference in the length of hospital stay (z = -0.391, p = 0.696), operative time (z = -1.289, p = 0.197), or intraoperative blood loss (z = -1.321, p = 0.186). However, compared with non-cerclage group, the fracture union time was shorter (z = -5.587, p < 0.001), the rate of nonunion was lower (χ2 = 6.030, p = 0.03), the anatomical reduction rate was higher (χ2 = 5.449, p = 0.03), and the Harris hip score was higher (z = -2.99, p = 0.003) in the cerclage group, all with statistically significant differences.

Conclusions

Intramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures. This technique can improve the reduction effect, increase the stability of fracture fixation, shorten the fracture union time, reduce the occurrence of nonunion, and contribute to the recovery of hip joint function.

Keywords

Hip fracture
Subtrochanteric fracture
Intramedullary nail
Cerclage wiring
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pmc1 Introduction

Subtrochanteric fractures occur within 5 cm distal to the lesser trochanter and account for about 5% of all femoral fractures. The occurrence of subtrochanteric fractures shows 2 peak distributions: high-energy trauma in young patients and low-energy fragility fractures in advanced-age patients.1,2 Compared to femoral fractures, subtrochanteric fractures are associated with more postoperative complications, including varus deformity of the hip, delayed union or nonunion of the fracture, internal fixation failure, and lower limb shortening, with an overall incidence ranging from 7% to 20%.3, 4, 5 The anatomical region below the femur has mechanical and biological characteristics that result in this area having the highest concentration of compression and tensile stress of the lower limb. The characteristics of poor blood supply, great muscle strength, and thick bone cortex in this region increase the difficulty of intraoperative reduction and hinder postoperative fracture healing. Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages.6 However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing. This study is performed to compare the clinical efficacy of intramedullary nailing with cerclage wiring and non-cerclage wiring in the treatment of irreducible subtrochanteric fractures.

2 Methods

2.1 General information

This case-control study involved 69 patients with subtrochanteric fractures who were admitted to the orthopedics department of our center from January 2013 to December 2021. General information of patients was obtained from medical records. The inclusion criteria were spiral subtrochanteric fractures in adults aged ≥ 18 years; inability to reduce the fracture by closed methods thus necessitating open reduction; performance of intramedullary nailing; and complete follow-up data. The enrolled patients were divided into the non-cerclage group and the cerclage group.

2.2 Surgical techniques

The patients underwent general or spinal anesthesia and were placed on a traction orthopedic table. The surgery was completed under C-arm fluoroscopy in the anteroposterior and lateral views. Closed reduction was performed while both lower extremities were retracted and the affected limb was appropriately internally rotated so that the patella was facing directly anterior. The hip and knee joints on the healthy side were flexed and abducted to facilitate intraoperative fluoroscopy. For patients who underwent unsuccessful closed reduction, a lateral femoral incision was used for auxiliary reduction, and tools were used for temporary fixation (Fig. 1). In the non-cerclage group, intramedullary nail implantation was performed after satisfactory reduction (Fig. 2). The entry point was located slightly medial to the apex of the greater trochanter, and a long intramedullary nail (Trigen InterTan, Smith & Nephew, UK; or Union Gamma Intramedullary Nail, Waston, China) was selected. In the cerclage group, the cable (Cable System, Synthes GmbH, Switzerland) was introduced through the auxiliary incision using a cable threader and then pre-tightened to temporarily fix the fracture end (Fig. 3). If the cable blocked the placement of the intramedullary nail screw, the cable was moved slightly distally and proximally to make way for screw placement. The cable was locked after implantation of the intramedullary nail. The patients performed postoperative functional exercises under the guidance of a rehabilitation specialist.Fig. 1 Intraoperative fracture reduction and temporary fixation.

Fig. 1

Fig. 2 A 73-year-old man with an irreducible subtrochanteric fracture treated with intramedullary nailing with non-cerclage wiring. (A) AP view of the both hips before surgery. (B) CT 3-dimensional reconstruction of the right hip before surgery. (C) AP view of the right femur after surgery. (D) Lateral view of the left femur after surgery. (E) AP view of the both hips at the 8-month follow-up visit. (F) Lateral view of the right femur at the 8-month follow-up visit.

AP: anteriorposterior.

Fig. 2

Fig. 3 A 58-year-old man with an irreducible subtrochanteric fracture treated with intramedullary nailing with cerclage wiring. (A) AP view of the left femur before surgery. (B) Lateral view of the left femur before surgery. (C) CT 3-dimensional reconstruction of the left hip before surgery. (D) CT 3-dimensional reconstruction of the left hip before surgery. (E) AP view of the both hips after surgery. (F) AP view of the left femur after surgery. (G) Lateral view of the left femur after surgery. (H) AP view of the left femur at the 6-month follow-up visit. (I) Lateral view of the left femur at the 6-month follow-up visit.

AP: anteriorposterior.

Fig. 3

2.3 Follow-up and evaluation

All patients will be followed up at least 4 times after surgery, including at 4 weeks, 3 months, 6 months, and 1 year, until the fracture heals. The clinical data collected included sex, age, comorbidities, operative time, intraoperative blood loss, hospital stay, rate of anatomical reduction, fracture union time, incidence of nonunion, and Harris hip score. The Harris hip score was recorded to evaluate the functional recovery of the affected limb.

2.4 Statistical analysis

SPSS Statistics Version 23.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. Categorical variables are expressed as rates and were compared with the Chi-square test or Fisher's exact test. Continuous variables with a normal distribution are expressed as mean ± standard deviation and were compared with Student's t-test. Variables with a non-normal distribution are expressed as median (Q1, Q3) and were compared with a non-parametric test (Mann-Whitney test). A p < 0.05 was considered statistically significant.

3 Results

A total of 75 patients met the inclusion criteria, among whom 4 died within 1 year of follow-up and 2 were lost to follow-up. The remaining 69 patients were included in this study. Among all continuous variables, only age conformed to a normal distribution and the other factors showed a skewed distribution.

The 69 patients comprised 41 (59.4%) men and 28 (40.6%) women. The mean age of patients was (55.89 ± 18.05) years (ranged from 19 to 90 years), and their length of hospital stay was 13 (11, 17) days (ranged from 7 to 89 days). A total of 34 patients had high-energy injuries and 35 had low-energy injuries. Nineteen patients had hypertension, 13 had pulmonary infection, 10 had diabetes mellitus, and 12 had coronary heart disease. The follow-up time was 12 – 18 months, with an average of 14.8 months.

There were 35 patients in the non-cerclage group (18 men and 17 women) with 19 low-energy injuries and 16 high-energy injuries. Comorbidities included cerebral infarction in 5 patients, pulmonary infection in 7, hypertension in 13, diabetes mellitus in 6, and coronary heart disease in 7. There were 34 patients in the cerclage group (23 men and 11 women) with 16 low-energy injuries and 18 high-energy injuries. Comorbidities included cerebral infarction in 1 patient, pulmonary infection in 6, cardiac disease in 5, hypertension in 6, and diabetes in 4. There were no significant differences in age, sex, injury type, or preoperative comorbidities (Table 1).Table 1 Patient demographic.

Table 1Variables	Non-cerclage (n = 35)	Cerclage (n = 34)	p value	
Age, mean ± SD	53.66 ± 19.27	58.21 ± 16.66	0.299	
Female, n (%)	17 (48.6)	11 (32.4)	0.222	
Injury type, n (%)			0.633	
 High-energy	16 (45.7)	18 (52.9)		
 Low-energy	19 (54.3)	16 (47.1)		
Seinsheimer classification, n (%)			0.850	
 II	9 (25.7)	8 (23.5)		
 III	14 (40.0)	11 (32.4)		
 IV	2 (5.7)	2 (5.9)		
 V	10 (28.6)	13 (38.2)		
Comorbidities, n (%)	
 Hypertension	13 (37.1)	6 (17.6)	0.106	
 Pulmonary infection	7 (20.0)	6 (17.6)	1.000	
 Diabetes mellitus	6 (17.1)	4 (11.8)	0.734	
 Coronary disease	7 (20.0)	5 (14.7)	0.752	
 Cerebral infarction	5 (14.3)	1 (2.9)	0.198	
SD: standard deviation.

The length of hospital stay and operation time was 13 (11, 17) days (ranged from 7 to 89 days) and 180 (135, 240) min (ranged from 60 to 375 min), respectively, with no significant difference between the 2 groups (z = -0.391, p = 0.696), (z = -1.289, p = 0.197) indicating that cable cerclage did not increase the length of hospital stay and operative time. The intraoperative blood loss of patients was 300 (200, 500) mL (ranged from 100 to 1500 mL) with no significant difference between the 2 groups (z = -1.321, p = 0.186), indicating that cable cerclage did not significantly increase the amount of bleeding (Table 2).Table 2 Outcomes of surgery.

Table 2Variables	Non-cerclage (n = 35)	Cerclage (n = 34)	p value	
Operation time (min)	180 (120, 210)	180 (150, 248)	0.197	
Blood loss volume (mL)	300 (200, 400)	300 (200, 600)	0.186	
Length of hospital stay (day)	14 (11, 17)	13.0 (10.8, 16.3)	0.696	
Anatomical reduction, n (%)	24 (68.6)	31 (91.2)	0.034	
Fracture union time (month)	9 (8, 10)	5.5 (4.0, 6.0)	< 0.001	
Bone non-union, n (%)	8 (22.9)	1 (2.9)	0.028	
Harris hip score	90 (87, 94)	94.0 (91.5, 96.0)	0.003	
Variables with a non-normal distribution are expressed as median (Q1, Q3).

Eight patients in the non-cerclage group had bone non-union, which healed after additional plate fixation plus bone grafting in all cases. One patient in the cerclage group had bone nonunion and there was significant statistical difference between the 2 groups (χ2 = 6.030, p = 0.028). The fracture union time was 7 (5, 9) months (ranged from 3 to 16 months) of the 2 groups and was significantly shorter in the cerclage than in non-cerclage group (z = -5.587, p < 0.001) (Table 2).

The anatomical reduction rate was 91.2% in the cerclage group and 68.6% in the non-cerclage group, showing a significant statistical difference between the 2 groups (χ2 = 5.449, p = 0.034). The Harris hip score of the 2 groups ranged from 65 to 100 (93 (89, 95.5)) and was significantly higher in the cerclage group (z = -2.990, p = 0.003) (Table 2).

4 Discussion

Our results suggest that intramedullary nail fixation for irreducible subtrochanteric fractures with cable cerclage significantly shortens the fracture union time, reduces the incidence of bone non-union, reduces the fracture deformity rate, and improves hip function scores without increasing the surgery time, bleeding, or length of hospital stay.

Subtrochanteric fractures are among the most challenging fractures because of the special anatomical location. The lateral wall is subjected to high distraction force and the medial side is subjected to high compressive stress, both of which are very strong and can exceed 5 to 6 times the patient's body weight.4 In addition to these 2 forces, torsional shear force occurs around the hip joint. After a subtrochanteric fracture occurs, the strong contraction force of thick muscles such as the abductor, external rotator, and iliopsoas muscles can lead to varus, external rotation, and flexion deformity of the fracture fragment, and the traction of the adductor muscle can lead to medial displacement of the distal fracture fragment.6 Fracture reduction will be very difficult under such strong muscle traction, readily leading to poor reduction and failure of internal fixation.7

Intramedullary nail fixation is the preferred method for the treatment of subtrochanteric femoral fractures.4,8,9 How to resist deformation force during the operation, reduce anatomically the fracture, and maintain the bone fragments in the optimal position are important considerations for the success of intramedullary nail fixation. Factors such as the level of the fracture line, degrees of fracture comminution and displacement, bone quality, reduction quality, length of the intramedullary nail, and number of distal locking screws will affect the stability and clinical effect of intramedullary nailing for subtrochanteric fractures.3,10 The proximal fracture fragment is difficult to control during the process of reduction. The best way to achieve reduction is to take the proximal fracture fragment as the base point and align the distal fracture fragment to the proximal fracture end. Irreducible subtrochanteric fractures cannot be reduced with closed reduction methods and instead require open reduction. For these refractory fractures, fixing the broken end with cerclage has gradually become an important option.11,12

4.1 Effect of cerclage on fracture reduction

Mingo-Robinet et al.13 performed minimally invasive clamp-assisted reduction and then implanted an intramedullary nail to treat subtrochanteric fractures without cerclage. Among 26 patients, 2 had severe varus deformity and 3 had a limb length difference of 1 cm. Hoskins et al.14 analyzed 45 irreducible subtrochanteric fractures treated with non-cerclage intramedullary nailing and 20 treated with cerclage and found that cerclage significantly improved the quality of reduction and improved the degree of fracture displacement. They recommend cerclage fixation for refractory subtrochanteric fractures. Similarly, in a study of 115 patients treated with intramedullary nails, Fauconnier et al.15 found that 23 patients treated with cerclage had less mean displacement of the lateral wall than patients treated without cerclage (1.3 mm vs. 9.0 mm, p = 0.003). Our study showed a significant difference in the anatomical reduction rate between the 2 groups, and the surgical reduction effect after cable cerclage was significantly better than that after non-cerclage.

4.2 Effect of cerclage on fracture union time

Kang et al.16 applied cerclage fixation in the treatment of irreducible subtrochanteric fractures and found that the fracture union time was 3 – 14 months, mean (4.19 ± 4.04) months. Kim et al.17 reported a mean union time of 19.1 weeks (ranged from 16 to 24 weeks) for intramedullary nailing after wire cerclage for subtrochanteric fractures. A meta-analysis of 14 studies showed that the fracture union time was 1.03 months shorter in the cerclage group than in the non-cerclage group (p < 0.001).18 Our results are consistent with these studies, in which the fracture union time was significantly shorter in the cerclage group than in the non-cerclage group (p < 0.001).

4.3 Effect of cerclage on complications

There is a concern that cerclage fixation will destroy the blood supply and increase the risk of complications such as infection and non-union.13 Kim et al.17 reported no complications in 12 subtrochanteric fractures treated with cerclage and intramedullary nailing, and all patients returned to the state of activity before injury. Fauconnier et al.15 compared infection rates between cerclage and non-cerclage groups and found no significant difference. A meta-analysis also showed no difference in blood loss, infection rate, or non-union rate.18 In our study, there was no significant difference in the operative time, intraoperative blood loss, or hospital stay. The incidence of nonunion was significantly higher in the non-cerclage group than in the cable cerclage group. We considered that this might have occurred because of poor control of the fracture location and poor stability of the fracture end in the non-cerclage group. A study by Panteli et al.12 also demonstrated that the use of anatomical reduction followed by wire cerclage significantly reduced the risk of non-union of subtrochanteric fractures (odds ratio = 0.20, p = 0.015).

4.4 Effect of cerclage on postoperative functional recovery

Kang et al.16 treated 17 irreducible subtrochanteric fractures with wire cerclage and intramedullary nailing. The postoperative Harris hip score was 80.81 ± 9.67 (ranged from 66 to 95). Codesido et al.19 compared the social function score (Jensen index) and quality of life score (EuroQoL 5-Dimension) between using cerclage and non-cerclage after intramedullary nailing for subtrochanteric fractures and found that the social function score and quality of life score were better in the cerclage group. The results of a meta-analysis also showed that the Harris hip score was significantly higher in the cerclage group than in the non-cerclage group (p = 0.002).18 The results of our study are consistent with those of the above studies.

4.5 Limitations

Our study has several limitations. First, the number of patients was relatively small. Second, the follow-up time was relatively short. Third, the study was retrospective with numerous confounding factors. Nonetheless, we believe that our results are sufficient to show that intramedullary nailing with cable cerclage does not significantly increase intraoperative blood loss and postoperative complications in subtrochanteric fractures, especially irreducible fractures, but has some advantages in improving the fracture reduction quality, incidence of nonunion, and functional recovery.

The application of cable cerclage with intramedullary nailing in the treatment of irreducible subtrochanteric fractures can obtain a better reduction effect, increase the stability of the fracture end, shorten the fracture union time, reduce the occurrence of non-union, and facilitate the recovery of hip joint function. It is a safe and reliable surgical method.

Funding

Nil.

Ethical statement

This study was approved by the Research Ethics Committees of the Seventh Medical Center of Chinese PLA General Hospital (No. 2023–12).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Author contributions

The authors confirm that their contributions to the paper are as follows. Lian-Hua Li conceptualized and designed the study. Yan-Hui Guo wrote the original draft. Yan-Hui Guo, Zhan-Lin Song, Jie Gao, Yi-Yun Lin, and Hua-Yong Zheng provided the research materials. Lian-Hua Li performed statistical analysis and interpreted results. Zhi Liu revised the manuscript. All authors read and approved the final manuscript.

Peer review under responsibility of Chinese Medical Association.
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