Management of subtrochanteric femur fractures: is open reduction associated with poor outcomes?

Abstract

Purpose The aim of this study was to identify factors associated with the need for open reduction in subtrochanteric femoral fractures and investigate the effect of cerclage wiring compared to open reduction alone, on the development of complications, especially infection and non-union. Methods All consecutive patients with a fracture involving the subtrochanteric region were retrospectively identified, over an 8-year period. Data documented and analysed included patient demographics, fracture characteristics, patient comorbidities, time to fracture union and development of complications. Results A total of 512 patients met the inclusion criteria (523 fractures). Open reduction was performed in 48% (247) of the fractures. Following matching and regression analysis, we identified diaphyseal extension of the fracture to be associated with an open reduction (OR: 2.30; 95% CI 1.45–3.65; p < 0.001). Open reduction was also associated with an increased risk of superficial infection (OR: 7.88; 95% CI 1.63–38.16; p = 0.010), transfusion within 48 h following surgery (OR: 2.44; 95% CI 1.96–4.87; p < 0.001) and a prolonged surgical time (OR: 3.09; 95% CI 1.96–4.87; p < 0.001). The risk of non-union, deep infection and overall mortality was not increased with open reduction. The use of cerclage wires [50 out of 201 fractures (24.9%) treated with an open reduction] to achieve anatomical reduction as compared to open reduction alone significantly reduced the risk of non-union (OR: 0.20; 95% CI 0.06–0.74; p = 0.015). Conclusion Open reduction of subtrochanteric fractures is not associated with an increased risk of deep infection and non-union, even though it is associated with an increased risk of superficial infection, prolonged surgical time and transfusion. The use of cerclage wire is associated with reduced risk of non-union with little evidence of an increase in complications. Level of evidence III.

Sterile Inflammatory Response and Surgery-Related Trauma in Elderly Patients with Subtrochanteric Fractures

“…In the present study, days to surgery (p = 0.048), duration of surgery (p < 0.0001), and LOHS (p = 0.004) were all surgical measurements that were positively associated with the aggression sustained by the organism during the reduction technique of the STFs. An indirect estimation of higher blood loss could be made between the two groups due to the significant hemoglobin level drop postoperatively (p = 0.004) that necessitated transfusions, which is in concordance with results presented by Panteli et al [41].…”

“…A set of limitations can be highlighted from this study. Firstly, it is not clear if the proposed markers can distinguish sterile inflammation/SIRS from sepsis using their cut-off values, as open reduction of STFs has been linked with a higher probability of superficial infection and tough deep infection, and non-union rates remain controversial [41]. Furthermore, while these parameters can quantify the sterile inflammatory response to surgical trauma, this study cannot demonstrate the consequences of complications, morbidity, and mortality resulting from an increased sterile inflammatory response.…”

Utilizing the Radiographic Union Score for Hip (RUSH) to Evaluate the Healing of Subtrochanteric Fractures after Intramedullary Fixation

“…Subtrochanteric fractures generally refer to fractures in which the center of the fracture is located 5 cm below the lower edge of the lesser trochanter (14). Fractures in this region primarily affect the cortical bone, with the fracture line extending into the cancellous bone within the trochanteric region.…”

Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results

“…For Type V fractures, it is more challenging to perform a reduction when intertrochanteric fractures fail by the closed method. Some have suggested using open reduction maneuvers to improve the quality of reduction; however, the morbidities associated with this technique, such as increased blood loss, operative time, and nonunion rate due to periosteal damage, remain a major concern [ 5 ]. To achieve adequate reduction and minimize disturbing the periosteal blood supply, multiple minimally invasion-assisted reduction methods and tools, such as ball spike pushers, bone hooks, pointed clamps, and cerclage wires or cables, have been described [ 6 – 8 ].…”