Subtrochanteric Fracture Treatment: A Retrospective Study of 46 Patients

Objective: To investigate whether or not reconstruction of the medial cortex in subtrochanteric fracture can reduce the risks of internal fixation failure, fracture malunion, and nonunion. Subjects and Methods: Between 2005 and 2008, 46 patients with subtrochanteric fracture were treated with intramedullary nailing and followed up. The average age was 42 years. According to the Seinsheimer classification, 26 patients were type IIIA, 7 were type IIIB, 11 were type IV and 2 were type V. Medial cortex alignment was achieved under traction in 40 cases. In 5 cases, the medial fractures were too far away and we used minimally invasive open reduction with wire or titanium cable cerclage. In 1 case of type IIIA subtrochanteric fracture, the displaced medial fracture was not reconstructed and was fixed with a long Gamma nail. We reviewed all patients’ radiographs before and after treatment to evaluate bone healing. Results: The 46 patients were followed up for an average of 24.3 months. Bone union was achieved within an average of 18.7 weeks in 45 cases. One case, a type IIIA fracture nonunion with displaced medial fracture, was not reconstructed. Instead, we used a free fibular transplantation on the medial side and fracture union was achieved 6 months after revision surgery. Conclusions: Received: June 1, 2010 Accepted: March 21, 2011 Wang Qiugen Department of Orthopaedic Surgery The First People’s Hospital of Shanghai Jiaotong University No. 85 Wujin Road, Shanghai, 200080 (China) Tel. +86 21 6324 0090, E-Mail wangqiugen @ 126.com © 2011 S. Karger AG, Basel 1011–7571/11/0206–0519$38.00/0 Accessible online at: www.karger.com/mpp Li/Sang/Wang/Huang/Lu Med Princ Pract 2011;20:519–524 520 Restoring continuity and integrity of the medial cortex has not received great attention in the treatment of subtrochanteric fractures. We retrospectively analyzed 46 cases between 2005 and 2008 to discuss the clinical significance of restoration of the medial cortex in the treatment of subtrochanteric fractures. Subjects and Methods We retrospectively analyzed 46 cases of subtrochanteric fracture treated between 2005 and 2008. The fractures were found among 30 males and 16 females; their average age was 42 years. Of the 46 cases, 31 involved car accidents, 12 involved falls from high buildings, and 3 involved walking falls. According to the Seinsheimer classification [9] , 26 cases were type IIIA, 7 were type IIIB, 11 were type IV, and 2 were type V. Four cases also involved ipsilateral tibia fractures, and 3 cases involved ipsilateral femoral shaft fractures. Two cases of Gustilo type IIIA subtrochanteric fracture were treated with debridement and external fixation in the emergency department, followed by intramedullary nailing 10 days later. All other cases were treated with intramedullary nailing at the first stage without bone grafting. We used proximal femoral nails in 25 cases, Gamma nails in 7 cases, and Trigen nails in 14 cases. Apparent medial cortex displacement was found in 6 cases. We used a minimally invasive open reduction with wire or titanium cable cerclage, except in 1 case. Skin traction or femoral condyle bone traction was routinely done when patients were admitted to the hospital. Surgery was performed within 3 days, except for open fractures. General anaesthesia and a traction bed were used in operations. Closed reductions were attempted using clamps, bone hooks, and a spiked pusher. Then we sought to observe and estimate the reduction with a fluoroscopic image, especially of the medial cortex. If the medial cortex was comminuted (39 cases in this series), we did not open the fracture site and fixed it with intramedullary nailing using a closed method. If the medial fracture was not comminuted and apparently displaced, we used a minimally invasive open reduction and wire or titanium cable cerclage. We believe it is important to avoid excessive soft tissue stripping and to maintain the continuity of the subtrochanteric medial cortex.