Comminuted Subtrochanteric Fractures Research Articles

Comparative biomechanical analysis of reconstruction and cephalomedullary nails in the treatment of osteoporotic subtrochanteric fractures

IntroductionThis study aimed to compare the biomechanical properties of two types of intramedullary nails – reconstruction nails (RCN) and cephalomedullary nails (CMN) – each with different proximal fixations, in a model of an osteoporotic subtrochanteric femoral fracture. This study focused on assessing stiffness and load to failure of RCN and CMN nails to provide insight into their clinical applications in osteoporotic fracture treatments. Materials and MethodsTen synthetic osteoporotic femoral models were used to generate a comminuted subtrochanteric fracture model. Five femurs were fixed using an RCN, and the remaining five were fixed using a CMN. The constructs were subjected to axial compression to measure their structural stiffness, load to failure, and failure modes. ResultsThe CMN group demonstrated a slightly higher load to failure (mean, 2250 N) than the RCN group (mean, 2100 N), which was statistically significant (p = 0.008). However, the stiffness in both groups was statistically similar (RCN, 250 N/mm; CMN, 255 N/mm; p = 0.69). Both groups showed a load to failure exceeding 1500 N, a typically exerted load on the femoral head by a 75 kg individual. The failure patterns differed, with CMN failures starting at the nail insertion area and RCN failures starting at the reconstruction screw area. ConclusionThe RCN offers stiffness comparable to that of the CMN; although its load to failure is slightly lower than that of the CMN, it still exceeds the physiological tolerance limit. These findings suggest that the RCN is a viable alternative for treating osteoporotic subtrochanteric fractures.

BIOLOGICAL PLATING OSTEOSYNTHESIS IN COMMINUTED SUBTROCHANTERIC FRACTURES WITH DYNAMIC HIP SCREW

Background: Comminuted subtrochanteric fractures represent a challenge for trauma surgeons. Fractures in the subtrochanteric region present challenges to achieving stable fixation and appropriate reduction because the subtrochanteric region of the femur is one of the highest stressed zones in the human skeleton where tensile or compressive stresses can exceed several multiples of body weight. Aim: The aim of this study is to observe the results of biological DHS fixation in the management of comminuted subtrochanteric fractures of femur in adults. Method: A prospective study was conducted on a group of 25 patients in the Postgraduate Department of Orthopaedics, Government Medical College, Srinagar. In all the patients along with personal data, mode of trauma, type of fracture, intra-operative & post-operative complications, follow up examination including hip joint examination, duration of full weight bearing was considered. Patients were assessed clinically for pain, hip and knee range of motion, angular and rotational deformities and leg-length discrepancy. Union was assessed radiographically. Results: Majority of the patients had trauma due to RTA (76%), fall from height/stairs/standing position (20%), and direct impact (4%). There were 5 type 3A, 6 type 3B, 8 type 4 and 6 type 5 fractures according to Seinsheimer classification. According to criteria laid by Trauma hip rating scale, excellent results were achieved in 16 patients, good in 8 patients and poor in 1 patient. However, no case of failure was reported. Union occurred in all cases. None of the patients had clinical pain or dysfunction. Conclusion: Biological DHS is an effective and reliable option in the treatment of comminuted subtrochanteric fractures as, DHS allows good fixation of a fracture that extends into piriformis fossa (type 5). This procedure offers the significant advantage of being less technically demanding, simple and familiar to most surgeons and Leads to less blood loss.

Efficacy and safety of proximal femoral anatomical locking compression plate and proximal femoral nail antirotation for long-segment comminuted subtrochanteric fractures of the femur: a non-randomized controlled trial

Background and objective: The proximal femoral anatomical locking compression plate and proximal femoral nail antirotation device are commonly used in the treatment of long-segment comminuted subtrochanteric fractures of the femur. However, few studies have evaluated the difference in efficacy and safety between these two implants. The present study is being performed to compare the efficacy and safety of the proximal femoral anatomical locking compression plate versus proximal femoral nail antirotation in the treatment of long-segment comminuted subtrochanteric fractures of the femur. The results will be used to identify the optimal implant treatment plan. Participants and methods: This prospective, single-center, non-randomized controlled clinical trial will include 180 patients with long-segment comminuted subtrochanteric fractures of the femur from Sanya Traditional Chinese Medicine Hospital, China. The patients will be equally divided into a locking compression plate group and a proximal femoral nail antirotation group. All patients will be followed up at 2 and 10 months postoperatively. Patient recruitment and data collection will begin on June 30, 2019 and end on June 30, 2020. Analysis of the results will be performed from 1 to 30 July 2020. This study will be scheduled to end on August 1, 2022. This study was approved by the Medical Ethics Committee of Sanya Traditional Chinese Medicine Hospital in China in March 2013 (approval No. (2013) (02)). Study protocol version is 1.0. This study will be performed in strict accordance with the Declaration of Helsinki formulated by the World Medical Association. Written informed consent regarding the study protocol and surgery procedure will be obtained from the participants. Results: The primary outcome measure is the rate of excellent and good Harris hip scores at 10 months postoperatively; this rate will be used to evaluate the recovery of hip function after repair. The secondary outcome measures are the rate of excellent and good Harris hip scores preoperatively and 2 months postoperatively, intraoperative blood loss, operation time, incision length, hospital stay, fracture healing time, hip morphology on radiographs preoperatively and 2 months postoperatively, and incidence of adverse events 2 and 10 months postoperatively. Our pilot study involved 80 patients with long-segment comminuted subtrochanteric fractures of the femur from February 2013 to February 2016 (locking compression plate group, n = 40; proximal femoral nail antirotation group, n = 40). The 10-month follow-up results showed that the intraoperative blood loss, operation time, incision length, hospital stay, and fracture healing time were lower in the proximal femoral nail antirotation group than in the locking compression plate group (P 0.05). These pilot study results verified higher efficacy and safety of proximal femoral nail antirotation than locking compression plate fixation in the treatment of long-segment comminuted subtrochanteric fractures of the femur. Conclusion: The results of the present study will provide evidence indicating whether proximal femoral nail antirotation in the treatment of long-segment comminuted subtrochanteric fractures of the femur can facilitate better recovery of hip function and higher safety than anatomical locking compression plate fixation. Trial registration: This study was registered with the Chinese Clinical Trial Registry on February 3, 2019 (registration number: ChiCTR1900021251).

Reverse distal femoral locking plate for subtrochanter femur fracture

In these case series, we used titanium locking compression plate-distal femur (LCP-DF) plate (Synthes) 9–11 hole using less invasive stabilization system or open reduction technique. This case series aims to determine the functional scores on reverse distal femoral locking plate for subtrochanteric femur fracture. A 34-year-old male with closed subtrochanteric fracture of the right femur (Seinsheimer 2B) with Harris hip scores (HHS) of 17, 96, and 97 obtained consecutively in 0, 6, and 12 months, respectively. A 24-year-old male with closed comminuted subtrochanteric fracture of the right femur (Seinsheimer V) with HHS of 13, 93, and 97 at 0, 6, and 12 months respectively. A 39-year-old male with non-union, left subtrochanteric femur fracture (Seinsheimer 2C) yielded HHS of 38, 73, and 77 at 0, 6, and 12 months, respectively. A 35-year-old female with close subtrochanteric fracture of the right femur (Seinsheimer IIB) yielded HHS of 23, 40, and 73 at 0, 6, and 12 months, respectively. Mean initial HHS and scores at 6 and 12 months reached 22, 75, and 86, respectively.

Functional outcome of comminuted unstable subtrochanteric fractures treated by proximal femoral nail [PFN

Background: Subtrochanteric fractures are often difficult to treat and may well be associated with a mortality of more than 20%. The subtrochanteric region is the site of very high mechanical stresses, the medial and posteromedial cortices were subject to high compressive forces whereas the lateral cortex experiences high tensile forces. Operative management is the treatment of choice to achieve the goals of early rehabilitation and optimal functional recovery. The purpose of the present study is to evaluate functional outcome of the subtrochanteric fractures -both high energy and low energy -treated by PFN. Functional as well as anatomical results were evaluated with regard to pain, limping, activities, deformity and range of movements. The present study was done with the hope to find out a solution for the treatment of unstable comminuted subtrochanteric fractures. Materials and Methods: A total of 24 patients with subtrochanteric fractures presenting in the Department of Orthopaedics from August 2015 to August 2016 were treated by closed intramedullary nailing using PFN and the peroperative and postoperative complications and the functional outcome were studied. All the data was arranged in a tabulate form and analyzed using SPSS software. Chi square test was applied as a test of significance. Probability value of less than 0.05 was considered significant. Result: Out of the 24 patients 16 (66.66%) were males and 8 (33.34%) were females. Most of the cases came under. Type IB (62.50%) and Type IA (20.84%). There were 8.3% cases each of Type II A and Type II B. In this study, 14 cases (58.34%) were locked proximally and distally with 2 screws each. In 4 cases (16.66%), 2 proximal screws and 1 distal screw, in 2 cases of intertrochanteric fracture, only 2 proximal screws were used. Average duration taken for union in this study was 4.5 months (Ranges from 3 months to 7.5 months). 22 (90%) united by 6 months. There were no cases of infection. No shortening in 10 cases. Less than 1 cm shortening in 9 cases and 3.2 cm shortening in one case was found. Proximal screw penetration was noted in one case (RT type II A) at the time of 3 months follow up. Conclusion: PFN is a safe, effective and patient friendly device useful for the treatment of all subtrochanteric fractures irrespective of their comminution. Early mobilization and rehabilitation is possible since it is a closed intramedullary procedure.

Management of compound subtrochanteric fractures of the femur caused by bullets using an external fixator: A prospective study

Background Compound subtrochanteric fractures of the proximal femur caused by bullet injuries are a severe form of injury that are not common, and yet their management represents a major challenge. A specially designed external fixator can be used to treat these fractures, with avoidance of possible complications such as infection or nonunion. The author reviewed his experience with an external fixator in the management of this pattern of fractures. Aim A prospective evaluation was carried out of the result of treatment of bullet-caused subtrochanteric fractures by an external fixator. Patients and methods During the period between February 2011 and January 2012, eight male patients presented to the Kasr Al-Ainy School of Medicine and New Kasr Al-Ainy Teaching Hospital with compound subtrochanteric fractures of the femur caused by bullets. The patients were between 19 and 48 years of age (mean 33.5 years). All cases were primary fractures. They were followed prospectively after fixation of the fractures using a specially designed external fixator. Results The mean duration of healing was 20 weeks (range 18-26 weeks) according to the degree of comminution and soft tissue injury. Three patients developed pin-tract infection that resolved after removal of the frame. One patient developed shortening of about 2 cm. No deformity developed in any patient. No extra measures were needed. At the last follow-up, the results of all cases were scored as good (five cases) to excellent (three cases), with no fair or poor results. Conclusion An external fixator can be a reliable method to treat comminuted subtrochanteric fractures caused by bullet injuries.

3 cases of surgical treatment for comminuted subtrochanteric femoral fracture with intramedullary nail and Nesplon cable

3 cases of surgical treatment for comminuted subtrochanteric femoral fracture with intramedullary nail and Nesplon cable

Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate

IntroductionSubtrochanteric fractures are difficult fractures associated with high incidence of complications and various implants, both intramedullary and extramedullary, are available for their fixation. Traditional extramedullary implants are associated with higher rate of implant failure and varus collapse while the biomechanically better intramedullary nails are technically demanding and are associated with higher re-operation rates. This study was done to evaluate the outcome following biological (indirect) fixation of unstable comminuted subtrochanteric fractures with proximal femur-locking compression plate (PF-LCP). MethodsThirty-five consecutive patients with comminuted subtrochanteric fractures were operated upon with PF-LCP by using an indirect reduction technique. Seinsheimer types 3–5 fractures were included in the study. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications. The Harris Hip Score was used to document hip function at final follow-up. ResultsThirty-two patients with average age of 44.7 years were available for final evaluation. The mean operating time was 79.5min and total blood loss averaged 233.13ml. Union was achieved in all cases with an average time of 15.62 weeks. Complications included two cases of delayed union and two cases of infection. Two cases had a shortening of 1cm and one case had malunion with external rotation. No instances of implant failure or nonunion were recorded. ConclusionBiological fixation of comminuted subtrochanteric fractures with PF-LCP provides stable fixation with high union rate and fewer complications.

A Biomechanical Comparison of a Locking Plate, a Nail, and a 95° Angled Blade Plate for Fixation of Subtrochanteric Femoral Fractures

To compare the biomechanical performance of a cephalomedullary nail (CMN), a proximal femoral locking plate, and a 95° angled blade plate in a comminuted subtrochanteric fracture model. A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 pairs of human cadaveric femora confirmed to be nonosteoporotic. The femora were randomized to treatment with one of the previously mentioned 3 devices. Each was tested under incrementally increasing cyclic load up to 90,000 cycles from 50% to 250% of body weight to simulate progressive weight bearing during 3 months of an average 700-N (approximately, 70 kg or 150 lb) person. Force, number of cycles, and total load sustained to reach 10 mm of displacement were compared. Failure modes were also noted. The CMN construct withstood significantly more cycles, failed at a significantly higher force, and withstood a significantly greater load than either of the plate constructs (P < 0.001). Varus collapse was significantly lower in the CMN construct (P < 0.0001). Modes of failure differed among implant-bone constructs with damage to the femoral head through implant cutout in 5 of 10 blade plate specimens and 2 of 10 CMN specimens, whereas no damage to the femoral head bone was observed in any of the locking plate constructs. The CMN construct was biomechanically superior to either the locking plate or 95° blade plate constructs. The locking plate construct was biomechanically equivalent to the blade plate construct.

Management of Comminuted Subtrochanteric Femur Fractures by Indirect Reduction and Biological Fixation with Dynamic Condylar Screw

Background: The Comminuted subtrochanteric femoral fractures are considered as one of the most difficult fractures to treat in the orthopaedic literatures. The aim of this prospective study was to evaluate the indirect reduction and biological fixation technique with Dynamic condylar screw and plate fixation for the treatment of comminuted subtrochanteric femoral fractures. Method: Thirty one cases suffered from comminuted subtrochanteric fractures femur, AO classification (type C), were treated by biological fixation, indirect reduction method with Dynamic condylar screw and plate fixation. Results: The cases were followed up by clinical and radiological examination from 12 to 32 months (mean 22 months). In all cases union in acceptable alignment were achieved from 15 to 24 weeks (range from 3 to 6 months) (mean 4.5 months) in all cases except, three cases (9.7%) with failures of the fixations due to osteoporosis and early full weight bearing one week after surgery. With exception of 3 cases with fixation failures who excluded from the analysis of the functional results, all the cases had good functional outcome as regarding to Harris hip score which varying from 70 to 95 (mean 85). Conclusion: Indirect reduction and biological fixation with Dynamic condylar screw and plate fixation is considered as a valuable cheap fixation method for the management of comminuted subtrochanteric fractures femur especially in young patients’ populations.

A Biomechanical Analysis of Locking Plate Fixation With Minimally Invasive Plate Osteosynthesis in a Subtrochanteric Fracture Model

The objective of this study was to establish the relative fixation strengths of a locking plate, a dynamic condylar screw (DCS) plate, and a long proximal femoral nail (PFN). The study involved three groups of composite large femoral synthetic bones of five specimens per group; plating using a locking compression plate-distal femur (LCP-DF), plating using a DCS plate, and nailing using a long PFN. A gap osteotomy model was used to simulate a comminuted subtrochanteric femur fracture. For each femur, a minimal preload of 100 N was applied before loading to failure. A vertical load was applied at 10 mm/min until femur failure. Load to failure, mode of failure, and displacement at load to failure were documented. Fixation strength (load or moment to failure) of LCP-DF (1,330 N; range, 1,217-1,460 N) was 26.6% and was greater in axial loading compared with DCS (1050.5 N; range, 956.4-1194.5 N) and 250% less in axial loading compared with long PFN (3633.1 N; range, 3337.2-4020.4 N; p=0.002). Ultimate displacement in axial loading was similar for LCP-DF (18.4 mm; standard deviation [SD], 1.44), DCS (18.3 mm; SD, 3.25), and long PFN (16.7 mm; SD, 1.82). The LCP-DF construct proved stronger than the DCS in terms of ultimate strength by biomechanical testing of a simulated subtrochanteric femur fracture with comminution. Although the nail construct proved strongest, the biomechanical performance of the locking plate construct may lend credence to the use of a locking plate versus the DCS plate for minimally invasive plate osteosynthesis of subtrochanteric femur fractures, which may be technically difficult to fix using a nail.

Minimally invasive percutaneous plate osteosynthesis with dynamic condylar screw for comminuted proximal femoral fracture.

Objective To evaluate the technique, indications and results of minimally invasive per-cutaneous plate osteosynthesis (MIPPO) with dynamic condylar screw (DCS) for the treatment of young adults unstable comminuted subtrochanteric fracture. Methods From January 2001 to January 2006, 25 patients with unstable subtrechanteric fracture were treated. There were 18 males and 7 females, with the average age of 35 years (ranged from 25 to 40 years). 20 cases suffered traffic accident injuries, and 5 cases suffered falling down injuries. According to Seinsheimer classification, 15 cases fracture were ⅢA classification, 4 cases fracture were ⅢB classification, 6 cases were ⅣV classification. All of patients were closed fracture, and underwent MIPPO with DCS. The hip joint function was evaluated according to Harris's scale after surgeries. Results All patients were followed up from 9 to 24 months, with the average of 16 months. All subtrochanteric fractures were healed and the healing time was 3--4 months, with the average of 3.5 months. No patients suffered from the complications of plate fracture, screw loosening or cutting out, delayed healing, re-fracture, hip varus deformity, and limb shortening. According to Harris's scale, there were 14 eases excellent, 8 cases were good, 3 cases were fair on the hip joint function, the excellent and good rate was 92%. Conclusion M1PPO with DCS is the credible method for the treatment of young adults unstable comminut-ed subtrochanteric fracture, which can reduce operation complications, and benefit for fracture heal and hip function recovery. Key words: Femoral fractures; Bone screws; Surgical procedures, minimally invasive

Biomechanical Comparison of Proximal Locking Plates and Blade Plates for the Treatment of Comminuted Subtrochanteric Femoral Fractures

The 95 degrees angled blade plate is an accepted standard for plating subtrochanteric femoral fractures but can be technically demanding and often requires extensive soft tissue exposure. Proximal femoral locking plates (PFLPs) have been developed for subtrochanteric and pertrochanteric fractures and are potentially easier to apply with less soft tissue dissection. Clinical experience has raised concerns regarding the strength of the PFLP. The purpose of our study was to compare the relative stability of two designs of PFLP with the 95 degrees angled blade plate under loads simulating the first 3 months of progressive weight bearing after fracture fixation. A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 synthetic femora. Fracture fixation of three plates (95 degrees angled blade plate [blade plate], the original version of the PFLP [O-PFLP], and the newest version of the PFLP [N-PFLP]), all manufactured by Synthes, Inc., Paoli, PA, was tested under progressive cyclic loading to reproduce progressive weight bearing during 3 months after fracture fixation. The force and number of cycles to reach 5 mm of displacement of the femoral head or failure of the implant were compared for each implant. N-PFLPs were significantly stiffer than blade plates and O-PFLPs (P = 0.01) and had a trend toward withstanding more cycles before failure (P = 0.06). All five O-PFLPs demonstrated catastrophic fatigue failure before completion of the protocol. One each of the blade plates and the N-PFLPs failed to complete the protocol (P = 0.04). In the model studied, N-PFLPs were shown to have biomechanical properties that were at least equivalent to those of the blade plate. The fatigue failures of O-PFLPs mirrored our clinical experience. Use of the N-PFLP might be a viable alternative fixation method for comminuted subtrochanteric femoral fractures that currently are treated with blade plates.

Mini-Incision Dynamic Condylar Screw Fixation for Comminuted Subtrochanteric Hip Fractures

To review the results of indirect reduction and mini-incision dynamic condylar screw (DCS) fixation for comminuted subtrochanteric femoral fractures. 29 men and 14 women aged 25 to 65 (mean, 44) years with comminuted subtrochanteric femoral fractures underwent indirect reduction and mini-incision DCS fixation. Fractures were classified according to the AO classification (10 type 32B and 33 type 32C) and Seinsheimer classification (6 type III, 15 type IV, and 22 type V). Functional outcomes were assessed using the Harris hip score and Merle d'Aubigne score. The mean time to full weight bearing was 11 (range, 8-19) weeks. The mean time to union was 16 (range, 13-22) weeks. There were no cases of non-union or implant failure after a mean follow-up period of 25 (range, 18-30) months. Seven patients had a mean limb length discrepancy of 1.5 (range, 1-2) cm. Two patients had coxa vara and persistent limp. According to the Harris hip score, functional results were excellent in 12 and good in 31 patients. The mean Harris hip score was 88 (range, 80-99) and the mean Merle d'Aubigne score was 17 (range, 14-18). There was no deep infection or avascular necrosis of the femoral head. Restriction of knee flexion beyond 90 degrees was noted in 2 patients. Results of indirect reduction and mini-incision DCS fixation for comminuted subtrochanteric femoral fractures are favourable. Proper planning and execution of the technique is required to achieve good functional outcomes and avoid complications. Preservation of vascularity of the medial fragments leads to rapid callus formation and early union and hence avoids implant failure and secondary bone grafting.

Biologic Plating Versus Intramedullary Nailing for Comminuted Subtrochanteric Fractures in Young Adults: A Prospective, Randomized Study of 66 Cases

Published reports about treatment of comminuted subtrochanteric fractures in young patients are few. This study compared the effectiveness of biologic plating and intramedullary nailing in the treatment of such fractures. A prospective, randomized, and nonblinded study was conducted. Closed reduction and fracture osteosynthesis were performed with either a dynamic condylar screw (DCS) or a Russell-Taylor reconstruction nail (RTRN) in all 66 patients. The average age of the patients was 36.1 years. The average follow-up period was 28.1 months. All but two patients had uneventful bone union and the average time to union was 15.1 weeks. One implant failure in the RTRN group and one delayed union in the DCS group required additional surgery to achieve bone union. Shorter fluoroscopic time, reduced blood loss, and fewer patients requiring blood transfusion were found in the DCS group, though the DCS group had a higher hip pain score 2 years postoperatively. Otherwise, the surgical results and functional outcomes were comparable between groups. With the enhanced fixation properties demonstrated in the present study, the DCS proved to be a feasible fixation device for comminuted subtrochanteric fractures in young patients. Our results indicated that intramedullary nailing by a RTRN revealed no advantages over biologic plating by a DCS for treatment of such fractures.

Indirect reduction and biological internal fixation of comminuted subtrochanteric fractures of the femur

Surgical treatment of comminuted subtrochanteric fractures may be associated with high incidences of non-union and implant failure. Biological fixation may solve this problem by encouraging rapid callus formation which buttresses the medial cortex. In all, 33 patients with comminuted subtrochanteric femur fractures underwent indirect reduction and biological internal fixation. The mean age of the group was 39.12 (19-64) years. Patients were followed up for a mean of 24.6 (12-66) months. Union was achieved within a mean of 15.10 (13-22) weeks, with no cases of delayed union or non-union but with limb-length discrepancy, mean 1.22 (1-2) cm, in nine cases. According to the Traumatic Hip Rating Scale, functional results were excellent in 23 and good in 10 cases. Indirect reduction and biological internal fixation yield acceptable results in comminuted fractures. These good results can be attributed to early weight-bearing with rapid solid callus formation and early union, which are particularly advantageous in comminuted subtrochanteric fractures, avoiding the implant failure which is not uncommon in these fractures.

Removal of a broken nail using a guide wire and a screw

An 80-year-old man sustained a closed displaced comminuted subtrochanteric fracture in a fall accident. The fracture was stabilized with a Long Gamma locking nail (Stryker Trauma, Schonkirchen, Ger...

The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture

A study was designed to examine the outcomes of patients with closed comminuted subtrochanteric femoral fractures fixed with a dynamic condylar screw (DCS) and using biological (indirect) reduction techniques at a tertiary referral centre. Thirty-one consecutive patients with a mean age of 32.6 years, who sustained subtrochanteric femoral fractures, were treated with this method. Twenty-seven cases (87.2%) sustained these fractures either from traffic crashes or falls from height and the remaining four had a simple fall. Average follow-up was 3 years (range 14–65 months). Patients were assessed clinically and radiographically with regards to fracture classification, operating time, blood loss, time of union, malunion and other complications. Union was achieved in all cases (100%), with full-weight bearing after an average of 4.9 months. The average operating time was 2 h and blood loss averaged 430 ml. There was only one case of superficial infection, which settled with local debridement and antibiotics. Malunion was seen in 2 cases out of 31 (6.4%) without the need for further surgery. In conclusion, use of biological (indirect) reduction techniques instead of anatomic, open reduction has proven to be successful, especially in comminuted subtrochanteric fractures. The early appearance of callus avoids the need for primary cancellous bone grafting, emphasising the importance of preserving biology of the fracture fragments.

Technique of Biologic Fixation of Subtrochanteric Femoral Fractures with Dynamic Condylar Screw (DCS)

Objective Treatment of closed comminuted subtrochanteric fractures using the dynamic condylar screw (DCS), with the goal of reducing operating time, blood loss, and incidence of delayed union. Indications Comminuted subtrochanteric fractures, especially types B and C of the AO classification. Fracture line extending to piriformis fossa precluding use of an intramedullary device. Poor general condition, i. e., unable to withstand prolonged anesthesia as required in open reduction and internal fixation (ORIF)/nailing. Contraindications Compound fractures. Obesity. Calcar comminution is not a contraindication. Surgical Technique Approach either through small proximal and distal incisions or limited exposure of the fracture site without opening the region of comminution and preservation of medial fracture hematoma. DCS inserted under image intensifier control. Plate slid beneath vastus lateralis. Rotated 180° to allow barrel to slide over condylar screw. Alignment in all three planes confirmed under radiologic control. Proximal and distal screws inserted to stabilize the fracture. Results Between 10/1995 and 02/1999, 28 men and three women with subtrochanteric fractures were treated with a DCS using biologic principles. Union was achieved in all 31 patients (100%) and full weight bearing possible after an average of 4.9 months. The average operating time was 2 h, and blood loss averaged 430 ml. Only one patient had a superficial infection, which settled on local debridement and antibiotics. Malunion was seen twice (6.4%) which did not require further surgery. These results are superior to open technique in respect to blood loss, surgical time, and union rate.

A Warm Air Blanket Causes Intraoperative Airway Obstruction

THE safety of the anesthetized patient is facilitated by the use of many devices, such as standard monitors, eye tapes, warm air blankets, and heat moisture exchangers (HMEs). However, this myriad of ancillary devices occasionally may complicate airway management. We report a case of a foreign body causing a potentially lethal intraoperative airway obstruction.A 32-yr-old man was brought to the operating room 1 day after a 9-m fall for repair of a tile-C left hemipelvic disruption and a closed comminuted subtrochanteric fracture of the left proximal femur. History and physical examination showed that the man weighed 100 kg, had no previous medical problems, and had a class II airway. No hemodynamic or neurovascular derangements were noted. The patient was anesthetized with thiopental, fentanyl, and rocuronium and was intubated on the first attempt with an 8.0-mm ID endotracheal tube (ETT). Mechanical ventilation was initiated, and anesthesia was maintained with a mixture of N2O in oxygen and isoflurane. A warm air blanket (Bair Hugger; Augustine Medical, Eden Prairie, MN) and an HME (Humid Vent; Lous Gilbeck AB, Upplands-Vasby, Sweden) were used to help decrease heat loss during the procedure.After reduction of the hemipelvic disruption, preparations were made to transfer the patient to a fracture table for the femur repair. Fractional inspired oxygen was increased to 1.0 for several minutes before the transfer. Then, the circuit was disconnected from the HME, which remained connected to the ETT, and the patient was moved to the fracture table. The circuit was reconnected quickly, but the patient could not undergo ventilation as evidenced by the absence of chest movement and end-tidal carbon dioxide, a peak inspiratory pressure of more than 50 cm H2O, and a tidal volume of less than 100 ml. Then, ventilation was attempted vigorously with use of the reservoir bag, without success. As oxygen saturation began to decrease, the circuit was disconnected from the ETT, and a suction catheter was advanced, showing patency of the ETT lumen. While the circuit was disconnected, it was noted that the reservoir bag did not collapse. An Ambu bag was connected immediately to the ETT, the patient underwent ventilation easily, and oxygen saturation returned to 100%.Subsequent examination of the circuit showed a piece of plastic from the warm air blanket (fig. 1) lodged in the HME. The plastic head drape apparently had become trapped between the circuit and the HME, resulting in a small piece being torn off and occluding the airway. After removal of the obstructing plastic piece, the circuit was reconnected, and surgery was resumed without further incident. Many cases of intraoperative airway obstruction have been reported in the literature. 1–5Hosking et al. 1have proposed a practical algorithm for the management of airway obstruction. The first step is for the patient to undergo manual ventilation with the reservoir bag to remove the ventilator as a source of obstruction. If ventilation is performed easily, it is likely the fault lies within the ventilator. The second step, in the event of continued obstruction, should distinguish between circuit and ETT causes. ETT obstruction can be ruled out by passing a suction catheter or by successful direct ETT ventilation. If direct ETT ventilation is successful, then the circuit comes under suspicion. When the circuit and ETT have been eliminated as causes, patient sources of resistance, such as bronchospasm, pneumothorax, or pulmonary edema must be considered. In the current case, the ETT and the patient were eliminated as causes of obstruction when ventilation was restored by direct ETT ventilation.In the current patient, disconnecting and subsequent reconnecting of the circuit trapped a piece of the warm air blanket within the HME, producing total obstruction of the airway. An HME was implicated previously in airway obstruction in an infant. In that case, a small piece of paper was caught in the HME, preventing effective ventilation. 6Various causes of airway obstruction exist in the operative environment. When an obstruction is recognized, a systematic approach to diagnosis and treatment must be implemented. Because of the wide variety of adjunct devices used by anesthesiologists, we must always be aware of the possibility of an obstructing foreign body.