Iatrogenic femoral artery injury due to cerclage wiring for diaphyseal femoral fracture: A case report and review the literature.

INTRODUCTION AND IMPORTANCE: During femoral fracture osteosynthesis, the superficial femoral artery can be incarcerated in the cerclage wiring. We report a case that had an iatrogenic superficial femoral artery injury due to cerclage wiring during femoral osteosynthesis. CASE PRESENTATION: I reported a 57-year-old patient presented with a fracture at the distal third of the left femur. He had undergone a femoral nailing and a cerclage wiring. Four hours postoperative, his left leg was colder, and his dorsalis pedis and posterior tibial pulse were absent. A CTA revealed his left superficial femoral artery entrapment by cerclage wire. After cerclage removal, the superficial femoral artery and vein had normal flow. The dorsalis pedis and posterior tibial pulse could be palpated. One day following, there was no compromising of blood flow, sensation, or motor-nerve function. CLINICAL DISCUSSION: Cerclage wiring in the proximal half of the femur was less risk to the femoral artery than in the distal part. The SFA entrapment into a femoral cerclage wire requires an urgent diagnosis and treatment. A missed diagnosis could lead to necrosis of the lower extremity and even death. CONCLUSION: Our case shows that the superficial femoral artery can be incarcerated in the cerclage wiring during osteosynthesis. Cerclage wiring in the proximal half of the femur was less risk to the femoral artery than in the distal part. We recommend using a suitable cerclage passer precautionary in any femur fracture, particularly in the distal third of the femur. LEVEL OF EVIDENCE: A case report.

Intramedullary nailing for irreducible spiral subtrochanteric fractures: A comparison of cerclage and non-cerclage wiring.

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 was 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 value < 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.

Management of Vancouver B3 Periprosthetic Femur Fracture Using a Modular Uncemented Long Femoral Stem Prosthesis With Cerclage Wiring Technique.

Periprosthetic fractures (PPF) of the femur in connection with total hip arthroplasty are becoming common and also frequently challenging to repair. Such patients typically are frail, elderly, and have osteoporosis. Owing to a scarcity of research there are no clear strategies for its effective management. However, the Vancouver classification may help in facilitating treatment decisions. For fractures around a loose femoral prosthesis (types B2 and B3), revision using a modular uncemented long stem, with or without additional fracture fixation, has been known to provide a reliable outcome. It is prudent to treat osteoporosis for fracture healing and to prevent further fractures. In this case report, we share our experience with the use of an uncemented modular long femoral stem prosthesis with a cerclage wiring technique for the management of Vancouver type B3 PPF of the left femur in a 63-year-old male patient. Revision arthroplasty using a long stem prosthesis with a cerclage wiring technique can provide better fixation, stability, and functional outcomes for the patient.

Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series.

PURPOSE: Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA. METHOD: Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures. RESULTS: Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection. CONCLUSION: Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.

The Effect of Cerclage Banding Distally to a Clamshell Fracture Pattern in Total Hip Arthroplasty-A Biomechanical Study.

OBJECTIVES: As currently there is no existing biomechanical work on the topic of interest, the aim of the current study was to investigate the effect of cerclage banding distally to an intraoperatively occurring proximal periprosthetic femoral clamshell fracture versus a non-fractured femur after total hip arthroplasty. METHODS: A diaphyseal anchoring stem was implanted in twenty paired human cadaveric femora, assigned to a treatment and a control group. In the treatment group, each specimen was fitted with a cerclage band placed 3 mm distally to a clamshell fracture, created with an extent of 40% of the anchoring length of the stem. The resulting fragment was not treated further. The contralateral specimens were left with the stems without further fracture creation or treatment. All constructs were tested under progressively increasing cyclic axial loading until failure. Relative bone-implant movements were monitored by motion tracking. RESULTS: Number of cycles and the corresponding load at stem loosening, defined as 1 mm displacement of the stem along the shaft axis, were 31,417 ± 8870 and 3641.7 ± 887 N in the control group, and 26,944 ± 11,706 and 3194.4 ± 1170.6 N in the treatment group, respectively, with no significant differences between them, p = 0.106. CONCLUSION: From a biomechanical perspective, cerclage banding distally to an intraoperative clamshell fracture with an extent of 40% of the anchoring length of the stem demonstrated comparable resistance against hip stem loosening versus a non-fractured femur. It may therefore represent a valid treatment option to restore the full axial stability of a diaphyseal anchoring stem. In addition, it may be considered to keep the medial wall fragment unfixed, thus saving operative time and minimizing associated risks.

Adjunctive intraosseous wiring fixation technique for the comminuted distal humeral fractures.

Distal humeral fractures are among the most challenging injuries to treat. Although precise repair of the articular surface is essential during surgery, accurate reconstruction of the metaphysis contributes to the overall stability of the fracture construct. The intraosseous wiring technique has been used for small-fragment fractures. However, its efficacy as an adjunct for distal humerus fixation has yet to be thoroughly investigated. This study aimed to demonstrate the applicability of this technique to comminuted, distal humeral fractures. In this retrospective case series, we describe 6 cases of intra-articular distal humerus fractures treated with this technique, followed by dual plating. We observed successful bone union in all patients, with the Mayo Elbow Performance Scores indicating "good" to "excellent" clinical outcomes for this procedure at the final follow-up. We believe that this intraosseous wiring technique should be an integral part of the toolbox of every surgeon because it is a relatively simple and highly effective procedure that requires no special instrument and can be used on various types of fractures.

Effectiveness of laser welding in cerclage wiring fixation: a biomechanical study.

Introduction: Cerclage wiring is a common orthopedic procedure for fracture fixation. However, previous studies reported wiring-related perioperative complications, such as wire loosening or breakage, with an incidence rate of up to 77%. Recently, the use of laser welding on medical implants was introduced to connect biomedical materials. This study used laser technology to weld between wires after conventional cerclage fixation. We hypothesized that the laser welding could significantly increase the biomechanical properties of cerclage wiring fixation. Materials and methods: Twenty-five wiring models underwent biomechanical tests in five cerclage wiring configurations (five models per group), namely, (1) single loop, (2) single loop with laser welding, (3) double loop, (4) double loop with one-side laser welding, and (5) double loop with two-side laser welding. Characteristics such as load to failure, mode of failure, and wiring failure were compared between groups. The biocompatibility for a 316L stainless steel wire with laser welding was evaluated via an in vitro hemolysis test. Results: Mean load to failure of the double loop with one-side and two-side laser welding groups were 3,596 ± 346 N and 3,667 ± 240 N, which were significantly higher than for the double-loop group (2,919 ± 717 N) (p = 0.012 and p = 0.044, respectively). Conversely, no significant difference was shown in the comparison of the mean load to failure between the single loop and the single loop with laser-welded cerclage wire (1,251 ± 72 N, 1,352 ± 122 N, and p = 0.12). Untwisted wire and wire breakage were the most common mode of failure. All welding specimens revealed non-hemolytic effects from in vitro hemolysis test. Conclusion: Laser welding on cerclage wiring significantly increases the biomechanical property of double cerclage wire fixation. However, further biocompatibility tests and clinical studies are still recommended.

Management and Outcome of Elderly Patients With Patellar Fracture Treated With Novel Modified Cerclage Wiring.

Introduction: The purpose of this study is to assess the efficacy and security of a fixation method for fixing patellar fractures in elderly patients utilizing modified cerclage wire. Methods: From January 2015 to December 2020, 31 cases (age≥65 years old) of closed patellar fracture were treated by modified cerclage wiring. Patients in these instances ranged in age from 65 to 87 (73.7 ± 7.2 years), with 15 men and 16 women. 4 instances were type 34-C1 (transverse fracture) according to the AO/OTA classification, 27 cases (87%) were comminuted fractures, including 11 cases that were type 34-C2 (3 fragments), and 16 cases that were type 34-C3 (more than 3 fragments). Postoperative problems such as fragment re-displacement, nonunion, internal fixation loosening, infection, and internal fixation rupture were evaluated. The clinical grading systems of Böstman were used to assess the postoperative clinical outcomes. Results: Thirty one patients in all were monitored for 14 to 31 months (22.2 ± 4.5 months). After the procedure, the fracture took 2.5-3.5 months (2.92 ± .25 months) to heal. There were no postoperative issues like infection, dislocation, implant breakage, uncomfortable hardware, or post-traumatic osteoarthritis. According to the clinical grading scales of Böstman, the average score of the final follow-up was 28.6 ± 1.1 (range 26-30). 29 (94%) of the patients had excellent results, whereas just 2 (6%) had good results. The patient's knee flexion activity ranged from 110 to 140°, making for a favorable prognosis. Conclusion: Most patella fractures in the elderly are comminuted. Elderly patients with patellar fractures may be successfully treated with modified cerclage wire, with good results and no noticeable side effects.

Hybrid Tension Band Wiring for Olecranon Fractures.

Tension band wiring (TBW) is a standard surgical technique for treating olecranon fractures (OFs). We devised a hybrid TBW (HTBW) combining TBW using wires with eyelets and cerclage wiring. Twenty-six patients with isolated OFs with Colton classification groups 1-2C were subjected to HTBW, and the data was compared with those treated with conventional TBW (38 patients). The mean operation time and hardware removal rate were 51 versus 67 minutes (p < 0.001) and 42% versus 74% (p < 0.012), respectively. The HTBW group had one patient (4%) with surgical wire breakage. The conventional TBW group had 14 patients (37%) with symptomatic backout of Kirschner wires, three patients (8%) with loss of reduction, two patients (5%) with surgical site infection and one patient (3%) with ulnar nerve palsy. The motion and functional score ranges of the elbow were not significantly different. Therefore, this procedure may be a feasible alternative. Level of Evidence: Level V (Therapeutic).

Management of comminuted inferior patellar pole fractures with cerclage-wire-augmented separate vertical wiring: a retrospective clinical study.

PURPOSE: Comminuted inferior patellar pole fractures are challenging injuries and require effective treatment due to the extension mechanism of the knee. This study aims to evaluate the outcome of above fractures treated with a modified technique of cerclage-wire-augmented separate vertical wiring (SVW) with cerclage wiring passed through the proximal patella. METHODS: Retrospective analysis (1/2017-1/2020) were performed for patients that were treated with three SVWs through the posterior margin of proximal fragment and directly to the anterosuperior border of patella, combined with a cerclage wiring passed through the proximal patella. Patients who experienced comminuted inferior patellar pole fractures within 3 weeks were included, and the outcome was evaluated radiologically and clinically by Bostman score after a minimum of 12 months following surgery. Further evaluation included the operation time and complication rate. RESULTS: A total of 20 patients (10 males, 10 females) with a mean age of 54 ± 14.5 years (26-83 years) and a follow-up of 18.9 ± 6.6 months (12-36 months) were evaluated. The average operation time was 45.7 ± 8.8 min (30-60 min). At final follow-up, the average range of motion was 131.3° ± 3.5° (125°-135°), and the mean Bostman score was 29.4 ± 0.7 points (28-30) and graded excellent in all cases. Two patients experienced occasional giving way of the knee. Radiologically no loss of reduction, implant breakage, nonunion or skin irritation was observed. CONCLUSIONS: The cerclage-wire-augmented SVW with cerclage wiring passed through the proximal patella appears to be a safe and simple technique which can effectively treat the comminuted inferior patellar pole fractures.

Treatment of a Mandibular Diastemal Fracture Using Locking Compression Plate and Cerclage Wire in a Mare.

This report describes the combination of two surgical fracture repair techniques and the postoperative management of a mandibular diastemal fracture in a two-year-old mare. The mare was referred to a veterinary hospital with a laceration over the body of the right mandible. Radiographic assessment revealed two mesial fracture lines involving the second premolar tooth and a ventrally displaced bone fragment. The mare was treated under general anesthesia and the fracture was corrected using open reduction and plate fixation. A 3.5 mm narrow 15-hole locking compression plate with seven locking screws were used in a bridge form. Cerclage wire was also used to anchor the incisor teeth to the second and third premolar teeth. The cerclage wire and incisor teeth were covered with polymethylmethacrylate to prevent implant failure and avoid injury to the oral mucosa. Implants were removed 55 days after surgery and the mare was discharged from hospital five days later. The mare returned for cerclage wire removal after 90 days and was allowed to resume exercise thereafter. The combination of two surgical techniques, proper implant choice and appropriate postoperative management, including use of pelleted feed, contributed to successful bone healing and return to function.

Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature.

Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.

The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures. METHODS: MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring. RESULTS: Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002). CONCLUSIONS: Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.

Iatrogenic sciatic nerve injury due to cerclage wiring for proximal periprosthetic femoral fracture: A rare case report.

Cerclage wiring is used to reinforce the stability of fractures and optimize plate fixations for femoral fractures such as periprosthetic fractures. However, cerclage wiring requires attention to neurovascular structures to prevent injuries. We have presented a case of iatrogenic sciatic nerve injury after osteosynthesis with cerclage wiring. A 71-year-old woman underwent osteosynthesis with cerclage wiring for a proximal periprosthetic femoral fracture. Immediately after the operation, the patient developed motor and sensory disorders, particularly in the sciatic nerve area, leading to a suspicion of nerve injury. Consequently, reoperation showed that the right sciatic nerve was strangulated by the cerclage wire, but the nerve was functional. Since the sciatic nerve was partially continuous and retained sensation to some extent, strangulation release was performed. Subsequently, both sensory and motor disorders improved. This case suggests that attention should be given to not only the blood vessels in the anterior region but also the sciatic nerve in the posterior region when performing cerclage wiring for femoral fractures.

Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study.

BACKGROUND: Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability. METHODS: Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured. RESULTS: No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW. CONCLUSIONS: Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time.

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

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.

Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures.

OBJECTIVE: To explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail. METHOD: From February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self-made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double-stranded steel wire was introduced into a self-made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x-rayed front and side fractures before and after surgery and the maximum displacement and formation of the three-dimensional CT-scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery. RESULT: A total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X-ray and three-dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair. CONCLUSION: For refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.

Surgical outcomes of minimally invasive cerclage clamping technique using a pointed reduction clamp for reduction of nonisthmal femoral shaft fractures.

BACKGROUND: We modified the general application method of the pointed reduction clamp, focusing on the function of encompassing the fracture site, and applied it to femoral shaft fractures. The purpose of the present study is to describe the minimally invasive cerclage clamping technique (MICC) and compare radiological and clinical results of MICC with that of percutaneous cerclage wiring (PCW). MATERIALS AND METHODS: A retrospective comparative study was performed in two institutions from 2010 to 2019. Patients aged ≥18 years with acute femoral shaft fractures that were treated with intramedullary nailing and reduced using MICC or PCW were included. Patients with open fractures, atypical fractures, and follow-up less than 12 months were excluded. A total of 68 patients were finally included and divided into two groups based on the reduction technique each patient underwent. We then compared radiological and clinical results between the two groups, including coronal and sagittal alignment, time for union, and complications. RESULTS: The average time needed for the technique in the MICC group was shorter than that in the PCW group (7.1±4.6 min vs. 11.5±4.8 min, P < 0.001). There was no significant difference in the quality of reduction or alignment between the two groups. The mean union time was not different between the two groups (24.1±8.7 weeks vs. 24.1±8.6 weeks, P = 0.990). The MICC group had one nonunion patient and the PCW group had one postoperative infection patient. There were no cases of major neurovascular injury such as femoral artery injury or sciatic nerve palsy. CONCLUSIONS: MICC, using a pointed reduction clamp for nonisthmal femoral shaft fractures, demonstrated satisfactory reduction and favorable surgical outcomes with intramedullary nailing. We believe that MICC can be a reliable and safe reduction method for femoral shaft fractures.

Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures?

PURPOSE: The aim of this study was to assess functional and radiological results following cephalomedullary nailing with and without use of auxiliary cable cerclages in a large series of trochanteric and subtrochanteric femoral fractures. METHODS: In a retrospective study of prospectively collected data between January 2014 and March 2019, a total of 260 consecutive patients (155 women and 105 men) with the diagnosis of AO/OTA A1 to A3 fractures were included. The mean age of patients was 76.4 ± 15.6 years. According to the AO/OTA classification, 72 A1 fractures, 124 A2 fractures, and 64 A3 fractures were found. In 72 patients with auxiliary cerclage wiring three A1 fractures, 27 A2 fractures and 42 A3 fractures were assessed. In the patient group with auxiliary cerclages, fracture healing according to the Radiographic Union Score for Hip (RUSH) within one year after surgery was assessed in 68 out of 72 patients (healing rate 94%). The mean RUSH in the group with cerclages was 28.7 ± 2.2 points and was 28.5 ± 2.2 points in the group without cerclages (p = 0.72). In 91 patients available for a complete follow-up, mean functional outcome according to the Lower Extremity Functional Scale (LEFS) was 65.3 ± 17.2 points in the group with cerclages versus 58.4 ± 21 points in the group without cerclages (p = 0.04). CONCLUSION: The additional use of cerclages provides intrinsic stability and enables axial alignment and medial cortical support during anatomical fracture reduction and cephalomedullary nail insertion. In the current study, this technique resulted in significantly better functional long-term outcomes than without cerclages. Therefore, it can be recommended as a useful supportive tool especially in comminuted trochanteric and subtrochanteric fractures. Trial registration number DRKS00020550, 01/30/2020, retrospectively registered.

Anthropometric Factors on Safe Distances between Popliteal Vessels to the Femur for Cerclage Wiring of the Distal Femoral Fracture: A Magnetic Resonance Imaging Study.

Background and Objectives: The proximity of the popliteal vessels in the distal femur may increase the risk of iatrogenic vascular injury during cerclage wiring. In this study, the closest location and distance of the popliteal vessels to the femur was examined using magnetic resonance imaging (MRI). The associations between anthropometric factors and the distance that would guide the placement of wires safely during surgery were also identified. Materials and Methods: We reviewed adult knee magnetic resonance images and recorded: (1) the relation and the shortest horizontal distance (d-H) from the femoral cortex to the popliteal vessels in axial images and (2) the vertical distance (d-V) from the adductor tubercle to the axial level of the d-H values in coronal images. The effects of anthropometric factors (sex, age, body height, body weight, body mass index, thigh circumference, femoral length and femoral width) on these distances were analysed. Results: Analysis of 206 knee magnetic resonance images revealed that the closet locations of popliteal vessels were at the posteromedial aspect of the femur. The d-H and d-V were 7.38 ± 3.22 mm and 57.01 ± 11.14 mm, respectively, and were both shorter in women than in men (p < 0.001). Multivariate analysis identified thigh circumference and femoral length as the most influential factors for the d-H and d-V, respectively (p < 0.001). Linear regression demonstrated a strong positive linear correlation between the thigh circumference and the d-H and between the femoral length and the d-V (Pearson's r = 0.891 and 0.806, respectively (p < 0.001)). Conclusions: The closet location and distance of the popliteal vessels to the femur provide useful information for wire placement during distal femoral fracture surgery while minimising the risk of vascular injury. Given that patients with a smaller thigh circumference and a shorter femoral length are more likely to have a smaller d-H and a shorter d-V, respectively, cautious measures should be taken in such cases.