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.

Eponyms: errors in clinical practice and scientific writing.

Eponymous terms are in daily use in medicine. This system of nomenclature which simply commemorates a person is inconvenient, poses difficulties to students and leads to frequent mistakes in scientific writings. Nevertheless it can be helpful in completely describing a multi-symptomatic medical condition or a complex surgical procedure which otherwise would not be neatly encapsulated in a reasonably convenient word or phrase. We used Finkelstein's test as an example to demonstrate that the use of such nomenclature in clinical practice and scientific writing creates inaccuracies. We contacted 62 consultant orthopaedic surgeons and 47 specialist orthopaedic registrars of whom 53 consultant and 39 registrars responded. Three different descriptions of Finkelstein's test were used as described in current literature. Only 10 (10.7%) surgeons recognised the correct method as described by Finkelstein and 83 (89.3%) were unable to do so. The results shows that a statistically significant proportion of surgeons uses the test (p < 0.0001) but fails to identify the correct method (p < 0.0001). We also found that Finkelstein's test was inaccurately described in literature since Leao's incorrect description in 1958 (quoting Eichhoff's manoeuvre) and the mistake persisted for over 50 years before it could be accredited. Such mistakes are frequent not only in hand surgery but in other sections of medicine as well. We conclude that in the modern era of evidence based medicine, use of such trivial nomenclature should be avoided. Efforts should be made to introduce proper descriptive nomenclature, by devising criteria systems which would be easy to use and not fictitious.