Comparative study of intramedullary nailing in reverse obliquity intertrochanteric fractures with or without Cerclage wire augmentation

Abstract

Background: Reverse obliquity intertrochanteric fracture is a challenging injury encountered by orthopaedic surgeons. The patients are usually osteoporotic, with multiple co-morbidities and poor tolerance for complications and re-operations. In such a difficult scenario an intramedullary nail is recommended to give a stable fixation. This study aims to compare results between fracture fixation by only intramedullary nailing and nailing with augmentation by cerclage wires. Material and Methods: This prospective study includes 53 patients from August 2016 to September 2018 that presented to our institute with a reverse obliquity intertrochanteric fracture. They were sequentially operated with either intramedullary nailing (IMN) or nailing with additional use of cerclage wires. Patients were followed up for a minimum of 12 months. Radiological union time, complications and functional outcome (using Harris Hip Score) were noted at 1 year. Statistical analysis was performed to compare the results in both groups. Results: The mean union time was 4.3±0.534 months in Group A and 3.8±0.534 months in group B. The mean operating time needed for cerclage-augmentation was 10 minutes more than IMN only. The incidence of complications like screw cut out, back out and non-union, re-operation rate was lower in cerclage group. But the incidence of deep infection at the fracture site was more in cerclage group. Cerclage group had good functional outcome which was statistically significant. Conclusions: The technique of using cerclage wires in addition to intramedullary nail in reverse obliquity intertrochanteric fractures for lateral wall reconstruction provides good radiological and functional outcomes. It also reduces many complications of the procedure. Only concerning factor remains the increased risk of infection at the fracture site.

The role of cerclage wiring in the management of subtrochanteric and reverse oblique intertrochanteric fractures: a meta-analysis of comparative studies

“…Codesido et al, Trikha et al and Patil et al scored the maximum of two stars for the comparability domain [ 5 , 22 , 26 ]. Regarding the outcome domain, Codesido et al, Trikha et al and Annappa et al scored the maximum of three stars, Baht et al and Patil et al scored two stars, and Hoskins et al scored one star [ 1 , 4 , 5 , 10 , 22 , 26 ]. A summary of the qualitative assessment, according to the Newcastle–Ottawa scale, is shown in Supplementary Table1.…”

“…In this review three articles (Trikha, Codesido and Patil) compared closed reduction with or without percutaneous techniques versus open reduction and cerclage wiring, two articles (Hoskins, Annappa) compared closed reduction or clamp-assisted open reduction versus open reduction and cerclage wiring [ 1 , 5 , 10 , 22 , 26 ]. And one article (Bhat et al) included only cases with IMN after open reduction; Bhat et al, in the only prospective comparative study on the topic, compared open clamp-assisted reduction versus open reduction and cerclage wiring in reverse oblique intertrochanteric fractures [ 4 ]. They reported 14% varus malreduction and 6% nonunion rate in the no cerclage group compared to 6% varus malreduction and no nonunion reported in the cerclage group.…”

“…Not all fracture configurations are amenable to cerclage wiring; this can be considered an important source of bias when comparing reduction techniques in subtrochanteric fractures. Three articles in this review included only fractures configuration that considered suitable for cerclage wiring (Bhat, Annappa, Trikha); Trikha et al included long oblique, spiral or spiral wedge and comminuted fractures in their retrospective cohort, and quality of reduction was significantly better in the open reduction and cerclage group compared to closed reduction with shorter time to union and lower nonunion rate [ 1 , 4 , 26 ]. On the other hand, surgical time and blood loss were significantly higher in the cerclage group.…”

The Comparison of Dynamic Condylar Screw Plate to Proximal Femoral Nail in Reverse Oblique and Transverse Intertrochanteric Fractures: A Retrospective Study on 61 Patients

“…Kumar et al reduced the fracture with the help of a plate and clamp [ 19 ]. Imerci et al [ 20 ] and Bhat et al [ 21 ] proposed to provide lateral cortex continuity by open reduction and with the help of cerclage wires. Lateral cortex continuity can be very important.…”