Role of percutaneous cerclage wire in the management of subtrochanteric fractures treated with intramedullary nails

Abstract

Purpose: Cerclage wire application has emerged as a potential therapeutic adjunct to intramedullary nailing for subtrochanteric fractures. But its popularity is plagued by the concern of possible negative effect on fracture zone biology. This study was intended to analyze the clinico-radiological outcome and complications associated with cerclage wire application.

Methods: Retrospective analysis was performed on all the subtrochanteric fractures operated with intramedullary nailing between January 2012 and January 2016. After exclusion, 48 patients were available with an average follow-up of 20.8 months. Long oblique, spiral, spiral wedge or comminuted fracture configurations with butterfly fragments were particularly considered for cerclage wire application, which was employed by percutaneous cerclage passer in 21 patients. Assessment was done in terms of operation time, blood loss, quality of reduction, neck-shaft angle, follow-up redisplacement, union time, complications, and final functional evaluation by Merle d'Aubigne'-Postel score.

Results: Average operation time and blood loss were significantly higher in cerclage group (p < 0.05). However, cerclage use substantially improved quality of reduction in terms of maximum cortical displacement (p = 0.003) and fracture angulation (p = 0.045); anatomical reduction was achieved in 95.23% of cases as compared to 74.07% without cerclage. Union time was shorter, although not statistically different (p = 0.208), in cerclage group. Four patients in non-cerclage group developed non-union, 2 of them had nail breakage. No infection or any other implant related complications were reported with cerclage use.

Conclusion: Minimally-invasive cerclage wire application has proved to be beneficial for anatomical reconstruction in difficult subtrochanteric fractures, whenever applicable, without any harmful effect on fracture biology.

Keywords: Cerclage wire; Fracture; Intramedullary nailing; Outcome; Percutaneous; Subtrochanteric.

Fig. 1

Pre-operative radiograph (A) in a 50 year-old-lady following fall from height. Cerclage wire assisted reduction was performed through a small lateral incision by percutaneous cerclage passer device (DepuySynthes^®). It consists of two dividable forceps which is passed ventral and dorsal to the fracture, and clamped outside. SS wire is passed through the cannulation inside the forceps (B). Reduction achieved and cerclage loop was tightened around the fracture (C). Anatomic reduction facilitated accurate localization of entry portal (D, E) for intramedullary (IM) nailing. Head-neck screw was inserted through the same incision (F). Post-operative antero-posterior (AP) and lateral radiographs (G) showing stable anatomical reduction.

Fig. 2

Pre-operative radiographs in a 26-year-old male following road traffic accident (A). Percutaneous cerclage wire assisted reduction and IM nailing was performed (B). AP and lateral radiographs (C, D) one and half years post-operatively depicting satisfactory fracture reduction, and alignment with complete bony healing.

Fig. 3

32-year-old man sustained subtrochanteric femur fracture following fall from height (A). Post-operative radiographs (B, C) after cephalomedullary nailing with additional cerclage wire showing anatomic reduction and stable construct. Two years Post-operative radiographs revealing uneventful healing of fracture in satisfactory alignment (D, E). Patient regained excellent function and resumed pre-injury activity level (F, G).