Subtrochanteric fracture non-unions with implant failure managed with the “Diamond” concept

Injury (Impact Factor: 2.14). 01/2013; 44:S76–S81. DOI: 10.1016/S0020-1383(13)70017-2


Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clinical problem. This study assessed the clinical outcome of patients treated according to the principles of the “Diamond” concept.Methods
Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union in the setting of metalwork failure (broken cephalomedullary reconstruction nail), and treated in a single tertiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures were excluded. The revision strategy was based on the “Diamond concept”; optimisation of the mechanical and the biological environment (implantation of growth factor (rhBMP-7), scaffold (RIA bone graft from contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The minimum follow up was 26 months (16–48).ResultsFourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with initial breakage of the distal locking screws followed by nail breakage at the lag screw level. The intraoperative examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases, with an average of 5.2 degrees (0–11). The average time to distal locking screw failure was 4.4 months (2–8.5) and nail failure was 6.5 months (4–10). The time to union after the revision surgery was 6.8 months (5–12). Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism, one myocardial infarction, one below the knee deep vein thrombosis and one blade plate failure that required further revision with double plating and grafting.Conclusion
Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures. Distal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis, a single stage procedure based on the “Diamond concept” that simultaneously optimizes the mechanical and biological environment is a successful method for managing complex subtrochanteric atrophic non-unions with failed metalwork.

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    • "Secondly, are the different surgical steps going to be taken at a single setting or at multiple stages? The majority of the more complex cases are treated in multiple stages with first priority of the eradication or at least the control of the infection [7] [48]. Often, the first stage consists of the verification of the presence of an infection, usually in the form of an open tissue biopsy [7]. "
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    ABSTRACT: Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Injury 08/2015; DOI:10.1016/j.injury.2015.08.009 · 2.14 Impact Factor
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    • "Additionally, the position of the proximal fragment makes obtaining the correct nail entry site difficult, with a lateral entry point promoting varus deformity [2]. Varus deformity is an important predictor of complications following subtrochanteric fracture fixation [3] [6] [7] [17]. Significant sequelae of varus deformity include: delayed and nonunion [4] [9], increased length of inpatient stay and delay in return to preoperative mobility [3]. "
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    ABSTRACT: Subtrochanteric neck of femur fractures are a challenge to treat due to anatomical and biomechanical factors. Poor reduction, varus deformity, nonunion and return to theatre risks are high. A cerclage wire can augment an intramedullary nail to help fracture reduction and construct stability. Concerns exist regarding the use of cerclage wire on fracture zone vascularity. The aim of this study was to assess the benefits and adverse outcomes associated with the use of cerclage wiring. A 7-year retrospective review of all subtrochanteric fractures at a Level 1 trauma centre was performed. Pathological fractures, those associated with bisphosphonate use and segmental fractures were excluded. A clinical and radiographic review was performed. Our primary outcome measure was a composite of the major complications of this surgery, defined as either return to theatre for fixation failure, nonunion or implant failure. Fracture displacement, angulation and quality of reduction were measured as secondary outcome measures. Specific complications of the use of cerclage wiring were also reported. One hundred and thirty four cases met the inclusion criteria for primary outcome. Reduction was achieved closed in 51.9% (n=70), open in 33.3% (n=45) and open with cerclage wire in 14.8% (n=20). Overall there were a total of 13 (9.7%) major complications. No cases with cerclage wire had a return to theatre. If cerclage wire was not used the major complication rate was 11.4%. Fracture displacement (11.0mm vs. 7.69mm) and distraction were related to return to theatre (p<0.05). Cerclage wire use improved fracture displacement (3.2mm vs. 8.8mm), angulation and quality of reduction (p<0.05). Anatomical reduction is the key to success of subtrochanteric fractures. Cerclage wire use results in better fracture reduction. Some subtrochanteric fractures can be successfully treated with indirect reduction alone. If fractures cannot be reduced closed, reduction should be achieved by open methods. If a fracture is opened, a cerclage wire should be used, if the fracture pattern allows. Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.
    Injury 07/2015; 15(10). DOI:10.1016/j.injury.2015.07.001 · 2.14 Impact Factor
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    • "The vascularised and synovial regions contain stem cells, which contribute to meniscal regeneration [5]. Application of growth factors is an active area of research for tissue and bone regeneration [6] [7] [8] [9] [10]. "
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    ABSTRACT: This study analysed the influence of bone morphogenetic protein-7 (BMP-7) on cells and meniscal structure. The effect of treatment with BMP-7 was assessed in vitro and in vivo in lesions in the avascular area of the meniscus. Cells were extracted from the outer and inner part of eight menisci of four 2-year-old merino sheep. The menisci were digested with a collagenase mix, and meniscus cells of the synovium, vascular area and avascular area were extracted. The expression of genes for collagen (Col1 and Col2A), matrix metalloproteinases (MMP-2 and MMP-13) and aggrecan was analysed by real time quantitative polymerase chain reaction (qPCR) at baseline and after incubation with BMP-7. Eight sheep aged 2 years and weighing 35–40 kg were used for the in vivo study. Surgery was performed in both knees of every animal. Two holes were made in the avascular area of the medial meniscus of both knees and filled using Putty® (control groups) or OP-1 Putty®, which comprises BMP-7 mixed with a cellulose putty carrier (experimental groups). Animals were sacrificed at 6, 12 and 25 weeks.
    Injury 10/2014; 45 Suppl 4:S15-21. DOI:10.1016/S0020-1383(14)70005-1 · 2.14 Impact Factor
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