Thurs., 10/18/07 Femur, Paper #5, 1:31 pm OTA-2007
Are Subtrochanteric Cerclage Wires Really the Work of the Devil?
Bruce H. Ziran, MD (n); Thomas F. Hull, BA (n); Mary-Kate Barrette-Grischow, MA, MPH (n); Daneen M. Mace, BSN (n); James A. Shaer, MD (n);
St. Elizabeth Health Center, Youngstown, Ohio, USA
Background/Purpose: Subtrochanteric fractures are usually treated with indirect reduction using either plates or nails. In certain spiral/long oblique patterns, there is a significant deforming force of the proximal fragment that tends to flex/abduct/externally rotate. Without attention to reduction of this deformity, problems such as reaming of posterior-lateral cortex, deformity, and nonunion may occur. Anecdotally, we have noted common use of cerclage wires or cables by the community surgeons in our area for these vexing patterns. Traditional teaching has been that such devices are detrimental to bone healing and require excessive surgical dissection. The purpose of this study was to evaluate the use of cerclage wires or cables for such fractures.
Methods: From a prospectively entered registry, we first identified all cases using wires/cables, and then a cohort of similar fracture patterns where wires/cables were not used. Three independent groups were fractures with cerclage cable, cerclage wires, or no additional device. Outcome measures were radiographic healing and deformity (varus and/or flexion).
Results: Fracture types were those amenable to circumferential devices (AO/OTA 31 A1.3, A2.2, A2.3, A3.1, A3.3, and 32 A1.1, A2.1, B1.1, B2.1). Follow-up to the outcome measure of healing/nonunion was available in 80 patients (3 deaths, 4 lost) with mean age of 73 years. Fixation was nails (n = 73) or plates (n = 7). In the cable group there were 0/10 deformities and 4/10 nonunions; in the wire group there were 0/14 deformities and 0/14 nonunions; in the nothing group there were 9/56 deformities and 8/56 nonunions. Failure with cable use was statistically significant compared to wires (P <0.01) and nothing (P <0.05). Wires versus nothing was not significant (P = 0.14). Deformity comparison did not reach statistical significant among any groups. With further analysis of operative reports, all cables required a more extensive exposure to allow use of the tensioning and crimping device (9 nails, 2 plates), whereas the wires were placed using the existing exposure for fixation (10 nails, 1 plate).
Conclusion: Since use of cables/wires is generally frowned upon, we anticipated a very high failure rate with such devices, but were surprised to find that none of the failures occurred with wires, and that use of nothing also incurred problems. We surmise that cable application requires more dissection and is constrictive (ischemic) to periosteal vascularity due to its method of deployment. Wires are placed with less dissection and gently twisted to appose bone ends (reduction aid) and are not as ischemic. Such devices also aid with reduction since we encountered deformity only when nothing was used. Furthermore, bone apposition would theoretically enhance construct stability as described by Frankel et al. Biologic and mechanical studies would be helpful to further explore our findings. Based on our findings, we do not recommend use of cerclage cables but would consider judicious use of wires.
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