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Purpose: Perception that extra-medullary fixation of these fractures are fraught with difficulties and deficiencies is becoming inappropriate. This device provides angular stable fixation retaining fracture biology with minimum interference to osseous and soft-tissue vascularity and it does not require reaming which destroys 80% of endosteal vasculature for 6-12 weeks. PFLCP averts iatrogenic fracture in lateral trochanteric wall (LTW) which is frequent with DHS, protects LTW from secondary fracture in post-operative period. Aim is to assess outcome of unstable proximal femur fracture fixation by PFLCP. Methods: Study included 64 from 2016 to 2020, divided in two groups. (A) Unstable intertrochanteric fracture and (B) subtrochanteric fracture (Seinsheimer types II-V). All fractures fixed by MIPO with PFLCP. Loss of reduction, infection, cut-out, cut-through, backing of screws, bending or breaking of plate and screw, malunion, non-union and revision were evaluated. Fracture healing and functional recovery assessed by Reborne Score and Parker Mobility Score (PMS) respectively. Results: Out of 64, 24 achieved pre-injury PMS, 32 declined by 1 point, 6 declined by 2 points and 1 by 3 points, one required revision. Using various parameters 37.5% patients had excellent results and 50% had good results, 9.38% had average and 3.12% had poor result. None reported non-union or breakage of plate. Conclusions: PFLCP provides angular stable fixation, torsional stability with high biomechanical strength to resist deforming stresses. MIPO avoids soft-tissue stripping reducing blood-loss, retains periosteal blood supply to inter-fragmentary bone fragments, enhancing fracture healing, reducing complications, such as delayed healing, nonunion, infection and implant failure.
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BACKGROUND: Subtrochanteric fractures are challenging to treat because of their anatomical and biomechanical behaviours. Non-unions of this region become much more difficult to treat because of the previous surgical scar, fibrosis, mal-reduction, presence of an implant, compromised soft tissue, and osseous vascularity, bone-mass loss etc. The aim is to provide a stable mechanical environment by PF-LCP, augmented by LCP (dual plating) where biology can work uneventfully. Biology is re-initiated by decortication (shingling) and autologous cancellous bone graft. METHODS: Twelve cases of failed aseptic subtrochanteric non-union either with intact or broken implant were included in this study in a period of 3 years from August 2016 to July 2019. The interposing fibrous tissue resected in patients with mal-aligned fragments. The mechanical stabilization is achieved by orthogonal dual plating. PF-LCP on lateral and 4.5 mm LCP anteriorly, decortication, and cancellous graft applied before applying for the anterior plate. Patients were encouraged for a toe-touch walk with walking-frame from 3rd post-operative day. Functional outcomes were assessed using Parker Mobility Score (PMS). RESULTS: All fractures united in 7 ± 1.53 months. ROM at the knee remained unchanged but improved at the hip after revision surgery. Average PMS improved to 7.58 from pre-revision 1.75 validating the efficacy of this protocol. CONCLUSION: Adequate stability by dual-plate construct and re-initiation of cellular and biochemical processes by decortication and cancellous bone-graft reunited ununited subtrochanteric fractures. This particular combination of plates and decortication has not been employed earlier as per our review of the literature. AIM: To offer a new paradigm for the management of surgically failed subtrochanteric non-unions.
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INTRODUCTION: The aim is to re-unite post nail aseptic non-union of diaphyseal femoral fractures in an economical and safe way with almost certainty, reducing dependence on others with early rehabilitation. The cascade of fracture healing is dependent on mechanical stability and uninterrupted cellular and bio-chemical responses (biology). Intra-medullary nailing in fresh diaphyseal femoral fractures is gold standard treatment with high success rate, still non-union of these fractures is reported, though the incidence has declined considerably. METHOD: This prospective study conducted at level one trauma centre on twenty-one patients in four years starting from July 2015 to June 2019. Eighteen patients had non-union with intact implant and three had broken nail. Non-union site approached through lateral approach. Non-union site fixed by 4.5 broad combi-hole LCP or distal femoral locking compression plate (DF-LCP) depending on fracture site. Decortication, Bone grafting done retaining the previous nail in situ in eighteen patients and in three patients, broken nail was exchanged with same size of unreamed nail and then, similar procedure carried out. RESULT: All non-unions in 21 patients reunited without any complications. All patients regained painless unsupported walk. DISCUSSION: The most preferred treatment for this complex non-union is reamed exchanged nailing. Larger nail increases mechanical stability by better frictional contact with surrounding bone in isthumic fracture but fails in cases of fractures with comminution, spacious distal fragment and fracture with small distal fragment. Various studies reported success rate in reamed exchange nailing from 53-96% with an average 74%. The main cause of instability is rotational stress which is completely obliterated by augmentation plating and various studies report 100% success. Augmentation plate with retained nail increases stiffness and strength of construct. Concomitant decortication and cancellous bone graft stimulates osteogenesis. CONCLUSION: It is a simple, safe and economical procedure, correcting and providing both mechanical and biological environments to convert non-union into osseous union. It will be a treatment of choice in times to come.