Evolving Technique or Pass: The Role of the Proximal Femoral Locking Plate in Subtroch Femur Fractures Gil R. Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Orthopaedic Trauma Director, Mayo Clinic Arizona Residency Program Vice Chair, Department of Surgery, Scottsdale Osborn Level 1 Trauma Center, Scottsdale, AZ, USA
Disclosures • Founding Member, Orthopaedic Board of Advisors: Carbofix • Founding Member, Orthopaedic Board of Advisors: Artross Nanobone • Consultant: Smith and Nephew
Why Plate a Subtroch?
PFLP of Subtrochs • Some studies report implant failure due to loss of the posteromedial bone support and recommend anatomical reduction • Other studies report excellent to good results with indirect (biological) fixation without anatomical reduction
Why You Should Consider PFLP for a Subtroch • Short-term clinical results of PF-LCP fixation for subtrochanteric fractures using both conventional and biological fixation • Forty six patients with comminuted subtrochanteric fractures • Treated by either conventional (open, direct) or biological (indirect) reduction method and internal fixation with PF-LCP
Why You Should Consider PFLP for a Subtroch • 44 cases continued to final follow-up – 23 open fixation group and 21 biological fixation group • Open group – Greater blood loss (756 ± 151 vs. 260 ± 39ml; P<0.0001) – Longer operative times (129 ± 16.9 vs. 91 ± 8min; P<0.0001) and incisions (s) length (20.4 ± 3 vs. 13.4 ± 1cm; P<0.0001) – More patients needed blood transfusion in open group (11 patients vs. six in closed group; P<0.0001) – Biological group demonstrated longer fluoroscopy time (80.9 ± 7.3 vs. 47.2 ± 5.8sec.; P<0.0001)
Why You Should Consider PFLP for a Subtroch – For each group, one case of implant failure was recorded – Low patient compliance was detrimental factor for implant failure in both cases – No major difference for healing rate (open group; 18.3 ± 3.7 vs. biological group16.5 ± 4 weeks; P<0.058) and for functional outcome (open group; excellent/good: 54%/37%, biological group; excellent/good: 57%/33%; P=0.766) El-Desouky II 1 Clinical outcome of conventional versus biological fixation • of subtrochanteric fractures by proximal femoral locked plate. Injury. 2016 Jun;47(6):1309-17. doi: 10.1016/j.injury.2016.03.016. Epub 2016 Mar 17
Why You Should Pass on PFLP for a Subtroch • Comparison of a cephalomedullary nail (CMN), a proximal femoral locking plate, and a 95 ° angled blade plate in comminuted subtrochanteric fracture model • Comminuted subtrochanteric femoral fracture model was created with 2-cm gap below lesser trochanter in 15 pairs of human cadaveric femora confirmed to be nonosteoporotic
Why You Should Pass on PFLP for a Subtroch • CMN construct withstood significantly more cycles, failed at significantly higher force, and withstood significantly greater load than either of plate constructs (P < 0.001) • PFLP equal to blade plate • Varus collapse was significantly lower in CMN construct (P < 0.0001) Forward et al. A biomechanical comparison of a locking plate, a nail, and a 95 ° angled • blade plate for fixation of subtrochanteric femoral fractures J Orthop Trauma. 2012 Jun;26(6):334-40. doi: 10.1097/BOT.0b013e3182254e
Why You Should Pass on PFLP for a Subtroch • Retro study, 10 cases with 7 failures – Three acute peritrochanteric fractures – One case failure of compression hip screw – Three nonunions – Implant failure in 4 cases – Loss of fixation in 3 cases with varus collapse and implant cutout – Five of 7 failures within first 3 weeks – All failures within 40 days – Tejwani et al. Failure of proximal femoral locking compression plate: a case series J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc
Why You Should Pass on PFLP for a Subtroch • 18 patients with PFLP • At 3 months postop, four patients had varus collapse • At 6 months postop, two patients had cutouts and one other patient had implant failure • 7 of 19 patients requiring reosteosynthesis or prosthesis implantation due to secondary loss of reduction or hardware removal • C. Wirtz et al
Why You Should Pass on PFLP for a Subtroch • Biomechanical comparison of PFLP, DCS, and PFN in synthetic bones with gap osteotomy for comminuted subtrochanteric femur fracture • Fixation strength (load or moment to failure) of LCP-DF (1,330 N; range, 1,217-1,460 N) was 26.6% and was greater in axial loading compared with DCS (1050.5 N; range, 956.4-1194.5 N) and 250% less in axial loading compared with long PFN (3633.1 N; range, 3337.2-4020.4 N; p=0.002) • Ultimate displacement in axial loading was similar for LCP- DF (18.4 mm; standard deviation [SD], 1.44), DCS (18.3 mm; SD, 3.25), and long PFN (16.7 mm; SD, 1.82)
Why You Should Pass on PFLP for a Subtroch • PFLP stronger than the DCS but Nail strongest • Kim et al. A biomechanical analysis of locking plate fixation with minimally invasive plate osteosynthesis in a subtrochanteric fracture model. J Trauma. 2011 Jan;70(1):E19-23. doi: 10.1097/TA.0b013e3181d40418
Why You Should Pass on PFLP for a Subtroch • Comminuted subtrochanteric femur fracture was created with a 2-cm gap below lesser trochanter in 15 synthetic femora • Compared Blade plate, New PFLP, and Old PFLP • N-PFLPs were significantly stiffer than blade plates and O-PFLPs (P = 0.01) and had trend toward withstanding more cycles before failure (P = 0.06)
Why You Should Pass on PFLP for a Subtroch • All five O-PFLPs demonstrated catastrophic fatigue failure before completion of protocol • One each of blade plates and N-PFLPs failed to complete the protocol (P = 0.04) • N-PFLPs were shown to have biomechanical properties that were at least equivalent to those of blade plate • Floyd et al Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures.J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835
Conclusion • There is more evidence that shows you should pass on using a PFLP for a Subtrochanteric femur fracture and that a Cephomedullary Nail is likely better clinically and radiographically
Thank You
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