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Prospective Study of Closed Reduction of Trochanteric Fractures via a Novel Intraoperative Femoral Fracture Reduction Device

Early Clinical Results

Wang, Zhigang, MM*; Hao, Wei, MD; Liu, Dong, MM*; Zhang, Kai, MD*; Jia, Long, MM*; Yang, Shuye, MD*; Wang, Zhaolin, MM*; Zhang, Degang, MM*; Zhang, Dechun, MD*

doi: 10.1097/BOT.0000000000001230
Original Article

Objective: Traction achieved using an intraoperative femoral fracture reduction device (IFFRD) was compared with that observed using a traction table (TT) for closed reduction of trochanteric fractures and cephalomedullary nail fixation.

Design: Prospective cohort study.

Setting: Level 1 trauma center.

Patients: One hundred forty-one eligible patients with 141 fractures (Orthopaedic Trauma Association type 31-A1, n = 28; A2, n = 75; and A3, n = 38 cases) were randomized to the IFFRD (n = 73) or TT (n = 68) group.

Intervention: The IFFRD was used while the patient was placed on a normal radiolucent operation table with 25–30 degrees elevation of the injured side to allow for antero-posterior and lateral fluoroscopic examination and facilitate entry-point guide wire insertion.

Main Outcome Measures: Patient demographics, operative and fluoroscopy duration, quality of fracture reduction, and radiological bone union time were recorded.

Results: Patient demographics were similar between groups. Duration of patient positioning was longer in the TT group (P < 0.05); duration of fluoroscopy, fracture reduction, and time to union were comparable.

Conclusions: An IFFRD used with a normal radiolucent operation table decreased patient positioning time, with efficacy comparable to the TT approach for closed reduction of trochanteric fractures.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedics and Traumatology, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong Province, China; and

Department of Orthopaedics and Traumatology, Yantai YuHuangDing Hospital Affiliated to Qingdao University Medical College, Yantai, Shandong Province, China.

Reprints: Zhigang Wang, MM, Department of Orthopaedics and Traumatology, Affiliated Hospital of Binzhou Medical University, Binzhou, Shandong Province 256603, China (e-mail:

Supported by the Binzhou Science & Technology Development Program (2014ZC0153).

The authors report no conflict of interest.

Z. Wang and W. Hao have contributed equally to this work.

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Accepted March 28, 2018

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The worldwide increase in the elderly population has resulted in a higher incidence of osteoporotic fragility fractures, including trochanteric fractures, which are common and increasing in parallel with life expectancy.1 Standard treatment for these fractures include patient placement on a traction table (TT) and fixation using either a cephalomedullary nail or a sliding hip screw and side plate. Although a femoral distractor avoids the inconvenience and complications of TTs, it is unsuitable for trochanteric fractures because of its proximal screw insertion site.

We have designed an intraoperative femoral fracture reduction device (IFFRD), in which the proximal pin is inserted at the anterior inferior iliac spine (AIIS) toward the posterior inferior iliac spine, a site also routinely used for external fixation of lateral compression type II pelvic fractures. This device has been successfully used for closed reduction of femoral fractures (diaphyseal and metaphyseal) and fixation via intramedullary nails without a TT.2 Therefore, we conducted a prospective analysis to compare traction through our IFFRD with that of a TT for cephalomedullary nail fixation of trochanteric fractures. We hypothesized that the IFFRD would be more efficient than a TT for these fractures.

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This study was approved by our hospital's ethics review board. Inclusion criteria were Orthopaedic Trauma Association (OTA) types 31-A1, A2, and A3 trochanteric fractures in elderly patients (>60 years) and those that underwent closed reduction and internal fixation with cephalomedullary nails at our hospital between October 2013 and October 2015. Exclusion criteria were nonambulatory patients and those with additional or pathological fractures. We enrolled 141 patients with 141 fractures (OTA type 31-A1, n = 28; OTA type 31-A2, n = 75; and OTA type 31-A3, n = 38). Patients were randomized using a computer-generated random number table to IFFRD (n = 73) or TT (n = 68) groups. Patient demographics, types of fracture according to OTA classification, and the American Society of Anesthesiologists scores were recorded. All patients underwent routine preoperative blood tests, electrocardiography, and anesthetic assessments.

Patients were either placed on a TT and treated using standard protocols or were treated with the IFFRD. If the IFFRD was used, treatment was as follows (see Video, Supplemental Digital Content 1, Patients were placed supine on a radiolucent operation table with the injured side elevated 25–30 degrees using a radiolucent bump to conduct the fluoroscopic (anteroposterior and lateral) examination and facilitate intraoperative guide wire insertion at the entry point (Figs. 1A, B). The operative site was sterilized and draped. After maintaining the ipsilateral patella in an anterior orientation, the IFFRD (Figs. 2A, B) was assembled by inserting a 4.0-mm Steinmann pin from the AIIS toward the posterior inferior iliac spine and another through the femoral epicondyles (medially to laterally in parallel with the articular surface of the femoral condyle) (Figs. 2C–G). Arc-like rods were inserted into distal transverse holes of an end piece and tightened. The distal Steinmann pin was inserted through transverse holes at the end of the large rod and tightened. The proximal pin, through its cannulated sleeve, was connected to a large radiolucent cannulated spindle. Into this was inserted a smaller diameter radiolucent spindle, the distal end of which is fitted into the sliding carriage of the end piece. (Figs. 2A, B). Once fully assembled, the IFFRD is initially lengthened with manual distraction to slide the smaller spindle distally within the larger. Once sufficient distraction is achieved, shortening is prevented by placing a pin through holes in the larger spindle just proximal to the proximal end of the smaller one. Intraoperative distraction and reduction were performed by rotating the distal sliding carriage and abduction and adduction of the hip joint via proximal cannula rotation around the inner pin to facilitate intraoperative nail insertion. Connections between the smaller spindle and distal and proximal structures allowed internal and external rotation (Fig. 2H).





The same surgical technique was used for both groups. For each operation, 1 surgeon was in charge with 2 scrubbed or unscrubbed assistants. Close reduction was achieved with longitudinal traction in line with the axis of the femur to achieve the original limb length. Limb rotational alignment was confirmed on the basis of lesser trochanter shape sign.3 Reduction was facilitated with a percutaneous ball spike pusher or K wire, if needed. With both reduction techniques, the fracture was fixed with a cephalomedullary nail (proximal femoral nail antirotation; Shandong Hangwei, China). Under fluoroscopic guidance, the selected cephalomedullary nail was inserted across the fracture. Once reduction and nail position were suitable, the cephalic blade was inserted through the nail and into the femoral head with a tip–apex distance of <25 mm using the attached targeting device through stab incisions (for IFFRD, Figs. 3A–F). Distal screws were locked via a mini-incision. We recorded the duration of positioning (transfer from stretcher to normal radiolucent table for IFFRD or TT and positioning), closed reduction and nail insertion (from the beginning of IFFRD assembly or TT manipulation until locking of the distal screw), and fluoroscopy (from activating the foot pedal to image visualization), as well as total operative duration (from beginning of positioning to the end of nail insertion, during which fluoroscopy time was also included). Postoperative management was according to standard protocols.



Radiographs (posterior-to-anterior and lateral views) were obtained on postoperative days 1 or 2. Quality of fracture reduction was graded as good, acceptable (5–10 degrees varus/valgus and/or ante- or retroversion), or poor (>10 degrees varus/valgus and/or ante- or retroversion). Patients underwent clinical and radiological reviews 6 weeks after successful hospital discharge and at 3, 6, and 12 months. Radiographs were analyzed by an independent senior radiologist blinded to group information. Time from surgery to union or failure, complications, and further procedures, if needed, were reviewed.

There were 5 deaths (3—TT and 2—IFFRD) because of comorbidities [heart failure (n = 2); pulmonary infection (n = 3)] within 1 month postoperatively. Six patients (4—TT and 2— IFFRD) finished 6-month follow-up but could not be contacted or refused to return for the 1-year follow-up evaluation. These 11 patients were excluded from this study. The remaining 130 patients (69 cases in the IFFRD group and 61 cases in the TT group) were followed for a minimum of 1 year postoperatively.

Values of all parameters are presented as mean ± SD. Data were analyzed using the Fisher exact and t tests, with results deemed significant at P < 0.05. SPSS 22.0 (SPSS Inc, Chicago, IL) was used for statistical analysis.

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There were no significant differences in age, sex, laterality, American Society of Anesthesiologists grade, preoperative motility, residence status, or fracture classification between the groups (P > 0.05, Table 1). The time required for patient positioning was longer in the TT group (17.82 ± 1.48 minutes) than the IFFRD group (7.26 ± 1.73 minutes; P < 0.05). Durations of surgery (IFFRD, 39.67 ± 3.01 minutes; TT, 41.83 ± 3.31 minutes) and fluoroscopic examination (IFFRD, 3.78 ± 0.78 minutes; TT, 3.91 ± 0.60 minutes) were comparable between the groups (P > 0.05). Total operative duration was longer in the TT group (59.65 ± 3.89 minutes) than the IFFRD group (46.93 ± 3.51 minutes) (P < 0.05). Throughout all 69 IFFRD procedures, 1 scrubbed assistant assembled the IFFRD. In the TT group, a scrubbed assistant was required only during fracture reduction (6/61 procedures) (P < 0.05). No instances of IFFRD failure, including loosening, cut-out of Steinmann pins, or bone fractures at the insertion site, were recorded intraoperatively in this study.



Duration of follow-up ranged from 12–18 months in both groups. Average follow-up was 12.19 ± 1.02 months in the IFFRD group and 12.20 ± 1.08 months in the TT group. No fracture reductions were assessed to be poor postoperatively in either group. Union occurred in all patients of both IFFRD and TT groups. Postoperative fixation failed in 3 IFFRD patients (8, 9, and 14 months postoperatively) and 2 TT fractures (8 and 10 months postoperatively) because of lag screw cut-out postoperatively after weight-bearing.

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The IFFRD can be rapidly assembled in a minimally invasive manner and facilitates fracture reduction and nail insertion because of easy abduction and adduction of the hip joint at will. The anteroposterior supra-acetabular proximal pin is located at the thickest portion of the iliac wing and is firm enough to act as an ideal fulcrum for fracture reduction. The distal connecting point in the middle of the arc-like frame is directly above, in parallel with, the long axis of the patella. The caudal part of the distal arc-like frame is triangular in the sagittal plane, providing sufficient stability with resistance once the distal sliding carriage is stretched to distract the fracture site. As shown in Figure 2H, the IFFRD was well aligned with the long axis of the femur and produced axial distraction forces that were large enough for satisfactory bone fracture reduction. We conducted a pilot study on cadavers and found that, after insertion, both proximal and distal pins could sustain forces up to 26.84 and 28.33 kg, respectively, before pin deformity.

Posterior sag is largely alleviated because the injured lower leg is sustained by the distal part of the radiolucent operating table and can be resolved with bumps, pads, or inflatable floats.4 Although a TT can help achieve the original limb length, external rotation of the proximal fragment because of the short external rotators is possible. Internal rotation of the distal lower leg with the ipsilateral patella oriented anteriorly is a common solution, but only suitable for OTA type A1.1–2.1 fractures; fractures with ≥2 independent fragments (OTA 2.2–3.3), if fixed after internal rotation, are predisposed to malrotation deformities that must be corrected.5 However, with the IFFRD, the support underneath the injured side can not only counteract the external rotation force on the proximal fragment to some extent but also raise the horizontal level of the entry point at the greater trochanter. It may then be easy to perform fracture reduction and nail insertion.

Zhang's reductor has also been indicated for rapid femoral shaft fracture reduction6 and can be indicated for trochanteric fractures as well; it has a proximal pin insertion site (anterior superior iliac spine) and a different distal design. Although anterior-superior iliac spine or AIIS access is equally easy, the excellent supra-acetabular bone stock used by the IFFRD is biomechanically advantageous over the gluteus medius tubercle and pillar used by Zhang's reductor.7 In contrast to the smaller, simpler, triangular distal IFFRD, the distal Zhang's reductor, a 4-legged scaffold combining a distal pin with a connected traction bow, must be supported by a table during traction.6

After completion of this study, we improved the distal structure of IFFRD to simplify assembly and widen its indications. The IFFRD plus a tibia set (for tibia fractures) is currently commercially available (ShanDong HangWei medical instruments, China) for a low price (less than 5000 USD). Therefore, the application of IFFRD may be cost effective. Capital equipment costs may decrease because multiple, expensive fracture tables are not needed. Although scrubbed assistants assemble the IFFRD, their cost is offset by the short operative duration, simple surgical procedure, and wide indications besides trochanteric fractures and shaft fractures of the femur. We applied this device for closed reduction and cephalomedullary nail insertion of trochanteric fractures and found that the IFFRD is efficient, reliable, and easy to use.

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1. Güven M, Kocadal O, Akman B, et al. Proximal femoral nail shows better concordance of gait analysis between operated and uninjured limbs compared to hemiarthroplasty in intertrochanteric femoral fractures. Injury. 2016;47:1325–1331.
2. Wang ZG, Zhang K, Jia L, et al. Closed femoral nailing with the technique of using a new femoral distractor: a preliminary report. J Biol Regul Homeost Agents. 2015;29:683–687.
3. Krettek C, Miclau T, Grün O, et al. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury. 1998;29:C29–C39.
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5. Riehl JT, Widmaier JC. Techniques of obtaining and maintaining reduction during nailing of femur fractures. Orthopedics. 2009;32:581.
6. Chen W, Zhang T, Wang J, et al. Minimally invasive treatment of displaced femoral shaft fractures with a rapid reductor and intramedullary nail fixation. Int Orthop. 2016;40:167–172.
7. Cole PA, Dyskin EA, Gilbertson JA. Minimally-invasive fixation for anterior pelvic ring disruptions. Injury. 2015;46(suppl 3):S27–S34.

trochanteric fracture; closed reduction; intraoperative femoral fracture reduction device; traction table

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