Authors of section

Authors

Derek Donegan, Michael Huo, Michael Leslie

Executive editor

Michael Baumgaertner

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Isolated cerclage

1. Principles

In the setting of a stable femoral prosthesis, the goals include pain control, fracture healing, and maintaining a stable hip prosthesis.

This is typical of proximal fit prostheses that present spiral and/or short oblique minimally displaced fracture patterns, that can undergo direct reduction and compressive fixation with isolated cerclage.

Note: Careful evaluation of the femoral prosthesis must be performed to ensure that the stem is stable, or preparation for a possible revision must be considered.
Isolated cerclage in a periprosthetic femoral fracture with a stable prosthesis

2. Approach

Direct lateral approach

Direct lateral approach to the femoral diaphysis is typically utilized. This can be performed in a minimally invasive fashion for some fracture patterns and proximal and/or distal extension of deep surgical approach can be utilized in a fracture specific manner.

Direct lateral approach for hip periprosthetic fractures

Positioning for direct lateral approach

This approach can be performed in the supine or lateral position.

If there is any suspicion of prosthetic loosening that may be discovered intraoperatively, the surgeon should position the patient for a potential revision arthroplasty.

Other approaches

Other approaches that can be used to perform this procedure are:

These approaches can be performed with the patient in a lateral or supine position.

3. Reduction

Direct reduction

Reduction is typically carried out in a direct manner with clearance of fracture hematoma and stabilization with pointed bone reduction clamps.

The Collinear reduction clamp can be extremely helpful in facilitating reduction. It is easily applied from the direct lateral incision.

Direct reduction and stabilization of a hip periprosthetic fracture

Traction aids

The reduction can be facilitated with manual traction and/or distal femoral skeleton traction.

Skeletal traction may be placed in the distal femur or the proximal tibia, depending on surgeon's preference.

However, the distal femur is much more effective in facilitating reduction of periprosthetic femur fractures.

Traction aids to facilitate fracture reduction

Note: Traction in osteoporotic patients should be used with caution, because it may injure the patient. In case of severe osteoporosis, this may result in the traction pin pulling through the bone into the knee joint.
Risk of pin migration during traction in osteoporotic patients

4. Fixation

Implant selection

Compression can be achieved for these fractures with:

  • Non-beaded cerclage type cables
  • Beaded cerclage type cables: this type of system enables a more minimally invasive approach
  • Large gauge wires (no less than an 18 gauge)

This can be performed in a minimal invasive or open technique, depending on available equipment and the amount of displacement of the fracture.

Cerclage implant selection

Instrument selection

Care should be taken in passage of either construct. If available, a closed loop passage system is both safe and effective. However, a more traditional cerclage cable passer can be safely utilized also.

Cerclage instrument selection

Cable/wire positioning

The first wire or non-beaded cable should be placed in the middle of the fracture.

The female component of the closed loop passage system is inserted from the posterior side.

Cable/wire positioning

The male component is inserted from the anterior side.

Handle male component insertion

The handle components are aligned together, creating a closed loop system.

Handle components alignment

The wire is passed inside the closed loop system.

Wire insertion

The closed loop system is removed, and the wire is left in place.

Closed loop system removal

The same procedure is repeated for the insertion of each wire.

At least one proximal and one distal cable are placed to stabilize the fracture.

Other wires are inserted

Wires should be tensioned in a sequential manner to avoid fracture displacement.

All provisional reduction aids should be maintained until all cables are crimped.

Alternatively, cable tension is performed.

Cable tensioning

Radiographic verification

Antero-posterior and medio-lateral radiographs of both the fracture sites and the arthroplasty are obtained at the end of the procedure, to ensure that:

  • There is no displacement
  • The joint articulation is preserved
  • There is no dislocation, that may be caused by excessive distraction of the limb or a malreduction of the femur

5. Aftercare following ORIF

Postoperative management

Postoperative management should include careful monitoring of hematocrit and electrolytes particularly in the elderly patients.

Postoperative IV antibiotics should be administered up to 24 hours.

Consideration should be given to anticoagulation for a minimal course of 35 days. If there are thromboembolic complication this treatment is extended.

Drains can be discontinued when output is less than 30 to 50 cc per 12 hours.

Patient mobilization

Immediate mobilization of the patient should commence. If fracture stability will allow, the patient should be made weight bearing as tolerated as soon as possible. Long periods of limited weight bearing are extremely detrimental to patient recovery.

Patient mobilization with limited weight bearing

Wound healing

Avoidance of edema postoperatively is critical for both wound healing and patient mobilization. This can be aided by pneumatic compression devices. If negative pressure wound therapy is utilized, it can be discontinued after 5 to 7 days. Staples or sutures are typically removed at 14 to 21 days.

Pneumatic compression device