Isolated cerclage

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

Fracture patterns are typically spiral and/or short oblique that can undergo direct reduction and compressive fixation with isolated cerclage.

Direct lateral approach to the femoral diaphysis is typically utilized. This will require an extension to the proximal femur. Depending on the location of the greater trochanteric fracture, the vastus lateralis origin may need to be released and repaired after stabilization.

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.

The lateral position is preferred when:

• Repair of the lesser trochanteric fracture is indicated, to adequately visualize the posteromedial aspect of the proximal femur.
• The patient is obese

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

• Anterolateral approach
• Direct anterior approach
• Iliofemoral (Smith-Petersen) approach
• Posterolateral approach
• Trochanteric osteotomy

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

A radiolucent table or a fracture specific table, that can provide traction through the foot and ankle, may be used.

Reduction is typically carried out using a combination of direct and indirect methods. Limb abduction will help in an indirect manner. Direct reduction with clearance of fracture hematoma and stabilization with pointed bone reduction clamps can then be completed.

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

It is applied from the direct lateral incision with proximal extension.

Fracture patterns typically involve the greater trochanter…

…or the lesser trochanter.

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 a 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.

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.

Select a wire or non-beaded cable. The female component of the closed loop passage system is inserted from the posterior side.

The male component is inserted from the anterior side.

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

The wire is passed inside the closed loop system.

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

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

Wires should be tensioned in a sequential manner to avoid fracture displacement. All provisional reduction aids should be maintained until all wires are tensioned.

Alternatively, cable tension is performed.

The crimp from the cable should be placed directly over the trochanter with the medial aspect of the cable distal to the lesser trochanter, if possible.

The typical pattern that requires stabilization has a large distal extension.

This allows for cerclage placement just proximal to the lesser trochanter and around the proximal diaphysis.

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

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.

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.

If a greater trochanteric fracture has been treated, the patient should not be allowed to perform active abduction exercises until at least 6 weeks postoperatively. An abduction brace may be considered.

Traditionally, extended periods of limited weight bearing were utilized, however increasing stability of the fracture should be a priority to facilitate mobilization.

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.