Contoured DCS plate with Valgus reduction successful in recalcitrant subtrochanteric non-unions

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature.

Barakat El Alfy et al conducted a study to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries. In this study, they converted the subtrochanteric non-union, known by its resistance to the union, into a subtrochanteric valgus osteotomy, known for its high healing potential. The study has been published in ‘International Orthopaedics.’

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery were included in the study. The exclusion criteria were as follows: septic non union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The mechanical axis is adjusted to pass just lateral to the medial cortex at the fracture site. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

Key findings of the study were:

• The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case.

• The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value< 0.001).

• The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union.

• The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value< 001), achieving 15 excellent, ten good, and one poor results.

The authors concluded that – “Recalcitrant subtrochanteric non-unions are more challenging to treat. Combining debridement, resection of the bone edges, valgus reduction, and fixation by contoured DCS plate with or without iliac bone graft resulted in a successful, encouraging outcome in managing such difficult cases. It is a valid option to consider when treating patients with aseptic subtrochanteric non-unions who have experienced single or multiple failed revision surgeries. 

Further reading:

The effect of valgus reduction on resistant subtrochanteric femoral non unions: a single centre report of twenty six cases

Barakat El Alfy, Alaa Abououf et al

International Orthopaedics

https://doi.org/10.1007/s00264-023-06085-1