Compared with femoral shaft fractures and intertrochanteric fracture, subtrochanteric femur fractures present significant treatment challenges.1 Failure to appreciate the complexities of this injury may lead to serious consequences like this case. Increased understandings of biomechanical characteristics of the subtrochanteric fracture and comprehensions of the implant materials can reduce the incidence of complications.5
The lesson of this case was worth summarizing. In the first operation, the quality of reduction was dissatisfied. Furthermore, it was a short femoral nail which was lack of mechanical advantages that was chosen by surgeons. The choice of the appropriate implant to be critical for fixation of subtrochanteric femur fractures. The appearance of intramedullary nail provides the basis for closed reduction or minimally invasive open reduction.6 A long femoral nail is the first choice for subtrochanteric fractures which has become a consensus.3,4,7
In the second and third operations, anatomical open reduction could disturb the biological composition of the fracture environment.Due to extensive incision, the blood supply was destroyed. Failures again were inevitable. The core concept of fracture healing is the balance between the stability of fixation and the blood supply of bone. 8 Units biomechanical and biological aspects were the “diamond concept”.8 Open reduction may disturb the biological composition of the fracture environment. Althouth the advantage is represented by anatomical reduction, open reduction internal fixation techniques in this fracture is not necessary. Proximal femoral locking plates are associated with a high complication rate9. Plates have an eccentric location relative to the mechanical axis of the femur, making them biomechanically inferior to nails in bending.9 Some minimal invasive techniques could help the surgeon achieve satisfactory reduction in Subtrochanteric fractures.3,4,7
By the fourth operation, the biological advantage was gone. Different from the treatment of fresh fracture, when replacing the internal fixation, it should be taken into account that the long intramedullary nail not be as relatively stable fixation. The strain at the fracture end had exceeded the requirements for relatively stable internal fixation, whick had become absolutely unstable. Despite advances in surgical techniques, alternatives to fracture fixation and assistive means of healing, femoral nonunion continues to be a significant clinical problem. It’s a horrible complication that greatly prolongs rehabilitation and introduces risk of other complications.5,10 The prevention of nonunion should be emphasized. Half cases of nonunion are caused by improper selection or use of internal fixation.11Reduction quality is the critical factor to prevent nonunion in treatment of subtrochanteric fracture with intramedullary nail.12
We judged that the reason why nonunion was that medullary cavity here was relatively wide. This patient was a atrophic, unstable fracture end with rotation, ischemic nonunion. With the retention of PFNA, the patient was healed by the freshening of the broken end, bone grafting, auxiliary steel plate at the last operation. For the treatment of nonunion after failed nailing, augmentative plate fixation which is applied to the fracture site to provide a rigid fixation can be an ideal choose.13It healed in an average of six months, with no complications were reported.14
It was a tragedy for the man and his family, as well as for previous surgeons. The case had the potential to improve the cognition of subtrochanteric fractures for surgeons, especially beginners and juniors.
Choice of fixation method, meticulous preoperative planning, master the surgical techniques, respect the principles of biological osteosynthesis and concept of minimally invasive surgery for subtrochanteric fractures ars critical to reduce nonunion and reoperation rates.