Subtrochanteric Fractures: One Case Reports of Terrible Treatment

Background: Deforming muscle forces make treatment of subtrochanteric fractures challenging. Choice of xation method, meticulous preoperative planning, master the surgical techniques, respect the principles of biological osteosynthesis for subtrochanteric fractures are critical to reduce nonunion and reoperation rates. Case presentation: We present a clinical case who underwent sever years of treatment with ve operations. It was a tragedy for the man and his family, as well as for surgeons. We hope this case has the potential to improve the cognition of subtrochanteric fractures for orthopedics surgeons, especially beginners and juniors. Conclusion: Choice of xation 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.


Background
Subtrochanteric fracture occurs within 5 centimeter of the distal end of the trochanter. 1 Because a growing prevalence of osteoporosis and motor vehicle accidents, the number of subtrochanteric fractures is increasing worldwide. 2 The subtrochanteric region has certain anatomical and biomechanical features that can make fractures in this region di cult to treat. Under the trochanter is the area where the cancellous bone between the trochanters moves to the cortex of the femoral shaft, which is the place where the stress conduction is highly concentrated. The inner side is compressive stress and the outer side is tensile. Conservative treatment for this fracture cannot provide good reduction, so malalignment usually occurs. 3 Thus, internal xation is advocated by most Surgeons 4 . Intramedullary nail has many advantages of managing a femoral subtrochanteric fracture such as small skin incisions, central xation, closed indirect reduction can be achieved through minimally invasive techniques. 4 If one didn't respect the principles of biological osteosynthesis, master the surgical techniques, follow the concept of minimally invasive surgery, it would be painful and serious for the patient. We presented one clinical case, the patient underwent sever years of treatment with ve operations. The lesson was profound and worth rethinking thoroughly.

Case Presentation
The patient was a 30 year old men. He fell from a height of three meters, causing a shortened deformity, swelling in the proximal portion of the left thigh. Plain X-ray image viewed revealed a subtrochanteric The lesson of this case was worth summarizing. In the rst operation, the quality of reduction was dissatis ed. 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 xation 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 rst 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 xation 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 xation techniques in this fracture is not necessary. Proximal femoral locking plates are associated with a high complication rate 9 . 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 xation, it should be taken into account that the long intramedullary nail not be as relatively stable xation. The strain at the fracture end had exceeded the requirements for relatively stable internal xation, whick had become absolutely unstable. Despite advances in surgical techniques, alternatives to fracture xation and assistive means of healing, femoral nonunion continues to be a signi cant 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 xation. 11 Reduction 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 xation which is applied to the fracture site to provide a rigid xation can be an ideal choose. 13 It 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 xation 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.
Declarations XZD is the rst author and HT is the corresponding author. XZD, HZ, DKT,JF performed the operation and substantially contributed to the drafting and revision of the manuscript. All authors revised the manuscript. All authors read and approved the nal manuscript.   Plain X-ray images revealed a subtrochanteric fracture.  3a,b In the second operation,a sawtooth-arm internal embracing xator was used. 3c It was broken thirtyeight months after the initial surgery.

Availability of data and materials
Page 8/9 Figure 4 4a,b In the third operation, a bridge combined internal xation system was performed. 4c,d It was broken sixty-ve months after the initial surgery. Figure 5 5a,b In the fourth operation, the case was treated with a long proximal femoral nail antirotation 5c,d The nonunion of the fracture was persisted.
Page 9/9 Figure 6 6a,b Locking compression plate was used to x the nonunion. 6c,d X-ray showed signs of fracture healing.