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Kinast et al.

compared their results of open reduction and blade plate fixation of


subtrochanteric fractures with indirect reduction and fixation. They found that delayed union
or nonunion resulted in 16.6% of fractures fixed with open reduction and in none fixed with
indirect reduction; infection rates were 20.8% and 0%. Siebenrock, Muller, and Ganz
reported indirect reduction and internal fixation with a condylar blade plate of 15
subtrochanteric fractures. Fourteen of 15 fractures healed (93%) after an average of 3 months.
They emphasized the importance of not disturbing the vascular supply to the fracture
fragments.
TECHNIQUE 52-5
Kinast et al.

Position the patient supine on a standard operating table, and make a standard lateral
approach to the hip joint (see Chapter 1).

Free the fascia of the vastus lateralis laterally and transversely at the inferior aspect
of the greater trochanter. Carefully retract the vastus lateralis to expose only the
lateral aspect of the femur.

Insert the blade of the plate into the proximal fragment at the level determined by
preoperative radiographs (Fig. 52-30A). Apply the shaft of the plate to the main
distal fragment with self-centering bone-holding forceps, and reduce the fracture to
the shaft of the plate. If shortening is significant, apply the femoral distractor
laterally and distract the fracture (Fig. 52-30B).

If shortening is minimal, place an outrigger screw in the cortical bone distal to the
plate, and use the plate tension device as a distractor to overdistract the fracture
slightly. The medial fragments often reduce spontaneously (indirectly) because of
their soft-tissue attachments. If further reduction is necessary, manipulate the
fragments with a small pestle; to prevent soft-tissue stripping, do not manipulate the
fragments from the cortical surfaces. Attempt to obtain anatomical reduction if
possible; however, anatomical reduction and restoration of the medial buttress are
not absolutely necessary.

When the medial fragments have been aligned, use the tensioning device to
compress the fracture axially (Fig. 52-31A), locking the fragments and holding
them. The fracture must accept axial compression, and the fragments should be
trapped medially if possible. If the medial fragments are not locked, they are
considered vascularized bone grafts and are left in place, but the plate is still loaded
with the tension device.

When the fracture is stable and accepts the applied load, fix the plate to the femoral
shaft with enough screws to ensure stability (Fig. 52-31B).

Obtain interfragmentary fixation through the plate or outside it, but avoid further
periosteal stripping.

Close the wound in the usual manner.

Fig. 52-30 Indirect reduction technique of Kinast et al. A, Blade is inserted into proximal fragment. B, Lateral application of femoral distractor.
(From Kinast C, Bolhofner BR, Mast JW, et al: Subtrochanteric fractures of the femur: results of treatment with the 95-degree condylar blade-plate,
Clin Orthop Relat Res 238:122, 1989.)

Fig. 52-31 A, Use of tensioning device. B, Plate is fixed to shaft with screws.
(From Kinast C, Bolhofner BR, Mast JW, et al: Subtrochanteric fractures of the femur: results of treatment with the 95-degree condylar blade-plate,
Clin Orthop Relat Res 238:122, 1989.)

AFTERTREATMENT

Aftertreatment is similar to that for hip compression screw fixation of intertrochanteric


fractures. Generally, the medial buttress is not completely restored, and only touch-down
weight bearing is allowed until signs of early fracture healing are present at 6 to 8 weeks. Full
weight bearing usually is delayed for up to 3 months after surgery.

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