Injury, Int. J. Care Injured 44 (2013) 168–174 Contents lists available at SciVerse ScienceDirect Injury jo urnal homepage: www.elsevier.com/locate/injury Percutaneous cerclage wiring, does it disrupt femoral blood supply? A cadaveric injection study T. Apivatthakakul *, J. Phaliphot, S. Leuvitoonvechkit Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand A R T I C L E I N F O A B S T R A C T Article history: Background: A percutaneous cerclage wiring technique has been developed to reduce iatrogenic soft Accepted 14 October 2012 tissue and vascular disruption associated with classic cerclage fixation. Objectives: The purpose of this study was to evaluate the extent of femoral vascular disruption resulting Keywords: iatrogenically from the application of two percutaneous cerclage wire loops. Percutaneous cerclage wiring Methods: Pairs of cerlage wire loops were percutaneously inserted on 18 fresh cadaveric femurs. The Femoral blood supply position of the wire loops varied. The wire loops were either inserted 10 and 15 cm, 10 and 20 cm, or 15 Superficial femoral artery and 20 cm distal to the tip of the greater trochanter. Each study group had 6 cadavers. Contralateral Deep femoral artery femurs without cerclage wiring were used as controls. Liquid contrast–gelatin was injected into the Perforating arteries common femoral artery. Using axial and 3D CT scan images the superficial femoral artery (SFA), deep femoral artery (DFA), perforating arteries and their anastomotic patterns as well as endosteal perfusion were identified and their patency was graded. Results: Percutaneous cerclage wiring did not disrupt femoral endosteal blood supply and maintained the integrity of all of the superficial femoral arteries. Four specimens demonstrated maintenance of all 4 perforators, 11 showed disruption of 1 perforator, and 3 showed disruption of 2 perforators. One deep femoral artery was disrupted after its first perforator branched off; however, perfusion was maintained by fill from an alternative anastamosis. There was no significant difference between disruption of deep femoral arteries and perforating arteries (P = 1.000), location of wiring (P = 0.905) or spacing between wire loops (P = 1.000). Conclusion: Percutaneous cerclage wiring resulted in minimal disruption of the femoral blood supply. When partial disruption occurred the SFA, DFA, and their associated perforators compensated to maintain femoral perfusion through their anastomoses. The location of the cerclage wire and the distance between the wire loops in the proximal femur showed no significant difference in the rate of iatrogenic perforator injury. ß 2012 Elsevier Ltd. All rights reserved. Introduction well suited for obtaining and maintaining the reduction of oblique, spiral or spiral wedge fractures. Cerclage wiring is classically done Recent developments in modern surgical techniques for using an open technique, which requires soft tissue stripping. For fracture treatment have aimed to reduce the surgical insult to this reason many have the opinion that cerclage wiring can surrounding soft tissues and fracture zone vascularity. Conven- resulting in ‘‘Strangulation of blood supply’’. A cerclage itself is not tional open reductions performed through extensive surgical strong enough to withstand forces occurring during functional approaches afford great fracture visualization at a cost, potentially fracture aftercare and requires some form of augmentation. The increasing the risk of bone necrosis, delayed union and/or disrepute that cerclage technology has suffered for decades is infection. Minimizing ones surgical insult, accomplished using related to these disadvantages, and some disappointing early 4 indirect reduction techniques, allows for faster bone healing results. 1,2 because bone vascularity is maintained or can be restored early. It is possible that applying some of the principles of minimally Cerclage wiring is a well-known procedure in the treatment of invasive fracture surgery to cerclage application may improve the 3 5,6 periprosthetic femoral fractures. Its centripetal mode of action is technologies clinical utility. Apivatthakakul et al. described a percutaneous cerclage technique to treat femoral shaft fractures using a cerclage passer. The cerclage passing instrument 1 (Synthes ) facilitates minimally invasive direct fracture reduction * Corresponding author at: Tel.: +66 53 945544; fax: +66 53 217144. while leaving a small footprint on bone (Fig. 1). The newly E-mail address: [email protected] (T. Apivatthakakul). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.10.016 T. Apivatthakakul et al. / Injury, Int. J. Care Injured 44 (2013) 168–174 169 Fig. 1. The percutaneous cerclage passer consists of 2 dividable forceps which are connected in the middle flat part. When closing the forceps, the tube tips will meet together. developed instrument allows wire passage through a 2–3 cm small The common femoral vessels were exposed bilaterally at the femoral incision. It permits the ability to obtain and maintain fracture triangle using 8 cm longitudinal incisions. The common femoral reduction without obstructing definitive plate or intramedullary artery (CFA) was catheterized and secured with two non-exclusive nail fixation. Small incisions preserve the soft tissue envelope silk ties. The proximal part of the CFA was ligated to prevent the around the fracture zone, theoretically resulting in less iatrogenic liquid contrast gelatin from tracking proximally. The clotted blood blood flow disruption than an open wiring technique. was flushed from the artery with 300 ml of warm normal saline until The purpose of this study was to evaluate the extent of the saline flowed through the common femoral vein. iatrogenic femoral vascular disruption that resulted from the A pair of cerclage wire loops was inserted percutaneously at 3 application of two cerclage wire loops placed in different positions. different intervals depending on the assigned group. In the first This information will help define the clinical application of group of femurs the wire loops were inserted 10 and 15 cm distal percutaneous cerclage wiring. to the tip of the greater trochanter. In the second and third groups, the wire loops were placed 10 and 20 cm, and 15 and 20 cm distal Materials and methods to the tip of the greater trochanter, respectively. Each study group consisted of 6 cadavers. In each cadaver the non-cerclaged Eighteen fresh human cadavers (10 males and 8 females), age contralateral femur represented normal vascular anatomy and range from 22 to 72 years old, were obtained for this study. The allowed for a comparison. donors were free of conditions affecting lower limb vascularity. We The percutaneous cerclage technique consisted of making a 2– obtained Institutional Ethical Committee Board approval for the 3 cm longitudinal incision through skin, subcutaneous tissue and study protocol. The torso was supine during lower limb preparation. fascia at the designated level. Deep dissection was performed Fig. 2. (a) The cerclage passer inserted through a small incision, the wire was passed into the cerclage tube. (b) The wire tensioner was used to twist the wire around the femur. 170 T. Apivatthakakul et al. / Injury, Int. J. Care Injured 44 (2013) 168–174 Fig. 3. (a) Three dimensional reconstructed CT of the blood supply of the femur. (a) Anterior view, (b) lateral view, (c) posterior view and (d) medial view. (b) Three dimensional reconstructed CT of the blood supply of the femur after 2 cerclage wire loops (white arrows) were applied. (a) anterior view, (b) medial view, (c) posterior view and (d) lateral view. In this specimen the second perforator was interrupted, however, all the blood vessels were filled by the anatomosis. (c) The axial CT used to determine the nutrient artery (red arrow) and follow through the artery. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.) directly to the lateral aspect of the femur. A cerclage tunnelling device. The trocar was removed from both sides of the forcep and a device was used to facilitate the insertion of the cerclage passer cerclage wire was passed through the cerclage passer until the wire through the intermusucular septum. A trocar was placed in each passed through the opposite side (Fig. 2a). The forcep was unlocked tube of the cerclage passer to prevent the soft tissue from entering and the two halves of the forcep were disconnected and removed. the cannulated tubes. One half of the cerclage passer was inserted The wire tensioner was used for tightening each cerclage with gently into the prepared tunnel dorsally. The other half of the equal tension (Fig. 2b). The second wire loop was passed and forcep was inserted ventrally. The flat middle parts of the forceps tightened using the same technique. were connected and the forcep handles were then brought Liquid contrast (Omnipaque 0.35%) mixed with gelatin and dye together and secured by locking the bracket on the end of the 50–80 ml was injected through the catheterized CFA until the dye T. Apivatthakakul et al. / Injury, Int. J. Care Injured 44 (2013) 168–174 171 Fig. 4. (a) The DFA was interrupted by the upper wire loop resulted in decrease the blood supply to the posterior and medial part of the femur. However, the distal part of the perforator was demonstrated by the anastomosis from perforating anastomosis or SFA (lower red arrow). (b) The perforating anastomosis system from first to fourth perforators and the distal part of DFA (red rectangular area). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.) was seen at the subcutaneous incision on the medial side of the Results proximal tibia. The torso was left at room temperature for 20 min to allow the gelatin to harden. An axial CT scan with a 3D There was no notable variation in the vascular anatomy 1 reconstruction (Siemen , Somatom definition) of both femurs was between the left and the right side.