Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications

Outcomes of surgical hip dislocation combined with bone graft for adolescents and younger adults with osteonecrosis of the femoral head: a case series and literature review

Background

Osteonecrosis of the femoral head (ONFH) may occur in the adolescent and younger adults (AYAs). Total hip arthroplasty (THA) is not the best treatment option for younger patients. Surgical hip dislocation (SHD) combined with bone graft can be used in patients at different stages to reconstruct the bone structure in the head and delay the replacement time. The purpose of this study was to evaluate the effect and potential influencing factors of this surgery for ONFH in AYA patients. 

Methods

We conducted a literature review and a retrospective research of our own cases. The Pubmed, Cochrane Library, EMBASE and CNKI databases were searched from 1 January 2001 to 1 October 2021, for clinical studies. A retrospective case series study of 34 patients (38 hips) treated with SHD combined with bone graft was performed.

Results

A total of 13 studies were included and the results showed that SHD combined with bone grafts had better clinical results for patients with pre- or early post-collapse. In the case series study, we retrospectively analyzed 34 patients (38 hips), and the mean follow-up time was 40.77 ± 15.87 months. One patient died and three patients were converted to THA finally. The post-collapse degree and post-lesion size were better than those before the operation (P < 0.05). The iHOT-12 at the last follow-up was significantly higher than that before the operation (P < 0.05). There were significant differences in the results of hip Harris score (HHS), visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before the operation, 2 years after the operation and at the last follow-up, but the difference was not related to the follow-up time (P < 0.05). There were no significant differences in the final clinical score and arthritic changes among different Japanese Investigation Committee (JIC) classification, the degree of collapse and the size of the necrotic (P > 0.05).

Conclusions

In AYA patients, SHD combined with bone grafting is a potentially good option for hip preservation in ONFH. The differences in JIC classification, collapse degree and lesion size did not affect the final clinical function and the risk of osteoarthritis. Even for very severe cases at collapsed stage, good short-term clinical effects can still be achieved by SHD combined with bone graft.

Trial registration

ChiCTR2100055079.retrospectively registered. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05456-w.

Corticoperiosteal Pedicle Flap of Greater Trochanter for Salvage of Old Femoral Neck Fracture in Children: Outcomes After a Minimum 5 Years Follow-up

BACKGROUND

Old femoral neck fracture (OFNF) generally refers to fractures for more than 3 weeks. Corticoperiosteal pedicle flap of greater trochanter (CPPF-GT) was designed to restore blood supply and donor bone for OFNF. This study aimed to assess the efficacy and radiographic results of CPPF-GT for treatment of OFNF in children after a minimum 5 years follow-up.

METHODS

Twenty-three patients with OFNFs, age from 8 to 16 years old, who underwent open reductions, fracture fixations, and transpositions of CPPF-GTs were retrospectively reviewed. Clinical and radiological outcomes, including union, nonunion, avascular necrosis of femoral head, limb shortening, coxa vara, premature epiphyseal closure and Ratliff's assessment, were investigated in the postoperative follow-up. The results were compared with previously published joint-salvage study of OFNFs.

RESULTS

All patients were followed for an average of 5.9 years (range: 5 to 10 years). All cases (100%) achieved hip unions at an average duration of 3.5 months (range: 2.5 to 5 months). No nonunion hip was observed. Three hips (13.0%) progressed to avascular necrosis of femoral head after 1.5 to 3 years of operation, respectively, and the revision surgeries to hip replacements were conducted. Premature epiphyseal closures were observed in 3 hips. Three hips visibly presented an average 2 cm shortening of the femoral neck. Coxa vara deformities were observed in 2 hips. According to the Ratliff's criteria, there were 20 cases (87.0%) with satisfactory union, good results were achieved in 17 cases, fair results in 3 cases, and poor result in 3 cases.

CONCLUSIONS

Corticoperiosteal pedicle flap of greater trochanter is an effective and desirable option for treating old femoral neck fractures in children with a low rate of avascular necrosis and without nonunion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Controversies in the management of pediatric neck femur fractures- a systematic review

Purpose

To review controversies systematically in the management of pediatric neck femur fracture from the literature and to develop consensus for the optimum management.

Methods

Authors searched literature by using keywords of pediatric neck femur fracture, proximal femur fracture, complications, management by following PRISMA guidelines. A common dilemma was listed.

Results

Age, mechanism of injury, fracture type, presentation, treatment method, implant, and nature of complications were compared. Inference from recent literature was extracted for optimum management.

Conclusion

Immediate anatomical reduction with stable fixation must be accomplished. Complications continue to happen despite the best efforts and a longer follow-up is important.

Fractures of the Proximal Femur in Childhood: A Review

BACKGROUND

Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications.

PURPOSE

To review the current knowledge, discuss controversial aspects, and provide suggestions for future research.

METHODS

We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed.

CONCLUSION

There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.

Does the timing of treatment affect complications of pediatric femoral neck fractures?

Objectives

Pediatric femoral neck fractures were reviewed to compare complications with the time of presentation.

Methods

34 pediatric femoral neck fractures were studied to detect union time, avascular necrosis, premature physis fusion, and the neck-shaft angle. All complications were comparable between both groups.

Results

The mean union time was more in late presented group. Four children developed AVN. The neck shaft angle and pre mature fusion of growth plate were same in both groups.

Conclusions

The frequency of the complications except union time in pediatric neck femur fracture is comparable in early and late presented groups.

Surgical treatment with cannulated screws for pediatric femoral neck fractures: A case series

INTRODUCTION

Femoral neck fractures are uncommon injuries in children, but the high incidence of long-term complications makes it important clinical entity. Early surgical treatment to achieve optimal results and to avoid a high rate of complications is widely advised. The purpose of this study was to retrospectively analyze the outcome of 8 children who sustained a femoral neck fracture.

PATIENTS AND METHODS

The patients (6 boys and 2 girls with an average age of 9.2 years) were treated within 24 h following admission to hospital by closed reduction and internal fixation. The type of fracture was distinguished according to Delbet's classification system. The outcome was analyzed using Ratliff's criteria, and a detailed record of complications was maintained.

RESULTS

According Delbet's classification system, there were 3 type I, 2 type II, 2 type III, and 1 type IV fractures. The average follow-up was 39.2 months (range 8-95). A satisfactory outcome was obtained in 6 (75%) children. Avascular necrosis was the most notable complication, which was reported in the 2 fair outcomes (25%).

CONCLUSIONS

Early and aggressive surgical treatment aimed at anatomical reduction result in a satisfactory outcome in pediatric femur neck fractures. Development of avascular necrosis is the main complication.

Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis

PURPOSE

Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours).

METHODS

We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures. We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type femoral neck fractures. Descriptive and qualitative data was also extracted.

RESULTS

Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19, 95% CI 0.56, 2.51, I² = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I² = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I² = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I² = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively.

CONCLUSIONS

The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures.

LEVEL OF EVIDENCE

II/III.

Early prediction of outcomes in hip fractures: initial fracture displacement

We retrospectively analyzed the surgical treatment of 28 pediatric hip fractures. The majority of cases were Delbet type 2 (57%) and type 3 (29%). The average age of the patients was 10.8 years (range: 2-16 years). The mean follow-up period was 91 months. Displaced fractures were found in 18 cases (64%). The major factor in the development of avascular necrosis was the degree of displacement at the time of initial presentation (P<0.05), irrespective of fracture type. Although the degree of initial displacement cannot be prevented, careful exposure of soft tissue during open reduction will reduce avascular necrosis.

Osteonecrosis After Femoral Neck Fractures in Children and Adolescents: Analysis of Risk Factors

BACKGROUND

The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development.

METHODS

This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis.

RESULTS

Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment.

CONCLUSIONS

Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.

Femoral fractures in children

PURPOSE OF REVIEW

Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes.

RECENT FINDINGS

This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head.

SUMMARY

Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.

Free vascularised fibular graft for post-traumatic osteonecrosis of the femoral head in teenage patients

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement. Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients.