Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults

A recent update on the fixation techniques for femoral neck fractures: A narrative review

Femoral neck fractures present significant challenges in orthopedic surgery, particularly due to technical difficulties and a high complication rate. Surgical intervention is generally recommended, with osteosynthesis and arthroplasty being the main treatment options. Osteosynthesis techniques, including dynamic hip screw (DHS), multiple cannulated screws (MCS), and the femoral neck system (FNS), aim to achieve stable fixation and facilitate fracture healing. Factors influencing the choice of osteosynthesis include fracture displacement, bone quality, patient age, and the presence of posterior tilt. While DHS offers high stability, MCS is preferred in stable type fractures with minimal invasive procedures. FNS, a newer technique, combines the advantages of DHS and MCS, providing strong fixation with minimal soft tissue damage. Considering the comprehensive findings of biomechanical and clinical studies to date, when performing osteosynthesis for unstable femoral neck fractures, caution should be exercised with MCS as it may have slightly inadequate fixation strength compared to DHS and FNS. FNS, being the newest technique, demonstrates superior fixation strength comparable to DHS and is as minimally invasive as MCS. However, it is essential to remember that long-term follow-up results are lacking for FNS.

A Pilot Study of Functional Outcomes in Adult Patients Treated With Valgus Intertrochanteric Osteotomy as a Primary Modality for Intracapsular Femoral Neck Fracture

Background Intracapsular femoral neck fractures account for a majority of hip fractures. This study aimed to investigate the efficacy of valgus osteotomy as a primary treatment for intracapsular femoral neck fractures in adult patients aged 15-60 years, assessing its impact on functional outcomes and fracture union. Methodology A retrospective clinical analysis was conducted at the Department of Orthopedics and Traumatology, Osmania Government General Hospital, Hyderabad, India, focusing on patients treated with primary intertrochanteric valgus osteotomy for intracapsular femoral neck fractures. The study reviewed medical charts and radiographs of six patients aged between 15 and 60 years, diagnosed with recent isolated intracapsular femoral neck fractures, presenting between May 2019 and October 2021. The intervention involved Pauwels' intertrochanteric valgus osteotomy with various fixation methods. Main outcome measures included radiographic union, functional ability assessed by the Harris Hip Score, and evaluation for complications. Results All six patients achieved radiographic union at fracture and osteotomy sites, totaling a 100% success rate. The average follow-up duration was 14.8 months (12-20 months), with an average time of 5.1 months (2.5-6 months) from surgery to radiographic union. One patient experienced union with retroversion, while another developed avascular necrosis (AVN) by the study's conclusion. No instances of hardware failure or non-union were observed. The average Harris Hip Score obtained during the most recent clinical follow-up was 84, ranging from 69 to 94. All six patients regained independent walking ability without any support by the end of the follow-up period. Conclusion The combination of primary Pauwels' intertrochanteric valgus osteotomy with fixed-angle plating proves to be a highly effective method for addressing recent intracapsular femoral neck fractures, resulting in a 100% success rate in achieving union among the patient cohort.

Fixator-Assisted Nailing for Femur Neck Fracture Nonunion: A Case Series Study

Background

Femoral neck fractures in young adults tend to be a result of high-energy trauma with a common pattern of Pauwels type III fracture, and they require timely and meticulous diagnosis and management. The objective of this study was to assess the clinical and radiological outcomes of the fixator-assisted nailing technique for managing femur neck fracture nonunion. Methods. This was a case series study of 16 patients with nonunion femoral neck fractures treated via a fixator-assisted nailing technique. Our inclusion criteria comprised the inclusion of any patient between the ages of 14 and 60 years old with a neglected neck of femur fracture or nonunion of the femur neck. In addition, we only included patients without further posttreatment trauma and without known metabolic diseases. The conditions that were excluded from this study included hip joints with preexisting osteoarthritis, radiographic evidence of avascular necrosis of the femoral head, and associated ipsilateral acetabulum fracture or fracture-dislocation. The fracture characteristics that were selected for the fixator-assisted nailing (FAN) technique were clear signs of pseudoarthrosis (such as sclerosis, clear fracture line defects, and failure of implants), in addition to evidence of varus malalignment. All fractures were Pauwels type III. Radiographs of the pelvis with both hips and a posteroanterior (PA) view of the injured hip were taken. Full weight bearing was allowed in all the patients from the first day postoperatively. Physical therapy was started for pain reduction modalities, stretching, and abductor strengthening.

Results

Union of the femur neck fracture and osteotomy site was achieved in all patients. An excellent functional status after four months of follow-up was found based on a modified Harris hip score questionnaire. At follow-up, no patient was suffering from pain or flexion contracture. Preoperative limb length discrepancy (LLD) (cm) was 1.8 ± 0.8 cm and postoperative was 0 ± 0.1 cm, p < 0.001. Preoperative neck-shaft angle (NSA) (o) was 85.6 ± 4.4 and postoperative was 126.9 ± 2.5, p < 0.001. Preoperative Pauwels angle (o) was an average of 50.4 ± 5.9 and postoperative was 31.3 ± 2.5, p < 0.001.

Conclusion

Our study indicates that FAN has a high success rate in young patients with nonunited femoral neck fractures.

Management of femoral neck fracture non union with modified Pauwels' osteotomy

Modified Pauwels' intertrochanteric osteotomy is a promising procedure to heal a non union of the femoral neck fracture, with a success rate of 80-90%. Caxa vara correction and limb length equalization can be achieved simultaneously with this procedure. Two stage surgical procedure has the advantage of keeping blood loss and bone exposure to minimise the risk of infection. We herewith present some tips and tricks and the details of doing this osteotomy.

Gunshot Fracture of the Femoral Neck: Internal Fixation and Immediate Proximal Femoral Valgus Osteotomy: A Case Report

CASE

We report on a 22-year-old patient with a comminuted femoral neck fracture because of a low-velocity gunshot wound. Treatment consisted of reduction and internal fixation with a fixed angled blade plate and immediate valgus osteotomy. He went on to uneventful healing and an excellent clinical result.

CONCLUSIONS

A comminuted gunshot femoral neck fracture in a young patient is a rare and potentially devastating injury. If stable, and there are no other associated emergent injuries, reduction, internal fixation, and immediate valgus osteotomy should be considered.

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.

Valgus osteotomy in delayed presentation of femoral neck fractures using fixed angle simple dynamic hip screw and plate

PURPOSE

Reduction and fixation in femoral neck fracture in young patients have a problem of nonunion requiring additional procedure like valgus osteotomy but fixation devices are technically difficult for inexperienced surgeons. We aims to assess the results of valgus osteotomy in femoral neck fracture in our setup.

METHODS

We report a series of 20 patients of higher Pauwel's angled fracture of femoral neck fracture presenting late wherein for valgus osteotomy was added to reduction fixation secured with a commonly available 135° dynamic hip screw and plate.

RESULTS

Femoral neck fractures united in 16 patients (80%). Excellent to good results (Harris hip score >80) were seen in 70% patients. Angle of correction of preoperative Pauwels has been changed from 68.3 to 34.3.

CONCLUSION

135° dynamic hip screw and plate provides rigid internal fixation after valgus osteotomy and being a more familiar fixation device simplifies the procedure with good results.

Accuracy of valgus osteotomy using dynamic hip screw

BACKGROUND

Non-union of neck femur is a common but difficult situation to manage especially in young adults. There are two main options of arthroplasty or osteotomy. The aim of this study was to assess the results of intertrochanteric valgus osteotomy in non-union femoral neck fractures.

PATIENTS AND METHODS

We present a study of 44 cases of neck femur non-union including untreated fractures, late presentations (more than 3 weeks), treated with compression screw, DHS. From 2006-2016, 44 patients presented to our institute and we analyzed them prospectively on the following criteria: Pauwel's angle, Garden classification, union at fracture site, union at osteotomy site, osteoporosis and AVN changes. Inclusion criteria were age<65, neck not reabsorbed, no AVN. Powel's angle was calculated using the anatomic axis of femur. Wedge angle is equal to Powel's angle minus 30 degree. Entry point of DHS was at the base of greater trochanter and tip of the screw was in the inferior quadrant. Y osteotomy was done in the distal half of the lesser trochanter with a proximal straight cut.

RESULTS

Complete union was noted in 93% of the cases. One patient with uncontrolled diabetes developed severe infection and was treated with excision arthoplasty. AVN occurred in 3 cases. The Powell's angle was reduced to mean 30 (22-39). The neck shaft angle was increased to mean 140 (130-150). Limp was noted in almost all patients but they were able to walk full weight bearing with or without the support of a stick.

CONCLUSION

Valgus intertrochanteric osteotomy achieved good union rates and good functional outcome with minimal complications.

DHS osteosynthesis with internal bone grafting in unstable delayed presented intracapsular neck femur fractures

OBJECTIVES

The aim of this study was to assess fracture union and complications following use of dynamic hip screw (DHS) with internal bone grafting in treatment of unstable delayed presented intracapsular neck femur fractures in patients younger than 65 years of age.

MATERIAL AND METHODS

Thirty two patients with displaced intracapsular neck femur fractures(Garden III and IV, Pauwels III, with comminution) with delayed presentation (15-60 days) in the 45-65 year age group (mean 54.4±10.2 years) were included in this study. All patients were treated with dynamic sliding hip screw with closed cancellous bone grafting through a tunnel of a triple reamer. The average time to union was 3.8 months (3-5 months). Satisfactory union was achieved in all patients except two. One case developed avascular necrosis of the femoral head. Other complications were coxa vara in two, shortening of less than 10mm in three cases but there were no cases of infection or implant failure. Excellent results were achieved in 27, good/fair in 4 and poor in 1 patient.

CONCLUSION

Osteosynthesis with DHS and primary cancellous bone grafting in indicated cases is a simple, providing biological stimulation for early union. Failure in a particular case can be treated with any appropriate second procedure.

Nonunion paediatric femoral neck fracture treatment without open reduction

OBJECTIVES

Fractures of the proximal femur account for less than 1% of all children's fractures. Because of this, most orthopaedic surgeons lack enough experience in treating them. This adds to the rather high incidence of complications especially nonunion. At the time of this review there is no consensus on which method of treatment of the nonunion is the best. The objective of this study is to present our method of treatment to correct the nonunion without open reduction of the nonunion sites.

METHOD

9 children with nonunion of the proximal femur with an average age of 10.2 years (2-14 years old) were included in the study. There were 7 males and 2 females. All of them underwent at least 1 operation to treat the initial fractures and the nonunion. The nonunion in all these 9 cases was treated with valgus intertrochanteric osteotomy without open reduction of the nonunion site. The healing time of the nonunion, the postoperative neck-shaft angle and the functional outcome were evaluated.

RESULTS

All the nonunion cases had coxa vara and had bone resorption of the femoral neck with x-ray evidences of avascular necrosis (AVN). Ratliff classification was used to classify the AVN, Ratliff type 3 was found in 4 cases, Ratliff 2 in 1 case and Ratliff 1 in 4 cases. Patients were followed for an average of 68 (range 36-156) months. All patients had x-ray evidence of solid union of the nonunion in an average time of 15.4 (range 13-18) weeks and union of the osteotomy sites within10.6 (range 9-12) weeks. The postoperative neck-shaft angle averaged 135° (range 125°-150°) compared to 98° before the surgery. The increase in the amount of neck-shaft angle was statistically significant (p&lt;0.001). Using Harris Hip Score, 2 patients were graded as excellent, 3 patients were graded as good and 4 patients were graded as fair. Harris Hip Score was significantly improved compared to the preoperative status (p&lt;0.001).

CONCLUSIONS

Nonunion paediatric femoral neck fracture treatment could be successfully treated without open reduction by using valgus intertrochanteric osteotomy. All patients obtained union of the nonunion site and the osteotomy site in this study. Harris Hip Score showed significant improvement. This technique can be used to treat nonunion with associated coxa vara, bone resorption and AVN with satisfactory results even in cases who had received several operations before.

Valgus osteotomy for nonunion and neglected neck of femur fractures

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Femoral neck non-union treatment by valgus intertrochanteric osteotomy

OBJECTIVE

: The purpose of this study was to evaluate the performance of valgus intertrochanteric osteotomy in femoral neck non-union.

METHODS

: Forty-two patients with femoral neck fractures with non-union treated using Pauwels' intertrochanteric osteotomy were reviewed. Demographics, time elapsed between fracture and surgery, follow--up, osteosynthesis used, Garden's classification, limb shortening, and x-rays were evaluated.

RESULTS

: Twenty-two men and 20 women were reviewed. The youngest patient was 18 years old and the oldest 65 years old, with a mean age of 42.4 years (±11.2). The minimum follow-up was 2 years, with a mean of 10.2 years. The average time elapsed between initial fracture and osteotomy was 6.5 months. Twel-ve cases were neglected femoral neck fractures. Nineteen patients were classified as Garden III, and 23 patients as Garden IV. After valgus osteotomy, non-union healing was observed in 38 patients (38/42; 90.4%). Healing of thirty-seven cases of pseudoarthrosis were obtained after the first-attempt osteotomy, and one case required two operations for healing. The osteotomy failed in four cases. Conside-ring the healed osteotomies, good to excellent functional results were achieved in 80.9% (34/42) of the patients. Total hip replacement was subsequently performed in 14.2% (6/42) of the patients for unfavoura-ble outcomes (two for cutting out, two for osteonecrosis, and two for osteoarthritis).

CONCLUSIONS

: Valgus intertrochanteric osteotomy has a high success rate in archiving healing in femoral neck non-union with good functional results. It is a biological and effective method. Level of Evidence IV, Therapeutic Study.

Modified Pauwels’ intertrochanteric osteotomy in the management of nonunion of a femoral neck fracture following failed osteosynthesis

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

PET/CT study of temporal variations in blood flow to the femoral head following low-energy fracture of the femoral neck

Earlier studies on femoral neck fractures have assessed the blood flow in either the pre- or postoperative period and information is lacking regarding changes in vascular flow to the femoral head after injury. Sixty-two adults with low-energy intracapsular femoral neck fractures were studied prospectively. Mean patient age was 57.2 years (range, 45-82 years). All patients underwent positron emission tomography/computed tomography (PET/CT) prior to surgical intervention and 6 weeks after internal fixation. Internal fixation was done using cannulated cancellous titanium screws and serial follow-up radiographs were obtained (at monthly intervals for the first 3 months followed by 3 monthly intervals between radiographs up to 2 years). On the preoperative PET/CT, 13 patients showed intact vascularity, 31 showed total loss of vascularity, and 18 showed partial loss of vascularity of the femoral head. The 6-week postoperative PET/CT scan showed recovery of blood supply in 23 of the 31 patients with total loss of vascularity and 15 of the 18 patients with partial loss of vascularity of the femoral head. Eleven of 62 patients had total or partial avascularity at the 6-week postoperative PET/CT scan and all 11 patients showed evidence of avascular necrosis on plain radiographs at the end of 2 years. The association between the vascular status of the femoral head at 6 weeks and avascular necrosis at the end of 2 years was statistically significant (P<.001). This study shows that the femoral head undergoes temporal variations in blood flow following femoral neck fracture. Decreased or absent vascularity is seen in approximately 75% of the fractures and 80% of the femoral heads with initial vascular compromise seem to regain blood flow within 6 weeks. Thus, prognostication about vascularity based on single-point preoperative imaging is difficult. The 6-week postoperative PET/CT scan seems to be reliable in predicting the future status of the femoral head. However, decision making regarding hemiarthroplasty or internal fixation at the time of injury may have to depend on factors other than the preoperative vascular status of the femoral head.

Computed tomographic evaluation of the proximal femur: A predictive classification in displaced femoral neck fracture management

BACKGROUND

Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to define the term small head or inadequate size femoral head" objectively for its prognostic significance.

MATERIALS AND METHODS

70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs.

RESULTS

The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically significant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fixation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05).

CONCLUSION

Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classification based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.

[The use of blade plate and dynamic screw plate osteosynthesis]

Osteosynthesis in fracture treatment and in some reconstructive procedures with blade plates or dynamic screw systems was the standard procedure for several decades. In this review, the current options and concepts using blade plate osteosynthesis, stabilization of proximal and distal femur fractures and reconstructive procedures with the dynamic hip screw or the dynamic condylar blade are discussed. On the basis of a literature review, the present indications, results and region-specific complications are reported and discussed.Blade plates are used mainly in the context of reconstructive procedures, as well as in the treatment of pseudoarthroses. The Pauwel procedure in femoral neck non-unions is one of the best known indications. In contrast, the dynamic hip screw is the gold standard for stabilization of femoral neck and most pertrochanteric fractures, whereas the dynamic condylar screw is still an alternative to internal fixators for proximal and distal femoral fracture fixations.

Valgus osteotomy for delayed presentation of femoral neck fractures Pauwels Grade III

Fracture displacement, a high Pauwels angle, and delayed presentation decrease the potential for healing of femoral neck fractures. In the young individual, head preservation is paramount. Valgus intertrochanteric osteotomy may increase the healing potential of femoral neck fractures in the presence of those detrimental factors. Ten patients younger than 60 years of age with delayed presentation of displaced Pauwels III femoral neck fractures were treated by osteosynthesis and valgus intertrochanteric osteotomy fixed by dynamic hip screws. All osteotomies and nine fractures united with one case developing avascular necrosis.

Valgus intertrochanteric osteotomy with single-angled 130° plate fixation for fractures and non-unions of the femoral neck

Non-union of femoral neck fractures may occur due to mechanical and biological factors. Valgus intertrochanteric osteotomy (VITO) alters hip biomechanics and enhances fracture union. The double-angled 120° plate is usually used for internal fixation of the osteotomy. It allows the osteotomy to heal with medialisation and verticalisation of the femoral shaft. This deformity causes medial ligament strain of the knee joint, genu valgum and ultimately osteoarthritis. This work presents our experience in treating vertical fractures and non-unions of the femoral neck by VITO and fixation by a single-angled 130º plate. Thirty-six patients presented with 19 recent vertical femoral neck fractures, and 17 non-unions were included. They were 26 men and ten women, and their ages averaged 37 years. Preoperative planning and VITO technique are described. Union was achieved in 35 patients (97%), and one recent fracture failed to unite (3%). Time to fracture union averaged four months in recent fractures and eight months in un-united fractures. All patients with united fractures had an almost normal configuration of the upper femur. Avascular necrosis of the femoral head was reported in five patients. Twenty-two patients (61%) were pain free, nine (25%) had hip pain on lengthy walks and the remaining five (14%) had persistent pain. Preoperative limb shortening averaged 2.5 cm, and post-operative shortening averaged 0.5 cm. We recommend VITO and fixation by a single-angled 130º plate for vertical femoral neck fractures and non-unions in relatively young adult patients.

Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fracture

Many reported treatment methods for neglected femoral neck fractures do not always satisfactorily address nonunion, coxa vara, and limb shortening. We retrospectively reviewed the functional outcome of the modified Pauwels' intertrochanteric osteotomy in 48 adults (mean age, 48.1 years) to determine whether this approach would correct those problems. The average preoperative limb shortening was 2.7 cm (range, 1.5-5 cm) in 38 patients and mean neck-shaft angle was 107.3 degrees (range, 80 degrees -120 degrees ). The minimum followup was 2 years (mean, 6.1 years; range, 2-16.5 years). Union was achieved in 44 of the 48 patients. Union also was achieved in two of the four nonunions after revision osteotomy. Postoperative avascular necrosis of the femoral head developed in two of the 48 patients after an average followup of 6 years. Limb-length equalization was achieved in 40 (83%) patients and 40 had near-normal gait. The average neck-shaft angle at the final followup was 132.7 degrees (range, 120 degrees -155 degrees ). The average Harris hip score was 86.7 points and Merle d'Aubigné-Postel score was 14.1. We believe the primary modified Pauwels' intertrochanteric osteotomy is a reliable alternative to achieve fracture healing in neglected femoral neck fractures and simultaneously correct associated coxa vara and shortening. A two-stage surgical incision makes the procedure simple and less demanding.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Functional outcome of modified Pauwels' intertrochanteric osteotomy and total hip arthroplasty in femoral neck fractures in elderly patients

BACKGROUND

A high union rate (75%-100%) with a lower incidence of avascular necrosis (8%-9.3%) has been reported with intertrochanteric osteotomy in femoral neck fractures in elderly whereas arthroplasty eliminates the incidence of nonunion and avascular necrosis We present a series of femoral neck fracture in elderly treated with modified Pauwels' intertrochanteric osteotomy and total hip arthroplasty for their functional outcome.

MATERIALS AND METHODS

29 elderly patients of 60 years and above sustaining fresh subcapital femoral neck fracture underwent total hip arthroplasty (group I, n=14) and modified Pauwels' intertrochanteric osteotomy (group II, n=15). Functions were evaluated using modified Harris hip score, d'Aubigne and postel criteria and SF-36 score at 6, 12, 52 and 100 weeks.

RESULTS

The fracture union in group II was achieved in 14 (93.3%) patients at the fracture site at an average of 15 weeks and osteotomy united in all patients. Avascular necrosis of the femoral head was observed in one patient (6.7%). Average operative time was 88.9 and 65.6 minutes in group I and II, respectively (P value = 0.00001). An average of 0.8 and 0.2 unit blood was transfused in patients in group I and II, respectively (P value = 0.001). Average time of full weight bearing was 6.1 weeks and 11.6 weeks in group I and group II, respectively. At 100 weeks 71.4% (n = 10) patients in group I and 80% (n = 12) patients in group II showed good to excellent results on the basis of modified Harris hip score. 71.4% (n = 10) patients in group I and 66.6% (n = 10) patients in group II showed good to excellent results on the basis of d'Aubigne criteria. Average SF-36 score was 17.2% in group I and 17.6% in group II. Revision osteotomy was performed in one patient in group II because of implant cut through. Another patient in group II underwent THR because of painful hip. One patient in group I presented with dislocation after 3 weeks of surgery.

CONCLUSION

Functional results of total hip arthroplasty and intertrochanteric osteotomy are comparable and the valgus intertrochanteric osteotomy with osteosynthesis in subcapital femoral neck fractures in elderly patients of sixty years and above may be considered as an option.

Management of femoral neck fractures in young adults

Femoral neck fractures in young adults are uncommon and often the result of high-energy trauma. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Multiple factors can play a significant role in preventing these devastating complications and contribute to a good outcome. While achieving an anatomic reduction and stable internal fixation are imperative, other treatment variables, such as time to surgery, the role of capsulotomy and the fixation methods remain debatable. Open reduction and internal fixation through a Watson-Jones exposure is the recommended approach. Definitive fixation can be accomplished with three cannulated or noncannulated cancellous screws. Capsulotomy in femoral neck fractures remains a controversial issue and the practice varies by trauma program, region and country. Until there is conclusive data (i.e. prospective and controlled) we recommend performing a capsulotomy. The data available is inconclusive on whether this fracture should be operated emergently, urgently or can wait until the next day. Until there is conclusive data available, we recommend that surgery should be done on an urgent basis. The key factors in treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression and stable internal fixation.

Unstable recent intracapsular femoral neck fractures in young adults: osteosynthesis and primary valgus osteotomy using broad dynamic compression plate

BACKGROUND

Displaced intracapsular femoral neck fractures continue to be a difficult problem to treat. Various treatment modalities and their modifications have been proposed to improve the outcome. Osteosynthesis and primary valgus angulation osteotomy is one of them. Technique and outcome in a consecutive series of recent intracapsular femoral neck fractures in young adults, from a single center, is presented.

MATERIALS AND METHODS

Fifty-five patients of recent (<3 weeks old) displaced intracapsular fracture neck femur (Garden III and IV, Pauwels III, with or without comminution) in the age group 20-50 years (mean 35.4+/-10.4 years) were subjected to osteosynthesis and primary valgus intertrochanteric osteotomy using contoured broad dynamic compression plate (DCP). The patients were followed up from two to six years (mean 4.6 years).

RESULTS

Fifty-one fractures united by six months of the index procedure (92.7% union range). Avascular necrosis (AVN) developed in six patients (11%). The other complications were shortening (six), coxa vara (two), infection (two) and delayed union at osteotomy site (one). Excellent results were achieved in 48, good/fair in four and poor in three patients.

CONCLUSION

Osteosynthesis with cancellous screw and primary valgus intertrochanteric osteotomy stabilized by a contoured broad DCP is a simple, easy to perform, biological treatment. Failure in a particular case can be treated with any appropriate second procedure.

LEVEL OF EVIDENCE

IV.

Locking plate technology and its role in osteoporotic fractures

Osteoporosis is a public health issue that leads to increased morbidity and dependency in an increasing population. Fractures in osteoporotic bone have been a contraindication to internal fixation due to their past poor results. Various treatment methods and innovations have been attempted that have met with some success. This paper reviews one such innovation, locking-plate osteosynthesis, looking at its technology and success and its role in osteoporotic patients. As this is an evolving technology, surgeon's experience with these plates and screws are in advance of clinical studies and therefore the surgeons should proceed with caution when choosing locking plate technology in the treatment of osteoporotic fractures.

Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fractures in children: a report of 10 cases followed for a minimum of 5 years

OBJECTIVES

To evaluate the role of a modified Pauwels' intertrochanteric osteotomy (MPIO) in neglected femoral neck fractures in children.

DESIGN

Prospective study with retrospective analysis.

SETTING

Tertiary care Postgraduate Institute of Medical Sciences.

PATIENTS

Ten children (8 males, 2 females) with an average age of 10.2 years with neglected femoral neck fractures were seen from 1990 to 1998. A femoral neck fracture was considered neglected when no proper medical treatment was instituted for at least 1 month following the fracture. Nonunion was accompanied by coxa vara and resorption of the femoral neck in 9 patients; a 10th patient had a neglected femoral neck fracture for 1 month without coxa vara. Three patients at time of presentation with Delbet Type II displaced fractures with associated nonunion and coxa vara (2 with Ratliff Type III and 1 with Type I) also had avascular necrosis using plain radiographic criteria of increased density.

INTERVENTION

Modified Pauwels' intertrochanteric osteotomy. The children were immobilized in a hip spica for 6-10 weeks postoperatively and weightbearing was started after hip spica removal.

MAIN OUTCOME MEASUREMENTS

Fracture healing, neck-shaft angle, avascular necrosis, and functional outcome.

RESULTS

Patients were followed for an average of 8.2 years (range 5-12 years). All patients had union of their fracture within an average of 16.6 weeks (12-20 weeks) and of the osteotomy site within 8.2 weeks (7-9 weeks). Radiologic signs of avascular necrosis disappeared completely in the 3 patients who presented with avascular necrosis. In 1 patient with a preoperatively viable femoral head, radiologic signs of Ratliff Type I avascular necrosis appeared between 60 and 98 weeks. This radiologic finding became normal again, indicating viability of the femoral head somewhere between 98 to 205 weeks of follow-up. Postoperatively, an average of 135-degree neck-shaft angle was achieved (range 125-160 degrees). The average preoperative neck-shaft angle was 104.4 degrees (range 92-120 degrees) and on the normal hip side it was 127.7 degrees (range 124-132 degrees). Significant improvement in the neck-shaft angle was seen compared with the preoperative angle (P < 0.001) and normal hip angle (P < 0.05). Coxa vara and signs of chondrolysis were not observed in any of the patients. Premature proximal femoral epiphyseal closure resulting in a 1-cm and a 1.5-cm leg-length discrepancy was seen in 2 patients as compared with their normal side. A mild Trendelenburg gait was observed in 1 patient (10%). Using Ratliff's criteria, 9 patients (90%) were graded as a good result and 1 patient (10%) was graded as a fair result. The osteotomy plate was removed in 1 patient (10%).

CONCLUSION

An MPIO creates a biomechanical environment conducive to healing of a neglected femoral neck nonunion in a child while simultaneously correcting an associated coxa vara. The procedure also seems to have a biological role in helping restore viability to a noncollapsed femoral head with avascular necrosis.

Principles of fixation of osteoporotic fractures

Despite advances in the prevention and treatment of osteoporotic fractures, their prevalence continues to increase. Their operative treatment remains a challenge for the surgeon, often with unpredictable outcomes. This review highlights the current aspects of management of these fractures and focuses on advances in implant design and surgical technique.