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Hu Y, Yang Q, Zhang J, Peng Y, Guang Q, Li K. Methods to predict osteonecrosis of femoral head after femoral neck fracture: a systematic review of the literature. J Orthop Surg Res 2023; 18:377. [PMID: 37217998 DOI: 10.1186/s13018-023-03858-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Femoral neck fracture (FNF) is a very common traumatic disorder and a major cause of blood supply disruption to the femoral head, which may lead to a severe long-term complication, osteonecrosis of femoral head (ONFH). Early prediction and evaluation of ONFH after FNF could facilitate early treatment and may prevent or reverse the development of ONFH. In this review paper, we will review all the prediction methods reported in the previous literature. METHODS Studies on the prediction of ONFH after FNF were included in PubMed and MEDLINE databases with articles published before October 2022. Further screening criteria were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. This study highlights all the advantages and disadvantages of the prediction methods. RESULTS There were a total of 36 studies included, involving 11 methods to predict ONFH after FNF. Among radiographic imaging, superselective angiography could directly visualize the blood supply of the femoral head, but it is an invasive examination. As noninvasive detection methods, dynamic enhanced magnetic resonance imaging (MRI) and SPECT/CT are easy to operate, have a high sensitivity, and increase specificity. Though still at the early stage of development in clinical studies, micro-CT is a method of highly accurate quantification that can visualize femoral head intraosseous arteries. The prediction model relates to artificial intelligence and is easy to operate, but there is no consensus on the risk factors of ONFH. For the intraoperative methods, most of them are single studies and lack clinical evidence. CONCLUSION After reviewing all the prediction methods, we recommend using dynamic enhanced MRI or single photon emission computed tomography/computed tomography in combination with the intraoperative observation of bleeding from the holes of proximal cannulated screws to predict ONFH after FNF. Moreover, micro-CT is a promising imaging technique in clinical practice.
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Affiliation(s)
- Yi Hu
- Department of Orthopaedics, The First People's Hospital of Changde City, Changde, China
| | - Qin Yang
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jun Zhang
- Department of Orthopaedics, The First People's Hospital of Changde City, Changde, China
| | - Yu Peng
- Department of Orthopaedics, The First People's Hospital of Changde City, Changde, China
| | - Qingqing Guang
- Department of Orthopaedics, The First People's Hospital of Changde City, Changde, China
| | - Kaihu Li
- Department of Orthopaedics, The Second Xiangya Hospital of Central South University, Changsha, China.
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Chaudhuri S, Pal BM, Sarbadhikari A, Sarkar S, Ghosh K, Chowdhury R. Comparative Study Between Closed Reduction Internal Fixation Alone Versus Closed Reduction Internal Fixation and Addition of Muscle Pedicle Bone Graft for Prevention of Osteonecrosis in Cases of Displaced Femoral Neck Fractures. Indian J Orthop 2022; 57:52-61. [PMID: 36660493 PMCID: PMC9789268 DOI: 10.1007/s43465-022-00776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In patients of less than 60 years of age, osteosynthesis is the treatment of choice for displaced femoral neck fractures (Garden 3 and 4). Most of these fractures unite well but chances of osteonecrosis are quite high even after early operations and till date there is no well-defined method of prediction and prevention of osteonecrosis. Vascularized bone graft may prevent the development of osteonecrosis. MATERIALS AND METHODS This is a retrospective case control study done in an urban Medical College in eastern India and tried to evaluate efficacy of addition of quadratus femoris muscle pedicle bone graft in cases of osteosynthesis comparing the results of cases treated with closed reduction and internal fixation alone for femoral neck fractures We have taken into consideration 45 consecutive cases from each group with identical demographic background and of very similar age pattern of 20 years to 60 years.For further reference, we will describe Group I for closed reduction and CHS/DHS only, and Group II for closed reduction CHS and quadratus femoris muscle pedicle graft. RESULTS Satisfactory bony union occurred in 42 out of 45 follow-up patients in Group 1 (93.3%) and 43 out of 45 patients in Group 2. (95.5%) In 2- to 10-year follow-up period, eight patients (18.6%) developed osteonecrosis in Group I, and in Group 2, in the same period, there were no cases of osteonecrosis. CONCLUSION Addition of quadratus femoris muscle pedicle bone graft is a very effective procedure for prevention of osteonecrosis when we attempt osteosynthesis by closed reduction and internal fixation for displaced femoral neck fractures.
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Affiliation(s)
- Sibaji Chaudhuri
- grid.415509.c0000 0004 1763 8190Department of Orthopaedic Surgery, KPC Medical College, Jadavpur, Kolkata, West Bengal 700032 India
| | - Bhuban Mohan Pal
- grid.415509.c0000 0004 1763 8190Department of Orthopaedic Surgery, KPC Medical College, Jadavpur, Kolkata, 700032 India
| | - Abhijit Sarbadhikari
- grid.415509.c0000 0004 1763 8190Department of Orthopaedic Surgery, KPC Medical College, Jadavpur, Kolkata, 700032 India
| | - Shomik Sarkar
- grid.415509.c0000 0004 1763 8190KPC Medical College, Jadavpur, Kolkata, 700032 India
| | - Kaunteya Ghosh
- grid.415509.c0000 0004 1763 8190KPC Medical College, Jadavpur, Kolkata, 700032 India
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Hoover KB, Starks AO, Robila V, Riddle DL. Quantitative contrast enhanced dual energy CT to predict avascular necrosis: a feasibility study of proximal humerus fractures. BMC Med Imaging 2021; 21:191. [PMID: 34895190 PMCID: PMC8666015 DOI: 10.1186/s12880-021-00717-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/25/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Avascular necrosis is a delayed complication of proximal humerus fractures that increases the likelihood of poor clinical outcomes. CT scans are routinely performed to guide proximal humerus fracture management. We hypothesized iodine concentration on post-contrast dual energy CT scans identifies subjects who develop avascular necrosis and ischemia due to compromised blood flow. MATERIALS AND METHODS 55 patients with proximal humerus fractures enrolled between 2014 and 2017 underwent clinical, radiographic and contrast enhanced dual energy CT assessment. Iodine densities of the humeral head and the glenoid (control) were measured on CT. Subjects managed with open reduction internal fixation or conservatively (non-surgical) were followed for up to two years for radiographic evidence of avascular necrosis. Arthroplasty subjects underwent histopathologic evaluation for ischemia of the resected humeral head. RESULTS 17 of 55 subjects (30.9%) were treated conservatively, 21 (38.2%) underwent open reduction internal fixation and 17 of 55 (30.9%) underwent arthroplasty. Of the 38 subjects treated conservatively or with ORIF, 20 (52.6%) completed 12 months of follow up and 14 (36.8%) 24 months of follow up. At 12 months follow up, two of 20 subjects (10%) and at 24 months 3 of 14 subjects (21.4%) developed avascular necrosis. At 12 months, the mean humerus/glenoid iodine ratio was 1.05 (standard deviation 0.24) in subjects with AVN compared to 0.91 (0.24) in those who did not. At 24 months, subjects with avascular necrosis had a mean humerus/glenoid iodine concentration ratio of 1.06 (0.17) compared to 0.924 (0.21) in those who did not. Of 17 arthroplasty subjects, 2 had severe ischemia and an iodine ratio of 1.08 (0.30); 5 had focal ischemia and a ratio of 1.00 (0.36); and 8 no ischemia and a ratio of 0.83 (0.08). CONCLUSIONS Quantifying iodine using dual energy CT in subjects with proximal humerus fractures is technically feasible. Preliminary data suggest higher humeral head iodine concentration may increase risk of avascular necrosis; however, future studies must enroll and follow enough subjects managed with open reduction internal fixation or conservatively for two or more years to provide statistically significant results. Trial Registrations NCT02170545 registered June 23, 2014, ClinicalTrials.gov.
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Affiliation(s)
- Kevin B. Hoover
- Mink Radiology, Cedars-Sinai Health System, 8670 Wilshire Blvd Suite 101, Beverly Hills, CA 90211 USA
| | - Alexandria O. Starks
- Orthopedic Associates of Lancaster, 170 North Pointe Blvd, Lancaster, PA 17601 USA
| | - Valentina Robila
- Department of Pathology, Virginia Commonwealth University/VCU Health, 1101 East Marshall St, P.O. Box 980662, Richmond, VA 23298-0662 USA
| | - Daniel L. Riddle
- Otto D. Payton Professor of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Room B-100, West Hospital, 1200 East Broad Street, Richmond, VA 23298 USA
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ACR Appropriateness Criteria® Acute Hip Pain-Suspected Fracture. J Am Coll Radiol 2019; 16:S18-S25. [DOI: 10.1016/j.jacr.2019.02.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/23/2022]
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Using Naive Bayes Classifier to predict osteonecrosis of the femoral head with cannulated screw fixation. Injury 2018; 49:1865-1870. [PMID: 30097310 DOI: 10.1016/j.injury.2018.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/03/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
Predictive models permitting personalized prognostication for patients with cannulated screw fixation for the femoral neck fracture before operation are lacking. The objective of this study was to train, test, and cross-validate a Naive Bayes Classifier to predict the occurrence of postoperative osteonecrosis of cannulated screw fixation before the patient underwent the operation. The data for the classifier model were obtained from a ambispective cohort of 120 patients who had undergone closed reduction and cannulated screw fixation from January 2011 to June 2013. Three spatial displaced parameters of femoral neck: displacement of centre of femoral head, displacement of deepest of femoral head foveae and rotational displacement were measured from preoperative CT scans using a 3-dimensional software. The Naive Bayes Classifier was modelled with age, gender, side of fractures, mechanism of injury, preoperative traction, Pauwels angle and the three spatial parameters. After modelling, the ten-fold cross-validation method was used in this study to validate its performance. The ten-fold cross-validation method uses the whole dataset to be trained and tested by the given algorithm. Two of the three spatial parameters of femoral neck (displacement of center of femoral head and rotational displacement) were included successfully in the final Naive Bayes Classifier. The Classifier achieved good performance of the accuracy (74.4%), sensitivity (74.2%), specificity (75%), positive predictive value (92%), negative predictive value (42.9%) and AUC (0.746). We showed that the Naive Bayes Classifier have the potential utility to be used to predict the osteonecrosis of femoral head within 5 years after surgery. Although this study population was restricted to patients treated with cannulated screws fixation, Bayesian-derived models may be developed for application to patients with other surgical procedures at risk of osteonecrosis.
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Prasad KSRK. CORR Insights ®: Epiphyseal Arterial Network and Inferior Retinacular Artery Seem Critical to Femoral Head Perfusion in Adults With Femoral Neck Fractures. Clin Orthop Relat Res 2017; 475:2024-2026. [PMID: 28540632 PMCID: PMC5498391 DOI: 10.1007/s11999-017-5380-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/05/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Kodali Siva R. K. Prasad
- 0000 0004 0648 9863grid.415187.eDepartment of Orthopaedics, Prince Charles Hospital, Gurnos Estate, Merthyr Tydfil, CF47 9DT Wales, UK
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Morimoto M, Takahashi Y, Kubo T, Sugiura K, Tamaki Y, Toki S, Suganuma K, Inoue K, Adachi K, Chikawa T, Sairyo K, Nagamachi A. Prognostic value of dynamic MRI positive enhancement integral color mapping in osteosynthesis of undisplaced femoral neck fractures. J Orthop Sci 2017; 22:722-725. [PMID: 28431804 DOI: 10.1016/j.jos.2017.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/01/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
AIMS The common treatment for an undisplaced femoral neck fracture is osteosynthesis. Two major complications of osteosynthesis are non-union and late collapse of the femoral head. We speculated that femoral head perfusion is one of the most important factors that affect the outcome of osteosynthesis after femoral neck fracture. We have preoperatively estimated femoral head perfusion by dynamic MRI positive enhancement integral color mapping (PEICM). The purpose of this study was to evaluate the outcomes of undisplaced femoral neck fractures based on PEICM. PATIENTS AND METHODS Sixty-eight patients participated in this prospective study. All patients underwent PEICM in a 1.5-Tesla MRI machine using coronal fast spoiled gradient echo imaging sequences with gadopentetate dimeglumine as the contrast agent. Femoral head perfusion was displayed via color mapping using PEICM. Three types were distinguished. For type A, the color was identical to unaffected side indicated normal perfusion. For type B, the color was darker than unaffected side indicated decreased perfusion. For type C, the color was black indicated complete absence of perfusion. All patients underwent osteosynthesis with three cannulated screws. The rates of non-union and late collapse for each type were calculated. RESULTS Sixteen patients were classified as Type A, 43 as Type B, and 6 as Type C. The non-union rates were 0% for Type A, 6.7% for Type B, and 50.0% for Type C. The late collapse rates were 0% for Type A, 4.4% for Type B, and 0% for Type C. CONCLUSION PEICM precisely detected femoral head perfusion. Primary prosthetic replacement should be considered for older patients with Type C to minimize the chances of revision surgery, even in undisplaced femoral neck fractures.
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Affiliation(s)
| | | | - Takahiro Kubo
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | - Kosuke Sugiura
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | - Yasuaki Tamaki
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | - Shunichi Toki
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | | | - Kazumasa Inoue
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | - Keisuke Adachi
- Department of Orthopedics, Mitoyo General Hospital, Kagawa, Japan
| | - Takashi Chikawa
- Spine-Joint Reconstruction Centre, Tokushima Municipal Hospital, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Dargan DP, Callachand F, Diamond OJ, Connolly CK. Three-year outcomes of intracapsular femoral neck fractures fixed with sliding hip screws in adults aged under sixty-five years. Injury 2016; 47:2495-2500. [PMID: 27637999 DOI: 10.1016/j.injury.2016.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/14/2016] [Accepted: 09/06/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Intracapsular femoral neck fractures remain associated with high rates of post-traumatic femoral head necrosis, non-union, and revision surgery. AIM Our aim was to identify factors associated with revision surgery in intracapsular femoral neck fractures treated with sliding hip screws (SHS) in adults aged <65 years. PATIENTS AND METHODS Consecutive admissions were identified retrospectively from the Royal Victoria Hospital, Belfast, which was the largest volume hospital on the National Hip Fracture Database. Of 2201 hip fractures between 1st August 2008 and 31st December 2010, 97 (4%) intracapsular fractures treated with SHS in adults <65 years were followed for a mean of 2.9 years (range 0-6.6). RESULTS Twenty-one (22%) hips were revised to arthroplasty. Avascular necrosis developed in 28 (29%) femoral heads. Eight (8%) fractures proceeded to non-union. Displaced fractures (p<0.001, Fisher's exact [FE]), posterior comminution (p=0.049, FE), chronic respiratory disease (p=0.006, FE) and residual distraction (p=0.011, χ2) were associated with revision to arthroplasty. Multiple regression found displaced fractures (p=0.006) and chronic respiratory disease (p=0.017) significant; in the latter 4 of 6 were revised (67%), including all four patients with chronic obstructive pulmonary disease (COPD). Eleven (11%) individuals required walking aids before injury, which rose to 34 (35%) at one year (p<0.0001, χ2). Eighty-nine (92%) individuals could walk alone outdoors before injury, but only 76 (78%) at one year (p=0.009, χ2). CONCLUSIONS Displaced fractures in individuals with chronic respiratory disease should be considered high risk for revision to arthroplasty. Posterior cortex deficiency should be evaluated prior to choice of operation. Fracture biology and revascularisation play a greater role than operation timing. A significant proportion of individuals do not recovery pre-morbid mobility by one year.
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Affiliation(s)
- D P Dargan
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland.
| | - F Callachand
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland
| | - O J Diamond
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland
| | - C K Connolly
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, BT12 6BA, Northern Ireland
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Griffith JF. Functional imaging of the musculoskeletal system. Quant Imaging Med Surg 2015; 5:323-31. [PMID: 26029633 DOI: 10.3978/j.issn.2223-4292.2015.03.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 12/17/2022]
Abstract
Functional imaging, which provides information of how tissues function rather than structural information, is well established in neuro- and cardiac imaging. Many musculoskeletal structures, such as ligaments, fascia and mineralized bone, have by definition a mainly structural role and clearly don't have the same functional capacity as the brain, heart, liver or kidney. The main functionally responsive musculoskeletal tissues are the bone marrow, muscle and nerve and, as such, magnetic resonance (MR) functional imaging has primarily addressed these areas. Proton or phosphorus spectroscopy, other fat quantification techniques, perfusion imaging, BOLD imaging, diffusion and diffusion tensor imaging (DTI) are the main functional techniques applied. The application of these techniques in the musculoskeletal system has mainly been research orientated where they have already greatly enhanced our understanding of marrow physiology, muscle physiology and neural function. Going forwards, they will have a greater clinical impact helping to bridge the disconnect often seen between structural appearances and clinical symptoms, allowing a greater understanding of disease processes and earlier recognition of disease, improving prognostic prediction and optimizing the monitoring of treatment effect.
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Affiliation(s)
- James F Griffith
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
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The effect of antegrade femoral nailing on femoral head perfusion: a comparison of piriformis fossa and trochanteric entry points. Arch Orthop Trauma Surg 2015; 135:473-80. [PMID: 25708026 DOI: 10.1007/s00402-015-2169-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Piriformis fossa entry antegrade femoral nailing is a common method for stabilizing diaphyseal femur fractures. However, clinically significant complications such as chronic hip pain, hip abductor weakness, heterotopic ossification and femoral head osteonecrosis have been reported. A recent cadaveric study found that piriformis entry nailing damaged either the deep branch of the medial femoral circumflex artery (MFCA) or its distal superior retinacular artery branches in 100% of specimens and therefore recommended against its use. However, no study has quantitatively assessed the effect of different femoral entry points on femoral head perfusion. MATERIALS AND METHODS Twelve fresh-frozen cadaveric lower extremity specimens were randomly allocated to either piriformis fossa or trochanteric entry nailing using a 13-mm reamer. The contralateral hip served as an internal matched control. All specimens subsequently underwent gadolinium-enhanced fat-suppressed gradient-echo sequence MRI to assess femoral head perfusion. Gross dissection was also performed to assess MFCA integrity and distance to the opening reamer path. RESULTS MRI quantification analysis revealed near full femoral head perfusion with no significant difference between the piriformis and trochanteric starting points (95 vs. 97%, p = 0.94). There was no observed damage to the deep MFCA in either group. The mean distance from the reamer path to the deep MFCA was 3.2 mm in the piriformis group compared to 18.5 mm in the trochanteric group (p = 0.001). Additionally, there was a significantly greater number of mean terminal superior retinacular vessels damaged by the opening reamer in the piriformis cohort (1 vs. 0; p = 0.007). CONCLUSIONS No statistically significant difference in femoral head perfusion was found between the two groups. Therefore, we cannot recommend against the use of piriformis entry femoral nails. However, we caution against multiple errant starting point attempts and recommend meticulous soft tissue protection during the procedure.
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Abstract
Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.
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Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
- Address for correspondence: Dr. Sujit Kumar Tripathy, Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha, India. E-mail:
| | - Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ramesh Kumar Sen
- Department of Orthopedics, Fortis Hospital, Mohali, Punjab, India
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Kumar MN, Belehalli P, Ramachandra P. PET/CT study of temporal variations in blood flow to the femoral head following low-energy fracture of the femoral neck. Orthopedics 2014; 37:e563-70. [PMID: 24972438 DOI: 10.3928/01477447-20140528-57] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
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.
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Ward RJ, Weissman BN, Kransdorf MJ, Adler R, Appel M, Bancroft LW, Bernard SA, Bruno MA, Fries IB, Morrison WB, Mosher TJ, Roberts CC, Scharf SC, Tuite MJ, Zoga AC. ACR Appropriateness Criteria Acute Hip Pain—Suspected Fracture. J Am Coll Radiol 2014; 11:114-20. [DOI: 10.1016/j.jacr.2013.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 10/25/2022]
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Belehalli P, Kumar M, Prakash B, Veerappa L. Positron emission tomography-computed tomography in the assessment of viability of femoral head in acetabular fractures. INTERNATIONAL ORTHOPAEDICS 2014; 38:1057-62. [PMID: 24430428 DOI: 10.1007/s00264-013-2260-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 12/15/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to use positron emission tomography-computed tomography (PET-CT) imaging as a tool for assessment of viability of femoral head in acetabular fractures and help in early detection of complications like avascular necrosis (AVN) of the femoral head. METHODS In our study PET-CT was done pre-operatively and six weeks postoperatively in 31 patients who underwent open reduction and internal fixation (ORIF) of acetabular fractures and fracture-dislocations. There were 26 male and five female patients who were treated in our institute between January 2009 and July 2010. Patients were subsequently followed up with plain radiographs for a mean period of 3.8 years and minimum of two years. RESULTS Although seven out of 31 patients showed avascularity of the femoral head on PET-CT in the pre-operative period, only two patients progressed to AVN at final follow up, whereas the other five patients regained the vascularity at the end of six weeks. There was no statistically significant correlation between vascular status on pre-operative scan and the presence of AVN on final follow-up radiograph. There was a significant correlation between avascularity of the femoral head on the sixth week PET-CT and AVN in the final radiograph. CONCLUSION PET-CT seems to be useful as a prognostic investigation in the assessment of the vascular status of the femoral head following injuries around the hip. Both pre-operative and postoperative imaging are necessary to understand the time-dependent changes in blood flow following injury.
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Mishra PK, Gupta A, Gaur SC. Results of triple muscle (sartorius, tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients. Indian J Orthop 2014; 48:470-5. [PMID: 25298553 PMCID: PMC4175860 DOI: 10.4103/0019-5413.139856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture. MATERIALS AND METHODS This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction. RESULTS 14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks). CONCLUSION Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.
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Affiliation(s)
- Pankaj Kumar Mishra
- Department of Orthopaedics, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India,Address for correspondence: Dr. Pankaj Kumar Mishra, Room No. 21, Married PG Hostel, S. R. N. Hospital, Allahabad, Uttar Pradesh, India. E-mail:
| | - Anuj Gupta
- PRITI Nursing Home, Allahabad, Uttar Pradesh, India
| | - Suresh Chandra Gaur
- Department of Orthopaedics, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India,PRITI Nursing Home, Allahabad, Uttar Pradesh, India
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Dyke JP, Lazaro LE, Hettrich CM, Hentel KD, Helfet DL, Lorich DG. Regional analysis of femoral head perfusion following displaced fractures of the femoral neck. J Magn Reson Imaging 2013; 41:550-4. [PMID: 24338938 DOI: 10.1002/jmri.24524] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/09/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To assess regional variations in the arterial and venous blood supply to the femoral head following displaced fracture of the femoral neck using dynamic contrast enhanced (DCE)-MRI quadrant analysis. MATERIALS AND METHODS A total of 27 subjects with displaced femoral neck fractures were enrolled in the study. Quadrant specific DCE-MRI perfusion analysis was performed on a 1.5 Tesla MRI scanner. Simultaneous imaging of control and displaced fractured hips was done for comparison. RESULTS Quadrant specific decreases were found in the arterial (A (0.52 versus 0.27; P = 5.7E-13), Akep (1.0/min(-1) versus 0.41/min(-1) ; P = 1.3E-9) and venous (kel (0.05/min(-1) versus -0.02/min(-1) ; P = 5.1E-5) supply to the femoral head between control and injured sides using a two-factor analysis of variance test. The fractional perfusion (initial area under the curve) in the supero/inferolateral quadrants was 49% min/54% min, in the supero/inferomedial quadrants was 43% min/46% min and for the total femoral head was 39% min on the fracture versus control sides. CONCLUSION Quadrant specific decreases in arterial and venous perfusion on the fracture side were observed when compared with control.
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Affiliation(s)
- Jonathan P Dyke
- Department of Radiology, Weill Cornell Medical College, New York, New York, USA
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Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome. Eur Radiol 2013; 24:449-59. [DOI: 10.1007/s00330-013-3043-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/23/2013] [Accepted: 10/01/2013] [Indexed: 01/31/2023]
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Zahid M, Bin Sabir A, Asif N, Julfiqar M, Khan AQ, Ahmad S, Siddiqui YS. Fixation using cannulated screws and fibular strut grafts for fresh femoral neck fractures with posterior comminution. J Orthop Surg (Hong Kong) 2012; 20:191-5. [PMID: 22933677 DOI: 10.1177/230949901202000211] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the use of fibular grafting for fresh femoral neck fractures with posterior comminution. METHODS 18 women and 15 men aged 20 to 60 years underwent osteosynthesis and fibular strut grafting supplemented with 7.0-mm cannulated hip screws for Garden grades III (n=21) and IV (n=12) femoral neck fractures associated with posterior comminution. All fractures were reduced by closed methods, and no hip was aspirated. Clinical and radiological outcomes were evaluated. RESULTS The mean delay in presentation after injury was 3.2 (range, 1-12) days. The mean delay in operation was 8.8 (range, 5-21) days. The mean follow-up period was 2 (range, 1-4) years. According to the Harris hip score, outcome was good to excellent in 20 patients, fair in 7, and poor in 6. 27 of the 33 patients achieved bone union after a mean of 4.7 (range, 4.2-7) months. In 5 patients, the bone was united with a mean of 10º of varus collapse and a mean of 1 cm of shortening. Six patients had non-union. Other complications included screw migration in the joint space (n=1), graft migration into the joint space (n=3), and screw pullout (n=5). No patient had avascular necrosis of the femoral head. CONCLUSION Osteosynthesis and fibular grafting for freshly displaced femoral neck fractures with posterior comminution is an inexpensive and technically less demanding procedure for retaining a stable, painless, mobile, and functional hip.
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Affiliation(s)
- Mohammad Zahid
- Department of Orthopedic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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Bhuyan BK. Augmented osteosynthesis with tensor fascia latae muscle pedicle bone grafting in neglected femoral neck fracture. Indian J Orthop 2012; 46:439-46. [PMID: 22912520 PMCID: PMC3421935 DOI: 10.4103/0019-5413.97263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Neglected intracapsular femoral neck fracture in young patients may fail to unite because of the excessive shearing strain at the fracture site and it is a surgical challenge to any orthopedic surgeon. The problem is compounded by resorption of the femoral neck and avascular necrosis (AVN) of femoral head. There is no satisfactory solution available in the management of femoral neck fracture as far as the union of the fracture and AVN of femoral head are concerned. Muscle pedicle bone grafting has been advocated to provide additional blood supply to the femoral head. We report a retrospective analysis of 48 cases of neglected femoral neck fracture treated by internal fixation and tensor fascia latae based muscle pedicle bone grafting. MATERIALS AND METHODS 48 patients with femoral neck fractures with age varied from 20 to 53 years (average age 32.9 years) with male to female ratio of 2:1 were enrolled. All fractures were more than 3 weeks old with mean delay being 86 days (22-150 days). Open reduction and internal fixation along with tensor fascia latae muscle pedicle bone grafting was done in all cases. It was supplemented by multiple drilling and cortico-cancellous bone grafting. Fracture fixation was done with three parallel 6.5-mm AO cannulated cancellous lag screws and the graft fixed with a 4-mm cancellous screw to provide a secure fixation. During the followup period of 2-6.8 years (average 4.4 years) the results were assessed clinically by modified Harris hip scoring system and radiologically by the evidence of signs of fracture union. RESULTS Union was achieved in 41/48 (85.41%) cases which were followed for an average period of 4.4 years (2-6.8 years) with good functional results and ability to squat and sit cross-legged. Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 19, good in 22, fair in 5, and poor in 2 patients. Complications were nonunion, (n=3) avascular necrosis (n=2), and coxa vara deformity (n=2). CONCLUSION Internal fixation with muscle pedicle bone grafting is a suitable option to secure union in neglected femoral neck fractures in physiologically active patients with late presentation.
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Affiliation(s)
- Basant Kumar Bhuyan
- Department of Orthopaedics, R. D. Gardi Medical College and C. R. G. Hospital, Ujjain, Madhya Pradesh, India,Address for correspondence: Dr. Basant Kumar Bhuyan, Associate Professor, Department of Orthopaedics, R. D. Gardi Medical College and C. R. G. Hospital, Ujjain- 456 006, Madhya Pradesh, India. E-mail:
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Nakamura J, Ohtori S, Watanabe A, Nakagawa K, Inoue G, Kishida S, Harada Y, Suzuki M, Takahashi K. Recovery of the blood flow around the femoral head during early corticosteroid therapy: dynamic magnetic resonance imaging in systemic lupus erythematosus patients. Lupus 2011; 21:264-70. [DOI: 10.1177/0961203311425521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Disturbance of blood supply to the femoral head is a risk factor for corticosteroid-associated osteonecrosis. The aim was to measure blood supply of the proximal femur during corticosteroid therapy in systemic lupus erythematosus (SLE) patients. We repeatedly performed 78 dynamic MRIs of 19 hip joints in 19 SLE patients after initiation of corticosteroid administration for one year. Blood supply of the femoral head (epiphysis, growth plate, and metaphysis), the femoral neck, and the medial circumflex femoral artery were measured in terms of peak percent enhancement. At the first month, blood supply of the growth plate was significantly higher in the pediatric group (<15 years old) than in the adolescent and adult group (>15 years old). At the fourth month, blood supply in every part of the femoral head (epiphysis, growth plate, and metaphysis) was significantly higher in the pediatric group than in the adolescent and adult group. Multiple regression analysis revealed that blood supply to the femoral head depended on the number of days after initiation of corticosteroid administration and the age at the time of dynamic MRI. Blood supply to the femoral head is abundant in pediatric patients and is a function of the number of days after initiation of corticosteroid administration.
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Affiliation(s)
- J Nakamura
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - S Ohtori
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - A Watanabe
- Department of Orthopedic Surgery, Teikyo University Chiba Medical Center, Ichihara City, Chiba, Japan
| | - K Nakagawa
- Department of Orthopedic Surgery, Toho University Sakura Medical Center, Sakura City, Chiba, Japan
| | - G Inoue
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - S Kishida
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - Y Harada
- Department of Orthopedic Surgery, Chibaken Saiseikai Narashino Hospital, Narashino City, Chiba, Japan
| | - M Suzuki
- Research Center for Frontier Medical Engineering, Chiba University, Chiba-City, Chiba, Japan
| | - K Takahashi
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
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Can injection CT scan assess the residual femoral head vascularity after acute neck fracture? Orthop Traumatol Surg Res 2011; 97:367-72. [PMID: 21450547 DOI: 10.1016/j.otsr.2011.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Revised: 12/15/2010] [Accepted: 01/04/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral neck fracture jeopardizes the vital prognosis of the elderly subject and the functional prognosis of the young subject. The vascular consequence is important, with the risk of osteonecrosis of the femoral head. In young patients, predicting the risk of necrosis at the acute stage seems warranted so as to optimize the choice of therapy. CT with injection could be useful to study the residual bone vascularity after an acute fracture of the femoral neck. HYPOTHESIS The CT scan with injection can diagnose ischemia of the femoral head after neck fracture by demonstrating hypoperfusion and thus estimating the risk for osteonecrosis. PATIENTS AND METHOD A CT scan with injection was performed prospectively in 20 adult patients who had given informed consent after verification of the inclusion and exclusion criteria. Ten presented femoral neck fracture and 10 a pertrochanteric fracture, the latter making up the control group. The second control group was the healthy side of patients presenting a femoral neck fracture. The images were analyzed after delineating a region of interest as a volume at the center of the femoral head. The results were analyzed after modeling based on the physical principle of diffusion. RESULTS No differences were found between the "healthy hip," "fractured hip," "femoral neck fracture," and "trochanteric region fracture" groups. The only statistically significant correlation was found between the "fractured hip" and "healthy hip" of the same patient independently of the type of fracture. DISCUSSION The results do not confirm the working hypothesis. This study was mainly limited by the small number of patients included, but this did not substantially effect the study's conclusions. According to the results, it seems that this study provided a CT evaluation of bone mineral density. At the end of the study, it seems that CT with injection is not well adapted in assessing residual femoral head vascularity or estimating the risk of progression towards avascular necrosis. According to the literature, only dynamic MRI with injection seems to be effective in this assessment and estimation. LEVEL OF EVIDENCE Level III prospective comparative diagnostic.
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Functional outcome after antegrade femoral nailing: a comparison of trochanteric fossa versus tip of greater trochanter entry point. J Orthop Trauma 2011; 25:196-201. [PMID: 21399467 DOI: 10.1097/bot.0b013e3181eaa049] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study was performed to explore the relationship between entry point-related soft tissue damage in antegrade femoral nailing and the functional outcome in patients with a proximal third femoral shaft fracture. DESIGN Retrospective clinical trial. SETTING Level I university trauma center. PATIENTS Seventeen patients with a high femoral shaft fracture treated with an antegrade femoral nail joined the study. INTERVENTION Nine patients with an Unreamed Femoral Nail (UFN; Synthes, Bettlach, Switzerland) inserted at the trochanteric fossa and eight patients with a long Proximal Femoral Nail (PFN; Synthes) inserted at the tip of the greater trochanter. MAIN OUTCOME MEASUREMENTS Pain, gait, nerve, and muscle function along with endurance. RESULTS Five patients with a UFN had a positive Trendelenburg sign and a reinnervated superior gluteal nerve after initial injury of the nerve at operation. None of these findings occurred in the long PFN group (P = 0.01). Isokinetic measurements showed diminished abduction as well as external rotator function in the UFN group rather than in the long PFN group. Leg endurance was significantly lower in patients with a UFN. CONCLUSIONS Compared with the trochanteric fossa, femoral nailing through the greater trochanter tip may decrease the risk of damage to the superior gluteal nerve and intraoperative damage to the muscular apparatus of the hip region, resulting in some improved muscle function. Therefore, a lateral entry point may be a rational alternative for conventional nailing through the trochanteric fossa.
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Ansari Moein CM, Ten Duis HJ, Oey PL, de Kort GAP, van der Meulen W, van der Werken C. Intramedullary femoral nailing through the trochanteric fossa versus greater trochanter tip: a randomized controlled study with in-depth functional outcome results. Eur J Trauma Emerg Surg 2011; 37:615-22. [PMID: 26815474 DOI: 10.1007/s00068-011-0086-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE In a level 1 university trauma center, an explorative randomized controlled study was performed to compare soft tissue damage and functional outcome after antegrade femoral nailing through a trochanteric fossa (also known as piriform fossa) entry point to a greater trochanter entry point in patients with a femoral shaft fracture. MATERIALS AND METHODS Nineteen patients were enrolled and randomly assigned to two nail insertion groups; ten patients were treated with an Unreamed Femoral Nail(®) (UFN, Synthes(®), Solothurn, Switzerland) inserted at the trochanteric fossa and nine patients were treated with an Antegrade Femoral Nail(®) (AFN, Synthes(®), Solothurn, Switzerland) inserted at the tip of the greater trochanter. The main outcome measures were pain, gait, nerve and muscle function, along with endurance. Magnetic resonance imaging (MRI), electromyography (EMG), and Cybex isokinetic testings were performed at, respectively, 2 and 6 weeks and at a minimum of 12 months after surgery. RESULTS The MRI and EMG showed, in both groups, signs of iatrogenic abductor musculature lesions (four in the UFN group and four in the AFN group) and superior gluteal nerve injury (five in the UFN group and four in the AFN group). The isokinetic measurements and the patient-reported outcomes showed moderate reduction in abduction strength and endurance, as well as functional impairment with slight to moderate interference with daily life in both groups, with no appreciable differences between the groups. CONCLUSIONS Anatomical localization of the entry point seems to be important for per-operative soft tissue damage and subsequent functional impairment. However, the results of this study did not show appreciable differences between femoral nailing through the greater trochanter tip and nailing through the trochanteric fossa.
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Affiliation(s)
- C M Ansari Moein
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands. .,Department of Surgery and Traumatology, University Medical Centre Groningen, Groningen, The Netherlands. .,, P.O. Box 82239, 2508 EE, The Hague, The Netherlands.
| | - H J Ten Duis
- Department of Surgery and Traumatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - P L Oey
- Department of Neurology and Neurophysiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G A P de Kort
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - W van der Meulen
- Department of Sports Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Chr van der Werken
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Su Y, Chen W, Zhang Q, Li B, Li Z, Guo M, Pan J, Zhang Y. An irreducible variant of femoral neck fracture: a minimally traumatic reduction technique. Injury 2011; 42:140-5. [PMID: 20570257 DOI: 10.1016/j.injury.2010.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 04/20/2010] [Accepted: 05/03/2010] [Indexed: 02/02/2023]
Abstract
We present 25 cases of irreducible variant femoral neck fractures that require surgical management after routine manipulative manoeuvre attempts have failed. In our study, an irreducible variant of femoral neck fractures is defined as a reduction that cannot be achieved after multiple attempts at closed reduction. This was evident radiographically, as seen in displaced–impacted femoral neck fractures when the proximal femur compacts and rotates along with the distal part, and anatomical reduction cannot be achieved with manipulative manoeuvres. Another rare situation also included is when the proximal fragment disconnects from the femur and dislocates as a ‘floating’ component, consequently resulting in failure of alignment of the distal fragment to the proximal femur.Here, we describe a technique, applied as a minimally traumatic procedure to achieve anatomic reduction in such cases. With the patient placed in supine position on the fracture table under general anaesthesia, the injury site is exposed and the procedure performed under intra-operative radiographic control. Location of the femoral artery is done first by palpation. The insertion site of the K-wires or Steinman pins on the proximal thigh is 1.5–3 cm lateral to the femoral artery. The K-wires or Steinmanpins are inserted vertically into the middle 1/2–2/3 of the femoral head and more than 1 cm inferior to the sub-chondral bone of the femoral head to a depth of approximately, 1/2 diameter of the femoral head. The pins are then used as a joystick to control the movement of the proximal femur. With the help of the K-wires, surgeons can manually control the movement of the proximal femur and ensure anatomic reduction with the distal fragment using routine-closed reduction. Three cannulated screws are used to stabilise the fracture after anatomic reduction is achieved and maintained in a stable position. All cases were treated with this minimally invasive procedure and internal fixation, 25 fractures united,uneventfully, whilst two of them developed femoral head necrosis at 10 months and 4.5 years postoperatively, respectively.
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Affiliation(s)
- Yanling Su
- Department of Orthopaedics, 3rd Hospital, Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, Hebei 050051, PR China
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Ehlinger M, Moser T, Adam P, Bierry G, Gangi A, de Mathelin M, Bonnomet F. Early prediction of femoral head avascular necrosis following neck fracture. Orthop Traumatol Surg Res 2011; 97:79-88. [PMID: 21087905 DOI: 10.1016/j.otsr.2010.06.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/28/2010] [Accepted: 06/21/2010] [Indexed: 02/02/2023]
Abstract
Femoral neck fracture puts at risk functional prognosis in young patients and can be life-threatening in the elderly. The present study reviews methods of femoral head vascularity assessment following neck fracture, to address the following issues: what is the risk of osteonecrosis? And what, in the light of this risk, is the best-adapted treatment to avoid iterative surgery? Femoral head vascularity depends on retinacular vessels and especially the lateral epiphyseal artery, which contributes from 70 to 80% of the femoral head vascular supply. Fracture causes vascular lesions, which are in turn the prime cause of necrosis. Other factors combine with this: hematoma tamponade effect, reduced joint space and increased pressure due to lower extremity positioning in extension/internal rotation/abduction during surgery. Head deformity is not due to direct cell death but to the repair process originating from the surrounding living bone. In post-traumatic necrosis, proliferation rapidly invades the head, with significant osteogenesis. Pathologic fractures occur at the boundary between the new and dead bone. Many techniques have been reported to help assess residual hemodynamics and risk of necrosis. Some are invasive: superselective angiography, intra-osseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others involve imaging: scintigraphy, conventionnal or dynamic MRI. The future seems to lie with dynamic MRI, which allows a new classification of femoral neck fractures, based on a non-invasive assessment of femoral head vascularity.
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Affiliation(s)
- M Ehlinger
- Orthopedic Surgery and Traumatology Department, Hautepierre Hospital, Strasbourg University Hospitals, 1, avenue Molière, 67098 Strasbourg cedex, France.
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Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am 2010; 92:943-8. [PMID: 20360519 DOI: 10.2106/jbjs.h.01144] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The current consensus in the literature is that the anterolateral branch of the anterior humeral circumflex artery provides the main blood supply to the humeral head. While the artery is disrupted in association with 80% of proximal humeral fractures, resultant osteonecrosis is infrequent. This inconsistency suggests a greater role for the posterior humeral circumflex artery than has been previously described. We hypothesized that the posterior humeral circumflex artery provides a greater percentage of perfusion to the humeral head than the anterior humeral circumflex artery does. METHODS In twenty-four fresh-frozen cadaver shoulders (twelve matched pairs), we cannulated the axillary artery proximal to the thoracoacromial branch and ligated the brachial artery in the forearm. In each pair, one shoulder served as a control with intact vasculature and, in the contralateral shoulder, either the anterior humeral circumflex artery or the posterior humeral circumflex artery was ligated. Gadolinium was injected through the cannulated axillary arteries, and magnetic resonance imaging was performed. After imaging, a urethane polymer was injected, and specimens were dissected. For volumetric analysis, the gadolinium uptake on the magnetic resonance imaging was quantified in each quadrant of the humeral head with use of a custom automated program. The gadolinium uptake was compared between the control and ligated sides and between the ligated anterior humeral circumflex artery and ligated posterior humeral circumflex artery groups. RESULTS The posterior humeral circumflex artery provided 64% of the blood supply to the humeral head overall, whereas the anterior humeral circumflex artery supplied 36%. The posterior humeral circumflex artery also provided significantly more of the blood supply in three of the four quadrants of the humeral head. CONCLUSIONS The finding that the posterior humeral circumflex artery provides 64% of the blood supply to the humeral head provides a possible explanation for the relatively low rates of osteonecrosis seen in association with displaced fractures of the proximal part of the humerus. In addition, protecting the posterior humeral circumflex artery during the surgical approach and fracture fixation may minimize loss of the blood supply to the humeral head.
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Affiliation(s)
- Carolyn M Hettrich
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Kaushik A, Sankaran B, Varghese M. To study the role of dynamic magnetic resonance imaging in assessing the femoral head vascularity in intracapsular femoral neck fractures. Eur J Radiol 2009; 75:364-75. [PMID: 19625148 DOI: 10.1016/j.ejrad.2009.04.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 04/20/2009] [Indexed: 11/28/2022]
Abstract
Intracapsular femoral neck fractures remain unsolved fractures even after improvement in techniques of diagnosis and internal fixation. Individuals who sustain displaced femoral neck fractures are at high risk of developing avascular necrosis and non-union. Although several methods for predicting the viability of femoral head have been reported, they are not effective or widely used because of unreliability, potential complications and technical difficulties. Dynamic MRI was introduced in the recent past as a simple, non-invasive technique to predict the femoral head viability after the femoral neck fractures. In this study role of dynamic MRI was studied in 30 patients with 31 intracapsular femoral neck fractures. Fractures were divided in to three types according to dynamic curve patterns on MRI evaluation and were followed up for 6 months to 2 years to observe the final outcome. Sensitivity, Specificity and the Accuracy of dynamic MRI in predicting vascularity after femoral neck fracture are 87%, 88% and 87%, respectively. Type A or Type B curve pattern is a positive factor to successful osteosynthesis with p value <0.0001 (Chi-square test). This is a statistically significant value. From this finding it can be suggested that the reliability of dynamic curves A and B in predicting maintained vascularity of femoral head is high. This investigation can be used to predict the vascularity of femoral head after intracapsular femoral neck fractures. There was a good correlation between the outcomes of fractures and dynamic MRI curves done within 48 h of injury. This signifies the role of dynamic MRI in predicting the vascularity of femoral head as early as 48 h. A treatment algorithm can be suggested on the basis of dynamic MRI curves. The fractures with Type C dynamic curve should be considered as fractures with poor vascularity of femoral head and measures to enhance the vascularity of femoral head along with rigid internal fixation should be undertaken to promote revascularization process and better healing of fractures. Patients with these fractures should be on longer non-weight bearing ambulation than other patients. To conclude, the dynamic MRI seems to be reliable, non-invasive, sensitive, specific and accurate method of assessing the femoral head vascularity after intracapsular femoral neck fractures as early as 48 h of injury and to predict the outcome of fractures and may be used as a guideline for management of intracapsular femoral neck fractures.
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Affiliation(s)
- Abhishek Kaushik
- Department of Orthopedics, St Stephen’s Hospital, Tis Hazari, Delhi 110054, India.
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Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis PV. Classification of non-union: need for a new scoring system? Injury 2008; 39 Suppl 2:S59-63. [PMID: 18804575 DOI: 10.1016/s0020-1383(08)70016-0] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A new scoring system is proposed in order to assist surgeons with the complex analysis associated with non-union surgery. Patients with non-union are rarely easily compared with one another and this has frustrated research in this field. We have therefore attributed values to clinical features based on clinical experience and research evidence, so that patients of similar complexity can be compared with one another. When greater experience with this scoring system has been gained it will be further refined and validated. We propose that surgeons with a sub specialist interest in non-union surgery use this system in reporting results, and that non- specialist surgeons use it to inform their decision to treat the fracture themselves, or refer to a sub specialist.
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Affiliation(s)
- Giorgio Maria Calori
- Orthopaedics and Traumatology, Pini Institute, University of Milan, Milan, Italy
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Chaudhuri S. Closed reduction, internal fixation with quadratus femoris muscle pedicle bone grafting in displaced femoral neck fracture. Indian J Orthop 2008; 42:33-8. [PMID: 19823652 PMCID: PMC2759598 DOI: 10.4103/0019-5413.38578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of femoral neck fracture is still considered as an unsolved problem. It is more evident in displaced fractures where this fracture is considered as some sort of vascular insult to the head of the femur. We have used closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting in fresh displaced femoral neck fractures. MATERIALS AND METHODS From April 1996 to December 2004 we operated 73 consecutive patients of displaced femoral neck fracture in the age group of 24 to 81 years, mean age being 54.6 years. The patients were operated within one week of injury, the mean delay being 3.6 days. Closed reduction internal fixation along with quadratus femoris muscle pedicle bone grafting was done in all cases. They were followed up for an average period of 5.6 years (range 2-11 years). RESULTS Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 53, good in 12, fair in six and poor in two patients. Bony union occurred in 68 cases, no patient developed avascular necrosis (AVN) till date. CONCLUSION For fresh displaced femoral neck fracture in physiologically active patients closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting is a suitable option to secure union and prevent development of AVN.
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Affiliation(s)
- Sibaji Chaudhuri
- Consultant Orthopaedic Surgeon, Former Registrar of Orthpaedic Surgery, Bardhaman Medical College and R.G.Kar Medical College, Kolkata - 700 004, India,Correspondence: Sibaji Chaudhuri, 247 Lake Gardens, Kolkata - 700 045, West Bengal, India. E-mail:
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Watanabe Y, Terashima Y, Takenaka N, Kobayashi M, Matsushita T. Prediction of avascular necrosis of the femoral head by measuring intramedullary oxygen tension after femoral neck fracture. J Orthop Trauma 2007; 21:456-61. [PMID: 17762476 DOI: 10.1097/bot.0b013e318126bb56] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To measure the intramedullary oxygen tension of the proximal femur after a femoral neck fracture and to evaluate the usefulness of that monitoring for prediction of subsequent avascular necrosis. DESIGN Prospective case series with comparison group. SETTING University hospital. INTERVENTION Measurement of intramedullary oxygen tension of the femoral head and neck during internal fixation using the Hansson hook-pin system. MAIN OUTCOME MEASUREMENTS Intramedullary oxygen tension was measured directly during surgery in 17 patients with 18 femoral neck fractures treated by internal fixation between October 2000 and February 2002. The intramedullary oxygen tension was measured by using polarographic oxygen electrodes and an oxygen monitor at four points: (A) 1 cm distal from the joint surface; (B) 1 cm proximal from the fracture site; (C) 1 cm distal from the fracture site; and (D) 1 cm proximal from the lateral wall. The presence or absence of avascular necrosis was evaluated by magnetic resonance imaging (MRI) at 2, 6, and 12 months after surgery. RESULTS MRI evaluation showed 11 fractures healed without complications, and 7 fractures developed avascular necrosis. We found significant differences in the distribution of intramedullary oxygen tension of the femoral head between points A (1 cm from the joint surface) and B (1 cm proximal from the fracture site) in those patients who developed avascular necrosis (P = 0.039); that is the oxygen tension was lower at point A than at point B. In contrast, in those patients who did not develop avascular necrosis there was no significant differences between point A and B were found (P = 0.059). The sensitivity and specificity for prediction of avascular necrosis were 1.0 and 0.82 (Fischer exact probability test, P = 0.002), respectively, when the cut-off level of oxygen tension differences between points A and B was set at 3.1 mm Hg. CONCLUSION We believe that this method of measuring intramedullary oxygen tension is simpler and less invasive than other currently used methods and has the possibility for intraoperatively identifying a risk group that can develop a late segmental collapse of the femoral head secondary to avascular necrosis.
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Affiliation(s)
- Yoshinobu Watanabe
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan.
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Hsu WK, Feeley BT, Krenek L, Stout DB, Chatziioannou AF, Lieberman JR. The use of 18F-fluoride and 18F-FDG PET scans to assess fracture healing in a rat femur model. Eur J Nucl Med Mol Imaging 2007; 34:1291-301. [PMID: 17334765 PMCID: PMC3073515 DOI: 10.1007/s00259-006-0280-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 08/25/2006] [Indexed: 12/21/2022]
Abstract
PURPOSE Currently available diagnostic techniques can be unreliable in the diagnosis of delayed fracture healing in certain clinical situations, which can lead to increased complication rates and costs to the health care system. This study sought to determine the utility of positron emission tomography (PET) scanning with (18)F-fluoride ion, which localizes in regions of high osteoblastic activity, and (18)F-fluorodeoxyglucose (FDG), an indicator of cellular glucose metabolism, in assessing bone healing in a rat femur fracture model. METHODS Fractures were created in the femurs of immunocompetent rats. Animals in group I had a fracture produced via a manual three-point bending technique. Group II animals underwent a femoral osteotomy with placement of a 2-mm silastic spacer at the fracture site. Fracture healing was assessed with plain radiographs, (18)F-fluoride, and (18)F-FDG PET scans at 1, 2, 3, and 4-week time points after surgery. Femoral specimens were harvested for histologic analysis and manual testing of torsional and bending strength 4 weeks after surgery. RESULTS All fractures in group I revealed abundant callus formation and bone healing, while none of the nonunion femurs were healed via assessment with manual palpation, radiographic, and histologic evaluation at the 4-week time point. (18)F-fluoride PET images of group I femurs at successive 1-week intervals revealed progressively increased signal uptake at the union site during fracture repair. In contrast, minimal tracer uptake was seen at the fracture sites in group II at all time points after surgery. Data analysis revealed statistically significant differences in mean signal intensity between groups I and II at each weekly interval. No significant differences between the two groups were seen using (18)F-FDG PET imaging at any time point. CONCLUSION This study suggests that (18)F-fluoride PET imaging, which is an indicator of osteoblastic activity in vivo, can identify fracture nonunions at an early time point and may have a role in the assessment of longitudinal fracture healing. PET scans using (18)F-FDG were not helpful in differentiating metabolic activity between successful and delayed bone healing.
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Affiliation(s)
- W K Hsu
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Center for Health Sciences 76-134, University of California-Los Angeles, 10833 LeConte Avenue, Los Angeles, CA 90095, USA
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Karaeminogullari O, Demirors H, Atabek M, Tuncay C, Tandogan R, Ozalay M. Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery. Adv Ther 2004; 21:335-42. [PMID: 15727403 DOI: 10.1007/bf02850038] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study assessed the effect of fracture displacement and elapsed time before surgery on the development of avascular necrosis and nonunion after internal fixation of femoral neck fractures. Twenty-eight patients with 30 femoral neck fractures who underwent internal fixation and completed a minimum of 2 years' follow-up were retrospectively analyzed. The rates of avascular necrosis and nonunion were 12.5% and 25%, respectively, among patients who underwent surgery before 12 hours had elapsed and 14% and 27% among those who underwent surgery after that time. The rates of avascular necrosis and nonunion associated with fracture displacement were 6% and 18%, respectively, among patients with undisplaced (Garden stages 1 and 2) fractures and 23% and 38% among those with displaced (Garden stages 3 and 4) fractures. Nonunion and avascular necrosis led to the necessity for additional surgery in 11 of 30 (36%) hips. Internal fixation of femoral neck fractures is associated with a high initial complication rate, but if successful, the procedure ensures an excellent long-term outcome. Internal fixation should be considered the treatment of choice in young patients with nondisplaced fractures.
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Yoon TR, Chung JY, Jung ST, Seo HY. Malunion of femoral head fractures treated by partial ostectomy: three case reports. J Orthop Trauma 2003; 17:447-50. [PMID: 12843732 DOI: 10.1097/00005131-200307000-00011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Malunion of femoral head fractures has been rarely reported. We report on three cases of malunion of the femoral head, which were treated by partial ostectomy. All patients were involved in traffic accidents and had a posterior fracture-dislocation of the hip. The types of femoral head fractures were Pipkin type I with inferomedial fracture fragment in all cases. Initially, they were treated by closed reduction and skeletal traction for between 6 and 8 weeks. The patients were then transferred to our hospital; the chief complaint was of limited hip motion. A protruding bony mass limiting the hip motion was resected in all cases. The Smith-Petersen approach was used in all cases. The malunion sites were located distally to the original fracture site in all cases. Full weight bearing was permitted, and a range of motion exercises was started postoperatively. Excellent results were obtained with almost complete restoration of hip motion without pain. In the follow-up radiographs, there were no cases of avascular necrosis.
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Affiliation(s)
- Taek Rim Yoon
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Gwangju, Korea.
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