Intertrochanteric osteotomy for non-union of the femoral neck

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.

Hip-preserving surgery for nonunion about the hip

INTRODUCTION

Nonunions about the hip occur as a result of femoral neck, intertrochanteric, and certain subtrochanteric fractures. Treatment of a hip fracture nonunion allows for the choice between hip preservation or arthroplasty. The goal of this study was to examine outcomes of hip-preservation nonunion surgery METHODS: Patients who underwent hip preservation for a fracture nonunion of the femoral neck, intertrochanteric and subtrochanteric region to 1 cm below the lesser trochanter over a 10-year period were identified in our nonunion registry. Patients were followed for a minimum of 1 year. Functional outcomes were recorded at follow-up visits. For comparison regarding surgical and hospital outcomes, a group of 23 patients who underwent conversion total hip arthroplasties (cTHA) at the same academic medical center was reviewed. Quality measures such as length of stay, reoperation, and complications were collected. All statistics analysis utilized IBM SPSS 25 (Armonk, NY) RESULTS: Thirty patients who underwent 30 hip-preserving nonunion surgeries were analyzed and compared with 23 cTHA patients. Twenty-nine nonunions went on to heal (average time to union 6.3 months). There was improvement in functional outcome scores for the hip preservation group between baseline and latest follow-up (p < 0.001). Reoperation was required in five patients (17%), including four failed to heal and required a second repair to gain union and one failure that was converted to THA rather than attempt a second nonunion repair. Hip preservation failures were older than those that healed with the index treatment (p = 0.11). There was no significant difference in hospital length of stay, complication rate, or need for reoperation when compared to cTHA group.

CONCLUSION

Hip-preserving surgery is an option that should be considered for patients with nonunion of fractures about the hip. The rates of complications (20.3 vs 17.3%) and reoperation (16.7 vs 17.3%) were equivalent to conversion THA. Excellent outcomes can be achieved in terms of radiographic union and function with hip preservation.

Long-Term Outcome of Valgus Osteotomy and Fixation with Double Angled Dynamic Hip Screw for Nonunion Fracture of the Neck of the Femur in Young Adults

Objective  To evaluate the long-term results of valgus intertrochanteric osteotomy fixed with double angled dynamic hip screw for nonunion fracture of the neck of the femur in young adults. This implant allows more freedom of fixation in the sagittal plane. Very few studies have evaluated the long-term outcome for treatment of nonunion in fractures of the neck of the femur. Methods  This is a prospective interventional study that included 20 patients with nonunion of the fracture of the neck of the femur aged < 60 years old without avascular necrosis of the head and significant resorption of the neck of the femur. A lateral closing wedge osteotomy was performed just above the lesser trochanter after inserting the Richard screw across the nonunion site, and it was fixed with a double-angle 120° barrel plate. The outcome was evaluated using union rate and the Harris Hip Score for functional outcome. Results  The average postoperative decrease in the Pauwels angle was of 28.9°. A total of 80% of the cases progressed to union within a mean duration of 7.53 months. The mean Harris Hip Score at the final follow-up was 86.45. Conclusion  Valgus intertrochanteric osteotomy and fixation with a double angled dynamic hip screw is a reliable and effective method for preservation of head and promoting union in an ununited fractured neck of the femur in young patients.

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.

"Cage in Box" - A modification of AIIMS BOX technique for large gap nonunion in young patients with neglected femur neck fractures

Neck of femur fractures have often been termed as "The Unsolved Fractures", since they have a guarded outcome even after improved understanding of biomechanics and biology of this area. Gap-nonunion is one such dreaded complication of this fracture, especially in younger (<60 years) population, where arthroplasty may not be the best go-to option. We have earlier described "The AIIMS BOX" technique to manage such cases of gap non-union in neglected neck femur fractures [1]. Here we intend to describe a more successful modification of this technique. We operated 7 cases of gap non-union with our new "Cage in Box" strategy and followed these cases for 5 years. 6 patients from this group achieved excellent to good outcomes and only 1 reported a poor outcome. All the patients, except the one with poor outcome, could walk without aid and do activities of daily living independently. 3 patients developed AVN but had no evidence of collapse. 3 patients also developed Coxa vara, but it was significant only in one case. 6/7 patients were able to squat. We describe this method in detail and feel this can be a viable option in the armamentarium of orthopedic surgeons, along with valgus osteotomy, vascularized and non-vascularized fibular strut graft as well as Meyer's Graft, to help them solve this unsolved fracture.

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.

Use of an Angled Blade Plate for 31A3 Intertrochanteric Fractures

BACKGROUND

A subgroup of pertrochanteric fractures-namely, the AO/OTA 31A3 fracture-continues to be a difficult problem to treat, even with cephalomedullary nails. We present the results for 26 patients with a 31A3 fracture treated with the angled blade plate.

METHODS

The records of 26 consecutive patients with a 31A3 fracture that was treated operatively with the angled blade plate device between 2007 and 2012 at our center were reviewed, and the patients were contacted for follow-up. The functional outcome (traumatic hip rating score) and radiographic outcome (the neck-shaft angle at the time of fixation and final follow-up) were obtained for 20 of the 26 patients at a minimum follow-up of 1 year.

RESULTS

All 26 patients had primary surgery. At final review, 2 patients had died and 4 had been lost to follow-up. Of the 4 patients lost to follow-up, 2 had revision of the fixation with the angled blade plate. Of the 20 patients with follow-up, 1 had malreduction and implant failure but eventually had healing after revision of the fixation with the angled blade plate. The mean traumatic hip rating score at the time of follow-up was 50.0 with 4, 14, and 2 patients having excellent, good, and failed outcomes, respectively. The mean neck-shaft angle at the time of final union was 126.16°, which was an average of 4° less than that on the unaffected side. However, this did not correlate with functional outcome. There was no significant difference between the immediate postoperative and final neck-shaft angles.

CONCLUSIONS

This study demonstrated that blade plate fixation for 31A3 fractures is associated with low rates of failure (15%), revision surgery (15%), and infection (15%), which are comparable with the results of nail fixation (range, 5% to 12%) and superior to those of sliding hip screw fixation. This large series demonstrates that the angled blade plate can be utilized for these complex fractures and should be part of the armamentarium for these injuries.

LEVEL OF EVIDENCE

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

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.

[Effectiveness of triangular stabilization system for patients with postoperative nonunion of femoral neck fracture]

Objective

To explore the effectiveness of triangular stabilization system in the treatment of postoperative nonunion of femoral neck fracture.

Methods

The clinical data of 30 patients with postoperative nonunion of femoral neck fracture who met the selection criteria between December 2014 and December 2019 were retrospectively analyzed. There were 21 males and 9 females with an average age of 40.7 years (range, 15-65 years). The Pauwels angle at the time of injury was 51°-79°, with an average of 63.6°. According to the Pauwels classification, they were all type Ⅲ. The time from the first operation to this revision operation was 5-24 months, with an average of 9.7 months. The preoperative visual analogue scale (VAS) score was 4.2±1.3, the Harris score was 31.2±5.3, the neck-shaft angle was (116.3±7.9)°, and the lower limb shortening length was (1.73±0.53) cm. Triangular stabilization system, which was made of dynamic condylar screw and medial anatomical buttress plate, combined with the window bone grafting at the fracture site was used for bone nonunion revision. The postoperative lower limb shortening length, neck-shaft angle, fracture healing time, and complications were recorded; the Harris score was used to evaluate the hip joint function, and the VAS score was used to evaluate the pain improvement before and after operation.

Results

All patients were followed up 12-60 months, with an average of 27.7 months. There was no clear sign of femoral head necrosis and collapse after operation; 1 patient developed infection at 4 months after operation, and the incision healed after debridement and removal of internal fixator. All patients achieved bone healing, and the healing time was 2.8-6.0 months, with an average of 3.9 months. At last follow-up, the lower limb shortening length was (0.30±0.53) cm, which was significantly corrected when compared with preoperative one ( t=16.721, P=0.000); the neck-shaft angle was (133.9±5.7)°, which was significantly recovered when compared with preoperative one ( t=-11.239, P=0.000). The VAS score was 0.7±0.9, the Harris score was 88.3±5.9, both of which were significantly improved when compared with preoperative scores ( t=16.705, P=0.000; t=-40.138, P=0.000).

Conclusion

Triangular stabilization system combined with window bone grafting can provide a stable and balanced mechanical environment, promote fracture healing, and achieve satisfactory effectiveness in the treatment of postoperative nonunion of femoral neck fracture.

Evaluation and management of atypical femoral fractures: an update of current knowledge

Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.

Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results

PURPOSE

Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years.

METHODS

Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS).

RESULTS

After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points.

CONCLUSIONS

In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.

Treatment of non-united femoral neck fracture by a novel subtrochanteric angulation lateral translation valgus osteotomy (SALVA osteotomy)

PURPOSE

The ideal treatment of non-united and neglected fracture neck femur in the young adult still remains unclear and is characterized by many biological and biomechanical challenges.

METHODS

Twenty-one patients with non-united or neglected fracture neck femur aged between 19 and 50 years were treated by a novel subtrochanteric valgus osteotomy and were followed up for a mean of 26.7 months. Patients were assessed by radiological parameters, the Harris Hip Score, Oxford Knee Score, and Askin Bryan Criteria to categorize the overall outcome of the patients at 24 months. Other outcome measures included the occurrence of AVN, adductor lever arm, leg length discrepancy, and mechanical implant failure.

RESULTS

All patients treated with the SALVA osteotomy consolidated and displayed a marked improvement of functional and radiological outcome measures. Nevertheless, there were 2 mechanical failures in patients with marked osteopenia and three developed AVN.

CONCLUSIONS

In patients with un-united/neglected fracture neck femur, SALVA osteotomy appears to be reliable and reproducible. It also restores the abductor lever arm and improves the leg length discrepancy. Technically less demanding conversion to arthroplasty remains still possible prospectively.

Experience of valgus osteotomy for neglected and failed osteosynthesis in fractures neck of femur

PURPOSE

There is vast literature supporting valgus osteotomy in fracture neck of femur. However, little or no distinction has ever been made to evaluate the success of the procedure in these two different scenarios-non-unions due to failed osteosynthesis and neglected fractures neck of femur. The aim of our study was to compare the results of valgus osteotomy in neglected neck femur fractures and non-union fractures of neck of femur.

METHODS

This is a single tertiary centre-based retrospective study. The records of all patients aged less than 45 years who underwent valgus osteotomy for neck of femur fractures from 2012 to 2017 were evaluated. Patients with fracture neck of femur of over one month's duration, where no previous surgical intervention was undertaken were placed in neglected fracture group. Patients with failed primary osteosynthesis surgery, either cannulated cancellous screw or dynamic hip screw, were placed in fixation failure group. There were 23 patients in neglected group and 17 patients in fixation failure group. Demographical details, fracture patterns, and preoperative radiograph, surgery time, blood loss, post-operative complications, union time, and non-unions were studied in both groups.

RESULTS

Osteotomy site united in mean time of 11 weeks in fixation failure group and 11.3 weeks in neglected group (p = .434). Time to radiological union of fracture was 16 weeks (12-23 weeks) for neglected fracture group compared to 25 weeks (20-32 weeks) for fixation failure group which was statistically significant (p = .02). Seven out of 17 fractures did not unite in fixation failure group compared to one non-union out of 23 patients in neglected group. (p = .004) There were two loss of fixation with implant failure in fixation failure group compared to none in neglected group (p = .174). Neither of the groups had any surgical site infection.

CONCLUSION

Valgus osteotomy results in excellent union rates for neglected fractures of neck of femur. However, the union rates of valgus osteotomy are lower in neck femur fractures with failed implants compared to neglected fractures and the procedure should be cautiously used in such circumstances.

The utility of the angled blade plate in hip fracture nonunion treatment: A report of three cases and review of the literature

Objectives:

We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions.

Design:

Retrospective, case series.

Setting:

Tertiary academic hospital.

Patients/Participants:

Three.

Intervention:

We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP.

Main outcome measurements:

Radiographic union and clinical outcome.

Results:

All three patients achieved radiographic union, and were ambulating without pain at final follow-up.

Conclusions:

The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.

Valgus intertrochanteric osteotomy for femur neck pseudoarthrosis: a simple solution to a complex problem that has stood the test of time

Femoral neck nonunion in young patients has always been a difficult problem to deal with for surgeons. Numerous surgical procedures to address either the biological or mechanical issues at the nonunion have been described and most of them have been associated with variable results. Isolated biological augmentation is often associated with poor results and some techniques like vascularized grafting may require not so commonly available expertise. Valgus osteotomy is aimed to correct the abnormal fracture biomechanics associated with femoral neck fractures. By altering the nature of force transmission across the nonunion, shear forces are converted into compressive forces that lead to rapid osseous union without the need for bone grafting. Though the principles are sound and were described a long time ago, the technical aspects have evolved over time. Various modifications have been described to overcome shortcomings such as limb length discrepancy, reduction of femoral offset, alteration in mechanical axis, and the overall proximal femur anatomy. In this review, we look back at the fundamental principles and recent literature on the results of valgus intertrochanteric osteotomy for femoral neck pseudoarthrosis. We also highlight the important need for accurate preoperative planning and surgical execution. Lastly, we elaborate on the technical improvisations that have happened over time in order to improve functional results and to minimize complications and poor outcome after a valgus osteotomy.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods

Background

The purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures.

Methods

PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture.

Results

A total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties.

Conclusions

There are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.

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.

Principles of Valgus Intertrochanteric Osteotomy (VITO) after Femoral Neck Nonunion

Nonunion is a relatively rare, yet challenging problem after fracture of the femoral neck. Risk factors include verticality of the fracture line and presence of comminution of the posteromedial calcar, as well as quality of reduction. Treatment options consist of valgus intertrochanteric osteotomy versus arthroplasty. Treatment should be tailored to the individual patient, taking into account patient age and activity demands. This review outlines the principles and technical considerations for valgus osteotomy of the proximal femur in the setting of femoral neck nonunion.

Hip Fracture Nonunions: Diagnosis, Treatment, and Special Considerations in Elderly Patients

In the United States, more than 300,000 hip fractures occur annually in the elderly population with associated significant morbidity and mortality. Both intracapsular and extracapsular hip fractures have inherent treatment challenges and therefore are at risk of nonunion complications. A systematic assessment including radiographic, metabolic, and infectious evaluations should be completed for all patients suspected of nonunion. Failed internal fixation of intracapsular hip fractures is typically treated with arthroplasty, while extracapsular proximal femur nonunions may be amenable to revision internal fixation or arthroplasty. While not a classic hip fracture, bisphosphate associated subtrochanteric femur fractures affect a similar patient population and are historically difficult to treat. Atypical subtrochanteric femur fractures are at increased risk of nonunion given the altered biologic environment secondary to bisphosphonate use; therefore adjuvant therapies may be beneficial in setting of revision fixation. Having a thorough understanding of nonunion risks, recognition, evaluation, and treatment is necessary for appropriate patient care.

Head salvage of an infected neck of femur fracture in an adult: a case report

Head preservation of an infected neck of femur fracture appears to be extremely rare with no described cases in literature till date. We present the outcome of head salvage in a young adult with an infected neck of femur nonunion who in addition had chronic osteomyelitic sequelae of his entire femur with reactivation of latent infection in the distal femoral diaphysis. Osteosynthesis was performed by means of cancellous screw fixation augmented with bone substitute following a failed attempt at salvage with a valgus intertrochanteric osteotomy. The patient had an excellent functional outcome with near normal hip range of movements at a follow-up of 5 years after union.

Generic Preoperative Planning for Proximal Femoral Osteotomy in the Treatment of Nonunion of the Femoral Neck

Despite improvements in surgical technique and overall patient care, failed treatment of fractures of the femoral neck persists. For the physiologically young patient, joint preservation is the preferred method of treatment. Unfortunately, the best treatment option, proximal femoral osteotomy, is fast becoming a lost art. Preoperative planning is critical in this regard. The described preoperative planning work flow is a reliable method for obtaining the desired deformity correction for a variety of proximal femoral malunions and nonunion. Revisiting the classic Pauwels osteotomy for femoral neck nonunion is an appropriate vehicle to supply the first link in resurrecting this treatment modality by providing a standardized preoperative planning protocol.

Quadratus femoris muscle pedicle bone flap transplantation in the treatment of femoral neck fracture for Chinese young and middle-aged patients: A systematic review and meta-analysis

PURPOSE

To compare the efficacy of quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation versus AO hollow compression screw fixation in the treatment of femoral neck fracture for Chinese young and middle-aged patients.

METHODS

Case-controlled studies (CCTs) were used to compare the two operative methods in the treatment of femoral neck fractures. Data were retrieved from the Cochrane Library, Pubmed Database, CNKI, Chinese Biomedical Database. Wanfang Data published during the period of January 2005 to December 2014. Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical Software Revman 5.0 was used for data-analysis.

RESULTS

Eight articles were included in the meta-analysis. The results showed that there was statistical significance in the rate of fracture healing [OR = 5.43, 95% CI (2.89, 10.20), p < 0.05], the rate of good function of hip joint [OR = 5.12, 95% CI (3.21, 8.17), p < 0.05], the rate of femoral head necrosis [OR = 4.21, 95% CI (2.02, 8.76), p < 0.05], the time of fracture healing [WMD = -46.85, 95% CI (-65.13, -28.56), p < 0.05] between the two groups.

CONCLUSIONS

For the treatment of femoral neck fractures, the transplantation of quadratus femoris muscle pedicle bone flap combined with hollow compression screw; fixation is superior to the AO hollow compression screw fixation in terms of the rate; of fracture healing, the rate of good function of hip joint, the rate of femoral head; necrosis and the time of fracture healing.

Intertrochanteric Osteotomy for Femoral Neck Nonunion: Does "Undercorrection" Result in an Acceptable Rate of Femoral Neck Union?

OBJECTIVES

To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy.

DESIGN

Retrospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy.

INTERVENTION

Valgus-producing intertrochanteric osteotomy with a blade plate.

MAIN OUTCOME MEASUREMENTS

Femoral neck and intertrochanteric osteotomy osseous union.

RESULTS

Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014).

CONCLUSIONS

Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy.

LEVEL OF EVIDENCE

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

A sliding hip screw augmented with 2 screws is biomechanically similar to an inverted triad of cannulated screws in repair of a Pauwels type-III fracture

OBJECTIVE

Pauwels III femoral neck fractures are highly unstable. These fractures are commonly treated with three cannulated screws or sliding hip screw (SHS) implants, however high rates of non-union persist. A hybrid SHS construct has recently been proposed. The objective of the study was to compare this construct to the familiar inverted triad of cannulated screws and to a single SHS.

METHODS

Fourth generation biomechanical femur analogs were used to create a highly repeatable injury model. The hybrid SHS construct contained a SHS with two superior cannulated screws in an inverted triangle configuration. Eight samples for each construct were biomechanically evaluated and the results compared using ANOVA (p<0.05).

RESULTS

The cannulated triad and hybrid SHS provided similar stiffness and fracture gap motion. The single SHS exhibited significantly lower stiffness and larger fracture plane diastasis than either the inverted triangle of cannulated screws or hybrid SHS (p<0.05). None of the constructs exhibited catastrophic failure during cyclic loading nor under loading up to 2.5 times body weight.

CONCLUSIONS

The single SHS provided the least stable fracture fixation, while the inverted triad and hybrid SHS constructs were mechanically similar. The fracture repair simulated here illustrates how these repairs have the potential to return near pre-fracture strength in ideal conditions with young, healthy bone. However; in clinical situations where comminution impairs load transfer through the cortices the hybrid SHS may be the most favorable option.

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.

Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting

BACKGROUND

Ununited femoral neck fracture is seen commonly in developing countries due to delayed presentation or failure of primary internal fixation. Such fractures, commonly present with partial or total absorption of femoral neck, osteonecrosis of femoral head in 8-30% cases with upward migration of trochanter posing problem for osteosynthesis, especially in younger individuals. Several techniques for treatment of such conditions are described like osteotomies or nonvascularied cortical or cancellous bone grafting provided varying degrees of success in terms of fracture union but unsatisfactory long term results occurred due to varying incidence of avascular necrosis (AVN) of femoral head. Moreover, in presence of AVN of femoral head neither free fibular graft nor cancellous bone graft is satisfactory. The vascularied bone grafting by deep circumflex iliac artery based on iliac crest bone grafting, free vascularied fibular grafting and muscle pedicle periosteal grafting showed high incidence of success rate. Osteosynthesis is the preferred treatment of choice in ununited femoral neck fracture in younger individuals.

MATERIALS AND METHODS

Of the 293 patients operated during the period from June 1977 to June 2009, 42 were lost to followup. Seven patients with gluteus medius muscle pedicle bone grafting (MPBG) were excluded. Thus, out of 244 patients, 208 (85.3%) untreated nonunion and 36 (14.7%) following failure of primary internal fixation were available for studies. Time interval between the date of injury and operation in untreated nonunion cases was mean 6.5 months and in failed internal fixation cases was mean 11.2 months. Ages of the patients varied from 16 to 55 years. Seventy patients had partial and 174 had subtotal absorption of the femoral neck. Evidence of avascular necrosis (AVN) femoral head was found histologically in 135 (54.3%) and radiologically in 48 (19.7%) patients. The patients were operated by open reduction of fracture, cannulated hip screw fixation, iliac crest bone chips and quadratus femoris MPBG.

RESULTS

The mean followup is 12.5 years (range 3-35). The union of fractures occurred in 202 (82.8%), delayed union in 18 (7.3%), and established nonunion in 24 (9.8%) patients. Full weight bearing was permitted at 16-22 weeks after union of fractures. Mean Harris hip score at the longest followup was 85.5. Among the complications, superficial wound infection occurred in 20 (8.2%), deep infection in seven (2.9%), and coxa vara in 39 (16%) patients. Preoperative radiodensity of femoral head disappeared mostly after the union of fracture whereas fresh radiodensity of femoral head appeared in 20 (8%) patients; nine (45%) of them developed segmental collapse.

CONCLUSION

Ununited femoral neck fractureis characterized by absorption of femoral neck, posterior cortical defect, smoothening and overriding of fracture surfaces with intervening fibrous tissues associated with or without AVN of femoral head. The above method of osteosynthesis rectified the above pathology and provided satisfactory results with union of fractures in 90.1% patients at long term followup.

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.

Using a modified Pauwels method to predict the outcome of femoral neck fracture in relatively young patients

BACKGROUND

Pauwels classification has long been used in femoral neck fracture to measure the inclination of the fracture line and is still widely used. In recent years, however, some studies have contested the reliability of this measurement method. This study investigates modified measurement method to assess the inclination angle with assisted parameters to evaluate the correlation between the different angles and the incidences of loss of reduction, nonunion and avascular necrosis.

PATIENTS AND METHODS

A retrospective study was conducted to analyse the clinical data of 209 relatively young patients (between 20 and 60 years old) with intracapsular femoral neck fracture fixed by inverted triangular screws between January 2004 and December 2010, including 111 males and 98 females, with an average age of 47.08±9.93 years. Using the modified measurement method, the pre-operative inclination angles of patients with intracapsular femoral neck fracture were analyzed. The measured angles were classified into three types: type I, <30 degrees; type II, 30-50 degrees; and type III, >50 degrees.

RESULTS

With regard to loss of reduction, nonunion and avascular necrosis, there were no significant differences with respect to age, sex and fracture side. However, there were significant differences with respect to fracture type, reduction quality and different modified Pauwels types. In the multiple regression analysis, the factors associated with loss of reduction were the fracture type (odds ratio [OR]=7.22), reduction quality (anatomic vs unacceptable reduction, OR=0.11; acceptable vs unacceptable reduction, OR=0.23), and modified Pauwels type (type II vs type III, OR=0.36). The factors associated with fracture nonunion were the fracture type (OR=9.43), reduction quality (acceptable vs unacceptable reduction, OR=0.17) and modified Pauwels type (type II vs type III, OR=0.22). And the factors associated with avascular necrosis were the modified Pauwels type (type I vs type III, OR=0.15; type II vs type III, OR=0.36).

CONCLUSIONS

A displaced fracture, poor reduction quality and high modified Pauwels type are noted risk factors for loss of reduction and fracture nonunion in the post-operative follow up of intracapsular femoral neck fracture. The modified Pauwels type is also noted a risk factor for avascular necrosis. Thus, this modified method is a useful tool for correcting the deficiencies of traditional Pauwels classification and predicting the outcome of femoral neck fractures.

Combination of modified free vascularized fibular grafting and reverse Less Invasive Stabilization System (LISS) for the management of femoral neck nonunion in patients thirty years of age or younger

Femoral neck nonunion (FNN) is a potential complication in patients with displaced femoral neck fractures, occurring in 33%. This may lead to early hip dysfunction or arthroplasty. Combination of modified free vascularized fibular grafting (FVFG) and a reverse LISS may provide a reasonable means to salvage a painless, functional and native hip. Between August 2010 and August 2012, sixteen patients with femoral neck nonunion were treated with a combined procedure involving modified free vascularized fibular grafting and a reverse LISS. The average age of them is 20.3 years (range 12.0-28.0 years). After removing old implants, the nonunion site was debrided, reduced and fixed with a LISS. The fibular grafts were compacted into a trough in the femoral neck. The Harris Hip score system was used to assess hip function and anteroposterior and frog-lateral hip roentgenograms were used to evaluate bone healing. All femoral neck nonunion healed without severe complications. The mean follow-up time was 32.9 months (range 23.0-47.0 months) and the average union time was 7.6 months (range 5.0-10.0 months). All coxa vara deformities and retroversions of the femoral head were corrected. The Harris hip scores (HHS) were improved 36.6 points on average (59.6 points preoperatively to 96.2 points postoperatively). No incidences of osteonecrosis of the femoral head were observed. The combined modified FVFG and reverse LISS plating is a suitable procedure for the management of femoral neck nonunion in patients younger than 30 years, especially for those patients with a revision history.

Triple attack technique for non-union of femoral neck fractures

PURPOSE

The purpose of this study was to describe the technique and clinical results following the utilization of biomechanical and biological means for adequate fracture healing in management of non-union of the neck of femur while preventing distortion of normal hip biomechanics.

METHODS

Twenty-two patients with non-united fractures of femoral neck in adults were treated with what was termed the 'triple attack' procedure. This constituted iliac autogenous bone grafting, valgus subtrochanteric osteotomy together with static fixation across the non-union fracture site of the neck to avoid delayed femoral neck shortening.

RESULTS

All patients were classified as Pauwel's type III fractures. The mean time interval between the last operation and the current procedure was 4.6 months. Average operative time was 58.6 minutes. Patients were followed up for an average of 43.6 months. Complete union was achieved in all cases at an average of 4.3 months. Significant improvement of all radiological parameters was noticed together with the Harris hip score from an average of 21.2 pre-operatively to 89.6 at the last follow-up.

CONCLUSION

The present study provides encouraging clinical and functional results to suggest that this newly described procedure ('triple attack') might be a valuable option in the management of non-united femoral neck fractures.

Managing failed fixation: valgus osteotomy for femoral neck nonunion

Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.

[Pseudoarthrosis of the femoral neck treated with total hip replacement: report of 15 cases]

La pseudarthrose du col fémoral est une complication redoutée de la facture du col fémoral, elle est due soit à une négligence thérapeutique, soit à une ostéosynthèse imparfaite. Plusieurs facteurs sont incriminés dans sa genèse, l’âge, les caractéristiques de la fracture, l’état de la tête fémorale, et une ostéosynthèse non solide. Le diagnostic des pseudarthroses est essentiellement radiologique. Le traitement reste encore difficile et mal codifié, les limites entre traitement conservateur et arthroplastie de la hanche ne sont pas encore bien définies. Nous rapportons une série de 15 cas de pseudarthrose du col fémoral traités par arthroplastie de la hanche au service de traumato-orthopédie du Centre Hospitalier Universitaire de Rabat de 2008 à 2014 soit un recul de 40 mois en moyenne. Nos patients ont bénéficié d'une évaluation clinique et radiologique. L’âge de nos patients varie entre 48 et 81 ans, avec une moyenne de 69,2 ans. 85% d'entre eux sont âgés de plus de 60 ans. Nous avons dans notre série une prédominance féminine, soit 8 femmes pour 7 hommes. La négligence thérapeutique est la cause de la majorité des pseudarthroses du col du fémur traitées dans notre série. Par ailleurs, nous avons utilisé exclusivement la voie d'abord postéro externe de Moore. Nous avons mis en place une prothèse totale de couple polyéthylène-métal chez tous les patients, ces prothèses étaient cimentées chez 12 patients. Le résultat fonctionnel a été coté selon la classification de Merle d'Aubigné. Nos résultats ont été jugés bons selon cette cotation. L'arthroplastie totale de la hanche a une place importante dans le traitement des pseudarthroses du col fémoral et peut donner des résultats satisfaisants en permettant de récupérer une hanche mobile et indolore.

Does previous osteotomy compromise total hip arthroplasty? A systematic review

Hip osteotomy surgery has increased over the past several years, yet the impact of these procedures on subsequent total hip arthroplasty (THA) remains controversial. The purpose of this study was to perform a systematic review of the literature to determine the clinical results, procedure complications, and survivorship of THA following previous hip osteotomy. Ten studies met inclusion criteria. The operative time and estimated blood loss were higher in the post-osteotomy cohorts; while the clinical results and survivorship between groups were similar. THA following previous pelvic and femoral osteotomy provides pain relief and improved function with similar complication rates, clinical outcomes, and survivorship compared to hips undergoing routine primary THA. These procedures can be technically more demanding with increased operative times and intraoperative blood loss.

Do osteotomies of the proximal femur still have a role?

Trochanteric valgus and varus correction osteotomies have been described with or without associated rotational correction. In the last decade, new techniques have been described, including femoral neck osteotomy, femoral head reorientation, relative neck lengthening, greater or lesser trochanter distalization, and femoral head reduction osteotomy. While the overall number of femoral osteotomies in the young patients has decreased because of the efficacy of primary total hip arthroplasties, those osteotomy techniques may expand the indications for femoral osteotomies in select patients who meet the indications.

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.

Indices affecting outcome of neglected femoral neck fractures after valgus intertrochanteric osteotomy

OBJECTIVES

To evaluate preoperative neck resorption and postoperative valgus orientation as predictors of union and functional outcome after valgus intertrochanteric osteotomy for treatment of neglected femoral neck fractures and nonunions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

PATIENTS/PARTICIPANTS

Forty consecutive patients with neglected femoral neck fracture and nonunions were treated with valgus intertrochanteric osteotomy, and follow-up was available in 32 patients (average age, 43 years; range, 14-60 years; average nonunion duration, 6 ± 7 months; range, 1-36 months).

INTERVENTION

Valgus intertrochanteric osteotomy.

MAIN OUTCOME MEASUREMENTS

Clinical outcome was assessed with Harris hip score. Plain radiographs were evaluated for union, avascular necrosis, preoperative bone deficiency (neck resorption ratio), and postoperative femoral head fragment alignment (head-shaft angle).

RESULTS

Follow-up at 5 ± 3 years (range, 2-12 years) after surgery showed union in 29 patients (91%), and Harris hip score was 82 ± 13 points (range, 63-100 points). The 3 patients with persistent nonunion at the neck of femur had neck resorption ratio <0.52. Increased postoperative head-shaft angle was associated with lower follow-up Harris hip score; postoperative valgus alignment >15 degrees compared with the contralateral side was associated with poor functional outcome. The presence of avascular necrosis did not affect the outcome.

CONCLUSIONS

Valgus intertrochanteric osteotomy resulted in union and satisfactory functional outcome in most patients who had neglected femoral neck fractures and nonunions. Preoperative neck resorption ratio <0.5 was a risk factor for nonunion, and excessive valgus alignment was a risk factor for poor functional outcome after osteotomy.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Valgus osteotomy and repositioning and fixation with a dynamic hip screw and a 135º single-angled barrel plate for un-united and neglected femoral neck fractures

PURPOSE

To review the outcome of 60 patients who underwent valgus subtrochanteric osteotomy and its repositioning for un-united and neglected femoral neck fractures.

METHODS

60 patients (mean age, 35 years) underwent valgus subtrochanteric osteotomy and repositioning of the osteotomy and fixation with a dynamic hip screw and a 135° single-angled barrel plate for closed un-united femoral neck fractures after failed internal fixation (n=27) or neglected (>3 weeks) fractures (n=33). The most common fracture type was transcervical (n=48), followed by subcapital (n=6) and basal (n=6). All patients had displaced femoral neck fractures (Garden types 3 and 4). According to the Pauwel angle, 45 fractures were type 2 (30º-70º) and 15 were type 3 (>70º).

RESULTS

Patients were followed up for a mean of 3.5 (range, 2-7.5) years. The mean Pauwel angle of the fracture was corrected from 65° (range, 50°-89°) to 26° (range, 25°-28°). Bone union was achieved in 56 patients after a mean of 3.9 (range, 3-5.5) months. The mean Harris hip score improved from 65 to 87.5. Outcome was excellent in 30 patients, good in 24, and poor in 6. Four of the patients developed avascular necrosis; 2 of whom nonetheless achieved a good outcome.

CONCLUSION

Valgus osteotomy and repositioning and fixation with a dynamic hip screw and a 135° single-angled barrel plate was effective treatment for un-united and neglected femoral neck fractures.

Transfracture abduction osteotomy: A solution for nonunion of femoral neck fractures

BACKGROUND

Nonunion and avascular necrosis (AVN) of the femoral head remains one of the major complications following femoral neck fractures. Despite various surgical techniques and internal fixation devices, the incidence of nonunion and AVN has remained unsolved. Neglected nonunion of femoral neck fracture is common in the developing world. Treatment options include rigid internal fixation with or without bone grafting, muscle pedicle bone graft, valgus osteotomy of the proximal femur with or without bone graft, valgus osteotomy or hip arthroplasty. We conducted a retrospective analysis of cases of nonunion of femoral neck fracture treated by transfracture abduction osteotomy (TFAO).

MATERIALS AND METHODS

Over a period of 35 years (1974-2008), 30 patients with nonunion of femoral neck fractures were treated with TFAO over a period of 35 years (1974-2008), All patients were less than 50 years of age. Absence of clinical and radiological signs of union after four months was considered as nonunion. Patients more than 50 years of age were excluded from the study. Union was assessed at 6 months radiologically. Limb length was measured at six months. The mean duration of femoral neck fracture was 19 months (range 4 months 10 years). Results were analyzed in terms of radiological union at six months. Average followup was five years and six months.

RESULTS

Consistent union was noted at the followup after six months in 29 cases. One case was lost to followup after five and one-half months postoperatively. However, the fracture had united in this case at the last followup. Average shortening of the limb at six months was 1.9 cm. Average neck shaft angle was 127° (range 120-145°). Five cases went into AVN but were asymptomatic. Two cases required reoperation due to back out of Moore's pins. These were reopened and cancellous screws were inserted in the same tracks.

CONCLUSIONS

Consistent union of nonunion femoral neck fracture was noted at the followup after six months in 29 cases. The major drawback of the procedure is immobilization of the patient in the hip spica for eight weeks.

Evaluation of valgus intertrochanteric osteotomy in neglected fracture neck femur in young adults

BACKGROUND

Femoral neck fractures in young adults have always presented a difficult problem with high rates of non-union and avascular necrosis. At our centre we have been using the traditional Pauwels intertrochanteric osteotomy for neglected un-united femoral neck fractures in young adults. We have made certain modifications in this procedure to suit our resources and so we evaluated the outcome of this procedure at our institute.

METHODS

The study included fifty consecutive cases of neglected femoral neck fractures treated at our centre between February 1996 and October 2012. Patients in whom internal fixation had failed were excluded. The average age of the patients was 37 years (range: 17-55 years). Eleven of the patients were female & Thirty-nine were male. Fifteen patients belonged to Pauwels grade 1, Twenty-six patients belonged to grade 2, and nine belonged to grade 3. The interval between the injury and operation ranged from 1 to 12months (average: 4.3 months). The cases were operated on a normal table using a Watson Jones Approach. The fracture ends were freshened and fixed using a 6.5mm screw followed by a valgus osteotomy which was fixed by a double angle (120 degree) blade plate.

RESULTS

A fracture union rate of 90% (45 cases) was achieved. Two of the healed cases developed avascular necrosis. Results were graded using Askin and Bryan's criteria. Overall, an excellent result was seen in 35 patients, good in 5, fair in 5 and poor in 5. Of the five patients having poor result (3 non-union, 1 implant breakage, 1 implant cut out), two refused revision surgery. In remaining three, one underwent total hip arthroplasty and in two revision osteotomy was performed.

CONCLUSION

We believe that intertrochanteric osteotomy provides a good outcome for neglected femoral neck fractures. Performing the procedure on a routine table, with Watson Jones approach and fixing with double angle blade plate is a good option.

Valgus intertrochanteric osteotomy and fibular strut graft in the management of neglected femoral neck fracture

PURPOSE

A prospective study of neglected femoral neck fractures in mostly young patients was conducted to evaluate whether our technique of valgus intertrochanteric osteotomy with fibular strut grafting and osteosynthesis with dynamic hip screw and double-angle side plate can facilitate union with consistent satisfactory clinical outcomes.

METHODS

Forty-one consecutive patients (27 males, 14 females) of neglected femoral neck fractures treated between April 2002 and December 2009 were studied. The average age of patients was 45.41 years (±11.67, range 20-62 years). The average interval since injury was 14 weeks (±10.21, range 4-44 weeks). The cases were evaluated radiographically and clinically.

RESULTS

The average follow-up period was 32.5 months (±8, range 24-54 months). Radiographically union was seen in 39 patients at the nonunion site. The average time to radiographic union was 16.82 weeks (±3 weeks, range 12-24 weeks). Average Harris Hip Score (HHS) was 19.9 (±7.9, range 10-35) preoperatively and 90.9 (±10.35, range 62-100) at the latest follow-up. At that time clinical outcomes were excellent in 31, good in four, fair in three and poor in three patients.

CONCLUSION

Our mechanobiological surgical technique is reproducible with radiographic union achieved in 95.12% cases (39 patients) at the nonunion site and consistent excellent or good functional outcome in 85% of patients over a 32-month average follow-up. We recommend this procedure for neglected femoral neck fractures.

Valgus sliding subtrochanteric osteotomy for neglected fractures of the proximal femur; surgical technique and a retrospective case series

BACKGROUND

Conventional technique of valgus osteotomy of the proximal femur involves removal of a partial or full thickness lateral based wedge from the peritrochanteric region. The purpose of this article is to describe a novel technique of valgus subtrochanteric osteotomy for proximal femur nonunion.

METHODS

11 patients with proximal femur nonunions {intracapsular fractures--7, extracapsular fractures--4} were treated using a new technique of sliding subtrochanteric osteotomy and DHS fixation. Outcomes analysed include radiological outcome in terms of improvement in Pauwel's angle, neck-shaft angle and evidence of radiological union at the nonunion site and osteotomy site. Other outcomes analysed include, measurement of limb length discrepancy and functional outcome assessment with Oxford hip score.

RESULTS

Union at the nonunion site and the osteotomy site was achieved in all patients. There were significant improvements in the postoperative Pauwel's angle, neck shaft angle and Oxford hip score. Limb length discrepancy improved to less than 1 cm in all patients. There was no x ray evidence of avascular necrosis of the femoral head at one year follow-up.

CONCLUSIONS

The sliding osteotomy technique is simple, does not need extensive pre operative planning or removal of bone from the proximal femur.

Pseudarthrosis of femoral neck stress fracture treated with open reduction, sliding hip screw and bone morphogenic protein

INTRODUCTION

Pseudarthrosis of femoral neck stress fractures in young adults are associated with a high incidence of complications and revision surgery. The majority are treated urgently with closed reduction and internal fixation.

PRESENTATION OF CASE

We describe a displaced tension-type femoral neck fatigue fracture presenting late. Pseudarthrosis formation prior to surgery resulted in resorption and shortening of the femoral neck. Open reduction and internal fixation was performed, with adjuvant recombinant human bone morphogenic protein-7 therapy. Radiological union was achieved by twelve weeks and by one year the patient was asymptomatic.

DISCUSSION

Reports of successful management of femoral neck fatigue fracture non-unions are rare. Meyer's muscle pedicle graft, valgus subtrochanteric osteotomy, and cannulated screw fixation with autologous iliac crest bone graftare alternative procedures.

CONCLUSION

This extremely rare fracture type merits open reduction to enable accurate fracture reduction. Supplementing sliding hip screw fixation with an orthobiological agent was successful in this challenging situation.

Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures

BACKGROUND

The purpose of this study is to determine the biomechanical stability of a novel prototype femoral neck locking plate (FNLP) for treatment of Pauwels type C femoral neck fractures compared with other current fixation methods.

METHODS

Forty femur sawbones were divided into groups and a vertical femoral neck fracture was made. Each group was repaired with one of the following: (CS) three parallel cancellous screws; (XCS) two cancellous lag screws into the head and one transverse lag screw into the calcar; and (FNLP) a novel FNLP with two 5.7 mm locking, one lag screw into the calcar and two screws into the shaft; and (AMBI) a two-hole, 135° AMBI plate with a derotation screw. All groups were tested for change in axial stiffness over 20000 cycles, and rotational stiffness was measured before and after cyclic testing. A maximum load to failure test was also conducted. Results were compared with one-way analysis of variance (ANOVA) and Fisher protected least significant difference (PLSD).

RESULTS

Results for axial stiffness show that AMBI, CS, XCS and FNLP are 2779.0, 2207.2, 3029.9 and 3210.7 N-m mm(-1), respectively. Rotational rigidity results are 4.5, 4.1, 17.1 and 18.7 N-m mm(-1). The average cyclic displacements were 0.75, 0.88, 0.80 and 0.65 mm, respectively. Destructive failure loads for AMBI, CS, XCS and FNLP were 2.3, 1.7, 1.6 and 1.9 kN, respectively.

CONCLUSIONS

The results of this experiment show statistically significant increases in axial stiffness for the FNLP compared with three traditional fixation methods. The FNLP demonstrates increased mechanical stiffness and combines the desirable features of current fixation methods.

Management of neglected femoral neck fractures and nonunions using a novel triple surgery combination: an Indian experience

This study describes a 2- to 13-year follow-up of a novel technique for osteosynthesis of neglected femoral neck fractures and nonunions that combines internal fixation with the benefits of fibular grafting and valgus angulation osteotomy. Twenty-three patients were treated by the "3-in-1" surgery, which consisted of osteosynthesis with a dynamic hip screw, nonvascularized fibular grafting, and valgus osteotomy, between January 1996 and June 2009. Union was achieved in all patients at an average of 5.4 months. The average shortening was 0.9 cm. Although avascular necrosis was seen in 4 patients, 2 of them still had good functional scores. Excellent and good hip functional scores were seen in 18 patients. Well-executed surgeries combining biomechanics and biology can ensure union in neglected femoral neck fractures and nonunions provided an adequate length of the neck and proximal fragment is present and there is no subchondral collapse.

Neck reconstruction (AIIMS Box Technique) in the management of large femoral neck defects

Large femoral neck defects are frequently associated with neglected femoral neck fractures, sequelae of infection, and failed fixation devices. The AIIMS box technique of neck reconstruction has the objectives of femoral head preservation and restoration of hip function in such cases. 32 patients (age range 20-56, average 38 years) with large femoral neck defects were treated from January 1990 to May 1997 and were followed up for a minimum of 10 years (range 10 to 17 years). The neck defect was converted into a box using osteal flaps (base from greater trochanter, anterior wall from head, quadratus femoris muscle pedicle graft posteriorly), which was filled with cancellous bone autograft, and stabilized with cancellous screws. Union occurred in all patients in a mean time of 16 weeks (range 12-20 weeks). One patient developed avascular necrosis (AVN) of femoral head. 8 out of 32 results were classified as excellent, 22 good and 2 fair. Good functional mobility was seen in all but two patients. Complications included coxa vara in two patients, and fixation problems in four patients. Large femoral neck defects can be managed successfully by this technique with preservation of the viability of the femoral head, and therefore the procedure should be considered in appropriate cases, particularly in young adults.

Neglected femoral neck fractures in adults

PURPOSE

To assess treatment outcomes in adults with neglected femoral neck fractures, and propose a treatment protocol based on bone quality measured by the Singh index.

METHODS

16 men and 6 women aged 18 to 48 (mean, 33) years presented with neglected (>3 weeks old) femoral neck fractures. Those with good bone quality (Singh index, >3) underwent closed reduction and valgus osteotomy and fixation with 120º double angle blade plates (group 1, n=8), whereas those with poor bone quality (Singh index, >3) and/or communition of the posterior femoral neck underwent fibular grafting and internal fixation with one or two 7-mm cannulated cancellous screws (group 2, n=14). Functional outcome was assessed at the 6-month follow-up, according to modified Askin and Bryan criteria.

RESULTS

The mean delay in surgery was 12 (range, 4-21) weeks. Patients were followed up for a mean of 19 (range, 12-24) months. The mean time to union was 20 (range, 12-52) weeks. The mean time to full weight bearing was 18 (range, 12-40) weeks. All patients achieved bone union except one in group 1 who had non-union and breakage of the blade plate at week 20 and underwent total hip arthroplasty. Other complications included slippage of fibular graft (n=1), delayed union (n=1), avascular necrosis of the femoral head (n=2), limb length discrepancy (n=3), and superficial infection (n=1). Functional outcome was excellent in 2 patients, good in 17, and poor in 3.

CONCLUSION

Valgus osteotomy and double angle blade plate fixation, and fibular grafting and cancellous screw fixation appeared to be appropriate treatments for neglected femoral neck fractures in adults.

Modified free vascularized fibular grafting for the treatment of femoral neck nonunion

OBJECTIVE

To evaluate a modified free vascularized fibular grafting procedure with an anterior approach to the hip as a treatment for femoral neck nonunions.

DESIGN

Retrospective radiographic and clinical review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-six femoral neck nonunions treated between November 2000 and December 2005.

MAIN OUTCOME MEASUREMENTS

Harris Hip scoring system and radiographic standard evaluation for bone union.

RESULTS

The average follow-up period was 29.3 months (range, 12-63 months). The average duration of the surgery was 2.5 hours (range, 2-4 hours). Average blood loss was 300 mL (range, 200-400 mL). The neck-shaft angle was improved by 2.3 degrees on average. Twenty-four of 26 femoral neck nonunions healed without any severe complications. Average union time was 5.3 months (range, 3-9 months). Twenty-four patients had well-functioning hips with an average Harris hip score of 87.9 as compared with the average preoperative Harris hip score of 57.8. One case developed osteonecrosis of the femoral head requiring total hip arthroplasty 2 years after the index procedure. One case developed an immediate postoperative infection.

CONCLUSION

The clinical result indicates that the anterior approach modification of free vascularized fibular grafting is a valuable procedure in the treatment of femoral neck nonunions.

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.