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

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.

Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient

Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient’s family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.

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.

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.

Interventions for treating displaced intracapsular femoral neck fractures in the elderly: a Bayesian network meta-analysis of randomized controlled trials

Displaced intracapsular femoral neck (AO type 31 B2/3) fractures have various treatments, including internal fixation (IF), unipolar uncemented hemiarthroplasty (HA), bipolar uncemented HA, unipolar cemented HA, bipolar cemented HA, uncemented total hip replacement (THR), and cemented THR. Systematic literature retrieval was performed from the databases to compare them in a network meta-analysis. Forty studies (85 arms) containing 6141 patients were included. Overall, our network meta-analysis rank the orders of 7 procedures in reoperation, mortality, dislocation and infection, which indicates that IF may provide the highest reoperation incidence, unipolar cemented HA may provide the lowest reoperation incidence; uncemented THR contributes the highest dislocation incidence; and bipolar uncemented HA provides the lowest infection incidence. No differences in mortality were observed among the treatments. This conclusion is indirect; higher-quality direct comparisons are required.

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.

Meta analysis of different methods used for joint preserving procedures in the management of delayed, neglected and non-united femoral neck fractures in young adults

Background

Neglected fractures in young adults can be amongst the most difficult to treat in the spectrum of fractures of the femoral neck. Because of its complex anatomy and blood supply, timely fixation is paramount. When this does not occur, non-union and avascular necrosis are common complications. Here, we present a meta-analysis of three common options available to the surgeon treating such complications.

Methods

We identified 97 relevant papers by the keywords ‘femoral neck fractures’; ‘neglected’; ‘joint preserving’ and ‘young adults’; 23 met the inclusion criteria and reported on an overall population of 725 patients.

Results

Osteotomy with internal fixation had a union rate of 91.33% (95% CI 84.91–92.87). Fractures fixed by internal fixation with pedicled muscle graft proceeded to union in 86.25% (95% CI 78.92%–88.54%) of cases and those managed with free fibular graft in 88% (95% CI 78.35%–90.84%), respectively. Internal fixation alone, in this study, used as an illustrative control group, was successful in 76.5% (95% CI 65.58%–83.81%) of cases.

Conclusion

These findings show superiority of osteotomy with internal fixation in the management of non-united femoral neck fractures, and more complex options with potentially higher morbidity confer no patient benefit.

Salvage of failed osteosynthesis of an intracapsular fracture of the femoral neck using two cannulated compression screws and a vascularised iliac crest bone graft

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery.

At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001).

These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed.

Cite this article: Bone Joint J 2015; 97-B:988–91.