Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion: A Prognostic Study Based on Long-Term Outcomes

Comparison of femoral neck system versus cannulated cancellous screws for the fixation of femoral neck fracture: a single-center retrospective cohort study

INTRODUCTION

The dynamic hip screw (DHS) and cannulated compression screws (CCS) have been the two implants most frequently employed for the fixation of femoral neck fractures. The objective of this study is to compare clinical and radiographic outcomes between patients treated with the FNS and those treated with CCS.

MATERIAL AND METHODS

We conducted a retrospective analysis of a consecutive series of femoral neck fractures treated with FNS or CCS between May 2019 and June 2022. The study included 144 patients who met the inclusion criteria. Collected data encompassed age, sex, Garden fracture classification, Pauwels classification, duration of surgery, length of hospital stays, Harris Hip Score (HHS), complications, and injured side.

RESULTS

The FNS group comprised 70 patients, while the CCS group consisted of 74 patients. The operation time was 43.6 ± 12.09 min for the FNS group and 56.47 ± 22.42 min for the CCS group. At the end of the follow-up, the mean HHS was 87.07 ± 11.77 for the FNS group and 76.20 ± 13.64 for the CCS group. The mean reduction in hemoglobin levels from pre- to post-surgery was 1.05 mg/dl in the FNS group and 0.87 mg/dl in the CCS group. The reintervention rate was 8.1% for the CCS group and 2.85% for the FNS group.

CONCLUSION

The FNS does not demonstrate superiority over CCS regarding femoral neck shortening, complication rate, and reduction in hemoglobin levels. However, FNS does appear superior to CCS in terms HHS, operation time, and reoperation rate.

Current concepts of bone grafting in trauma surgery

Bone graft in trauma surgery is commonly used in managing bone defects, non-union, fracture related infections, arthrodesis or to provide structural support in fractures. A variety of bone grafts are made available to the treating physician, which includes autograft, allograft and bone graft substitutes. The future of bone grafting in trauma surgery is exciting with the incorporation of technological advancement such as gene therapy, 3D-printing and tissue engineering. Regardless, there are still limitations to what we understand regarding current bone grafting techniques with conflicting literature on their clinical utility and indication. The aim of this review article therefore is to take a step back and critically evaluate the current concepts of bone grafting in trauma surgery, with special emphasis made on reviewing the types of bone graft, biology of bone graft incorporation and indication for its use in various clinical scenarios.

Extracorporeal shock wave treatment for post‑surgical fracture nonunion: Insight into its mechanism, efficacy, safety and prognostic factors (Review)

Post-surgical fracture nonunion (PSFN) represents the failure to achieve cortical continuity at radiological examination after an orthopedic operation, which causes a considerable disease burden in patients with fractures. As one of the traditional treatment modalities, surgical therapy is associated with a high fracture union rate; however, post-surgical complications are not negligible. Therefore, less invasive therapies are needed to improve the prognosis of patients with PSFN. Extracorporeal shock wave treatment (ESWT) is a noninvasive method that presents a similar efficacy profile and favorable safety profile compared with surgical treatment. However, the application and detailed mechanism of ESWT in patients with PSFN remain unclear. The present review focuses on the mechanism, efficacy, safety and prognostic factors of ESWT in patients with PSFN, aiming to provide a theoretical basis for its application and improve the prognosis of these patients.

In-hospital waiting time to surgery and functional outcomes in geriatric hip fractures: a directed acyclic graph-based preplanned analysis from a prospective multicenter cohort study

BACKGROUND

The early recovery of hip function after hip fracture surgery values more attention, especially for patients with delayed surgery of longer than 48 h. We aim to evaluate the associations of in-hospital surgical waiting time with the functional outcomes [Harris Hip Score (HHS), Parker Mobility Score (PMS), and EuroQol 5 dimensions VAS (visual analogue scale) score (EQ-5D VAS)] in elderly patients who sustained hip fractures.

MATERIALS AND METHODS

Data on sociodemographic and clinical factors were prospectively collected using a multicenter hip fracture registry system. Participants in the cohort underwent a 12-month follow-up investigation. After adjusting potential confounders identified by the directed acyclic graphs, the associations between surgical waiting time longer than 48 h and functional outcomes were estimated by log-binomial regression and multivariable linear regression models with generalized estimating equations.

RESULTS

Of 863 survival participants with available functional data at 12 months after surgery, an increased risk was obtained from receiving surgery after 48 h and the poor functional outcomes (HHS<80: relative risk (RR)=1.56, 95% CI: 1.00-2.51; PMS<7: RR=1.49, 95% CI: 1.13-2.01; EQ-5D VAS<80: RR=1.97, 95% CI: 1.57-2.47). In-hospital waiting time greater than 48 h were time-invariantly associated with lower PMS during recovery (-0.44 units 95% CI: -0.70 to -0.18). In addition, delayed surgery was time-varying associated with HHS and EQ-5D VAS.

CONCLUSIONS

The associations between in-hospital waiting time and postoperative functional score suggest that delayed surgery can lead to poor functional outcomes, especially in patients waiting longer than 72 h from injury. Delayed surgery mainly impacted hip function and mobility recovery with a slower speed in early recovery of the first 3 months. More attention should be paid to mechanisms behind the associations between delayed surgery on general healthy status.

Comparison of retrograde anatomy iliac bone flap grafting versus anterograde anatomy iliac bone flap grafting for treatment of osteonecrosis of the femoral head

BACKGROUND

Iliac bone flap with deep circumflex iliac artery is a common option in the treatment of Osteonecrosis of the femoral head (ONFH), and dissection of iliac bone flap is the key step for successful operation. This paper aims to introduce a new operative technique for dissecting iliac bone flap with deep circumflex iliac artery based on analysis of its advantages.

METHODS

A total of 49 patients treated by retrograde anatomy and 52 patients treated by anterograde anatomy from January 2010 to December 2020 were recruited. The two groups were then compared in terms of the preoperative baseline conditions, intraoperative data, and postoperative Harris hip score (HHS).

RESULTS

Compared with the retrograde anatomy group, the anterograde anatomy group had a significantly longer operating time, a significantly heavier intraoperative blood loss, a significantly higher rate of donor complication morbidity, a significantly higher rate of donor-recipient delayed healing, a significantly higher failure rate of iliac bone flap resection, a significantly higher rate of lateral femoral cutaneous nerve (LFCN) injury, and a significantly higher rate of ectopic ossification. No difference was found in postoperative HHS score between the two groups.

CONCLUSION

As a new operative technique that can accurately locate the nutrient vessels of the iliac bone flap and quickly dissect the iliac bone flap with deep circumflex iliac artery while maintaining a comparable clinical effect, retrograde anatomy exhibited distinct advantages over anterograde anatomy in terms of simpler intraoperative operation, safer dissection, shorter operation time, lower blood loss, and fewer donor complications.

LEVEL OF EVIDENCE

III, Retrospective.

Glucocorticoid-induced expansion of classical monocytes contributes to bone loss

Classical monocytes are commonly involved in the innate inflammatory response and are the progenitors of osteoclasts. Excess endogenous glucocorticoids (GCs) can increase the levels of classical monocytes in blood and bone marrow. The role of this cell population in high-dose exogenous GC-induced osteoporosis (GIOP) remains to be elucidated. In this study, GIOP was established in rats and mice by daily methylprednisolone injection, and monocyte subsets were analyzed by flow cytometry. We demonstrated that classical monocytes accumulate in bone marrow during GIOP. Similarly, the monocyte proportion among bone marrow nucleated cells was also increased in patients with steroid treatment history. We sorted classical monocytes and analyzed their transcriptional profile in response to GCs by RNA sequencing. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis showed that classical monocytes isolated from GC-treated rats exhibited osteoclast differentiation potential. Deletion of classical monocytes by clodronate liposome treatment prevented GIOP via inhibition of osteoclastogenesis and restoration of CD31^Hiendomucin^Hi vessels. Regarding the molecular mechanism, classical monocytes express high levels of glucocorticoid receptors. In vitro treatment with GCs increased both the percentage and absolute number of monocytes and promoted their proliferation. In summary, classical monocytes mediated GC-induced bone loss and are a potential target for therapeutic intervention in GIOP treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Internal fixation using fully threaded cannulated compression screws for fresh femoral neck fractures in adults

Objectives

Internal fixation with multiple cannulated compression screws is an optional treatment for femoral neck fracture. Recently, fully threaded cannulated compression screws (FTCCS) have been introduced to fix fresh femoral neck fractures (FNF). The purpose of this study was to investigate the effectiveness of FTCCS.

Patients and methods

Patients with FNF fixed by multiple FTCCS from February 1st, 2014 to August 31st, 2017 were included in this study. They were followed for at least 12 months postoperatively. Nonunion, osteonecrosis of the femoral head (ONFH), fixation failure, reoperation, and femoral neck shortening (FNS) were used to evaluate the outcomes. Risk factors including age, sex, fracture side, fracture displacement, fracture stability, fixation configuration, and screw numbers were analyzed.

Results

A total of 113 patients including 67 males and 46 females with an average age of 48.4 ± 13.4 years were included. The mean duration of follow-up was 27.1 months (range: 12–51 months). The incidence of nonunion, ONFH, fixation failure, and reoperation was 15.9%, 22.1%, 8.8%, and 24.8%, respectively. The rates of nonunion and reoperation were significantly higher in displaced fractures and unstable fractures. And patients with an unstable fracture had a higher risk of internal fixation failure. The median length of FNS was 2.9 mm (interquartile range: 0.9–6.5 mm, range: 0–17.5 mm). Age was a significant risk factor for FNS.

Conclusions

The screw fixation method with FTCCS provided encouraging clinical results which may be a rational choice for the treatment of fresh FNF. Displaced fractures and unstable fractures were attributed to the higher incidence of complications.

Trial registration: ChiCTR, ChiCTR1800017200. Registered 17 July 2018-Retrospectively registered, http: www.chictr.org.cn/showprojen.aspx?proj=29182.

Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick

SUMMARY

Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.

Femoral Neck Non-union Treated using Compression Screw with or without Gluteus Medius Trochanteric Flap: A Case Series of Ten patients

Non-union is a challenging complication following a femoral neck fracture. Inability to achieve anatomical reduction and compression over the fracture leads to non-union. We reported a 10-case series of femoral neck non-union treated with sliding compression screw and anti-rotational screw with or without gluteus medius local trochanteric flap. When compression could not be achieved and a gap was present over the non-union site, a gluteus medius trochanteric flap was used to enhance the union. Surgeries were performed as a single-stage procedure through the Watson Jones approach. The initial implants were removed, followed by fracture reduction, during which the varus deformity was corrected, and the neck length was preserved as much as possible. Patients were advised for strict non-weight bearing until the presence of trabecular bone crossing the fracture on the radiographs. Union was achieved at three months in all cases. Patients undergoing surgery without trochanteric flap had normal abduction strength, and the neck length was maintained. All cases had no significant loss of function. Patients with trochanteric myo-osseous flap had neck shortening with weak abductors with MRC grade 4. Two out of 10 cases developed avascular necrosis of the femoral head before intervention. One case progressed to collapse of the femoral head requiring implant removal. This and the femoral neck shortening, caused this patient to have weak abductors and a positive Trendelenburg gait. We observed that delayed surgery leads to neck shortening and fracture gap requiring trochanteric myo-osseous flap to achieve union.

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.

Long-term differences in clinical prognosis between crossed- and parallel-cannulated screw fixation in vertical femoral neck fractures of non-geriatric patients

BACKGROUND AND PURPOSE

Vertical femoral neck fractures (VFNFs) are one of the most difficult fractures to stabilize, with high non-union (17%), avascular necrosis (AVN, 21%), and femoral neck shortening (FNS, 29.0%) rates. The objective of this investigation was to directly compare the long-term clinical complication rates of VFNFs repaired by crossed (Alpha fixation) or parallel screws in non-geriatric patients.

PATIENTS AND METHODS

We conducted a retrospective comparative study of VFNFs in patients (<60 years) between January 2014 and December 2017, with at least 2 years of follow-up. VFNFs were fixed with either three parallel screws (G-TRI) or augmented with a crossed screw (G-ALP). Confounding variables included age, gender, initial displacement, ISS (Injury Severity Score), general comorbidities, combined fractures, Pauwels angle, reduction quality. Complications, including non-union, AVN of the femoral head and FNS were compared as outcome indicators. Risk factors associated with these variables were further analysed using multivariate analysis.

RESULTS

A total of 157 patients (97 G-TRI; 60 G-ALP) met inclusion criteria. G-ALP had a significantly lower rate of FNS (8.3% vs. 28.9%, p = 0.039) than that of G-TRI. non-union (3.3% vs. 11.3%), AVN (21.7% vs. 25.8%), and reoperation rates (21.7% vs. 23.7%) were lower in G-ALP than G-TRI but was not statistically significant. Multivariate analyses showed significant relationships between NU and unacceptable reduction quality (OR=7.610; 1.823-31.770, adjusted-p = 0.015); between AVN and initial displacement (Garden III and IV) (OR=7.885; 1.739-35.744, adjusted-p = 0.021); and between FNS and screw configuration (OR=5.713; 1.839-17.743, adjusted-p = 0.009).

CONCLUSION

For the treatment of VFNFs, satisfactory reduction still remains the key surgical goal that prevents NU, while the incidence of AVN strongly depends on the initial displacement at the time of injury. Crossed screws were associated with a markedly lower FNS rate than parallel screws, which promote further randomised controlled trials to establish a guideline for optimal fixation selection in VFNFs.

Bone marrow lesion on magnetic resonance imaging indicates the last chance for hip osteonecrosis treated with vascularized fibular grafting before collapse

PURPOSE

Timing of surgery is the most critical prognostic factor for hip osteonecrosis treated with free vascularized fibular grafting (FVFG). Bone marrow lesion (BML) on MRI usually occurs immediately before femoral head collapse. We conducted a retrospective cohort study to evaluate whether the noncollapsed hips with BML can benefit from FVFG.

METHODS

Consecutive patients undergoing modified FVFG were identified from our clinical repository between January 2014 and December 2014. Based on whether BML was pre-operatively detected, the four year radiographic and clinical outcomes were compared.

RESULTS

In the BML cohort, 22 of 53 hips (42%) showed radiographic signs of osteonecrosis progression, which was significantly higher than that in the control cohort (8 of 49, 16%; P = 0.005). The BML hips showed a significantly lower pre-operative Harris Hip Score (HHS) than those without BML (77.8 vs. 85.5, P = 0.046), whereas no such difference was observed in the final HHS or its post-operative improvement (HHS 90 vs. 94, P = 0.397; HHS improvement 12 vs. 8, P = 0.067). In the subgroup of patients with a pre-operative HHS lower than 80, BML hips were associated with a slightly lower final HHS than hips without BML. Four of 5 (80%) failed hips with BML had a poor pre-operative hip function.

CONCLUSION

BML indicates the last chance for a reproducible improvement in the treatment of hip osteonecrosis with FVFG before collapse. However, the concomitant lower pre-operative HHS (< 80) is a poor prognostic factor for BML-positive hips.