Fibular Grafting: A Worthwhile skill to Master for Difficult neck of Femur Fractures - A Case Series

Introduction

Neck of femur fractures (NOF) in younger adults are often treated by head-preserving fixation procedures. Non-union is an infrequent but troublesome complication following internal fixation, especially in atypical presentations. Vascularized (VFG) and non-VFG (NVFG) fibular grafting and realignment procedures have been described as an adjunct to internal fixation. Reports are rare regarding the versatility of fibular grafts, their use, and their outcomes in the United Kingdom.

Case Report

We present three complex NOF cases performed in the United Kingdom. One case is a 29-year-old Asian female treated with NVFG for a pathological transverse NOF fracture secondary to fibrous dysplasia. One case is a non-union following failed surgical management and revised using NVFG and dynamic hip screws. The last case is a VFG in a complex non-union intra-capsular fracture following conservative management in a 17-year-old male. Certain patient characteristics are described which make joint preserving surgery more attractive. All fractures united with no revisions at the time of final follow-up. Distinctions between the use of VFG and NVFG grafts are discussed.

Conclusion

This case series demonstrates the important versatility of fibular grafting and how its properties are used in different cases. Fibular grafting is an effective technique in pathological, non-union, and late-presenting NOF. Both types of grafts introduce additional biology for difficult cases where neck resorption and adequate fixation are an issue, with NVFG grafts much easier to perform.

The role of Grey Scale Inversion Imaging (GSII) as a diagnostic tool of neck of femur fractures: is it more effective?

INTRODUCTION

Grey Scale Inversion Imaging (GSII), a radiology reading software, has been utilized to improve anatomical and pathological delineation and consequently increase the diagnostic accuracy in a variety of trauma and Orthopaedic conditions.

OBJECTIVE/AIM

The objective of this study was to assess whether Grey Scale Inversion Imaging (GSII) has any impact on the diagnostic accuracy and inter-observer reliability in diagnosing neck of femur fractures.

METHOD

We performed a retrospective, single-centre study, to identify 50 consecutive anteroposterior (AP) pelvis radiographs of patients who presented to our unit with suspected neck of femur fractures between 2020 and 2021. The images included a combination of normal pelvic radiographs and others with features suggestive either intracapsular or extracapsular neck of femur fractures, which had been confirmed on computed tomography (CT), magnetic resonance imaging (MRI) and/or subsequent surgery. Four independent observers (two Trauma and Orthopaedics (T&O) consultants, one T&O Trainee Registrar (ST3 level) and one Trainee Senior House Officer (SHO in T&O) reviewed the images and graded each radiograph image using the Likert scale in response to the statement "there is a fracture". Following this, the same radiographs were inverted to Grey Scale Inversion Imaging (GSII) grey scale images and reassessed. RAND correlation was used for statistical analysis.

RESULTS

Overall, observers appeared to have similar accuracy with normal radiographic imaging and with GSI sequences.

CONCLUSION

Grey Scale Inversion Imaging (GSII) of digital radiographs did not affect the diagnostic accuracy of detecting neck of femur fractures in our study.

Strategies for fixation of periprosthetic fragility fractures of the neck of femur below a well-functioning hip resurfacing arthroplasty: A case-series

Introduction

Metal-on-metal Hip Resurfacing (HR) was performed in many young individuals as it conserved bone stock and had low wear rates, before it became less popular due to the detection of Adverse Reactions to Metal Debris. As such, many patients in the community have well-functioning HRs and as they age, the incidence of fragility fractures of the neck of femur around the existing implant is expected to increase. These fractures are amenable to surgical fixation as adequate bone stock remains in the head of the femur and the implants are well fixed.

Case-series

We present a series of six cases which were treated by fixation using locked plates (3), dynamic hip screws (2) and cephalo-medullary nail (1). Four cases achieved clinical and radiographic union with good function. One case had a delayed union, though union was finally achieved at 23 months. One case had an early failure necessitating revision to a Total Hip Replacement after 6 weeks.

Discussion

We highlight the geometrical principles of placing fixation devices under an HR femoral component. We have also conducted a literature search and present details of all case reports to date.

Conclusion

Fragility per-trochanteric fractures under a well-fixed HR with good baseline function are amenable to fixation using a variety of methods including large screw devices that are commonly used in this location. Locked plates including variable angle locking designs should be kept available if needed.

Diagnostic value of full-length femur radiographs in patients with neck of femur fracture and co-existing malignancy

PURPOSE

In the UK, it is common practice to obtain full-length femur radiographs in patients admitted with neck of femur fractures (NOF) and co-existing malignancy. Limited literature exists studying this topic. Our aim was to identify whether full-length femur radiographs are of diagnostic and therapeutic value in this demographic.

METHODS

A retrospective observational analysis of the patients admitted with a neck of femur fracture over a 5-year period (2015-2020) using the National Hip Fracture Database was performed at a major trauma centre. Electronic patient records were accessed to screen the NOF patients who had co-existing malignancy and subsequently underwent a full-length femur radiograph. In addition to patient demographics, we also identified the plan and whether it was affected by findings of the full-length radiograph, the operation performed, any additional investigations undertaken for malignancy, the type of cancer, complications and 1-year mortality.

RESULTS

Of the 2416 patients screened, 18% had a co-existing malignancy (n = 431). Of the 431 with underlying malignancy, 424 patients underwent a full-length femur radiograph while only seven of these radiographs identified lesions. From the seven patients with findings of metastatic deposits on full-length radiographs, none required an alternative operation to that which they normally would undergo. Furthermore, no patients required a longer stem arthroplasty or longer internal fixation. One in four fractures was associated with co-existing breast malignancy (26.5%, n = 114), followed by prostate cancer (14.8%, n = 64). Colorectal, lung, bladder and skin (squamous cell carcinoma) contributed 6-10% (n = 44, 40, 33, 29, respectively). Other malignancies contributed to the rest of the 25%.

CONCLUSION

To conclude, full-length radiographs had no diagnostic or therapeutic value in our cohort of patients regardless of the full-length femur findings.

Peri-operative derangement in liver function tests in older patients with neck of femur fracture

Neck of femur fracture is a common consequence of falls in the elderly with a large burden of morbidity and mortality. Derangement in liver function tests (LFTs) is frequently seen in elderly people with neck of femur (NOF) fracture in the peri-operative period and can indicate serious and treatable underlying pathology as well as prognosis.On admission, raised alkaline phosphatase (ALP) levels with normal gamma-glutamyl transferase (GGT) suggest underlying bone pathology such as osteomalacia or Paget's disease but do not confirm or exclude osteoporosis. ALP can also be raised by non-bone pathology such as congestive cardiac failure and chronic kidney disease. LFT derangement in cardiac failure is associated with poorer prognosis. Post-operatively, ALP levels rise after the first week with a peak at 3-4 weeks and then fall thereafter. The rate at which they fall may help indicate bone healing in trochanteric fractures. Derangement in other LFTs is commonly due to hepatic injury; causes include trauma, alcohol, and viral hepatitis. There are also iatrogenic causes including surgery and commonly prescribed medication such as beta-lactam antibiotics, non-steroidal anti-inflammatories, and paracetamol.The differential diagnosis for deranged LFTs in the elderly peri-operatively is wide; however, most causes can be elicited through careful history and examination with occasional need for further investigations.

A cross sectional study of outcomes of muscle pedicle grafting in neck of femur fractures and avascular necrosis of femoral head

Avascular necrosis (AVN) of the femoral head is a progressive disease that generally affects patients in the second through fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. Treatments range from simple decompression of the femoral head, to muscle pedicle bone grafting of the involved area, or by using a vascularized fibular graft with varying degree of success. If the disease have progresses further causing secondary arthritis, Total Hip Arthroplasty may be necessary. We present a study of management of 60 young patients aged less than 50 years having either early stage AVN (stage I and II A/B of Ficat & Arlet classification) or Neck of the femur fractures, treated with quadratus femoris muscle pedicle bone grafting & cancellous screws. With aim To evaluate the results of the above modality in the management of AVN of the hip & neck femur fractures and to study the radiological & functional outcome of the procedure in young patients.

Informed consent for surgery on neck of femur fractures: A multi-loop clinical audit

Background

The Montgomery case in 2015 resulted in a pivotal change in practice, leading to a patient-centric approach for informed consent. Neck of femur (NOF) fractures are associated with a high rates perioperative morbidity and mortality. Using guidelines highlighted by the British Orthopaedic Association we performed a multi-loop audit within our department to assess the adequacy of informed consent for NOF fractures.

Methods

Two prior cycles had been performed utilising a similar framework. Prior interventions included ward posters, verbal dissemination of information at Junior Doctor's (JD) induction and amendments to the JD handbook. For the latest audit loop, a retrospective analysis of 100 patients was performed. Risk were classified as common, less common, rare and ‘other’ non-classifiable risks. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation in the signed Consent Form-1s for compos mentis patients.

Results

Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement included documentation of neurovascular injuries (98%), pain (75%) and altered wound healing (69%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). Poorly documented risk factors included mortality (21%), prosthetic dislocation (14%) and limb length discrepancy (6%).

Conclusion

Following the latest cycle, the trust has now approved the use of 2 consent-specific stickers (for arthroplasty or fixation), amendable on a patient-to-patient basis. As part of the multi-loop process, the cycle will be repeated every year, in line with Junior Doctor rotations. Medical professionals have an ethical, moral and legal obligation to ensure they provide all information regarding surgical interventions to aid patients in making an informed decision.

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The Montgomery case in resulted in a pivotal change in practice, leading to a patient-centric approach for informed consent.

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Medical professionals have an ethical, moral and legal obligation to ensure all pertinent information is passed to patients.

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Medico-legally, in the absence of formal documentation it is assumed that the process of informed consent is inadequate.

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The Trust-approved ‘consent sickers’ for arthoplasty/fixation are compliant with BOA-endorsed guidelines.

Injury specific trauma registry: Outcomes of a prospective cohort with proximal femur fractures

Background

The elderly population is prone to hip fractures, and treating such patients to achieve good outcomes can be challenging. Collection of outcomes data can support clinicians to modify their treatment protocols and improve outcomes over time. The aim of this study is to compare different surgical procedures in patients with neck of femur and intertrochanteric fractures in terms of clinical, functional and radiological outcomes using injury-specific outcome scores.

Methods

The study data was derived from the existing single-center, prospective orthopaedic trauma registry initiated from July 2015. Functional, clinical and radiological outcomes were assessed using Modified Harris Hip Score and The Radiographic Union Score for Hip. Mean radiological outcome scores was compared by Mann-Whitney U test and deaths by Chi-square and Odds ratio.

Results

Of the total 138 patients, 53 (38%) were neck of femur and 85 (62%) Intertrochanteric fractures with fall as leading cause of injury. At 12 months follow-up, modified Harris Hip Score showed 67% excellent-good results in both dynamic hip screw (N = 6) and total hip replacement (N = 3) followed by 50% in intramedullary nail (N = 2). Hemiarthroplasty has fair-poor outcomes with significantly higher deaths as compared to other procedure groups (p = 0.016). Radiological outcomes showed non-significant trend towards better outcomes in dynamic hip screw as compared to intramedullary nail (p = 0.08).

Conclusion

Our 12 months follow-up data suggest that dynamic hip screw and total hip replacement have better clinical, functional outcomes followed by intramedullary nail. Hemiarthroplasty has fair-poor clinical and functional outcomes with significantly higher deaths as compared to other procedure groups.

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To compare different surgical procedures in patients with neck of femur and intertrochanteric fractures in terms of outcomes.

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A Single center, prospective cohort study.

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Dynamic hip screw, total hip replacement, intramedullary nail, hemiarthroplasty.

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Functional, clinical and radiological outcomes assessment using Modified Harris Hip Score and The Radiographic Union Score.

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At 12 months, DHS and THR have better outcomes. Hemiarthroplasty has significantly higher deaths as compared to other groups.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

INTRODUCTION

Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort.

METHODS

We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon's grade, types of implant, patient's age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patient's age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared.

RESULTS

The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years.

CONCLUSION

A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.