Early Return to Function in Young Adults with Neglected Femoral Neck Fractures

Abstract

Neglected femoral fractures in young adults are a challenge to the orthopaedic surgeon, requiring prolonged treatment and with attendant risks of nonunion. We postulated treatment in this group by accurate reduction, two cannulated screws, and whole free fibular autograft would allow early mobilization and provide good bony union. Thirty-two patients aged 18 to 50 years were treated at our center in this manner. They presented to our center 3 to 6 months after injury, and had Garden's Grade III/IV fractures with varying degrees of neck resorption, but no avascular necrosis. No plaster was applied, and early return to function was encouraged. Bony union was achieved in 29 (90.6%) patients at a mean of 19.2 weeks (range, 16-24 weeks). All patients with union had good function at long-term followup at an average of 6.1 years postoperatively (range, 2-12 years), and the average Harris hip score was 87.1 points (range, 74.5-94 points). Our procedure allows early return of function in young, active patients disabled by old femoral neck fractures compounded by lack of early treatment.

Contemporary management of femoral neck fractures: the young and the old

“…Of the seven studies that looked at correlation between timing to surgery (within 12 hours or after 12 hours), no difference in rate of osteonecrosis was found. Finally, three case series have been published reporting on cohorts of patients treated after "inadvertent" delays of 6 days to two years, with rates of AVN and nonunion similar to those series in which patients were treated emergently (0 to 25 %) [33][34][35].…”

Modified Pauwels’ Intertrochanteric Osteotomy in Neglected Femoral Neck Fracture

“…Limb shortening of 1 to 3.4 cm (mean, 2.3 cm) has been reported in 91% of patients treated with free fibular grafting and osteosynthesis with two compression screws [28]. Similarly, shortening of 0.9 to 3.9 cm (mean, 2.9 cm) was reported by Nagi et al [25].…”

“…Union rates of 85% to 90% have been reported for the valgus osteotomy [11,30], and 88% to 95% for open reduction and internal fixation with compression screws and free fibular grafts [25,28,29]. The McMurray osteotomy has been performed for ununited fractures [28].…”

“…biomechanical or biologic factors [1-3, 9, 14, 16, 20, 22, 25, 28-30, 32]. However, persistence of nonunion, AVN, coxa vara, limb-length discrepancy, and persistent limp make treatment of neglected femoral neck fractures a challenge [21,25,28]. Our aims were (1) to evaluate the role of the modified Pauwels' osteotomy in adult patients with neglected femoral neck fractures regarding union and functional outcome; (2) to determine whether the osteotomy could address complications, such as nonunion, limblength discrepancy, coxa vara, and AVN of the femoral head, associated with other treatment methods, and (3) to compare our results using the osteotomy with published results.…”

“…In developing countries, it is not uncommon to see patients with femoral neck fractures after a delay of several months because of poverty, lack of facilities, ignorance, and faith in traditional healers [8,9,15,25,28,29]. Prosthetic replacement generally is the preferred treatment for patients older than 60 years [10,13,21], and salvage of the femoral head has been advocated for younger patients [10,14,21,27].…”