Femoral Neck Nonunion Associated With Delayed Union of Ipsilateral Femoral Shaft Fracture

Abstract

We report the case of a 36-year-old man, who presented to us five months after the initial trauma. He had been treated elsewhere with a cephalomedullary femoral nail. He described severe pain in his right thigh and groin that confined him to a wheelchair. He had shortening of the right lower limb and painful restriction of movements of the right hip. Radiographs demonstrated hypertrophic callus with a gap at the femoral shaft while the neck fracture was in varus malalignment with bone resorption; the neck fracture been fixed using two hip screws that were missing the nail. The patient was managed with removal of the previous hardware, reamed retrograde nailing and Pauwels' intertrochanteric valgus osteotomy fixed using a 120 o double-angled condylar blade plate. Both the fracture sites were not opened. Postoperatively, the femoral shaft showed radiographic evidence of union at three months, while the femoral neck and the intertrochanteric osteotomy site had united at five months. As per the Friedman and Wyman criteria, our patient has a "good" outcome at the four-year follow-up.

Hip Valgus Osteotomy in Presence of Ipsilateral Femoral Retrograde Nail: A Case Study and Literature Review

“…7,12,13 The aim of this osteotomy is to make the fracture line more horizontal, by decreasing the fracture Pauwels' angle, to bring compressive forces on the fracture site rather than shear forces, and hence promote fracture healing. [12][13][14][15] While nonunion of both femoral neck and femoral shaft fractures has been reported before in literature 3,7,11,16,17 and while nail removal, proximal femur VO, and concomitant exchange retrograde nailing have also been reported, 7,11 performing proximal femoral VO in the presence of an existing, ipsilateral retrograde femoral Keywords ► femoral neck fracture ► nonunion ► retrograde nail ► valgus osteotomy…”

“…7 While the ideal technique for management remains controversial, 7 with no clear advantage of double versus single implant fixation, 8,9 many surgeons prefer to use a dedicated implant for each fracture to potentially diminish the risk of nonunion 3,7,10,11 which may be higher than isolated femoral neck fractures, owing to the mode of trauma and the fracture characteristics in such concomitant fractures. 7,11 For management of nonunions of femoral neck fractures, the proximal femoral valgus osteotomy (VO) remains the gold standard technique with reported high success rates. 7,12,13 The aim of this osteotomy is to make the fracture line more horizontal, by decreasing the fracture Pauwels' angle, to bring compressive forces on the fracture site rather than shear forces, and hence promote fracture healing.…”