Free Vascularized Fibular Bone Grafting in the Management of Femoral Neck Nonunion in Patients Younger Than Fifty Years

Abstract

Rates of complications, such as nonunion and osteonecrosis, after femoral neck fractures in young patients have been reported to be as high as 86 percent. Treatments such as osteotomy, muscle-pedicle bone grafting, nonvascularized bone grafting, and vascularized bone grafting have reported variable results. Based on the results reported in this study, vascularized fibular bone grafting compares favorably with a high union rate (91 percent initially, 100 percent after secondary procedures) and successful long-term salvage of the femoral head in 91 percent of the patients. Free vascularized fibular bone grafting represents a promising solution for this difficult problem.

Valgus intertrochanteric osteotomy for non-union of femoral neck fracture

“…8,11 Several treatment methods that preserve the femoral head have been described in young patients, showing variable results; no one technique has proved entirely satisfactory. 9,10 Valgus intertrochanteric osteotomy alters the biomechanical environment of the non-union site and restores limb length, but few reports have dealt with the results of this procedure in the management of femoral neck non-union. 2,7,12,20 The main purpose of this study was to evaluate the clinical and radiographic results of valgus intertrochanteric osteotomy, performed at one centre and using a single surgical technique, in the treatment of femoral neck non-union.…”

Evaluation of osteosynthesis with dual fibular bone grafting for neglected femoral neck fractures

“…15,16 Vascularised free fibular graft has also been reported. 17,18 These grafts have improved the rate of union of fracture particularly if the treatment is delayed beyond 3 weeks or if closed reduction is not Fig. 17 e Preoperative radiograph.…”

Modified Pauwels’ Intertrochanteric Osteotomy in Neglected Femoral Neck Fracture

“…A 20°to 30°wedge is sufficient to place the head of femur into valgus and larger intertrochanteric wedges of bone based on Pauwels' angle are not required [18]. Bone graft donor-site morbidity associated with other procedures is avoided [3,14,25,28]. A satisfactory outcome can still be achieved through a revision osteotomy or arthroplasty if the initial procedure fails [12,20].…”

“…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]. With increasing life expectancy of patients with prostheses, late complications of prosthetic replacement are increasing [6,21].…”

“…Furthermore, open reduction is likely to interfere in an already precarious blood supply of the head of the femur [29]. Vascularized fibular grafting [3,14] reportedly has achieved 100% union; however, vascularized fibular grafting with or without osteotomy is time-consuming, requires a high degree of technical skill, and is beyond the competence of the typical orthopaedic surgeon [29]. Valgus osteotomy with or without bone grafting and THA have been widely accepted as the only two viable options for treatment of femoral neck nonunion [10,11,16,20,21,24,27,30].…”