Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck

Abstract

Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed. We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.

Valgus intertrochanteric osteotomy for non-union of femoral neck fracture

“…However, possible drawbacks to trochanteric osteotomy for non-union include the risk of avascular necrosis of the femoral head 2,12,20 and the technical difficulty of later conversion to THA necessitated by necrosis. 17 In addition to the two patients in our series whose preoperative bone scans showed no osteonecrosis even though they later developed it, seven patients in the series of Nagi et al 14 and the two in the series of Wu et al 20 exhibited the same phenomenon. The mechanism by which valgus osteotomy introduces osteonecrosis has not been clarified, but it is possible that the procedure interrupts the intramedullary blood supply.…”

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

“…Series by Nagi et al 21 showed 87.5% successful results while Yadav 23 reported 88% excellent to fair result. Thus our study showed comparable results with other similar studies.…”

“…The results with this procedure have given non-union rates between 0% and 17% and AVN rates of 0%e33%. 19 Nagi 20,21 The idea of biological fixation by twin fibular graft was put forward by Yadav. 23 In a study on 150 patients with fracture …”

Modified Pauwels’ Intertrochanteric Osteotomy in Neglected Femoral Neck Fracture

“…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].…”

“…One study reported muscle pedicle bone grafts had a 75% failure rate in neglected fractures when performed more than 90 days after injury [22]. Free fibular bone grafting reportedly provided satisfactory results in 88% of patients [25]; however, coxa vara in 28%, mean leg-length discrepancy of 2.9 cm, donor-site morbidity, and application of hip spica casts are drawbacks of the procedure. In another study, internal fixation and fibular bone grafting had a failure rate of 67% in patients with neglected femoral neck fractures presenting with either a proximal fragment smaller than 2.5 cm or with a fracture gap 2.5 cm or greater, or having AVN of the femoral head [29].…”