We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery.

At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001).

These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed.

Cite this article: Bone Joint J 2015; 97-B:988–91.

We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of avascular necrosis of the head.

Two fractures were Garden stage I, 12 stage II, and three stage III. We performed internal fixation under radiological control at a mean of five days (2 to 15) after injury using a titanium cannulated cancellous screw or a titanium compression hip screw. MRI was performed at one, six and 12 months and then yearly after operation. T1- and T2-weighted images were obtained by a spin-echo technique. The duration of follow-up of patients who did not subsequently require replacement of the head of the femur was from 2 to 5 years (mean 3.2).

One month after operation eight of the 17 hips showed a band of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images indicating lesions in the femoral head away from the fracture line. These were of three types: type I was a small infarct at the superolateral region of the femoral head and was seen in three hips; type II was a shallow lesion from the superolateral region to the fovea of the femoral head (three hips); and type III was a large lesion occupying most of the femoral head (two hips). No further changes were seen in the MRI after six months from operation. Collapse of the femoral head did not occur in the three hips with type-I lesions, but two of the three type-II hips and both type-III hips subsequently collapsed. At the final follow-up the three hips with a type-I lesion and one with a type-II were still asymptomatic but radiography showed sclerosis in the femoral head corresponding to the MRI lesions. The nine hips which showed no changes on MRI at one month had no abnormal findings on physical examination, radiography or MRI at final follow-up.

Background. Femoral neck nonunion is a challenging problem. If it is not treated properly, it will be ended with a catastrophe because the victims are younger and active patients and missing hip joint will result in a handicapped like person. If the head is viable, the best treatment is valgus osteotomy. In the original technique, site of nonunion was not explored but in our technique, there is exploration and cleaning of nonunion site and after reduction of fragments, fixation and subtrochanteric osteotomy were done. Materials and methods. Patients with established nonunion of femoral neck fracture entered in study. Inclusion criteria's were age under 60 years old, spherical head of femur without changing the density of it and femoral neck nonunion at least 6 months after fracture. Nonunion site was freshed and any hard ware was removed and head was reduced as possible and subtrochanteric valgus osteotomy to 150 degree was done and fixed with angle blade plate. Bone graft was not used. Patients were studied one year monthly for signs of union of fracture site and signs of avascular necrosis of femoral head. Results. 29 patients were entered in study. 21 male and 8 female with the mean age of 33 years(18 to 55). 19 had Garden type 4 and 7 garden type 3 and the rest 3 had garden type2 at first. Fracture of fixation device were seen in 15 patients. After average 4 months (3 to 5.5) 27 of them showed union of fracture site but in 7 cases, because of some collapse in fracture site, tip of hard ware entered the joint and in 2 cases avascular necrosis of head appeared. Discussion. Exploration of nonunion has some advantages. At first, in some cases removing of broken implants would be necessary for proper insertion of new device. Second, better reduction of fracture site may improve fixation and biomechanics. Third, it seems that in these cases there were through union but in the original method, there were metaplasia of fibrous tissue in the fracture site nonunion

Objective. The aim of this study was to determine the correlation between body weight and fracture union for displaced intracapsular fracture neck of femur treated by closed reduction and internal fixation. Patients and methods. A total of 197 patients with displaced intracapsular fracture of neck of femur, all of whom have been treated with closed reduction and internal fixation, were studied. The mean age was 71 years and 79% were female. Patients were followed up until fracture endpoint (union or non-union) with minimum follow up of 200 days. Results and conclusion. 118 (60%) of the fractures achieved clinical and radiological union. The mean body weight for the patients achieved fracture union was 64.6 kilograms versus 61.6 kilograms for those who developed fracture non union or avascular necrosis of the femoral head (p value for the difference p=0.15, not statistically significant). This study is the largest study indicates that the patient's weight is not an indicator of later fracture healing complications

Introduction. In most cases of stable type medial femoral neck fracture and some cases of dislocated medial femoral neck fracture, internal fixation was undertaken. Dual SC Screw (DSCS) System is an internal fixation device which has sliding mechanism and preventing mechanism of back out of the screw. The purpose of this study is to evaluate the results and complication of medial femoral neck fracture treated with DSCS. Methods. Fifty two patients operated for fractures of the medial femoral neck with DSCS were identified as the study population. All patients followed up at least 2years. Outcome measures included the period of bone union, revision surgery, operating times and clinical symptoms and complication. Results. The average operation time was 37 minutes and 49 cased achieved union. Moreover all patients could regain the pre-injury walking ability. Three patient did not achieve union and two patients suffered displacement of reduced fracture and three patients had avascular necrosis of the femoral head. However, the cases of subtrochanteric femral fracture or the back out of the screws were not found. The mechanical tests using imitation bone showed the strength of DSCS. Conclusion. Operative treatment with internal fixation using DSCS in femoral neck fracture gives favorable results because of its strong fixation and holding function of the screw. The operative technique was simple and the DSCS thought to be a useful tool for femoral neck fracture

Introduction. Femur neck fractures (NOF) in the young could result in mal-union, non-union and avascular necrosis of the femoral head. Osteosynthesis is the standard of management in NOFs in young patient above complications sometimes end in Arthroplasty. The aim of our study is to identify predictors of NOF failures in the young population. Method. A retrospective study conducted in a single center. Patients with NOF fractures below the age of <50y excluding pathological and osteoporotic fractures were assessed in the period from 2005–2008. The mean follow-up was 22 months (6–40). Fractures were classified according to Gardens classification. Our Aim was to identify causative factors for fixation failures. Analysis was done using SPSS 17.0. Results. Within the 4 year period we identified 41 NOF fractures, 24 (75%) fractures were displaced. 7 (25%) out of the displaced fractures went in to failure and required arthroplasty. 3 (42%) went in to avascular necrosis and 2(28.5%) went in to screw cut out and non unions. All failures were primarily fixed with cancellous screws. We identified Male sex (p=0.03), Pre-operative delay of >25h (p=0.04), Chronic alcohol intake (p=0.02) and intra operative time >107min (p=0.001) as the main predictors of NOF failures in the young. Conclusion. Early surgical intervention within 25h, restricting the operation time to less than 107min would reduce the failure rates. We would recommend arthroplasty for patients who are chronic alcoholics

Background. Using one-stage bilateral free vascularized fibular grafting (FVFG) to treat avascular necrosis of the femoral head (ANFH) remains controversy due to potential high-risk and technical complexity. The purpose of the present study was to evaluate the safety and effectiveness of one-stage bilateral FVFG procedure versus unilateral FVFG in the treatment of ANFH. Methods. One-stage bilateral FVFG was performed for 26 patients with bilateral ANFH between March 2001 and September 2006. The clinical and radiographic outcomes, hospital stays, and postoperative complications in this group were compared with those from another 33 patients (40 hips) receiving unilateral FVFG. Results. The two groups had similar hospital stays, clinical outcome, and few complications. In an average follow-up of 36 months, one major and five minor complications were encountered in the onestage bilateral group, and one major and three minor complications in the unilateral group. The mean Harris hip scores increased from 63.8±16.795%CI: 61.266.4 to 84.2±1795% CI: 81.586.9 points in the unilateral group and from 61.7±22.295%CI: 58.664.8 to 82.0±16.6 95%CI:79.784.3 points in the one-stage bilateral group. In radiographic, there was no obvious difference in progression of collapse between the two groups. Conversion to hip arthroplasty was performed in 2 (5%) hips in the unilateral group and none in the one-stage bilateral group, with no statistically significant difference between the two groups. Conclusion. Using one-stage bilateral FVFG to treat ANFH is a safe and effective method with minor postoperative morbidity

Introduction and aim. Avascular necrosis (AVN) of femoral head remains a major post-operative complication of the surgical fixation of femoral neck fractures (#NOF). In order to reduce the incidence of AVN following this type of fracture, the National Institute for Clinical Excellence (NICE) has stated that fixation must occur within 6 hours. However, there is a paucity of information concerning whether time to fixation influences the development of AVN. The aim of the present study was to assess whether time to fixation affects the development of AVN in patients aged under 60 who had sustained a fracture (#)NOF. Methods. We looked retrospectively at 101 patients (61 female, 40 male aged under 60 (mean age 47 years) who were admitted to a multi-tertiary centre having sustained an intracapsular #NOF. The underlying co morbidity of the patient sample was varied, as was the mechanism of trauma, though in the majority of cases the cause was a simple fall. The time delay (TD) between the time of injury and the time of operation for each patient was determined. Results. 72 patients sustained an intracapsular displaced fracture and 29 an intracapsular undisplaced fracture. Of these, 33 patients were treated with a dynamic hip screw (DHS), 10 received a DHS plus a cannulated screw, and 54 were treated with cannulated screws only. We looked at time to fixation(TD) as follows: Group A-less than 6 hours (7 patients), Group B-6 to 12 hours (16 patients), Group C-12 to 18 hours (15 patients), Group D-18 to 24 hours (18 patients), Group E −24 to 48 hours (26 patients) and Group F- more than 48 hours(15 patients). Out of 97 patients, 15 (15.46%) developed AVN. Of these, 13 were patients who had sustained an intracapsular displaced fracture, two had sustained an undisplaced fracture. Of the intracapsular displaced fractures patients, the time to fixation varied from 3 hours to 26 hours post-trauma. Of note, twelve of these patients received a cannulated screw and only one was treated with a DHS. The two patients with an undisplaced intracapsular fracture underwent fixation at 13 and 24 hours respectively. The method of fixation was a cannulated screw. Conclusion. Current NICE guidelines state that intracapsular #NOF must be fixed within 6 hours in order to prevent AVN of femoral head. In our sample, 15.46% of patients developed AVN post-fixation. Crucially, 2 patients out of the 7 patients (28.57%) developed AVN despite undergoing fixation within 6 hours. Interestingly, we have observed that fracture fixation with a cannulated screw has a greater propensity to develop AVN despite time to fixation, since 15.46% of patients treated in this manner developed AVN. Taken together, method of fixation rather than time to fixation appears to be a key factor in the incidence of AVN in our patient group

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9).

Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports.

Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p <  0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury).

In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities.

We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D).

There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle.

Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic.

This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation.

We prospectively analysed the epidemiology of acetabular fractures over a period of 16 years in order to identify changes in their incidence or other demographic features. Our study cohort comprised a consecutive series of 351 patients with acetabular fractures admitted to a single institution between January 1988 and December 2003.

There was no significant change in the overall incidence of acetabular fractures, which remained at 3 patients/100 000/year. There was, however, a significant reduction in the number of men sustaining an acetabular fracture over the period (p < 0.02). The number of fractures resulting from falls from a height < 10 feet showed a significant increase (p < 0.002), but there was no change in those caused by motor-vehicle accidents. There was a significant reduction in the median Injury Severity score over the period which was associated with a significant decrease in mortality (p < 0.04) and a reduction in the length of hospital stay. The incidence of osteoarthritis noted during follow-up of operatively-treated fractures declined from 31% to 14%, reflecting improved results with increasing subspecialisation. Our findings suggest that there will be a continuing need for some orthopaedic surgeons to specialise in the management of these fractures. In addition, the reductions in the Injury Severity score and mortality may be associated with improved road and vehicle safety.

There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel.

A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (> 3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17).

All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p < 0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d’Aubigné and Postel score of 13.7.

The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting.

We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score −1.6) and those with osteoporosis (34%, mean T-score −3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups.

Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful.

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome.

We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables.

The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.