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.

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.