Femoral Neck Nonunion Research Articles

Comparison of the surgical efficacy of robot-assisted and freehand nail placement in the treatment of sarcopenia combined with femoral neck fractures younger than 65 years

ObjectiveThere is limited research on the effectiveness of orthopedic robot-assisted treatment for sarcopenia combined with femoral neck fractures (FNF) in clinical settings. This study aimed to compare the clinical outcomes of orthopedic robot-assisted screw placement with traditional manual screw placement for treating sarcopenia combined with FNF. MethodsThe retrospective study included patients with FNF under the age of 65 who were admitted to the Department of Orthopedics at XX Hospital Affiliated to XX University between January 2019 and March 2022 and underwent internal fixation with cannulated screws. Grip strength of the dominant hand was measured, and the skeletal muscle index (SMI) was calculated based on the muscle tissue area at the level of the 12th thoracic vertebrae on chest CT divided by height squared. Sarcopenia was diagnosed when SMI was below 42.6 cm2/m2 for men or 30.6 cm2/m2 for women. Patients were then grouped based on whether they underwent orthopedic robot-assisted surgery, as the robot-assisted (RA) group or the freehand (FH) group. Follow-up evaluations over 24–36 months included various parameters such as operation time, blood loss, X-ray shots, number of needle drilling, cannulated nail parallelism, C-reactive protein (CRP) levels, time to weight-bearing, perioperative infection, VAS (visual analogue scale) scores at 1 and 6 months post-surgery, Harris hip score at 6 months post-surgery, and incidence of nonunions and femoral head necrosis within 24 months post-surgery. ResultsA total of 127 participants were enrolled in this study, with 46 individuals in the RG group and 81 in the FG group. Across both groups, factors such as gender, age, SMI, injury sides, Garden classifications, intraoperative blood loss, preoperative CRP, and VAS scores at 6 months post-surgery did not show statistically significant differences (p > 0.05). The RA group exhibited shorter operation time, fewer intraoperative X-ray shots, less needle drilling, and lower postoperative CRP levels compared to the FH group. The VAS score of the RA group was lower one month after surgery, whereas the Harris score was higher six months post-surgery (p < 0.05). The parallel angle of the hollow screws in the RA group was superior to that in the FH screw placement group, with an earlier time to bear weight on the ground post-surgery (p < 0.05). There were no statistically significant differences in incision infection, femoral neck nonunion (within 9 months after surgery), and patient satisfaction between the two groups (p > 0.05). Furthermore, the rate of femoral head necrosis after fracture within 2 years in the RA group was lower compared to the FH screw placement group, with statistically significant differences (p < 0.05).

Ложные суставы шейки бедренной кости: применение новой классификации при эндопротезировании у пациентов пожилого возраста

Introduction The risk of the femoral neck fracture nonunion is 48 % with avascular necrosis of the femoral head being reported in 42 % of cases. There are many classifications of acute intra-articular fractures of the proximal femur and there are no grading systems for femoral neck nonunions that would allow prediction of outcomes of total hip arthroplasty (THA). The objective was to evaluate mid-term results of THA in patients with femoral neck nonunion and develop a new classification of nonunions. Material and methods A prospective cohort single-center comparative study included 78 elderly patients with atrophic femoral neck nonunions treated with primary THA. The mean follow-up period was 24.2 months. Three prospective groups were identified. Separation criteria included shortening of the lower limb and femoral offset, changes in the Barnett-Nordin index, the Hounsfield bone density index, the presence of metal constructs and bone defects. Groups A and B were divided into 2 subgroups depending on the presence/absence of fixation metal constructs for a femoral neck fracture. Group C was divided into 2 subgroups: type C1, acetabular defect and type C2, proximal femur defect. Results Mean operating time was 81.1 minutes in group A, 102.9 minutes in group B and 145.2 minutes in group C. The minimum blood loss was recorded in group A measuring on average 429.25 mL in both subgroups. The maximum blood loss was seen in patients of groups B and C measuring 606.62 mL and 631.5 mL. Overall revision rate was 7.7 %. Conclusion A classification for femoral neck nonunions was developed suggesting grading patients into 3 types: type A, type B and type C which were further divided into 2 subtypes. The grading system was based on lower limb shortening and femoral offset, severity of osteoporosis, presence of metal constructs and acetabulum or proximal femur bone defect which prognostically affected the outcome of THA.

Mid-Term Results of Total Hip Arthroplasty for Femoral Neck Nonunions in Long-Term Hemodialysis Patients

Background. Performing primary arthroplasty in patient with renal osteodystrophy is associated with a number of difficulties due to low bone mineral density, which complicates the fixation of the endoprosthesis components, the presence of bone defects, and functional insufficiency of the gluteal muscles. The aim of the study evaluation of the mid-term results of primary total hip arthroplasty using cemented femoral and acetabular implants in hemodialysis patients with nonunions of the femoral neck. Materials and Methods. The authors conducted a study of 26 hemodialysis patients with pseudarthrosis of the femoral neck. The patients were divided into 3 groups: group I (12 patients) classification type A of the femoral neck nonunion, group II (10 patients) classification type B, group III (4 patients) of type C who underwent total hip arthroplasty. Results. The longest surgery duration was observed in patients of the III study group 121.2519.26 minutes. There were no statistically significant differences between the patients of the II and III study groups. The smallest rate of intraoperative blood loss was noted among patients of the 1st study group 440.83133.65 ml, the statistical significance of the differences was obtained both between the 1st and II, and between the I and III study groups, respectively. The smallest total number of complications after surgery was obtained in the 1st group 4 (8.33%). Revisions were performed in 8 (30.7%) patients among all three groups. There was a significant improvement on the Oxford hip score after 12 months (mean 29.8) and 24 months (mean 33.1) in all groups compared with preoperative results (mean 12.5). Twelve 12 months after surgery, the average value of the pain severity was reduced by 72.6% and amounted to 2.01. The risk of getting any orthopedic complication in cemented total hip arthroplasty of the classification type A of the pseudarthrosis is 2.5, with type B 3.4, with type C 5.7. Conclusion. The classification of femoral neck nonunions in hemodialysis patients allows to determine the tactics of surgical treatment. Cemented dual mobility cups are effective in patients with any type of femoral neck nonunions.

Clinical observation and finite element analysis of cannulated screw internal fixation in the treatment of femoral neck fracture based on different reduction quality

ObjectiveFemoral neck fracture is one of the most common bone types. The effect of reduction quality on hip joint function and complications after screw internal fixation is not fully understood. To investigate the clinical efficacy and mechanical mechanism of positive buttress, anatomical reduction, and negative buttress in the treatment of femoral neck fracture after cannulated screw fixation.MethodsRetrospective analysis of patients with femoral neck fracture treated with three cannulated screws internal fixation in our hospital from January 2013 to December 2018. According to the quality of fracture reduction, the patients were divided into positive buttress group, anatomical reduction group, and negative buttress group. Basic information such as injury mechanism, time from injury to surgery, Garden classification and Pauwels classification was collected, Harris scores were performed at 3 months, 6 months, and 12 months after surgery, and postoperative complications (femoral head necrosis, femoral neck shortening, and femoral neck nonunion) were collected. At the same time, three groups of finite element models with different reduction quality were established for stress analysis, their stress clouds were observed and the average displacement and stress of the three groups of models were compared. P < 0.05 was used to represent a statistically significant difference.ResultsA total of 225 cases of unilateral femoral neck fractures were included and followed up for an average of 4.12 ± 0.69 years. There was no significant difference in age, gender, side, injury mechanism, time from injury to surgery, BMI, Garden classification, Pauwels classification, and follow-up time among the three groups (P > 0.05). However, there was significant difference in Harris score at 6 and 12 months after operation among the three groups (P < 0.05), which was higher in the positive buttress group and anatomical reduction group than in the negative buttress group. In addition, the incidence of osteonecrosis of the femoral head in the negative buttress group (32.2%) was greater than that in the anatomical reduction group (13.4%) and the positive buttress group (5.4%) (P < 0.05). In addition, the incidence of femoral neck nonunion and femoral neck shortening in the negative buttress group was also higher than that in the anatomical reduction positive buttress group (P < 0.05). The finite element results showed that the stress and fracture end displacement in the negative buttress group were greater than those in the positive buttress group (P < 0.05).ConclusionBoth positive buttress and anatomical reduction in the treatment of femoral neck fracture with cannulated screw internal fixation can obtain better clinical effect and lower postoperative complications. Positive brace support and anatomic reduction can limit the restoration of femoral stress conduction. Therefore, it is not necessary to pursue anatomical reduction too deliberately during surgery, while negative buttress reduction should be avoided.

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head

IntroductionOsteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH. MethodsWe performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA. ResultsSeventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1–33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69–93), a mean improvement of 20.6 (p < 0.001). ConclusionsOur study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.

Valgus Osteotomy Outcome for Treating Femoral Neck Nonunion in Young and Active Patients

Background: Femoral neck fracture nonunion is a frequent and challenging complication, with several surgical options. Objectives: The present study reported the outcome of valgus osteotomy for treating femoral neck nonunion in patients aged &lt;65 years. Methods: This case series research included young patients who underwent valgus osteotomy for treating femoral neck nonunion or device failure of the index surgery. The fixation of the osteotomy site was performed using either a dynamic hip screw or a fixed angle blade. The union of the neck and osteotomy site (subtrochanteric region) was evaluated by monitoring callus formation in the postoperative radiographs. Limb length discrepancy, Pauwels’ angle, and the neck-shaft angle were evaluated before the surgery and at the last follow-up. Postoperative complications were extracted from the explored patients’ profiles. Results: Twenty patients with a Mean±SD age of 27.2±10.8 years were examined in this study‎. The Mean±SD follow-up time of the patients was 6.1±3.9 years. The femoral neck was united in 18 patients in a Mean±SD period of 5.1±2.3 months. The Mean±SD limb length discrepancy was measured as 1.3±0.8 cm before and 0.5±0.7 cm after the ‏osteotomy. The Mean±SD Pauwels’ angle was calculated as 65.5±16.9º before and 32.4±16.2º after the osteotomy. The Mean±SD neck-shaft angle was computed to be 121.9±22.8º before and 144.5±17.7º after the osteotomy. Revision surgery was performed for 6 (30%) patients. This measure included device removal in 4 and total hip arthroplasty in 2 patient. Conclusion: Valgus osteotomy is a safe and efficient technique for managing femoral neck nonunion. Therefore‎, this approach is suggested as a good alternative for total hip arthroplasty, particularly in young and active patients‎.

Role of Valgus Osteotomy and Fixation with Double Angle Blade Plate in the Management of Neglected and Ununited Femoral Neck Fracture

Introduction: Femoral neck fracture non union in young patients is a challenging complication as joint replacement is not readily recommended and hip salvageable procedures are relatively unsatisfactory. Valgus intertrochanteric osteotomy described by Pauwels F is one of the treatment options for management of non union of femoral neck in young patients, which was later reciprocated by other surgeons. Aim: To assess the efficacy of valgus osteotomy and fixation with double angle blade plate in the management of neglected and ununited femoral neck fracture. Materials and Methods: This was a prospective cohort study, which included 30 patients of femoral neck fracture non union in whom intertrochanteric valgus osteotomy was performed and fixed with 120° double angled blade plate. The preoperative and postoperative neck-shaft angle was compared using the paired t-test. A p-value of &lt;0.05 indicated statistically significant result. Results: There were 22 males (73.3%) and 8 females (26.7%). Mean age of patients was 35 years. Delay in presentation ranged from 8 weeks to 58 weeks (mean 24 weeks). By Pauwel’s classification, there were 13 Type II fractures and 17 Type III fractures. Mean follow- up was 18 months (12 to 36 months). The mean preoperative neck- shaft angle of 95° (range 80-110°) increased to 132° (range 120- 140°) after surgery. In all patients, there was improvement in leg length discrepancy after osteotomy. Femoral neck fractures united in 25 patients (83.3%). Conclusion: Valgus osteotomy and fixation with 120° double angle blade plate is a reliable method for treating non union femoral neck fracture in young adults. It provides rigid internal fixation and good results.

SAT-362 A Bone to Pick with FGF23

A 48 yo M with a past medical history of bilateral femoral neck stress fractures at age 44 status post closed reduction percutaneous pinning (CRPP) presented to the emergency room with bilateral lower extremity pain after a ground level fall. Plain films were notable for a right intertrochanteric fracture and left hip nonunion. The patient underwent removal of right CRPP hardware and revision fixation with a short TFN-Advanced Femoral Nailing System (TFNA) and fixation of the left femoral neck nonunion. Given his injuries following a ground level fall, endocrinology was consulted for recommendations. Labs during his hospital course were notable for hypophosphatemia as well as normal levels of alkaline phosphatase, serum calcium, and PTH. Serum protein electrophoresis and urine protein electrophoresis were within normal limits. A 24-hour urine calcium and phosphorous were done and the patient was found to have a low calculated renal phosphate threshold (TmP04/GFR), concerning for hypophosphatemic osteomalacia. An FGF23 level was drawn and was elevated, suggestive of an FGF23-induced hypophosphatemic osteomalacia. A low vitamin D 1,25-OH was also found consistent with this process, given interference of alpha-hydroxylation of vitamin D 25-OH from FGF23. The patient therefore underwent a PET scan to rule out a mesenchymal tumor-induced osteomalacia but his PET scan was largely unremarkable. Given that there were no issues with bone development or fractures during childhood, the suspicion for X-linked hypophosphatemia or autosomal recessive hypophosphatemia was low. The patient was believed to have either a small mesenchymal tumor not seen on PET scan or an autosomal dominant hypophosphatemia, which can manifest clinically during adulthood, and so was treated with daily Calcitriol and phosphate with subsequent correction of his serum phosphorous. Such a delayed presentation of hereditary hypophosphatemic osteomalacia, however, has been reported only in women either soon after puberty, during pregnancy, or after delivery (1). This case thus represents a possible autosomal dominant hypophosphatemia in a male patient or a rare case of tumor-induced hypophosphatemic osteomalacia.Reference: (1) Drezner MK, Whyte MP. Heritable renal phosphate wasting disorders. Genetics of bone biology and skeletal disease, 2nd ed. 2018; 761–782.

Surgical treatment of orthopedic complications in a patient with severe deficiency of bone mineral density on chronic hemodialysis (clinical case)

The article describes the observation of successful total hip arthroplasty in the patient with atrophic bilateral nonunion of femoral neck with end stage renal disease.Authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

Impaction Bone Grafting and Valgus Osteotomy: A Technical Trick for the Treatment of Femoral Neck Nonunions.

Femoral neck nonunions in young adults is among the most challenging problems to treat. This is due to their inherent problems, such as neck resorption, increase in fracture gap, sclerosis of fracture margins, and avascular necrosis. Hip salvage in these cases, although challenging, is recommended in the Asian subcontinent where social and religious activities require squatting and sitting cross-legged. Muscle pedicle grafts and other vascularized bone grafting techniques are preferred treatment options, but they are technically demanding and require advanced microsurgical skills. Valgus osteotomy, although successful in certain cases, has a high failure rate in patients with poor bone stock. We present a simple technique of valgus subtrochanteric osteotomy, impaction bone grafting, and stabilization with a sliding hip screw. Here, we describe in detail about the surgical technique and present the clinical outcomes in 44 patients, with a mean follow-up of 3.4 years and a union rate of 95.5%.

Vascularized Fibular Grafting for Femoral Neck Nonunions: Commentary on an article by Jimin Yin, MD, PhD, et al.: "Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion. A Prognostic Study Based on Long-Term Outcomes".

Vascularized Fibular Grafting for Femoral Neck Nonunions: Commentary on an article by Jimin Yin, MD, PhD, et al.: "Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion. A Prognostic Study Based on Long-Term Outcomes".

Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion: A Prognostic Study Based on Long-Term Outcomes.

The purpose of this study was to evaluate the long-term efficacy and prognostic factors predicting success of revision surgery with free vascularized fibular grafting (FVFG) for treatment of femoral neck nonunion. We prospectively enrolled patients who underwent revision surgery with FVFG between January 2001 and January 2013 in a tertiary hospital in China. A total of 98 patients with a minimum 5-year follow-up were included for analysis. The criteria for FVFG failure were conversion to hip arthroplasty, recommendation for a hip arthroplasty, or a Harris hip score of <80 points. Demographic information, the preoperative neck shortening ratio (NSR), the fixation method, and postoperative radiographic parameters including the postoperative NSR and neck-shaft angle (NSA) were recorded for prognostic analysis. At an average of 9.8 ± 3.5 years (range, 3 to 17 years) postoperatively, the overall success rate of this surgical procedure was 77% (75 of 98). The success and failure groups had no significant differences in age, fixation method, interval between initial fixation and revision surgery, or postoperative NSA. The success group had a significantly higher NSR than the failure group both preoperatively (77.8% versus 62.4%, p < 0.001) and postoperatively (87.6% versus 78.4%, p = 0.001). The receiver operating characteristic (ROC) curve analysis revealed an optimal cutoff for preoperative NSR of 60% to predict the outcome. Patients with a preoperative NSR of >60% had a success rate of 91% (68 of 75). Revision surgery with FVFG and internal fixation is an effective and important option for treating nonunion of the femoral neck in young patients without severe preoperative shortening and neck resorption (preoperative NSR of >60%). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of femoral neck nonunion with a new fixation construct through the Watson-Jones approach

ObjectiveThe aim of the study is to explore the clinical effect of a dynamic condylar screw (DCS) system, medial anatomical buttress plate (MABP), and autogenous iliac bone graft through the Watson-Jones approach in the treatment of femoral neck nonunion. MethodsThis prospective study included 15 patients (12 men and 3 women) with nonunion of femoral neck fracture, who were treated with the DCS and MABP with autogenous iliac bone graft through the Watson-Jones approach. The patients were followed up for an average of 16 months (range, 12–24 months). ResultsAll patients achieved bone healing with an average fracture healing time of 3.4 months (2.8–4.6 months). The Harris score significantly increased from 30 ± 3.9 before the operation to 87.6 ± 7.9 at the last follow-up, and the visual analogue scale significantly decreased from 4 ± 1.3 before the operation to 1 ± 1.7 at the last follow-up. The average limb shortening was reduced from 1.8 cm (range, 0–3.1 cm) before the revision operation to 0.5 cm (range, 0.1–1.3 cm) after the last follow-up. The neck-shaft angle of the injured side was restored from an average of 118° (range, 108–139°) before the revision operation to an average of 132° (range, 127–144°) at the last follow-up. No collapse of the femoral head, wound infections, screw backout, screw or plate breakages, or nerve injury was found. ConclusionTheDCS and MABP with autogenous iliac bone graft through the Watson-Jones approach is an effective option for the treatment of femoral neck nonunion or delayed healing. The translational potential of the articleThis article shows that the application of DCS and MABP provides a rigid fixation at the fracture site to promote bone graft integration and bone union. This new kind of technique could be one option of Hip conservation procedures, just special for young patients with femoral neck nonunion.

Principles of Valgus Intertrochanteric Osteotomy (VITO) after Femoral Neck Nonunion.

Nonunion is a relatively rare, yet challenging problem after fracture of the femoral neck. Risk factors include verticality of the fracture line and presence of comminution of the posteromedial calcar, as well as quality of reduction. Treatment options consist of valgus intertrochanteric osteotomy versus arthroplasty. Treatment should be tailored to the individual patient, taking into account patient age and activity demands. This review outlines the principles and technical considerations for valgus osteotomy of the proximal femur in the setting of femoral neck nonunion.

Vertical Neck angle and long-term outcomes of femoral neck fractures treated with cannulated screws

Objective To analyze the associations between long-term outcomes of fresh femoral neck fractures treated with cannulated screws and the classification based on vertical neck (VN) angle. Methods A retrospective study was conducted of the 162 fresh femoral neck fractures treated with 3 cannulated screws at Department of Orthopaedics, The Sixth People’s Hospital of Shanghai from January 2012 to December 2014. The relationships were analyzed using Logistic Regression between long-term complications and VN classification, including fixation failure, fracture nonunion and osteonecrosis of femoral head (ONFH). Results All the patients were followed up for an average of 25.7 months (from 6 to 36 months). Of them, 151 obtained fracture union after an average of 4.5 months (from 3 to 9 months). Internal fixation failure occurred in 23 cases, nonunion of femoral neck in 11, ONFH in 21 and femoral neck collapse in 13. Logistic Regression analysis showed no significant associations between internal fixation failure, nonunion or ONFH and gender, age or reduction method (P>0.05) but significant associations of VN classification with fixation failure (P<0.001) and nonunion (P=0.001) and insignificant association of VN classification with ONFH (P= 0.109). Conclusion VN classification, a new classification method for femoral neck fractures, may be closely related with incidences of fixation failure and nonunion. Key words: Femoral neck fracture; Bone nails; Prognosis; Vertical neck angle; Classification

Pauwels Osteotomy for Femoral Neck Nonunion in Two Adult Siblings with Osteogenesis Imperfecta

This is a retrospective review of two adult siblings with osteogenesis imperfecta (OI) type III (according to Sillence classification), who sustained a spontaneous femoral neck fracture and subsequent nonunion. The diagnosis of OI in these two patients was made based on clinical, radiological and genetic findings. The fracture was most likely caused by femoroacetabular impingement secondary to OI induced acetabular protrusio. A valgus osteotomy according to Pauwels'principles and fixation of the osteotomy and nonunion with a locking plate resulted in healing despite compromised bone quality and limited bone stock. Long-term follow up (4.5 years and 6.5 years, respectively) is provided.When treating this difficult problem, improving the mechanobiological environment and decreasing the femoroacetabular impingement by a Pauwels type osteotomy should be considered.

Successful treatment of nonuniting fracture ICNF with Teriparatide in young adult osteopenic male

&lt;p class="abstract"&gt;&lt;span lang="EN-IN"&gt;We present a case of fracture intra capsular neck of femur in a young adult osteopenic patient, who had a nonunion and early signs of avascular necrosis even after the initial surgical intervention. Teriparatide was administered for two monthly doses after diagnosis of nonunion and avascular necrosis of femoral neck. 90% successful union was achieved in 2 months without further surgical intervention, and no adverse events related to the use of teriparatide were observed. Our case report shows that teriparatide can be an alternative to surgical intervention in nonunion of ICNF with early signs of avascular necrosis.&lt;/span&gt;&lt;/p&gt;

Technical particularities of joint preserving hip surgery in osteopetrosis.

Proximal femoral fracture and coxarthrosis are the most common orthopaedic problems of osteopetrosis. Fracture fixation is difficult and one-third fail, with total hip replacement as the final solution. There is little reported experience about how to deal with this particular type of bone and what has been published to date is surprisingly non-specific. Corrective osteotomies are mainly undertaken in children for non-union of a fractured femoral neck and/or for coxa vara. However, any information about technical problems and solutions is scarce and barely instructive. Osteotomy experience for osteopetrosis in youngsters and young adults has not been reported. Osteopetrosis bone is characterized by a small tolerance for displacement and by the high friction experienced when penetrating instruments and implants are used. This article describes the risks of hip surgery in the presence of osteopetrosis and also discusses osteotomies around the hip and how to limit any related complications. Four patients, who underwent different types of hip preservation procedure, have been used to illustrate the difficulties that can be encountered. The article also suggests ways to make osteotomies feasible in osteopetrosis bone, even in adults.

Intertrochanteric Osteotomy for Femoral Neck Nonunion: Does "Undercorrection" Result in an Acceptable Rate of Femoral Neck Union?

To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy. Retrospective cohort study. Level-1 trauma center. Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy. Valgus-producing intertrochanteric osteotomy with a blade plate. Femoral neck and intertrochanteric osteotomy osseous union. Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014). Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fibular strut graft for nonunited femoral neck fractures in children.

PurposeTo evaluate the clinical and radiological outcomes of using fibular strut grafts as a fixation device for non-united femoral neck fractures in children with or without subtrochanteric valgus osteotomy.MethodsA total of 12 children with non-united femoral neck fractures (nine males and three females) with an average age of 8.2 years (5 to 12) were managed, and functional results evaluated, between July 2013 and July 2015. The mechanisms of injury were fall from a height in ten patients and road traffic accident in two cases. Nine cases of femoral neck nonunion followed failed internal fixation and three cases were neglected fractures. Six cases were treated by fibular strut graft and subtrochanteric valgus osteotomy with contoured plate and six cases were treated by fibular strut graft and hip spica.ResultsThe mean follow-up period was 20.4 months (12 to 36). Union was achieved in all 12 cases by a mean of 3.5 months (2.5 to 6). All patients were satisfied at five months. For final analysis of clinical and radiographic results, the Ratliff’s classification was used. We classed 11 cases as good results and one case as fair.ConclusionsFibular strut grafts are a reliable option for treatment of pseudo-arthrosis in femoral neck fracture nonunion in children. It is successful in restoration of femoral neck length in children with non-united femoral neck fractures.