Higher Rate Of Avascular Necrosis Research Articles

FIJACIÓN DE LAS FRACTURAS DE CUELLO FEMORAL DEL ADULTO: COMPARACIÓN RETROSPECTIVA ENTRE TORNILLOS CANULADOS Y EL SISTEMA DE CUELLO FEMORAL (FNS)

The FNS System DePuy Synthes® (EEUU, 2018) represents a recent alternative treatment for the fixation of femoral neck fractures, providing biomechanical advantages with respect to cannulated screws (3CS). The objective of this study is to compare the clinical results of both fixation methods. A retrospective collection of the 36 subcapital fractures treated with the FNS system was carried out compared with a retrospective search of the last 35 patients treated with 3CS. Age, sex, fracture pattern, delay until the intervention, lenght of intervention, hospital length stay, and haemoglobin loss were analyzed. In addition, the rate of avascular necrosis, nonunion, symptomatic femoral neck shortening, and material protrusion with or without its removal were recorded during a minimum follow-up of 6 months. No significant differences were found in age (p-value 0.32), fracture patterns (p-value 0.77), surgical delay (p-value 0.28), surgical time (p-value 0.226), length of hospital stay (p-value 0.921) and blood loss (p-value 0.086) between the two groups. A significantly higher overall complication rate was observed in the group treated with cannulated screws (p-value 0.004). Analysed separately, a higher rate of avascular necrosis, symptomatic shortening of the femoral neck, protrusion of the osteosynthesis material with or without removal was observed in the group treated with cannulated screws. The FNS system represents a safe and reproductible alternative for the fixation of femoral neck fractures, showing non-inferior outcomes to treatment with cannulated screws.

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis.

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). Retrospective cohort. Single level I trauma center. Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P=.175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Treatment perspective after failed open reduction of congenital hip dislocation. A systematic review.

Failure of open reduction of developmental hip dislocation is a serious complication and revision surgery appear to be technically demanding with high complication rates. Little attention has been given in literature to patients in whom open reduction of developmental hip dislocation has failed. We present a systematic review about current perspectives and timing when to perform surgical revision after failed open reduction of developmental hip dislocation in children. Following the recommendations of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statements we performed a comprehensive search of the PubMed and Google Scholar bibliographic database in order to select all studies published between 1980 and 2022. Studies were screened for the reasons for failure of open reduction, timing when revision surgery was performed, and for the surgical techniques used for revision. A total of 10 articles including 252 patients and 268 hips has been recorded. The most common causes of re-dislocation after open reduction are inadequate exposure and failure to release the obstructing soft tissues inside and around the hip. In 90% of the cases the anterolateral approach was performed for revision surgery. Avascular necrosis occurred in 5%-67% of cases and was the most encountered complication. Redislocation of developmental hip dislocation after an open reduction has poor long-term outcomes mainly due to a high rate of avascular necrosis of the femoral head. It is mandatory to obtain a stable reduction at the second surgery combining soft tissue release, capsulorrhaphy, pelvic and femoral osteotomies.

Association of Talar Neck Fractures With Body Extension and Risk of Avascular Necrosis.

The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99). We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. Level III, retrospective cohort study.

Hospital transfer and delayed reduction of traumatic hip dislocations.

Native hip dislocations are high energy injuries that cause substantial patient morbidity. Expedient reduction has been demonstrated to improve patient outcomes. The objective of our study was to compare complication rates in patients with native hip dislocations who presented directly to a level-one trauma center with those transferred from an outside hospital (OSH). Our hypothesis was that those transferred from an OSH would experience a delay in reduction and subsequently would experience higher rates of avascular necrosis (AVN), post-traumatic arthritis (PTA), and need for secondary surgery. We conducted a retrospective chart review of all native hip dislocations from our level-one trauma center between January 2007 and December 2020. The initial query resulted 628 patients which was refined to 90 patients after excluding patients for incorrect diagnosis code or less than 6months of follow-up. Our primary outcome was the development of AVN, PTA, and need for secondary surgery. Time from injury to reduction was recorded for all patients included. For every one hour of delay in time to reduction, there was a 3.4% increase in the risk of developing AVN (p = 0.004) and a 4.3% increase in risk for developing PTA (p = 0.01). The risk of requiring a secondary surgery increased 4.6% for each hour of delay in reduction (p = 0.03). The average time to reduction of transferred patients was higher compared to those who presented directly to our center (13.8h vs 5.7h); however, transfer status was not found to be an independent risk factor for the measured outcomes. Transfer status is not an independent risk factor for the development of AVN, PTA, or the need for a secondary surgery. However, transferred patients did experience an average delay of 8h in time to reduction compared to those who presented directly to a trauma center. Of the 27 patients with a reduction delay greater than 12h, 26 (96%) were transferred.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

IntroductionA stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. Patients and methodsRetrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. ResultsAfter a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DiscussionArthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

Comparison of salter osteotomy results in two different age groups in the treatment of developmental hip dislocation

Aim: Surgical treatment of developmental hip dislocation is highly challenging in children of walking age. The most common complications following surgery include avascular necrosis and redislocation. In this study, we aimed to compare the preoperative and postoperative acetabular index, avascular necrosis (AVN) and redislocation rates between two age groups of open reduction and Salter osteotomy in DDH (Developmental Dysplasia of the Hip). Methods: This prospective cohort study included patients who underwent open reduction and salter osteotomy for DDH between 2014 and 2017. Patients were grouped based on age as follows: Group 1: 18 -30 months old (n=44), Group 2: 31-48 months old (n=41). Preoperative, postoperative, and final acetabular indexes, AVN and redislocation rates were compared. Results: Among 85 patients included in the study, 20 were male and 65 were female. The mean ages of Groups 1 and 2 were 21.6 months and 38.5 months, respectively. Following surgery, Group 1 mean acetabular index reduced to 25.9 degrees from 35.1 degrees, while that of Group 2 decreased to 22.1 degrees from 33 degrees. AVN was present in 10 patients (22.72%) in Group 1 and 4 patients (9.75%) in Group 2. Conclusion: The acetabular index was adequately corrected in both groups. AVN was more frequent in children who had early interventions. We believe that the higher rate of avascular necrosis in children who underwent early intervention is due to surgical technique and using tighter sutures in the hip joint capsule.

The Modified Dunn Procedure for Unstable Slipped Capital Femoral Epiphysis: A Systematic review and Meta-analysis

Abstract Source of Support None, Conflict of Interest None. Background The management of unstable slipped capital femoral epiphysis is controversial and evolving as insight into the condition develops. Almost half of patients with unstable slip developed femoral head osteonecrosis. The modified Dunn procedure through safe surgical hip dislocation has rapidly gained popularity as a treatment for unstable slipped capital femoral epiphysis. In this review we analyzed the results and complications following this procedure. Materials and Methods We performed a retrospective chart review of 297 consecutive patients (302 hips) who had undergone the modified Dunn procedure through safe surgical hip dislocation from Feb 2009 to Feb 2017. Patients were169 males and 128 females, between the age group of 7 to 18 years (mean age 12.66 years) and BMI ranged from 14.7 to 42.1 Kg/m2 (mean BMI 26.32 Kg/m2). The duration of symptoms among the studied group ranged from 2 to 360 days with mean 84.75days. Regarding site and severity 57% had lesions in left side, 40.9% had lesions in right side, 2.1% had bilateral lesions and 58% had severe lesions. The duration of operation among the studied group ranged from 75 to 162 min with mean 128.19 min. Regarding time of operation 61.1% had operation after more than 24 h from admission. All the patients were assessed with slip angle degree, Harris hip score, alpha angle, flexion degree, internal rotation, external rotation and neck shaft angle. Results At the mean follow up of 26.3 months (range 12 months to 4.5 years), the mean slip angle improved from a preoperative Value10 to 80 degree with mean 55.6 degree and after operation it ranged from 0 to 28 degree with mean 6.7 degree with mean reduction 48.9 degree, the Harris hip score among the studied group after operation ranged from 46 to 100% with mean 90.98%, regarding post-operative range of motion alpha angle ranged from 23.6 to 52.8 degree with mean 44.3 degree, flexion ranged from 80 to 120 degree with mean 105.84 degree, internal rotation ranged from 5 to 60 degree with mean 30.08 degree and external rotation ranged from 10 to 60 degree with mean 42.3 degree and finally neck shaft angle ranged from 128 to 164 degree with mean 137.2 degree. Conclusion Unstable slipped capital femoral epiphysis is associated with a high rate of avascular necrosis. Etiology of the AVN is not completely known and likely multifactorial. The modified Dunn osteotomy through Ganz surgical hip dislocation is the treatment of choice for those with moderate and severe unstable SCFE, allowing anatomical restoration of proximal femur, direct inspection, and preservation of physeal blood supply and inspection of intra-articular pathology which can be evaluated and treated at the time of operation.

The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience.

PurposeBased on previous investigations on the vascular blood supply to the femoral head, a technique for anatomical reduction after slipped capital femoral epiphysis was developed. This technique is a modification of the original technique by Dunn using a retinacular soft-tissue flap. This allows the visual control of the epiphyseal vascular blood supply. We report the experience at the inventor’s institution with a critical discussion of the available literature.MethodsUsing a trochanteric osteotomy for surgical dislocation of the hip, a retinacular soft tissue flap is created containing the deep branch of the medial femoral circumflex artery, the external rotators and the capsule. The femoral epiphysis can be mobilised safely and reduced on the femoral neck after resection of the almost constantly present reactive metaphyseal callus.ResultsIn our institution, the rate of avascular necrosis with 2% is comparably low to Dunn’s original results. It is only present in cases where no bleeding was already evident before reduction of the epiphysis. The ten-year long-term results are favorable in these cases with a good functional result and only little progression of osteoarthritis. However, other authors have reported higher rates of avascular necrosis up to 24% in their initial experience.ConclusionsIn experienced hands using the correct meticulous surgical technique, the results are favorable regarding the rates of avascular necrosis, the functional outcome and the development of radiographic osteoarthritis – even in acute and severe cases. Avascular necrosis is rare but can be observed if there is no evidence of intra-operative femoral head perfusion before and after reduction of the epiphysis.

Outcomes of Proximal Humerus Fracture Open Reduction Internal Fixation with Concomitant Ipsilateral Shoulder Girdle Injuries: a Case Control Study.

Proximal humerus fractures treated in the face of ipsilateral injuries to the shoulder girdle may be predisposed to worse clinical outcomes. The purpose of this investigation was to examine outcomes of proximal humerus fractures treated with open reduction internal fixation (ORIF) using an endosteal augment in the presence of a concomitant shoulder girdle injury in comparison to isolated proximal humerus fractures treated with ORIF and endosteal augment. A prospective database was used to identify proximal humerus fractures with ipsilateral shoulder girdle injuries (glenohumeral and acromioclavicular dislocation, fractures of the acromion, clavicle, scapula, or humeral diaphysis). These were compared to isolated proximal humerus fractures treated in the same fashion (ORIF with endosteal augment). Minimum of 1year follow-up was required for inclusion. Outcomes assessed included range of motion (ROM), development of avascular necrosis (AVN), hardware-related complications, reoperation, and subjective outcome assessments including the Disabilities of Arm Shoulder and Hand questionnaire (DASH), Constant score, UCLA rating scale, and the Short Form-36 (SF-36). Fifteen ipsilateral injuries were seen in 14 patients. Seventy-seven isolated proximal humerus fractures were available for comparison. The ipsilateral injury group had significantly worse forward flexion (141 vs 156°, p = 0.02), external rotation (56 vs 64°, p = 0.03), higher rates of avascular necrosis (4 of 14, 28.6% vs 1 of 77, 1.3%, p = 0.002), and inferior SF-36 physical health scores (48.5 vs 63.5; p = .04). Despite these differences, no significant differences were seen with hardware-related complications or DASH, Constant score, or UCLA rating scale results. No patients required secondary reconstructive procedures. Despite a statistically higher rate of AVN and decreased ROM, patient-based outcomes of proximal humerus fractures with ipsilateral shoulder injuries approached those seen in isolated proximal humerus fractures. This suggests that these injuries can achieve similarly good clinical results provided any associated shoulder pathology is identified and treated appropriately.

Adverse Outcomes in Infantile Bilateral Developmental Dysplasia of the Hip.

It is believed that bilateral developmental dysplasia of the hip (DDH) has poorer outcomes with higher rates of avascular necrosis (AVN) and reintervention, compared with unilateral DDH. However, there is limited evidence in the literature, with few studies looking specifically at bilateral cases. A retrospective review of 36 patients (72 hips) with >4 years of follow-up. Patient population included surgically treated DDH including late presentations and failures of conservative treatment. The dislocated hips underwent either simultaneous closed or 1 open and 1 closed, or sequential open reduction. AVN and secondary procedures were used as endpoints for analysis as well as clinical and radiologic outcomes. At the last follow-up, 33% of hips had radiologic signs of AVN. Those hips that had no ossific nucleus (ON) at the time of surgery had an odds ratio of developing AVN of 3.05 and a statistically significant association between the 2 variables, whereas open/closed or simultaneous/sequential reduction did not increase the risk for AVN. In addition, 45.8% of those hips required further surgery. The estimated odds ratio of needing additional surgery after simultaneous reduction was 4.04. Clinically, 79.2% of the hips were graded as McKay I, whereas radiologically only 38.8% were Severin I. The AVN rate in bilateral DDH treated surgically is greater than the rate noted in unilateral cases from the same institution undergoing identical protocols. There was no difference in AVN rates between simultaneous and sequential or between the first and second hip to be sequentially reduced. Presence of ON decreases the risk for AVN, suggesting that in bilateral cases, awaiting the appearance of the ON is an important tool to reduce the incidence of AVN. IV.

Developing a sustainable hip service in Cambodia.

Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children's Surgical Centre. We describe indications for total hip replacement (THR) and initial results. A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included. High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years. AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving. Developing an affordable hip arthroplasty service in a country like Cambodia is challenging. Developing a local registry has helped to identify complications and modify techniques.

Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis.

BackgroundProximal humeral fractures are common lesions of the elderly, but there are no established treatment guidelines. A surgical treatment for comminuted and displaced fractures of the proximal humerus was developed and is still evolving. The aim of this study was to perform a quantitative review to evaluate the risk of avascular necrosis (AVN) in patients with proximal humeral fractures who were treated by operative fixation compared with conservative treatment.MethodsWe searched the PubMed, MEDLINE, Springer, Elsevier Science Direct, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (in Chinese), and Wanfang database (in Chinese) up to December 2013 to identify studies related to operative fixation and AVN in patients with proximal humeral fractures.ResultsSeven studies with a total of 291 patients (142 operative fixation cases and 149 conservative treatment cases) with proximal humeral fractures were considered in the meta-analysis. The overall meta-analysis showed no significant difference in the incidence of AVN between the two groups [odds ratio (OR) 1.42, 95% confidence interval (CI) 0.33–6.11, p = 0.64]. The subgroup meta-analysis by study design (retrospective/prospective), sample size (≤40/>40), and ethnicity (European/Asian) demonstrated similar results. However, the subgroup analysis by specific operative approach (plate fixation/tension band wiring fixation/others) indicated that plate fixation was associated with a higher rate of AVN than conservative treatment (OR 0.20, 95% CI 0.05–0.76, p = 0.019).ConclusionsPlate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures.

The incidence of avascular necrosis and the radiographic outcome following medial open reduction in children with developmental dysplasia of the hip

The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years' follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60° of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

What Is the Cause of Avascular Necrosis in Unstable Slipped Capital Femoral Epiphysis and What Can Be Done to Lower the Rate?

An unstable slipped capital femoral epiphysis (SCFE) is associated with a high rate of avascular necrosis (AVN). Etiology of the AVN is not completely known and likely multifactorial. Potential causes are a tear/anatomic disruption of the retinacular vessels to the epiphysis, kinking of the retinacular vessels, or vascular tamponade due to increased intracapsular pressure. A review of the recent literature of unstable SCFE was performed to abstract various potential causes of AVN. The overall rate of AVN was 21% (88 of 417). Kinking of the retinacular vessels was demonstrated angiographically in 5 unstable SCFEs where the vessels did not fill in 3; in 1 the vascularity returned after reduction. Intracapsular joint pressure was measured in 13 unstable SCFEs with an average of 48 mm Hg on the unstable side compared with 23 mm Hg in the opposite normal hip. After manipulative reduction the pressures increased to 75 mm Hg, and dropped markedly to 17 mm Hg after capsulotomy and decompression. Although a complete tear of the vessels is another possibility, there are no described cases in the literature. Means to lower AVN depends upon its etiology. In 28 unstable SCFEs urgent reduction, internal fixation and decompressive arthrotomy resulted in a rate of 14% (4 of 28). Urgent open reduction through an anterior approach with smooth Kirschner wire fixation resulted in a rate of 5% (3 of 64). The modified Dunn procedure using a surgical dislocation resulted in a rate of 8% (2 of 26). Larger and combined series will be needed to determine the best treatment to minimize the rate of AVN in the unstable SCFE. With today's present techniques, AVN in the unstable SCFE will never be a "never" event.

Factors affecting the outcome of fractures of the femoral neck in children and adolescents

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff's clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Displaced femoral neck fractures in the young: significance of posterior comminution and raised intracapsular pressure

Osteosynthesis in fracture neck of femur (NOF) in young is a universally acceptable procedure. Various factors affect the outcome; with AVN (avascular necrosis) and non-union primarily contributing to adverse results in such patients. To identify factors affecting outcome of displaced fracture NOF, a prospective cohort study was carried out in the setting of a tertiary care centre in developing country. 27 consecutive patients with displaced fracture NOF suitable for osteosynthesis underwent closed reduction and fixation with three 6.5 mm cancellous cannulated screws. A record of posterior comminution and its extent (as seen on CT scan) and the intracapsular pressure difference between the fractured and the opposite side was kept in all the patients. The patients were followed-up for 1 year. The main outcomes measured at 1 year were non-union (as identified by CT scan) and AVN (as identified by bone scan). Cases with pressure difference >30 mm were found to have a higher rate of AVN and this result was found to be statistically significant (p value 0.034). The patients with significant posterior comminution were found to have higher non-union rates and this result was also found to be statistically significant (p value 0.04). Prognosis of displaced fracture NOF is significantly associated significant with posterior comminution and intracapsular pressure difference between fractured and normal side.

Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy

Talar neck fractures are a rare injury that account for less then 2% of all foot fractures. Displaced fractures are associated with an exceedingly high rate of avascular necrosis (AVN). The incidence of AVN following Hawkins Type 3 fractures of the talar neck may approach 100%, particularly if diagnosis and reduction are delayed. Severe cases may present as pain and disability of the ankle and the subtalar joints due to a talar dome collapse, resulting in degenerative changes that usually require hind foot arthrodesis. We present two cases of traumatic displaced talar neck fractures which were treated surgically more than 2 weeks following injury due to a delay in diagnosis. Both patients underwent hyperbaric oxygen therapy (HBOT) after the operation and neither resulted in AVN of the talus in a three-year follow-up. We suggest that this favorable result may be due to the beneficial effects of HBOT.

Management of Femoral Neck Stress Fractures

Stress fractures are caused by repetitive submaximal loading of bone that causes microtrauma, where the bone either temporally or biomechanically does not have the ability to recover before repeated loading. Stress fractures are being diagnosed more frequently as the result of increased surveillance on the part of the physician and increased prevalence on the part of the patient. The diagnosis is made by a combination of history, physical examination, and imaging. Magnetic resonance imaging is the imaging modality of choice, after plain films, because of its greater specificity and sensitivity. Stress fractures are classified based on their cause, their location, their severity, their risk of progression, and the appearance of the fracture line. Treatment of femoral neck stress fractures is based on the duration of symptoms, the fracture classification, and the patient’s expectations. Treatment starts with activity modification and progresses to cannulated screws, sliding hip screw, blade plate, and/or intertrochanteric osteotomy. Predictors of successful surgical outcomes are accurate fracture classification, early anatomic reduction, addressing of any varus deformity in the reduction or the native neck, and placing the fracture line as horizontal as reasonable when performing an osteotomy. Mild fractures in the recreational athlete will lead to a period of decreased activity, rapid healing, and return to full activity, whereas more severe fractures will require more intervention and a longer recovery period. Displaced fractures have a high rate of avascular necrosis, pseudoarthrosis, refracture, and progressive arthrosis. Elite athletes require aggressive management and, even then, are unlikely to return to their previous professional level.