Incidence Of Avascular Necrosis Research Articles

Clinical Results of Internal Fixation of Subcapital Femoral Neck Fractures.

BackgroundSubcapital femoral neck is known to cause many complications, such as avascular necrosis (AVN) of the femoral head or nonunion, compared with other femoral neck fractures. The purpose of this study was to analyze the incidence of AVN and fixation failures in patients treated with internal fixation using cannulated screws for the subcapital femoral neck fractures.MethodsThis study targeted a total of 84 cases of subcapital femoral neck fractures that underwent internal fixation using cannulated screws. The average follow-up time after surgery was 36.8 months (range, 24 to 148 months).ResultsNine hips (10.7%) showing AVN of the femoral head and 6 hips (7.1%) showing fixation failures were observed. The factors affecting the incidence of AVN of the femoral head after sustaining fractures correlated well with fracture types in the Garden classification (p = 0.030). The factors affecting fixation failure were the degree of reduction (p = 0.001) measured by the Garden alignment index and firm fixation (p = 0.009) assessed using the technique of 3-point fixation through the inferomedial cortical bone of the femoral neck.ConclusionsThe complication rates for subcapital femoral neck fractures were lower than those previously reported; hence, internal fixation could be a primary treatment option for these fractures.

Homozygosity for the 2R Tandem Repeat Polymorphism in the Thymidylate Synthase (TS) Promoter Is Associated with Increased Risk for Bony Morbidity Among Children Treated for Acute Lymphoblastic Leukemia on DFCI Protocol 05-001

Introduction: Both fractures and avascular necrosis (AVN) of bone frequently complicate therapy for childhood acute lymphoblastic leukemia (ALL), resulting in significant pain and loss of function. Risk of bony morbidity has been associated with age >10 years and exposure to crucial components of leukemia therapy including corticosteroids, asparaginase, and methotrexate. To further define risk factors, we tested whether 19 common genetic polymorphisms were associated with bony morbidity among 637 children treated for ALL on Dana Farber Cancer Institute ALL Consortium protocol 05-001.Methods: Genomic DNA was isolated from peripheral blood or bone marrow collected at the time of remission. Nineteen candidate polymorphisms were selected a priori, targeting common variants within genes related to glucocorticoid metabolism, oxidative damage, and folate physiology. Single nucleotide polymorphisms were detected using PCR-based allelic discrimination assays. The number of 28bp nucleotide repeats within the 5' untranslated region of the gene for thymidylate synthase (TS) was assessed by PCR-product length analysis. The incidence of AVN and fracture were estimated by the cumulative incidence method identifying death and relapse as competing risks. Because the incidence of bony morbidity differed significantly between children above and below the age of 10 years, relationships between polymorphisms and bony morbidity were explored within these two age subgroups separately. Comparisons at the 0.10 significance level were modeled univariately and were considered in multivariable modeling using competing risks regression. Multivariable models for bony morbidity included sex, WBC at diagnosis, race, final risk group, and asparaginase randomization. Blood was collected during treatment for analysis of serum and RBC folate by HPLC.Results: Of the 637 patients tested, 627 achieved a complete remission and received post-induction therapy, of which 61 (9.7%) experienced AVN and 138 (22.0%) had ≥1 fracture. Both AVN and fracture were more common among those ≥10 years of age (22.9% AVN, 30.7% fracture) than younger children (5.5% AVN, p<0.0001 and 19.2% fracture, p=0.002). Homozygosity for the 2R TS polymorphism was observed in 129 (20.6%) of the 626 patients tested. This 2R/2R genotype was associated with a greater 5-year estimated incidence of AVN (11.6%; 95% CI 6.1-18.9%) than among those with 2R/3R or 3R/3R genotypes (4.1%, 95% CI 2.4-6.5%; p=0.0037; Figure [A]) among children < age 10, but not among older children. The increased risk of AVN in younger children remained significant in the multivariable risk regression model (adjusted hazard ratio 2.92; 95% CI 1.36-6.28; p=0.0059). Among children over age 10, this polymorphism was associated with an increased risk of bony fracture (multivariable HR 2.13; 95% CI 1.13-3.99; p=0.019; Figure [B]). No significant association was observed between bony morbidity and the other tested polymorphisms, including PAI-1 (rs6092), ABCB1 (rs1045642), and the vitamin D receptor Fok1 restriction site (rs228570) which have been previously linked to risk of AVN. Samples were available for analysis of serum and RBC folate at diagnosis (n=367), remission (n=347), 15 months post-remission (n=251), and at the conclusion of therapy (n=247). No significant association was observed between TS genotype and serum or RBC folate at any time point.Conclusions: Homozygosity for the 2R polymorphism in TS was associated with increased risk of bony morbidity among children treated for ALL. Interestingly, the impact of the polymorphism differed between those above the age of 10 years (associated with risk of fracture) and younger children (risk for AVN), suggesting that the pathophysiology of bony morbidity differs between these two age groups. This is the first report identifying a genetic risk factor for AVN specifically among children younger than 10 years, a group where AVN is significantly less frequent. This result suggests young children with ALL and the 2R/2R genotype should be monitored more closely for the development of AVN during therapy for ALL. [Display omitted] DisclosuresSilverman:Seattle Genetics, Inc.: Research Funding.

Femoral neck fractures in children and the role of early hip decompression in final outcome.

Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome. The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications. The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients. Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

Outcomes of war related femoral neck fractures.

In the civilian trauma literature, femoral neck fractures in young adults are considered an orthopedic 'urgency'. To our knowledge, there have been no studies looking at the outcomes of these injuries in the combat setting. The purpose of this study is to determine the outcomes of war related femoral neck fractures; the rates avascular necrosis associated with these injuries as well as the effect time to fixation has on the development of avascular necrosis. We performed a retrospective review of 21 patients who sustained combat related femoral neck fractures from October 2001 through October 2013. We collected demographic data, time to fixation, time to union, incidence of avascular necrosis, as well as complications and final recreational activity status. Our study included 21 males (100%). The average length of follow up was 19.0 (2.7-62.3) months, and the average length of radiographic follow up was 21.4 months. The average age was 25.2 (21-36) years. Displaced fractures were sustained in 71.4% of patients and 95.2% had a Pauwels' type 3 fracture. 56.9% had initial reduction and fixation within 24h of injury. Percutaneous screw fixation and dynamic hip screws were definitive fixation in 57.1% and 23.8% of patients, respectively, while the remainder had a cephalomedullary device or a salvage procedure. The average time to union was 5.5 months. There was 1 case of nonunion and 1 case of delayed union. Three of the patients (16.7%) developed avascular necrosis of the femoral head, 2 of which were initially reduced within 24h of injury. There were no statistically significant differences between time to fixation, type of reduction, or presence of displacement as a predictor of the development of avascular necrosis. We found a high rate of displaced and high Pauwels' angle fractures, consistent with the high-energy injury mechanisms. With nearly a two-year average radiographic follow-up, the incidence of avascular necrosis was 16.7%, despite only half of our patients receiving initial reduction within 24h of injury. Urgent reduction and fixation continues to be of utmost importance to decrease the risk of femoral head avascular necrosis.

Acetabuloplasties at Open Reduction Prevent Acetabular Dysplasia in Intentionally Delayed Developmental Dysplasia of the Hip: A Case-control Study.

Avascular necrosis (AVN) and residual acetabular dysplasia are the two main complications of developmental dysplasia of the hip (DDH) treatment. Although early reduction of the hip may decrease the incidence of residual dysplasia, it may increase the incidence of AVN and vice versa. However, we do not know if changes in surgical technique may lead to a modification in these outcomes. Does an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, (1) diminish the risk of developing acetabular dysplasia; or (2) increase the rate of AVN compared with patients treated with open reduction alone? We conducted a retrospective matched case-control study comparing 22 patients (27 hips) with early isolated DDH who underwent intentionally delayed open reduction and acetabuloplasty from 2004 to 2010 and followed up > 4 years (88% of the cohort) with early historic controls treated with delayed open reduction alone. Of 53 patients available for matching, 45 (85%) had enough followup (> 10 years) to be considered. They were matched one to one for age at presentation and bilaterality (fuzz 45, 0). This generated a control group of 25 patients (27 hips). The mean followup was different between the groups (p < 0.001). Residual dysplasia considered when center-edge angle < 15° (6-13 years old) or < 20° (≥ 14 years old) or as a nonevolving acetabular index > 30° and pelvic osteotomies were used as our primary outcomes. The proportion of patients with AVN was also compared. Patients treated with open reduction and an incomplete periacetabular acetabuloplasty were less likely to develop acetabular dysplasia and undergo pelvic osteotomies than were patients in the control group (0% [zero of 27] versus 37% [10 of 27]; odds ratio [OR], 11; 95% confidence interval [CI], 2-80; p = 0.02 and 0% [zero of 27] versus 26% [seven of 27]; OR, 8; 95% CI, 1-60; p = 0.025, respectively). With the available numbers, there was no difference in terms of the proportion of patients who developed AVN (11 of 27 [41%] both groups; OR, 1; 95% CI, 1-2; p = 1). The addition of an incomplete periacetabular acetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia, whereas it did not appear to have deleterious effects as evidenced by the similar AVN proportion. Level III, therapeutic study.

Developmental Dislocation of the Hip Successfully Treated by Preoperative Traction and Medial Open Reduction: A 22-year Mean Followup.

During the last 35years, the medial approach has been reported more frequently than the anterior approach for open reduction of developmental dislocation of the hip (DDH), however, few studies have followed children treated by medial open reduction to adulthood. The purposes of our study were: (1) to assess the development of 71 completely dislocated hips after medial open reduction, the incidence of additional surgery and avascular necrosis during the followup period, and the long-term radiographic and functional results; and (2) to compare our results with those obtained by others who performed open reduction either by the medial or anterior approach. We retrospectively evaluated, after the end of growth, 71 hips in 52 patients who underwent open reduction by the medial approach. The mean age of the patients was 16months (range, 3-36months). After surgery, the hips were immobilized in 100° flexion, 60° abduction, and neutral rotation for an average of 6months. All patients had staged clinical and radiographic followups until skeletal maturity. The length of followup averaged 22years (range, 13-32years). In all the surgically treated hips, the acetabular index normalized by the end of growth, the incidence of avascular necrosis was 18%, and additional surgery was required in 15% of our cases. At the last followup, 93% of the hips were classified as Severin Classes I or II and 7% as Class III; 76% of the hips had an excellent result, 17% had a good result, and 7% had a fair result according to the McKay scale as modified by Barrett and colleagues. Open reduction of DDH through a medial approach provided good long-term radiographic and functional results in patients 3 to 36months old and it was the only surgery performed in 85% of our cases. Future comparative studies are needed to confirm our results, especially in older children. Level IV, therapeutic study.

Su1270 Incidence of Avascular Necrosis of the Hip in a Large Well-Characterized Cohort of Patients With Inflammatory Bowel Disease

Su1270 Incidence of Avascular Necrosis of the Hip in a Large Well-Characterized Cohort of Patients With Inflammatory Bowel Disease

Classifications in Brief: The Hawkins Classification for Talus Fractures.

As reported by Coltart [5], Fabricius von Hilden first described talus injuries in 1608, and in 1919, Anderson et al. [1] reported a series of talus fracture dislocations in which they emphasized dorsiflexion as the mechanism of injury and coined the term ‘‘aviator’s astragalus’’ (astragalus being another term for talus) because of the impressive frequency with which the mechanism—aircraft accidents— was associated with the injury in question. In 1952, Coltart [5] reported on 228 talus injuries treated by surgeons in the British Royal Air Force in an attempt to describe the variety of injuries that occur to the talus and surrounding joints. He described various talus fracture patterns, fracture-dislocation combinations, and isolated peritalar dislocations [5]. Others have presented case series of talus injuries and associated rarely used classification schemes [15, 19], but all have noted high complication rates with injuries to the talus [5, 11, 15, 19]. In 1970, proposed treatment strategies for vertical fractures of the talar neck ranged from nonoperative management to urgent open reduction internal fixation, bone graft augmentation, fusion of the dorsal talus to the distal tibia, and even complete talectomy [11]. Although the importance of early, anatomic reduction of these injuries was noted at that time, the incidence of avascular necrosis (AVN) was not. In 1970 Hawkins [11] described injury patterns and AVN rates in a series of 57 vertical talar neck fractures in 55 patients from three different institutions. All 55 patients sustained forced dorsiflexion injuries, similar to the mechanism described by Anderson et al. [1] in pilots.

Prevalence, incidence, and associated factors of avascular necrosis in Korean patients with systemic lupus erythematosus: a nationwide epidemiologic study.

Avascular necrosis (AVN) is one of the most frequent types of organ damage in systemic lupus erythematosus (SLE). However, little is currently known about the epidemiology of AVN in SLE patients. The aim of this study was to estimate the prevalence and incidence of AVN in Korean patients with SLE based on National Health Insurance (NHI) claims data and to determine the risk factors for AVN among SLE patients. This study was conducted using the 2006-2010 data of 25,358 SLE patients from the NHI program. AVN cases were defined as those with at least one diagnosis of AVN. The prevalence was calculated by dividing the number of AVN cases by the number of SLE cases in the same year. The annual incidence was calculated by dividing the number of incident AVN cases by the number of SLE-prevalent cases not previously diagnosed with AVN. Patients who developed AVN in 2008-2010 were compared with SLE patients who did not develop AVN to identify any risk factors. The prevalence of AVN among SLE patients (2006-2010) was 31.5-34.2 per 1,000 persons and was similar in all the years studied. The incidence per 1,000 persons of AVN among SLE patients was 8.6 [95 % confidence interval (95 % CI) 6.9-10.3] in 2008, 9.8 (95 % CI 8.0-11.6) in 2009, and 8.4 (95 % CI 6.8-10.0) in 2010. Regression analysis indicated that taking an oral corticosteroid [odds ratio (OR) 2.12, 95 % CI 1.39-3.23] or an intravenous corticosteroid (OR 1.5, 95 % CI 1.2-1.89) was significantly associated with AVN. In addition, AVN was associated with use of immunosuppressive agents (OR 2.12, 95 % CI 1.66-2.72), hydroxychloroquine (OR 1.4, 95 % CI 1.09-1.81), and lipid-lowering agents (OR 1.78, 95 % CI 1.24-2.57) among the prescribed medications, and with hypertension (OR 1.39, 95 % CI 1.08-1.79) among the comorbidities. The prevalence and incidence of AVN among SLE patients, which were 31.5-34.2 and 8.4-9.8 per 1,000 persons, respectively, may be representative of the entire population of symptomatic AVN patients with SLE in Korea. AVN is associated with the use of corticosteroids, immunosuppressants, hydroxychloroquine, lipid-lowering agents, and with hypertension. Studies of large, prospective cohorts are needed to confirm these results.

High-grade SCFE: the role of surgical hip dislocation and reduction.

The patient with an unstable slipped capital femoral epiphysis poses a challenging problem to the treating physician to improve the position of the displaced epiphysis to avoid femoroacetabular impingement without developing avascular necrosis (AVN)-a potentially devastating complication. Although the standard operative procedure of in situ pinning following an incidental reduction while positioning the patient on the table, has been the mainstay of treatment in North America, other viable options are available including a surgical dislocation approach to the hip followed by a modified Dunn osteotomy with control of the retinacular vessels, reduction of the epiphysis, and internal fixation with pins or screws. Although technically demanding, this approach offers an opportunity to reduce the epiphysis to avoid femoroacetabular impingement, and limit the possibility for the development of AVN. The early results for this procedure are promising with all studies demonstrating excellent reduction of the epiphysis and an overall lower incidence of AVN when compared with in situ pinning.

Cannulated Screw Fixation For Femoral Neck Fractures : A 5-year Experience In A Single Institution.

Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur. femoral neck fractures, screw fixation.

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.

Surgical treatment of iatrogenic femoral neck fracture during closed reduction for posterior fracture dislocation of the hip: A technical note

Fracture-dislocation of the hip is a rare event that usually results from high-energy injury. These patients require a systemic trauma survey to uncover concomitant injuries. Early closed reduction within 6 h is recommended to decrease the incidence of avascular necrosis of the femoral head. Iatrogenic complete femoral neck fracture during closed reduction for posterior dislocation of the femoral head is a rare complication. A modified technique, the Kocher-Langenbeck approach, for open reduction of the femoral neck fracture using antegrade guide pins and retrograde cannulated screws fixation can resolute this situation in one stage. This method provides an anatomic reduction and stable fixation for this kind of injury.

Correlation between avascular necrosis and the presence of the ossific nucleus when treating developmental dysplasia of the hip.

This study assessed whether avascular necrosis (AVN) is correlated with the presence or absence of the ossific nucleus (ON) at the initiation of conservative treatment for developmental dysplasia of the hip (DDH). To date, the correlation between the presence of the ON and AVN manifestations remains ambiguous. The medical records of 148 patients with 234 dislocated hips who presented at our institution between January 2006 and December 2007 were reviewed. Based on ultrasound examination, the hips were classified according to Graf IIIa, IIIb, and IV criteria. Patients aged >6months were simultaneously examined by standardized pelvis radiography. The ON was present in 84 hips (35.9%) at the beginning of treatment. Treatment was begun at a mean age of 5months, with overhead traction for 2weeks followed by arthrography and a spica cast for 4weeks. Afterwards, we used a Tübingen hip-flexion splint. The mean age at final follow-up was 87months. Hips were radiographically evaluated at last follow-up according to the Ogden-Bucholz AVN classification scheme. There was no significant difference in AVN prevalence between ON(-) versus ON(+) hips in children aged ≤10months (P=0.681), whereas when all age groups were analyzed together, AVN was significantly increased in ON(+) hips (P=0.002). Clinical examination revealed no differences in limping, leg length inequality, and range of motion of hips in the ON(-) versus ON(+) groups. We conclude that DDH treatment should be performed early without regard to the presence or absence of the ON. Reduction should not be delayed beyond >10months of age because any delay in treatment increases the incidence of AVN.

Avascular Necrosis(AVN) and Surgical Intervention In Pediatric Acute Lymphoblastic Leukemia(ALL): A Retrospective Cohort Analysis From The Pediatric Health Information Systems (PHIS)

Cure rates for acute lymphoblastic leukemia (ALL) have improved dramatically, but the incidence of avascular necrosis (AVN) has increased over the past decade. No national administrative data on the incidence of AVN or surgical therapies for AVN exist. We sought to define the incidence of AVN and AVN surgical interventions after treatment for ALL in a national administrative data set.The Pediatric Health Information System (PHIS) is an administrative database including ICD-9 discharge diagnosis, procedure codes, and billing data for daily resource utilization from 43 free standing pediatric hospitals in the US. This study identified patients with an associated ICD-9 code for AVN (733.4X) in a cohort previously established by our group to have newly diagnosed ALL.Between January 1999 and September 2011 242(2.25%), of the 10,729 patients in the ALL cohort had at least one admission with AVN with a mean time of 1.6 years from first ALL treatment until a hospital admission with an associated AVN diagnosis. Table 1 compares demographic and treatment characteristics between ALL patients with and without AVN diagnosis. Age 10-18.99 years and prednisone exposure during ALL induction were associated with increased incidence of AVN. Dexamethasone exposure was associated with a decreased incidence of AVN. AVN diagnosis was associated with a statistically significant increase in mortality. The rate of surgical intervention was 13.7%. The type and location of surgical intervention are reported in Table 2.Table 2Surgical Interventions during first AVN admissionDescriptionPatient countExcision of lesion or tissue of femur10Bone graft of femur9Arthroscopy of knee5Total hip replacement4Arthrotomy of knee3Excision or destruction of lesion of hip joint3Wedge osteotomy of femur2Excision of lesion or tissue of tibia and fibula2Excision of other bone for graft2Bone graft of tibia and fibula2Arthrotomy of hip2Repair of knee2Partial hip replacement2Excision of elbow joint2Excision of lesion or tissue of humerus1Excision of femur for graft1Partial ostectomy of femur1Bone graft of humerus1Arthrotomy of elbow1Arthrotomy of other specified site1Arthroscopy of hip1Excision or destruction of lesion of elbow joint1Excision or destruction of lesion of knee joint1Excision or destruction of lesion of ankle joint1To our knowledge, this is the first report using a national administrative database to determine the incidence of AVN in ALL. As expected, age was associated with AVN risk. The association of increased in-hospital mortality was unexpected and warrants further study. Surgical interventions typically involved lower extremity procedures. Work is ongoing to define the rates of subsequent surgical procedures and complication rates. These data demonstrate the feasibility of using administrative data to study surgical interventions for patients with AVN. Disclosures:Rheingold:Novartis: Research Funding.

Complications after treatment of femoral neck fracture with single-headed and double-headed cannulated screws

Objective To compare complications after of treatment of femoral neck fracture with single-headed and double-headed cannulated screws.Methods The 126 patients who had been admitted for femoral neck fracture from April 2001 to June 2009 were prospectively assigned to treatment with either single-headed or double-headed cannulated screw fixation following closed reduction according to the odd or even number of their admission date.In the single-headed group,there were 65 patients,41 males and 24 females (mean age,61.5 ±:3.2 years),29 cases of Garden types Ⅰ and Ⅱ and 36 cases of Garden types of Ⅲ and Ⅳ.In the double-headed group,there were 61 patients,35 males and 26 females (mean age,59.6 ± 2.6 years),24 cases of Garden types of Ⅰ and Ⅱ and 37 cases of Garden types of Ⅲ and Ⅳ.The two groups were compared in terms of nonunion,avascular necrosis of thefemoral head,screw backing-out,and the axis length of femoral head and neck after fracture union.Results The 126 patients were followed up for 3 to 11 years (mean,79 months).The single-headed group had a higher rate of nonunion [15.4％ (10/65) versus 3.3％ (2/61)],a higher rate of screw backing-out [16.9％ (11/65) versus 1.6％ (1/61)],a shorter axis length of femoral head and neck (7.00±0.36 cm versus 8.33±0.24 cm) than the double-headed group.All the above differences were statistically significant between the 2 groups (P ＜ 0.05).There was no significant difference between the 2 groups in femoral head avascular necrosis [16.9％ (11/65) versus 13.1％ (8/61)] (P ＞ 0.05).Conclusion Compared with single-headed cannulated screws,double-headed cannulated screws can reduce nonunion rate and screw backing-out,and maximally retain the axis length of femoral head and neck in the treatment of femoral neck fracture,but cannot reduce incidence of avascular necrosis of the femoral head. Key words: Femoral neck fractures; Fracture fixation, internal; Bone nails; Postoperative complications

The incidence of avascular necrosis of the femoral head changes with the hip abduction angle in the hip spica in treatment of developmental dislocation of the hip

The incidence of avascular necrosis of the femoral head changes with the hip abduction angle in the hip spica in treatment of developmental dislocation of the hip

The Pavlik harness in the treatment of developmentally dislocated hips: results of Japanese multicenter studies in 1994 and 2008

BackgroundIt has already been more than 50years since the Pavlik harness was introduced in Japan, and today the Pavlik harness is widely recognized as the standard initial treatment modality for developmental dysplasia of the hip. We performed a multicenter nationwide questionnaire study concerning the results of Pavlik harness treatment twice in 1994 and 2008. MethodsIn 1994 and in 2008, we sent questionnaires to 12 institutes in Japan specializing mainly in pediatric orthopedics. We compare the results of these two studies and discuss differences in reduction rates, incidence of avascular necrosis in the femoral epiphysis and the percentage of joints with acceptable morphology (Severin grade I+II/total) at skeletal maturity. We statistically assessed these results to see whether there were changes in the treatment outcomes over this 14-year period. ResultsReduction of the dislocated hips was obtained by the Pavlik harness in 80.2% (1990/2481 hips; 1994) and 81.9% (1248/1523 hips; 2008). The incidences of avascular necrosis of the proximal femoral epiphysis in the dysplastic hips were 14.3% (119/835 hips; 1994) and 11.5% (76/663 hips; 2008). The type of avascular necrosis in hips from the 2008 study was determined according to the classification of Kalamchi and MacEwen: 24/69 hips (34.8%) were classified as group I; 20/69 hips (29.0%) as group II; 11/69 hips (15.9%) as group Ill; 14/69 hips (20.3%) as group IV. The percentages of hips with acceptable outcomes at skeletal maturity discerned from Severin X-ray changes (grade I+II/total) were 72.3% (604/835 hips; 1994) and 77.7% (488/628 hips; 2008). ConclusionReduction rates and the incidence of avascular necrosis in 2008 were statistically similar to the results in 1994. The rate of acceptable outcome (Severin grade I+II/total) in 2008 was statistically higher than that of 1994.

Management of a neglected femoral neck fracture – a case report and review of literature

Femoral neck fractures are less frequent in children. A neglected femoral neck fracture is one where there has been a delay of more than 30 days to seek medical attention from the time of injury1. It is one of the most challenging problems encountered by orthopaedic surgeons especially in young adults and children. Avascular necrosis (AVN) is a severe complication following a neglected fracture neck of femur in children with a reported incidence of <15 %. We report a case of a young girl presenting with neglected displaced fracture neck of femur that was successfully managed by initial immobilisation with skeletal traction followed by a closed reduction and internal fixation using dynamic hip screws. No clinical or radiological signs of avascular necrosis were observed in the 1 year of follow-up. Remarkable post-operative improvement in the symptoms and decrease in the limp was noted. Patient had no hip pain or discomfort. Accurate anatomical reduction and internal fixation are crucial to reduce the incidence of avascular necrosis after femoral neck fracture. Internal fixation with dynamic hip screw is a reliable method with decent long-term functional outcomes even in children.