Muscle Pedicle Bone Graft Research Articles

Muscle-pedicle Bone Grafting With Periosteum Coverage for Osteochondritis Dissecans

Objective/Hypothesis: There are several treatment options for osteochondritis dissecans (OCD) of humeral capitellum. In a previous study, we reported muscle-pedicle bone grafting with periosteum coverage for OCD. The purpose of the current study was to review the results of this surgery. Materials and Methods: Eight patients who underwent muscle-pedicle bone grafting with periosteum coverage for OCD between 2011 and 2015 were reviewed retrospectively. The surgical technique is as follows: Unstable OCD lesion was debrided. Cuboid bone graft with the anconeus muscle pedicle was harvested from the posterior side of the capitellum. When obtaining the bone graft, extra periosteum was also obtained and kept attached to the bone graft. Bone tunnel was created from the harvested site to the debrided site. The bone graft was covered with the attached periosteum and inserted through the tunnel. The periosteum edge of the inserted graft was sutured with cartilage around the debrided site. The patients were placed in a long-arm splint for 2 to 3 weeks, followed by gentle mobilization. Gradual return-to-play program was started after radiographic signs of healing. Patients were usually allowed to recover to full sports activity around 6 months after surgery. The medical records of the 8 patients were reviewed for the following information: (1) sports and position; (2) preoperative and final range of motion; (3) duration from surgery to return to sports activity; (4) radiographic outcomes, including size of OCD lesion, grafted bone union, and enlargement of the radial head; and (5) complications. Enlargement of the radial head was defined as an increase in the diameter of more than 20% between preoperative and final anteroposterior radiographs. Results: Eight elbows in 8 patients (7 male and 1 female) with a mean age of 14 years (range, 12-16 years) underwent muscle-pedicle bone grafting with periosteum coverage during the period. Mean follow-up duration was 19 months (range, 6-34 months). Sports, the patients performed, include baseball (7 patients) and tennis (1 patient). In the 7 baseball players, 2 patients were pitchers, 1 was a catcher, 3 were infielders, and 1 was an outfielder. Preoperative range of flexion and extension were 129.4 ± 6.8° (mean ± SD) and −4.4 ± 8.6°, respectively. Final range of flexion and extension were 131.9 ± 11.9° and −2.5 ± 12.8°, respectively. There were no significant difference in preoperative and final range of motion. Patients returned to sports activity in 5 to 7 months after surgery. Seven of 8 patients returned to the same sports level, but 1 patient returned to other sports. The mean anteroposterior and transverse diameters of the cartilage defect were 12.0 (range, 8-14 mm) and 10.6 mm (range, 7-13 mm), respectively. Grafted bone union was achieved in all patients. Enlargement of the radial head was observed in 2 patients. Conclusions: Muscle-pedicle bone grafting with periosteum coverage was one of the acceptable treatment options for OCD of humeral capitellum. Reconstruction of articular defect in OCD was possible with minimum donor site morbidity.

Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting.

Background:Ununited femoral neck fracture is seen commonly in developing countries due to delayed presentation or failure of primary internal fixation. Such fractures, commonly present with partial or total absorption of femoral neck, osteonecrosis of femoral head in 8–30% cases with upward migration of trochanter posing problem for osteosynthesis, especially in younger individuals. Several techniques for treatment of such conditions are described like osteotomies or nonvascularied cortical or cancellous bone grafting provided varying degrees of success in terms of fracture union but unsatisfactory long term results occurred due to varying incidence of avascular necrosis (AVN) of femoral head. Moreover, in presence of AVN of femoral head neither free fibular graft nor cancellous bone graft is satisfactory. The vascularied bone grafting by deep circumflex iliac artery based on iliac crest bone grafting, free vascularied fibular grafting and muscle pedicle periosteal grafting showed high incidence of success rate. Osteosynthesis is the preferred treatment of choice in ununited femoral neck fracture in younger individuals.Materials and Methods:Of the 293 patients operated during the period from June 1977 to June 2009, 42 were lost to followup. Seven patients with gluteus medius muscle pedicle bone grafting (MPBG) were excluded. Thus, out of 244 patients, 208 (85.3%) untreated nonunion and 36 (14.7%) following failure of primary internal fixation were available for studies. Time interval between the date of injury and operation in untreated nonunion cases was mean 6.5 months and in failed internal fixation cases was mean 11.2 months. Ages of the patients varied from 16 to 55 years. Seventy patients had partial and 174 had subtotal absorption of the femoral neck. Evidence of avascular necrosis (AVN) femoral head was found histologically in 135 (54.3%) and radiologically in 48 (19.7%) patients. The patients were operated by open reduction of fracture, cannulated hip screw fixation, iliac crest bone chips and quadratus femoris MPBG.Results:The mean followup is 12.5 years (range 3-35). The union of fractures occurred in 202 (82.8%), delayed union in 18 (7.3%), and established nonunion in 24 (9.8%) patients. Full weight bearing was permitted at 16–22 weeks after union of fractures. Mean Harris hip score at the longest followup was 85.5. Among the complications, superficial wound infection occurred in 20 (8.2%), deep infection in seven (2.9%), and coxa vara in 39 (16%) patients. Preoperative radiodensity of femoral head disappeared mostly after the union of fracture whereas fresh radiodensity of femoral head appeared in 20 (8%) patients; nine (45%) of them developed segmental collapse.Conclusion:Ununited femoral neck fractureis characterized by absorption of femoral neck, posterior cortical defect, smoothening and overriding of fracture surfaces with intervening fibrous tissues associated with or without AVN of femoral head. The above method of osteosynthesis rectified the above pathology and provided satisfactory results with union of fractures in 90.1% patients at long term followup.

Sartorius muscle pedicle iliac bone graft for the treatment of avascular necrosis of femur head.

Avascular necrosis (AVN) of femoral head needs to be addressed early in the course of the disease, to prevent progression to osteoarthritis. A revascularizing procedure which can help preserve the head should be considered in young adults to alleviate the need for total hip arthroplasty. We included 40 cases (53 hips) of AVN of femoral head operated with Sartorius muscle pedicle iliac bone grafting, done by the senior author. Early post-operative rehabilitation was done. The weight bearing was delayed for 6 weeks. All the patients were followed clinically and radiologically at regular intervals. The operated femoral heads, were grouped according to Ficat’s staging: 24 in stage IIA (45.3%), 22 in stage IIB (41.5%) and 07 in stage III (13.2%). The average duration of surgery was 85 min (range: 55–130 min). The total duration of follow-up was average 4.2 years (range: 2.2–15 years).The Harris hip score was excellent (>90) in 18 hips (33.96%), good (80–89) in 24 hips (45.28%), fair (70–79) in 9 hips (17%) and poor (<70) in 2 hips (3.7%). AVN of the femoral head is a painful and disabling condition in young adults. Sartorius muscle pedicle bone graft technique allows adequate decompression, re vascularization and osteogenesis of the femur head in Ficat’s stage IIa, IIb and III, in young adults. This is an effective and easy technique to adopt with excellent to good results in 80% cases and is associated with only minimal complications.

Sartorius muscle-pedicle bone graft for osteonecrosis of the femoral head.

This study summarises the clinical efficacy of sartorius muscle-pedicle bone graft in osteonecrosis of the femoral head. A total of 58 patients, including 53 men (61 hips) and five women (6 hips) with osteonecrosis of the femoral head, underwent sartorius muscle-pedicle bone grafting. Association Research Circulation Osseous (ARCO) staging was performed. The ARCO staging revealed 23 hips of stage I, 36 hips of stage II and eight hips of stage III. The average surgical duration was 65minutes (range 45-90minutes). A total of 55 (64 hips) of the 58 patients undergoing surgery were followed up, with a mean follow-up duration of 34.48months (range, 24-48 months) and a median of 34months. The outcome was excellent in 27, good in 24, normal in two, and poor in 11 hips, with a total good rating of 79.68%. The Harris score of the hip joints in the last follow-up was significantly improved compared with pre-surgical scores (P < 0.01). Imaging results showed that 21 hips were improved, 31 hips were stabilized and 12 hips were aggravated (of which 9 hips underwent total hip replacement). The survival rate of femoral head was 81.25%. Sartorius muscle-pedicle bone graft significantly promotes repair of osteonecrosis of the femoral head, improves the Harris score of the hip joints, with good clinical efficacy. It effectively improves the survival rate of femoral head, delaying or preventing artificial hip replacement.

Treatment of neglected femoral neck fracture.

Intra-capsular femoral neck fractures are seen commonly in elderly people following a low energy trauma. Femoral neck fracture has a devastating effect on the blood supply of the femoral head, which is directly proportional to the severity of trauma and displacement of the fracture. Various authors have described a wide array of options for treatment of neglected/nonunion (NU) femoral neck fracture. There is lack of consensus in general, regarding the best option. This Instructional course article is an analysis of available treatment options used for neglected femoral neck fracture in the literature and attempt to suggest treatment guides for neglected femoral neck fracture. We conducted the “Pubmed” search with the keywords “NU femoral neck fracture and/or neglected femoral neck fracture, muscle-pedicle bone graft in femoral neck fracture, fibular graft in femoral neck fracture and valgus osteotomy in femoral neck fracture.” A total of 203 print articles were obtained as the search result. Thirty three articles were included in the analysis and were categorized into four subgroups based on treatment options. (a) treated by muscle-pedicle bone grafting (MPBG), (b) closed/open reduction internal fixation and fibular grafting (c) open reduction and internal fixation with valgus osteotomy, (d) miscellaneous procedures. The data was pooled from all groups for mean neglect, the type of study (prospective or retrospective), classification used, procedure performed, mean followup available, outcome, complications, and reoperation if any. The outcome of neglected femoral neck fracture depends on the duration of neglect, as the changes occurring in the fracture area and fracture fragments decides the need and type of biological stimulus required for fracture union. In stage I and stage II (Sandhu's staging) neglected femoral neck fracture osteosynthesis with open reduction and bone grafting with MPBG or Valgus Osteotomy achieves fracture union in almost 90% cases. However, in stage III with or without AVN, the results of osteosynthesis are poor and the choice of treatment is replacement arthroplasty (hemi or total).

Single-stage osteosynthesis and augmented muscle pedicle bone grafting in pathological fracture neck femur with fibrous dysplasia

The present report is a case of fibrous dysplasia of the proximal femur with pathological fracture neck of femur treated by single-stage surgery of curettage, internal fixation, nonvascularized fibular grafting and tensor fascia latae-based muscle pedicle bone grafting. At latest (2.6 years) follow-up, fracture is united without any evidence of local recurrence and patient is pain free with good clinical and functional results.

Results of triple muscle (sartorius, tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients.

Background:Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture.Materials and Methods:This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction.Results:14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks).Conclusion:Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.

The Superolateral Thigh Flap: A Reliable Skin Flap Based on the Terminal Cutaneous Branch of the Ascending Branch of the Lateral Circumflex Femoral Artery. Cadaver and Computed Tomography Angiography Studies with a Clinical Series”

Introduction: Few are the references to the reconstructive possibilities of the ascending branch of the lateral circumflex femoral artery (LCFA/a) other than the tensor fasciae latae muscle (TFL) flap and the so-called muscle pedicle bone grafting technique. Since the introduction of perforator-based tissue transfer, the computed tomography angiography (CTA) has emerged as a valuable technique in preoperative planning of perforator flaps.

Transfracture abduction osteotomy: A solution for nonunion of femoral neck fractures

Background:Nonunion and avascular necrosis (AVN) of the femoral head remains one of the major complications following femoral neck fractures. Despite various surgical techniques and internal fixation devices, the incidence of nonunion and AVN has remained unsolved. Neglected nonunion of femoral neck fracture is common in the developing world. Treatment options include rigid internal fixation with or without bone grafting, muscle pedicle bone graft, valgus osteotomy of the proximal femur with or without bone graft, valgus osteotomy or hip arthroplasty. We conducted a retrospective analysis of cases of nonunion of femoral neck fracture treated by transfracture abduction osteotomy (TFAO).Materials and Methods:Over a period of 35 years (1974-2008), 30 patients with nonunion of femoral neck fractures were treated with TFAO over a period of 35 years (1974-2008), All patients were less than 50 years of age. Absence of clinical and radiological signs of union after four months was considered as nonunion. Patients more than 50 years of age were excluded from the study. Union was assessed at 6 months radiologically. Limb length was measured at six months. The mean duration of femoral neck fracture was 19 months (range 4 months 10 years). Results were analyzed in terms of radiological union at six months. Average followup was five years and six months.Results:Consistent union was noted at the followup after six months in 29 cases. One case was lost to followup after five and one-half months postoperatively. However, the fracture had united in this case at the last followup. Average shortening of the limb at six months was 1.9 cm. Average neck shaft angle was 127° (range 120-145°). Five cases went into AVN but were asymptomatic. Two cases required reoperation due to back out of Moore's pins. These were reopened and cancellous screws were inserted in the same tracks.Conclusions:Consistent union of nonunion femoral neck fracture was noted at the followup after six months in 29 cases. The major drawback of the procedure is immobilization of the patient in the hip spica for eight weeks.

Role of muscle pedicle bone graft as an adjunct to open reduction and internal fixation in the management of neglected and ununited femoral neck fracture in young adults: a prospective study of 17 cases

To evaluate the role of quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation in the treatment of neglected and ununited femoral neck fractures in young adults. Young adults within the age group of 15-45 years with ununited, old neglected fractures of femoral neck were included in the study. All patients underwent quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation. The post-operative complications and functional recovery was assessed using Charnley's modification of Merle D'Aubigne and Postel hip scoring. A total of 17 patients were included in the study. The average time of union following the procedure was found to be approximately 8 months. There were two cases of delayed union and no cases of avascular necrosis. Ten patients (58.8%) had excellent or very good post-operative functional results and 6 patients (35.3%) had good or satisfactory results. Muscle pedicle bone grafting is a useful adjunct to open reduction and internal fixation for ununited femoral neck fractures. It achieves good final functional results comparable with other methods, but requires greater expertise.

Low Bone Density In Sickle Cell Disease Is a Risk Factor in The Development Of Avascular Necrosis

Introduction Sickle cell disease (SCD) is a highly prevalent disorder in the world, specifically in the region of Kuwait. A wide population suffers from sickle cell anaemia. It has been known that bone involvement is one of the most common clinical manifestations of sickle cell disease, both in the acute setting such as painful vaso-occlusive crises, and as a chronic, progressive process such as osteoporosis ,osteopenia and avascular necrosis (AVN), which can develop due to the low bone mass and the deterioration of the micro architecture of bone tissue. In this ongoing project, we used the radionuclide imaging technique for bone and bone marrow scintigraphy and dual-energy x-ray absorptiometry (DEXA). We attempted a correlation between low bone density and the bone infarct for SCD, and identified if low bone density is a risk factor for the severity and development of osteonecrosis in an at-risk population of sickle cell patients. Patients and Methods A total of 13 sickle cell patients participated in this correlation study; 5 males and 8 females, ages ranged from 16 to 55 years with a mean age of 35.5 years. To meet the participant selection criteria, patients were selected if they were never prescribed bisphosphonates or any type of medicine used to help strengthen bones weakened by osteoporosis, nor exposed to any other AVN risk factors other than SCD. Subjects were subjected to a scintigraphy (3-phase bone SPECT-CT, bone marrow) and bone mineral density scan (BMD). All subjects consented to the study approved by the ethics committee. Bone scintigraphy was performed by Tc-99m MDP, HDP 20mCi / 70kg intravenous injection. Bone Marrow Scintigraphy was performed by Tc-99m sulfur or tin colloid, 10-15 mCi / 70 kg I.V, Bone with Bone marrow scintigraphy imaging is required to assess bone marrow infarction and infection. BMD dual-energy x-ray absorptiometry (DEXA) was also performed to indicate the reliably changes in bone mineral content of the lumbar spine and proximal femur. Statistical analysis involved descriptive statistics and chi-square test. Results According to the WHO criteria used; low bone density was found in 9/13 (69%) while normal bone density was found in 4/13 patients (31 %). Based upon the application of a chi-square test, all those subjects 9/9 having a low bone density were showing AVN in several severity and multiple sites of the skeleton; it was found that there is an association between low bone density and incidents of AVN. However, it is of importance to note that 2/4 (50%) of the normal bone density patients were found to have AVN. Conclusion The preliminary conclusion discern from this ongoing project suggest that low bone mineral density in SCD could be considered a risk factor contributing to the development of AVN. We hypothesise that the severity of AVN develops due to the low bone mass and the deterioration of the micro architecture of bone tissue. The results have shown that low bone density is highly associated with osteonecrosis. Further case studies are needed to confirm or disprove these findings. The findings of this project could inspire new protocols required for effective management of this disease. Our findings could also potentially point out and diagnose new clinical cases, which would normally not be clinically suspected. We also speculate that increasing bone density of this patient population may decrease the severity and incidents of AVN. References 1-Sch2-nog JB, Duits AJ, Muskiet FA, ten Cate H, Rojer RA, Brandjes DP. Sickle cell disease; a general overview. Neth J Med. 2004 Nov;62(10):364-74. Review. PubMed citation 2-Digiovanni, Cw; Patel, A; Calfee, R; Nickisch, F (Apr 2007). “Osteonecrosis in the foot”. The Journal of the American Academy of Orthopaedic Surgeons 15 (4): 208–17. ISSN 1067-151X. PMID 17426292. 3-eMedicine Specialties &gt; Avascular NecrosisAuthor: Jeanne K Tofferi, MD, MPH, FACP; Coauthor: William Gilliland, MD, MPHE, FACP, FACR. Updated: Dec 17, 2009 4-Baksi, Dp (May 1983). “Treatment of post-traumatic avascular necrosis of the femoral head by multiple drilling and muscle-pedicle bone grafting. Preliminary report”. The Journal of bone and joint surgery. British volume 65 (3): 268–73. ISSN 0301-620X. PMID 6341373. Disclosures: No relevant conflicts of interest to declare.

Posttraumatic osteonecrosis and nonunion of distal pole of scaphoid

Posttraumatic osteonecrosis of distal pole of scaphoid is an extremely rare with only two reported cases so far. We present a case of a 30-year-old male with a 2-year-old posttraumatic osteonecrosis and nonunion of distal pole of scaphoid left wrist. He presented with complaints of pain and restriction of movements. There was no evidence of radiocarpal arthritis. He was managed with open reduction and internal fixation with k-wires, supplemented by a pronator quadratus based muscle pedicle bone graft. The fracture union was achieved at 6 months. After 2 years, he had almost complete range of wrist motion and had returned to his preinjury level of functional activity. His MRI (magnetic resonance imaging) scans showed evidence of revascularization suggesting successful incorporation of bone graft.

Benign lytic lesions of the femoral neck: mid-term results of extended curettage and sartorius muscle pedicle bone grafting

Benign lytic lesions of bone encompass a group of neoplastic or developmental disorders of human skeleton. They may involve different sites with varied clinical presentation and pattern of aggressiveness for which the treatment strategy needs to be tailored accordingly. Planning a treatment protocol for a lytic lesion in the femoral neck is a matter of concern for the operating surgeon with due consideration to the risks involved. This prospective study comprised of 16 patients (9 females and 7 males) with an average age of 23.37 years (range 14 to 35) who presented with lytic lesion in the neck of femur. Only those lesions which were involving the anterior or the inferior aspect of the femoral neck in which the destruction was more than 50% of the cortex in a single view or there was a pathological fracture were included in this study. There were six cases of giant cell tumour, five cases of fibrous dysplasia, four cases of aneurysmal bone cyst and one case of benign fibrous histiocytoma. All the lesions were operated using anterior approach, and after extended curettage, the cavity was packed with bone chips and sartorius-based muscle pedicle bone grafting (MPBG) was done. Four patients presented with pathological fracture in which the fibula strut grafting was done in addition to MPBG. The patients were assessed using Musculoskeletal Tumour Society (MSTS) score. The mean follow-up period was 32months (range 26-74months). The average time to clinical healing was 8weeks (range 6-12weeks) in patients without pathological fracture at the presentation. At final follow-up, the average MSTS score was 28.2 and full radiological consolidation had occurred in all but one patient who developed recurrence. There was no evidence of avascular necrosis or pathological fracture in any of the cases. Sartorius muscle pedicle bone grafting using anterior approach is a good and reliable option in patients presenting with benign lytic lesion in the neck of femur.

The Superolateral Thigh Flap

There are few references to the reconstructive possibilities of the ascending branch of the lateral circumflex femoral artery other than the tensor fasciae latae muscle flap and the so-called muscle pedicle bone grafting technique. An anatomical study was performed to evaluate the ascending branch of the lateral circumflex femoral artery and its contribution, through direct branches, to the iliac crest and skin. In nine of 20 dissections, a small branch of the ascending branch of the lateral circumflex femoral artery was found to reach the iliac crest in the space defined by the rectus femoris, gluteal muscles, and tensor fasciae latae. After emergence of the tensor fasciae latae pedicle, the ascending branch coursed through an anatomical triangular space before entering the trochanteric skin as a direct terminal branch and running for a considerable distance in a posteroinferior direction in the subcutaneous fat. This pretrochanteric triangle was defined by the tensor fasciae latae, the trochanteric insertions of the vastus lateralis and gluteus medius muscles, and the greater trochanter. The superolateral skin of the thigh can be transferred based on terminal branches of the ascending branch of the lateral circumflex femoral artery. Although inconstant, a small branch of the ascending branch reaches the iliac crest and might support vascularized bone transfer, although more studies are needed to define its role in composite tissue transplantation. This ascending branch might be a good alternative in pedicle or microvascular skin/fat transfer, breast reconstruction, tendocutaneous reconstructions, or composite tissue transplantation. Diagnostic, II.

Results of internal fixation and anterior muscle pedicle bone grafting in old femoral neck fracture

Sixteen cases of old fracture neck femur were treated by internal fixation and anterior muscle pedicle bone grafting of rectus femoris, sartorius bone block from anterior superior iliac spine. The treatment period were from January 2000 to December 2009 at Khulna Medical College Hospital and some private hospital. Different methods of fixation and bone grafting procedure were reported. We did this procedure by open reduction and internal fixation by cannulated hip screws and muscle pedicle bone grafting. Additional cancellous bone grafting were done in every cases. Follow up period was 2 to 7 years (average 5 years). Evaluation parameter were union, non union. collapse of neck, avascular necrosis of femoral head (AVN) coxavara, shortening, pain, range of movement and functional activities and over all satisfaction of patient. The results of fracture healing rate was good (9), fair (4) and poor (3). The technique is simple, rewarding and easy access of fixation and muscle pedicle bone grafting. Bone graft was placed by making a gutter at fracture site and maintained by a screw or prolin suture. DOI: http://dx.doi.org/10.3329/bmjk.v43i1-2.13016 Bang Med J (Khulna) 2010; 43: 10-11

The medium and long term effects of the quadratus femoris muscle pedicle bone graft with screw internal fixation for the treatment of femoral neck fractures in youth

Objective To analysis the medium and long term effects of the quadratus femoris muscle pedicle bone graft with screw internal fixation for the treatment of femoral neck fractures in adults.Methods From March 2003 to December 2008,sixty-two patients with femoral neck fractures were operated.There were 50 males and 12 females,with an average age of 39 years (ranged from 16 to 62 years).Fifteen cases suffered from traffic accidents and 47 from falling injury.There were 8 cases which fracture site was infer-head in Garden type Ⅱ,twenty-nine cases in type Ⅲ and 25 cases in type Ⅳ.The average time were 12 hours (2-96 hours) from injured to hospital admission and 4 days (2-8 days) from injured to operation.Partial weight bearing started on 3 months postoperatively and full weight bearing on 6 months.The postoperative duration of follow up was 3 to 5 years in 39 cases.Healing of fractures and avascular necrosis of the femoral head were evaluated based on the X-ray results or MRI if necessary.The pain,function,deformity,range of motion were evaluated based on Harris joint function scores.Results Nonunion of fracture was noted in 2 cases during the follow-up period.The fracture healing rate was 96.8％.The avascular necrosis of the femoral head was noted in 6 cases (15.4％).There were statistical significant differences between 3 months of postoperation and 3 years of postoperation in the pain,function,deformity,range of motion.After 3 years of postoperation,there were excellent in 29 cases,good in 6 cases,general in 1 case,poor in 3 cases according to Harris joint function scores.Conclusion This technique is relatively simple and has high rate of fracture healing.The avascular necrosis of the femoral head rate is low.The medium-and long-term results are satisfactory. Key words: Femoral neck fractures; Bone transplantation; Fracture Internal Fixation; Microsurgical operation

Augmented osteosynthesis with tensor fascia latae muscle pedicle bone grafting in neglected femoral neck fracture

Background:Neglected intracapsular femoral neck fracture in young patients may fail to unite because of the excessive shearing strain at the fracture site and it is a surgical challenge to any orthopedic surgeon. The problem is compounded by resorption of the femoral neck and avascular necrosis (AVN) of femoral head. There is no satisfactory solution available in the management of femoral neck fracture as far as the union of the fracture and AVN of femoral head are concerned. Muscle pedicle bone grafting has been advocated to provide additional blood supply to the femoral head. We report a retrospective analysis of 48 cases of neglected femoral neck fracture treated by internal fixation and tensor fascia latae based muscle pedicle bone grafting.Materials and Methods:48 patients with femoral neck fractures with age varied from 20 to 53 years (average age 32.9 years) with male to female ratio of 2:1 were enrolled. All fractures were more than 3 weeks old with mean delay being 86 days (22–150 days). Open reduction and internal fixation along with tensor fascia latae muscle pedicle bone grafting was done in all cases. It was supplemented by multiple drilling and cortico-cancellous bone grafting. Fracture fixation was done with three parallel 6.5-mm AO cannulated cancellous lag screws and the graft fixed with a 4-mm cancellous screw to provide a secure fixation. During the followup period of 2-6.8 years (average 4.4 years) the results were assessed clinically by modified Harris hip scoring system and radiologically by the evidence of signs of fracture union.Results:Union was achieved in 41/48 (85.41%) cases which were followed for an average period of 4.4 years (2–6.8 years) with good functional results and ability to squat and sit cross-legged. Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 19, good in 22, fair in 5, and poor in 2 patients. Complications were nonunion, (n=3) avascular necrosis (n=2), and coxa vara deformity (n=2).Conclusion:Internal fixation with muscle pedicle bone grafting is a suitable option to secure union in neglected femoral neck fractures in physiologically active patients with late presentation.

Comment on Sen et al.: Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture

Dear Sir, We read with interest the article entitled Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall [6]. In the study, the authors used iliac crest strut graft for reconstruction of the comminuted posterior acetabular wall fracture. A series of eight patients were evaluated clinically by Merle d’Aubigne and Postel score and radiologically by Matta score at their final follow-up. The outcome after a mean follow-up of 3.34 years (minimum two years and maximum five years) showed a good-to-excellent result in seven patients (87.5%) clinically and in five patients (62.5%) radiologically [6]. We appreciate the described technique using iliac crest strut graft for reconstruction of the comminuted posterior acetabular wall fracture, and also the medium-term clinical and radiological results of this technique are satisfactory. However, in their discussion, the authors concluded “Iliac crest strut graft can be better compared to a single fragment of posterior acetabulum wall which has lost its soft tissue attachment”; we have doubts about this conclusion. There is consensus that good prognosis is clearly related to anatomical reduction and stable fixation of posterior wall fractures. Only 30% of posterior-wall acetabular fractures involve a single large fragment. The majority are multifragmentary or have areas of impaction, where open reduction is often necessary with elevation of the depressed articular fragments [1]. Whether the fragments have soft-tissue attachments or not was rarely mentioned in published reports. In our experience, although soft-tissue stripping was done extremely carefully intra-operatively, we often found fragments became free after elevation and reduction in severely comminuted posterior acetabular wall fractures. This has also been mentioned by Giannoudis et al. in their report [3]. Using primary severely comminuted fragments, which may be without soft tissue attachment, to reconstruct the posterior wall produced good results for different authors. The following patients were all evaluated clinically by modified Merle d’Aubigne and Postel score and radiologically by Matta score at their final follow-up. Im et al. retrospectively examined 15 patients with a single fragmented or moderately comminuted posterior acetabular wall fracture using screws alone, whereby 14 patients (94%) had a good-to-excellent result clinically after a follow-up period of more than two years [4]. Ebraheim et al. retrospectively studied 32 comminuted posterior acetabular wall fractures combining a spring plate and reconstruction plate to reconstruct the posterior wall; the average follow-up was 43 months (range 24–70 months), and clinical evaluation gave a good-to-excellent result in 24 patients (76%) and radiologically in 23 patients (73%) [2]. Recently, Giannoudis et al. reported a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. The clinical outcome was graded as a good-to-excellent result in 27 patients (93%), and radiological outcome was graded as a good-to-excellent result in 25 patients (86%) at a mean follow-up of 35 months (range 24–90) [3]. No complication in the form of non-union, loss of fixation and absorption of fragments was noticed. As the Spearman correlation between the original and modified Merle d’Aubigne-Postel Score was R = 0.89, it is equivalent to using the two grading systems clinically [5]. From these data, we therefore favour using primary severely comminuted fragments to generate better results. Whether the iliac crest strut graft is better than a single fragment without soft-tissue attachment or not, requires further study. Furthermore in our opinion, to ensure the blood supply of the bone graft, using muscle pedicle bone graft is a reliable and easy technique in the clinical setting. However, in the study of Sen et al., the authors did not mention whether the iliac crest strut graft had a muscle pedicle or not, but Fig. 3b in that article shows a free iliac crest strut graft. In conclusion, only with muscle pedicle iliac crest strut graft application in this study, can we conclude that it is better than a single fragment of posterior acetabulum wall which has lost its soft tissue attachment. The word “definative” in the last paragraph, it should be “definitive”.

Management of a Neglected Femoral Neck Fracture in a Limb Affected by Poliomyelitis - A Case Report

Neglected femoral neck fractures are difficult to treat successfully without resorting to total hip arthroplasty. Baksi described a tensor fascia lata muscle pedicle bone graft procedure for such cases. Management of such fractures following poliomyelitis presents additional challenges. We present a case of a neglected femoral neck fracture in a young adult with late sequelae of poliomyelitis managed by Baksi's procedure. At final follow up at 2 years the patient was able to walk without aids and had returned to his job.

Treatment of Post-traumatic Avascular Necrosis of the Femoral Head and Nonunion of Femoral Neck Fracture by Muscle Pedicle Bone Grafting

Treatment of Post-traumatic Avascular Necrosis of the Femoral Head and Nonunion of Femoral Neck Fracture by Muscle Pedicle Bone Grafting