Rate Of Avascular Necrosis Research Articles

Outcome Analysis of Hemiarthroplasty vs. Total Hip Replacement in Displaced Femoral Neck Fractures in the Elderly.

Management of displaced fracture neck femur in the elderly population is frequently done by Hemiarthroplasty or Total Hip Replacement (THR). It avoids high rates of nonunion and avascular necrosis which usually occur after internal fixation of neck femur fractures in this age group. The present study aimed to evaluate patient function and complications following hemiarthroplasty and total hip replacement in elderly population with displaced femoral neck fractures. Patients above 60 years of age with displaced fracture neck femur were studied over the period of four years. All the clinical parameters and co-morbid conditions were noted at the time of presentation. The patients associated with co-morbid conditions and underlying pathology were excluded from study. Garden's classification was used for classification of neck femur fractures. After due informed consent patients of displaced fracture neck femur were randomized by simple randomization and allocated for hemiarthroplasty or THR. Antibiotics were given preoperatively at the time of induction and postoperatively for 5-7 days. Surgery was carried out by Modified Gibson approach. Any complications during pre and postoperative period were noted. Follow-up of patients was done 1 month, 3 months, 6 months and 1 year interval with the help of Harris hip score. Total 80 patients were enrolled in the study group, with 40 patients in each group. The mean age of patients was 73 years in hemiarthroplasty group and 78 years in THR group. Female to male ratio was 55:45. Mean operative time was 35 minutes in hemiarthroplasty group and 45 minutes in THR. Average intraoperative blood loss was 200cc and 300cc in hemiarthroplasty and THR respectively. The mean hospital stay was 14 days in both the groups. Superficial wound infection was noted in hemiarthroplasty group while in THR group deep wound infection (n=1) and prolonged ICU stay (n=1) were noted. The mean Harris hip score was better in THR group as compared to Hemiarthroplasty group at one year follow-up. In elderly patients with fracture neck femur hemiarthroplasty takes less operative time, less blood loss per operatively and few complications postoperatively as compared to THR. The functional outcome at one year is better with THR as compared to hemiarthroplasty.

Valgus osteotomy for nonunion and neglected neck of femur fractures.

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Intracapsular Pressures After Stable Slipped Capital Femoral Epiphysis.

Stable slipped capital femoral epiphysis (SCFE) has been shown to have a lower rate of avascular necrosis than unstable SCFE. A recent study found increased intracapsular hip pressures in the setting of unstable SCFE, thus increasing the risk of osteonecrosis. The purpose of this study was to measure the intracapsular pressure in stable SCFE and compare it to the intracapsular pressure in normal hips and in unstable SCFE. Thirteen hips with stable SCFE and 15 hips with unstable SCFE were identified. Using a side-bored needle, intracapsular hip pressures were measured at the time of surgery. Within these 2 study groups, 11 unaffected (normal) hips were also measured. Diastolic blood pressure and mean arterial pressure at the time of measurement were also recorded. The average intracapsular hip pressure in the stable SCFE group was 27.0 mm Hg, whereas the average pressure in the unstable SCFE group was 48.2 mm Hg and the average pressure in the normal group was 21.8 mm Hg. There was no significant difference between the normal and stable SCFE groups. There was a statistically significant difference between the stable SCFE and unstable SCFE groups (P<0.001). We found similar trends when comparing the intracapsular hip pressure as a percentage of the mean arterial pressure as well as the difference between diastolic blood pressure and hip pressure. As expected, the intracapsular pressure in the setting of stable SCFE approaches that of normal hips. This may explain why the risk of AVN in stable SCFE is significantly lower than that of unstable SCFE. It also supports the idea that capsulotomy is indicated for unstable slips to decrease the elevated hip pressure but not in stable SCFE.

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.

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.

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

We read the article by Farsetti et al. [1] with great interest. Their study evaluated the long-term results of medial open reduction in the treatment of developmental dysplasia of the hip. The authors concluded that medial open reduction is a safe procedure with satisfactory results in patients up to the age of 36 months [1]. Although we appreciate the work by Farsetti and colleagues, we have some concerns. In their study, the age groups lack homogenity. We also found patient selection bias [1]. Group 3 consisted of 11 patients (18 hips) who were 25 to 36 months old at the time of operation, equaling 25% of all hips in the study. The authors observed avascular necrosis in 44% of these hips [1]. This rate is higher than the other groups in the study. Additionally, it is well-known that medial open reduction is associated with a higher incidence of secondary procedures in children older than 18 months to 24 months of age [2, 3]. We would like to thank Farsetti and colleagues for this paper. However, we do not agree with the their conclusions due to the high avascular necrosis rate and need for secondary procedures in children 25 to 36 months old. We believe that medial open reduction should be used in children up to the age of 18 months to 24 months.

The safety and efficacy of a transarticular pin for maintaining reduction in patients with developmental dislocation of the hip undergoing an open reduction.

Redislocation after an open reduction for develpmental dislocation of the hip is relatively common. The purpose of this study was to determine if the use of a transarticular pin (TAP) is safe and effective in maintaining reduction. A total of 578 patients (645 hips) were reviewed after an open reduction, mean age at the time of surgery was 2.1 years. In 621 cases a smooth Kirschner wire was placed across the joint. The rates of redislocation, avascular necrosis (AVN), and other complications were determined. AVN was classified according to Kalamchi et al. Outcome was determined at a minimum of 6 years using the Severin classification. Redislocation occurred in 27 cases (4.1% rate), 24 had a TAP (3.8%) and 3 did not (12.5%). AVN was observed in 127 cases (19.7%), it was type I in 73 cases, type II in 38 cases, type III in 14 cases, and type IV in 2 cases; AVN was seen in 123 cases which had a TAP (19.8%) and 4 cases which did not (16.7%). Analyzing pin placement: when it was in the inferior third of the neck the rate of AVN was 15.2% (32/211), in the middle third it was 21.7% (71/326), and in the superior third it was 28.6% (24/84). According to the Severin classification for the hips with a TAP, 496 were type I or II (79.8%), 113 were type III (18.2%), 10 were type IV (1.6%), and 2 were type V (0.3%); in the group without a TAP 19 cases were type I or II (79.2%), 4 were type III (16.7%), and 1 was type IV. The use of a TAP was effective in maintaining reduction and was not associated with significant morbidity. Placing the pin in the inferior third of the neck was associated with the lowest rate of AVN. Level IV--therapeutic.

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PurposeTreatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).Methods This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients' charts were analyzed for clinical and radiographic features.Results Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11–28) months, and the average follow-up was 5.5 (range 3–9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi–McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair–plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.Conclusions We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.

Surgical hip dislocation is a reliable approach for treatment of femoral head fractures.

Femoral head fractures are rare injuries; incongruency and instability are indications for surgical intervention. Anterior, posterior, and transtrochanteric surgical approaches have been proposed, but the exposure is limited with classical approaches. Surgical hip dislocation allows for a 360° view of the head and may facilitate a reduction in selected head fractures, but to our knowledge, few studies have reported on the results with this technique. We therefore report on the (1) quality of fracture reduction; (2) modified Harris hip score at a minimum of 2 years (mean, 6 years, range, 26-122 months); and (3) frequency of complications, including avascular necrosis (AVN), arthritis development, and heterotopic ossification, in a case series of patients with femoral head fractures treated with this approach. The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. Using this technique we are able to reduce all displaced femoral head fractures under direct view. Definitive fixation is performed through this approach with 2.7-mm nonabsorbable screws. The same technique may be used also for Pipkin IV fractures to fix transverse, T-type, posterior wall, or posterior column acetabular fracture. Between 2004 and 2011, we used this approach to manage all displaced femoral head fractures in patients younger than 55 years old. A total of 17 patients were thus treated; of those three were lost to followup before 2 years, and one was excluded from study because of severe preoperative neurological impairment, leaving 13 for analysis here. Patient demographic, injury, and surgical variables as well as complications were recorded and retrospectively evaluated. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs. Outcomes were evaluated with the modified Harris hip score. Minimum followup was 24 months (mean, 77 months; SD, 32.8 months). Fracture reduction was anatomic in eight hips and imperfect in five. Mean clinical score was 82 points (SD, 7.7). One patient developed symptomatic femoral head AVN and underwent total hip arthroplasty 4 years after the index procedure; no other patient underwent arthroplasty. Besides this patient, signs of arthritis (Grade I according to Tönnis classification) were found in one patient and heterotopic ossification was recorded in two patients, but neither was symptomatic. Our experience with surgical dislocation shows clinical results comparable to previously reported outcomes in femoral head fractures treated with common approaches; we also present a similar rate of AVN and a lower rate of posttraumatic arthritis, but a higher risk of heterotopic ossification. Further case-control studies are necessary to confirm these statements. Level IV, therapeutic study.

Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock

IntroductionThe Humerusblock (HB) represents a minimally invasive implant allowing for the stabilisation of proximal humeral fractures after closed or percutaneous reduction. The aim of the study was to perform a general clinical and radiological midterm follow-up focusing on the quality and complications in a large series of patients of younger age (<70 years). Patients and MethodsA total of 126 patients with an average age of 53.6 years treated surgically using the HB device were evaluated clinically using the Constant score (CS) and radiologically by biplanar radiographs after a mean follow-up time of 59 months. Thirty-three patients had a two-part fracture, 58 a three-part fracture and 35 a four-part fracture. Ultrasound imaging for bilateral rotator cuff evaluation was performed, and complications regarding implant failure, revision rate and post-traumatic avascular necrosis (AVN) were analysed. ResultsThe average CS was 77.3 points for the affected shoulder and 86.5 points for the unaffected shoulder (P=0.001). The subjective shoulder value was 84.2%. Two-part fractures achieved 77.5 points, three-part fractures 81.7 points and four-part fractures 69.8 points. Surgical neck non-union was observed in 1.3% and AVN was observed in 11% associated with a CS of 46.4 points. Implant failure occurred in 9.6%. Varus malposition was present in 36%, and it was clinically relevant when exceeding 25°. ConclusionPercutaneous fracture treatment using the HB achieves good functional outcomes with an acceptable complication rate. The rate of AVN was surprisingly high, especially in four-part fractures (26%), which presumably is due to the longer follow-up period. Varus malalignment was clinically relevant when exceeding 25°. Study designRetrospective case series (evidence-based medicine (EBM) level IV).

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

T he Ludloff medial approach to the hip for the treatment of pediatric developmental hip dysplasia is popular in some centers with reports of equivalent clinical outcomes and lower avascular necrosis (AVN) rates. Some surgeons may be unfamiliar or lacking confidence in this approach. Therefore, it is only reasonable to believe that surgeons who are unfamiliar with the Ludloff approach will likely prefer traditional anterior access. The current study by Farsetti and colleagues involves 71 hips treated by medial open reduction with followup to skeletal maturity. The authors are commended for their thoughtful preoperative program (including 4 weeks of preoperative traction), for their long-term followup efforts, and for their thorough assessment of the patients involved. The benefit of preoperative traction remains controversial and warrants well-designed and controlled trials. A similar recent Level III paper by Hoellwarth et al. [3] also compared medial and anterior approaches, with 19 in each matched group, and found no differences in AVN rates or need for further surgery. They reported no protective benefit of a preoperative ossific nucleus. The current study by Farsetti and colleaguies reports a lower AVN rate in children without ossification of the femoral head at the time of surgery—22 of their 71 patients did not have ossified heads. This remains a topic of debate however, with mixed reports.

Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis.

Avascular necrosis (AVN) of the femoral head is an irreversible complication seen in the treatment of developmental dysplasia of hip (DDH) with the Pavlik harness. Its incidence is reported to be low after successful reduction of the hip but high if the hip is not concentrically relocated. We aim to investigate its incidence after failed Pavlik harness treatment. We prospectively followed up a group of children who failed Pavlik harness treatment for DDH treated at our institution by the senior author between 1988 and 2001 and compared their rates of AVN with a group of children who presented late and hence were treated surgically. AVN was graded as described by Kalamchi and MacEwen and only grade 2 to 4 AVN was considered significant and included in the analysis. Thirty-seven hips were included in the failed Pavlik group (group 1) and 86 hips in the no Pavlik group (group 2). Ten hips in group 1 developed AVN (27%), whereas only 7 hips in group 2 (8%) developed AVN; the odds of developing AVN after failed Pavlik treatment was 4.7 (95% confidence interval, 1.3-14.1) (P=0.009) with a relative risk of 3.32 (range, 1.37 to 8.05). There was no statistically significant association observed with duration of splintage and severity of AVN (Spearman's correlation, -0.46; P=0.18). However, there was a positive correlation noted with age at presentation and severity of AVN. Therefore, we advise close monitoring of hips in the Pavlik harness and discontinue its use if the hips are not reduced within 3 weeks. Level III.

Ultrasound-guided gradual reduction using flexion and abduction continuous traction for developmental dysplasia of the hip: a new method of treatment.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome.

Traditionally, the anterior surgical approach of choice for acetabular reconstruction was ilioinguinal. There has been an increasing usage of the midline "Stoppa" or "anterior intrapelvic approach." The aim is to report the techniques, early results (minimum 1 year), and complications of anterior approaches for acetabular reconstruction. Retrospective case-note review. Pelvic and acetabular tertiary center. A consecutive series of acetabular fractures treated at 1 tertiary specialist unit were retrospectively reviewed. The fracture patterns, incisions used, intraoperative and postoperative complications, reduction achieved (measured on postoperative radiographs and computed tomography scans), and early postoperative results (minimum 1-year follow-up), were recorded. Postoperative reduction (measured by postoperative plain radiographs and computed tomography). Of 160 consecutive patients who underwent acetabular reconstruction, 56 (mean age, 44 years) underwent reconstruction using only anterior approaches (mean of 7 days after injury). Iatrogenic complications, postoperative infection, arthritis, and avascular necrosis rates are comparable with the literature. Overall, anatomic reduction was seen in 71% of cases and concentric reconstruction of the dome in over 90%. Thirty-six of the 56 patients (64%) were symptom-free at the latest follow-up and 34 (61%) had returned to work. The results reported suggest the use of dual approaches using the lateral 2 windows, and/or a midline anterior intrapelvic approach in anterior acetabular reconstructions has a relatively low complication rate and can lead to anatomic reconstructions in 71%. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

The Targon FN system for the management of intracapsular neck of femur fractures: minimum 2-year experience and outcome in an independent hospital.

BackgroundThe Targon FN implant was developed in 2007 to treat intracapsular neck of femur fractures. Early results from the design centre have shown good results in terms of fracture complications. We wished to see if these results can be reproduced in an independent institution.MethodsThe records of consecutive patients, treated with this implant between 2008 and 2011 at Queen Elizabeth Hospital, were identified and collected for this study. Operations were performed by all grades of surgeons under supervision as appropriate. These patients went on to have both clinical and radiological assessment for fracture healing and function.ResultsFifty-one patients were identified with 43 patients available for final follow-up. The average age was 66 years with a minimum follow-up of 24 months. A non-union rate of 0% in the undisplaced fracture group and 1 in 12 (8%) in the displaced fracture group was observed. An avascular necrosis rate of 6% and 8% was observed for undisplaced and displaced fracture types, respectively. No significant change in premorbid to postoperative ambulation was observed and there was no wound complication.ConclusionsOur study shows similar results with those of the design centre and which are superior to those currently found in the literature for the more traditional fixation methods. It also shows that the promising results with this new implant as seen from the design institutions can be reproduced by all cadres of surgeons in non-specialist practice.

Locked plate osteosynthesis of humeral head–splitting fractures in young adults

Humeral head-splitting fractures occur in younger patients and can be associated with poor outcome. We decided to study the functional outcome and complications in simple and complex humeral head-splitting fractures. We hypothesized that simple head-splitting fractures will perform better compared with complex head-splitting fractures. Records of 16 patients <55years who underwent locked plating for humeral head-splitting fractures were reviewed. Five fractures were classified as simple (isolated head-splitting fractures) and 11 as complex fractures (associated tuberosity fractures). Union and quality of articular and tuberosity reduction were assessed radiologically. Shoulder and upper limb function was assessed by Constant and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Complications such as osteonecrosis, nonunion, and arthritic changes were also recorded. Of 15 fractures, 13 had united at a mean follow-up of 34months (25-47months). No osteonecrosis or nonunion was seen in simple fractures. In complex fractures, osteonecrosis was seen in 4 patients (P=.01), nonunion in 2 patients, and glenohumeral arthritis in 1 patient. The mean Constant score (66.5 [56-77]) and DASH score (21 [7.5-35.8]) showed significantly better outcomes in simple fractures (Constant score, P=.02; DASH score, P=.029). Locked plating achieves satisfactory results in simple head-splitting fractures. Complex fractures are associated with higher rates of nonunion, avascular necrosis, and inferior shoulder function.

The Role of Capital Realignment Versus In Situ Stabilization for the Treatment of Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) can be treated by a variety of methods with the traditional method of in situ pin fixation being most commonly used. More recently, the Modified Dunn (Mod. Dunn) procedure consisting of capital realignment has been popularized as a treatment method for SCFE, particularly for more severe cases. Over the last 5 years, our institution has selectively used this method for more complex cases. The purpose of this article is to evaluate the differences between these 2 treatment methods in terms of avascular necrosis (AVN) rate, reoperation rate, and complication rate. Eighty-eight hips that were surgically treated for SCFE between July 2004 and June 2012 met our inclusion criteria. The in situ fixation group included 71 hips, whereas 17 hips were anatomically reduced with the Mod. Dunn procedure. Loder classification, severity, acuity, complication rate, and reoperation rate were determined for the 2 cohorts. The χ analysis was performed to evaluate the relationship between the treatment method and outcome. As expected, stable slips did well with in situ pinning with no cases of AVN, even in more severe slips. Ten stable slips were treated with the Mod. Dunn approach and 2 (20%) developed AVN. Unstable slips were more difficult to treat with 3 of the 7 hips stabilized in situ developing AVN (43%). Two of the 7 unstable slips treated by the Mod. Dunn procedure developed AVN (29%). The other outcomes studied (reoperation rate and complication rate) were not significantly related to the surgical treatment method (P = 0.732 and 0.261, respectively). In situ pinning remains a safe and predictable method for treatment of stable SCFE with no AVN noted, even in severe slips. Attempts to anatomically reduce stable slips led to severe AVN in 20% of cases, thus this treatment approach should be considered with caution. Treatment of unstable slips remains problematic with high AVN rates noted whether treated by in situ fixation or capital realignment (Mod. Dunn). Level III retrospective comparative study.

Anatomical considerations in adult femoral neck fractures: How anatomy influences the treatment issues?

Femoral neck fractures in physiologically young adults are relatively uncommon. The reported incidence of avascular necrosis and nonunion rates remain relatively high despite the advancement in understanding and surgical management. Understanding the normal femoral neck anatomy and its relationship to presenting fracture pathology in young adults could help to lessen reported high complication rates to provide better clinical outcomes.

Acute, unstable, slipped capital femoral epiphysis: is there a role for in situ fixation?

Slipped capital femoral epiphysis, a common disorder in adolescents, may be increasing in incidence in North America because of the obesity epidemic. In most cases, the slip is mild and can be treated with in situ fixation. Even in more severe cases of a stable slip, in situ fixation remains a widely accepted choice. When the slip is acute and unstable, treatment remains controversial. We reviewed the orthopaedic literature and our personal experience in managing acute, unstable slipped capital femoral epiphysis. The reported range of avascular necrosis (AVN) is high and the literature shows no clear recommendations for the best treatment choice. Treatment choices include: in situ stabilization with possible later corrective osteotomy, formal manipulative closed reduction plus screw fixation, partial reduction through an open approach with the hip joint decompressed (Parsch method), and anatomic reduction by the modified Dunn method. Review of the literature and our experience suggests a high AVN rate in acute unstable slips no matter what treatment method is selected. Most North American reports suggest an AVN rate with in situ screw fixation ranging from 20% to 50%. The method described by Parsch, which includes an urgent, open capsulotomy, joint decompression, and gentle partial reduction, shows a low AVN rate as reported from his institution (<10%). The AVN rate reported for anatomic reduction (modified Dunn procedure) performed through an open surgical hip dislocation was initially quite low, but after being restudied in North American centers appears to be about 25%. Safe treatment of an acute unstable slip remains problematic. The literature suggests that these patients should be treated urgently; however, simple in situ stabilization results in a high AVN rate. A likely safer modification is to open the hip anteriorly to decompress the joint and to stabilize after partial reduction as described by Parsch. The modified Dunn method is becoming more widely used, but results in North American centers cite a significant AVN rate.