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Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy
Orthop Clin N Am 35 (2004) 335 – 343
Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy Alexandros E. Beris, MDa,b,*, Alexander H. Payatakes, MDb, Vassilios K. Kostopoulos, MDc, Anastasios V. Korompilias, MDa,b, Alexandros N. Mavrodontidis, MDb, Marios D. Vekris, MDa,b, Vassilios A. Kontogeorgakos, MDb, Panayotis N. Soucacos, MDd b
a School of Medicine, University of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece Department of Orthopaedic Surgery, University Hospital of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece c Department of Orthopaedic Surgery, NNA Naval Hospital of Athens, 70 Deinokratous Street, Athens, 11 521, Greece d Department of Orthopaedic Surgery, School of Medicine, University of Athens, 2 Nikis Street, Athens, Greece
It is well known that non-union and osteonecrosis of the femoral head frequently complicate intracapsular femoral neck fractures, hence the terms ‘‘unsolved fracture’’ coined by Speed [1], and ‘‘unsolvable fracture’’ later used by Garden [2]. These complications are especially common in young patients, where high-energy trauma is usually involved, leading to increased displacement and shearing forces [3 – 5]. Treatment with reduction and internal fixation in this patient population is associated with a 0 to 59% rate of non-union and a 1% to 86% rate of osteonecrosis [3 – 9]. Although hip arthroplasty provides an acceptable and reliable solution for the aged population, an attempt to salvage the femoral head is warranted in patients younger than 50 years [8,10,11]. A multitude of surgical techniques have been used to deal with the difficult and severe clinical problem of the complicated femoral neck fracture in an attempt to avoid or delay hip replacement. Reduction and internal fixation has been reported to give satisfactory results in selected patients [12]. Several osteotomies have been described, aiming to improve the
* Corresponding author. School of Medicine, University of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece. E-mail address: [email protected] (A.E. Beris).
biomechanics at the non-union site and promote healing by converting shearing into compression [12 – 15]. A variety of procedures have addressed the biologic factor with use of nonvascularized bone grafts, muscle pedicle vascularized bone grafts, pedicled vascularized bone grafts, and free vascularized fibular grafts [16 – 25]. The results reported in the literature with use of the existing techniques have been variable. This article describes the surgical technique and evaluates the results of a new procedure, which consists of subtrochanteric valgus osteotomy, internal fixation, and free vascularized fibular grafting. This combination of pre-existing techniques addresses both the biomechanics and biologic environment of the non-union site while revascularizing the femoral head.
Patients and methods During a period of 3 years (1997 – 1999), five patients (four men and one woman) with non-union of traumatic femoral neck fractures and concomitant osteonecrosis of the femoral head were treated at the University of Ioannina Department of Orthopaedic Surgery with a combination of subtrochanteric valgus osteotomy, internal fixation, and free vascularized fibular grafting. The same procedure was performed on two additional patients who were excluded
0030-5898/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ocl.2004.02.008
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from the present study. The first of these was a 26-year-old man who received a nonvascularized fibular graft because of an anatomic variation (absence of the posterior tibial vessels). The second case was a 22-year-old woman with a pathologic femoral neck fracture secondary to a large aneurysmal bone cyst of the femoral head and neck. The patients included in the study had a mean age of 26.6 years (range, 16 – 37 years). The mechanism of injury was a motor vehicle accident in all five cases. The femoral neck fracture was subcapital in two patients, transcervical fracture in another two, and a basilar neck fracture in one case. All patients had received initial treatment at other centers, which consisted of early open reduction and internal fixation with cannulated screws in three cases, Steinmann pins in one case, and a sliding compression screw in one case. The mean delay between the injury and reoperation was 10.6 months (range, 6 – 16 months). At the time of referral to the authors’ department, all patients presented non-union with various degrees of absorption of the femoral neck. Osteonecrosis of the
femoral head at various stages was also present in all cases (stage II according to the Steinberg classification in two cases, stage III in two cases, and stage IV in one case). Additional bone scanning or MRI scanning was performed in three cases. All patients had significant hip pain and were able to ambulate only with the assistance of crutches.
Operative technique The patients were positioned supine on a fracture table. Two surgical teams were present in every procedure. A Watson-Jones approach of the hip was used in all cases. The ascending branch of the lateral femoral circumflex vessels was identified, prepared, and protected to avoid trauma during later maneuvers. At this point, hardware from the initial procedure, present in three cases, was removed. The origin of the vastus lateralis was reflected to expose the base of the greater trochanter.
Fig. 1. (A) Initial treatment of 16-year-old male with a basilar neck fracture using four Steinmann pins. (B) 12 months later: nonunion, partial absorption of femoral neck, and stage III osteonecrosis. (C) Postoperative radiograph following subtrochanteric valgus osteotomy and free vascularized fibular grafting. (D, E) 4.5 and 9 months postoperatively: satisfactory union. (F) 51 months postoperatively: no progression of osteonecrosis and excellent clinical outcome.
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Closed reduction of the fracture was performed under image intensification. The femoral head was temporarily fixed in a reduced position with two Kirschner wires. A subtrochanteric valgus osteotomy according to the principles described by Pauwels [26] was then performed. The amount of valgus angulation given varied from 20° to 30°. The osteotomy was fixed in its altered position with a 120° to 150° blade plate. The blade was positioned in the inferior portion of the femoral neck to provide adequate space for the subsequent insertion of the fibular graft. The temporary Kirschner wires were then removed, and a femoral tunnel was prepared for reception of the fibular graft. The drilling of the tunnel was followed by de´bridement of the necrotic bone in the femoral head. Autologous cancellous bone graft acquired during the drilling was placed in the femoral head subchondrally. The ipsilateral fibula was harvested by the second surgical team through a lateral approach. The posterior tibial vessels were routinely recognized before the vascular pedicle of the fibular graft was divided.
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The necessity of this practice was proven in a case previously mentioned, in which the posterior tibial vessels were absent. In such a case, the surgeon should consider use of the fibula as a nonvascular graft or use of the contralateral fibula. Division of the vascular pedicle was performed only after the femoral tunnel had been prepared, thus reducing graft ischemia time. The fibular graft was then placed in the femoral tunnel and stabilized with a titanium Kirschner wire to allow for the possibility of future evaluation with MRI scanning after hardware removal. Vascular anastomoses between the vascular pedicle of the graft and the ascending branch were then performed with microsurgical technique. Additional stabilization was provided in two cases with the insertion of a supplementary cancellous screw. Patients were mobilized on the second or third postoperative day. They remained non – weight bearing for 2 months and were allowed only partial weight bearing for an additional 6 to 9 months. All patients were followed with clinical and radiologic evaluation.
Fig. 2. (A) Initial treatment of 20-year-old man with a transcervical neck fracture using two cannulated cancellous screws. (B, C) 6 and 9 months later: non-union, varus deformity, and early stage IV osteonecrosis. (D) Postoperative radiograph following subtrochanteric valgus osteotomy and free vascularized fibular grafting. (E) 6 months postoperatively: satisfactory progress of healing. (F) 54 months postoperatively, following hardware removal: hip salvage and satisfactory clinical outcome despite early arthritic changes.
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Results The mean operative time was 7.2 hours (range, 6.3 – 9.0 hours). Blood loss was not significant, and no patient required a transfusion of more than 1 unit of homologous blood. There were no intraoperative or postoperative complications. Patients were available for follow-up for a mean period of 65.2 months (range, 51 – 74 months). Osseous union was achieved in all five patients after a mean period of 5.6 months (range, 4 – 8 months). No adjunctive procedures were necessary to achieve union. There were no cases of hardware migration. Progression of osteonecrosis was arrested in three cases (Fig. 1). One patient with stage III osteonecrosis progressed to stage IV. The patient with preoperative early stage IV osteonecrosis showed radiologic signs of early arthritis; however, hip movement remains relatively painless (Fig. 2). All hips were therefore salvaged until the most recent follow-up. Two patients underwent a second operation for hardware removal, 26 and 57 months, respectively, after the osteotomy and grafting procedure. The achievement of union was associated with a significant decrease in hip joint pain and an improvement of range of motion. At the most recent evaluation, all patients reported minimal to mild hip pain and were able to walk a considerable distance and climb stairs with little or no support despite femoral head collapse in two patients and radiologic evidence of early arthritis in one of these. Range of motion was nearly normal in three cases and satisfactory in the remaining two. The mean Harris hip score at last follow-up was 88.8 (range, 77 – 97), as compared with a mean score of 61.4 preoperatively. No significant morbidity was associated with the donor site in any of the patients. In the patient who received a nonvascularized fibular graft, union was also achieved after a period of 8 months, with no progression of the osteonecrosis. The result in the patient with the pathologic fracture was excellent as well. Union was achieved within 6 months, with filling out of the cystic space and preservation of the femoral head.
Discussion Because of anatomy of the blood supply to the femoral head and contributing biomechanical factors, femoral neck fractures are associated with high complication rates and present a challenge to the orthopedic surgeon. These complications are especially common in patients younger than 50 years old,
with whom every attempt should be made to avoid or delay hip arthroplasty [8,10,11]. This age group, however, presents the highest rates of non-union and osteonecrosis, because the high-energy trauma involved usually leads to significant displacement and a relatively vertical fracture plane [3 – 5]. Non-union and osteonecrosis after femoral neck fractures The rates reported in the literature for development of non-union and osteonecrosis in young patients with femoral neck fractures vary widely. Protzman and Burkhalter [3] reported rates as high as 59% for non-union and 86% for osteonecrosis in a study of a military population. Significantly lower rates have been reported in other studies. Swiontkowski et al [4] treated 27 patients under 50 years old as vascular emergencies with immediate reduction, internal fixation with compression, and capsulotomy. They reported no non-unions and only 20% osteonecrosis, which, however, caused severe symptoms in most cases. Tooke and Favero [6] treated 32 patients under 50 years old with a similar protocol and reported 3% non-union and 19% osteonecrosis, which reached 5.5% and 33%, respectively, when dealing with significantly displaced fractures. Again, most of the osteonecrosis cases recognized were severe and led to arthroplasty. Gautam et al [7] reported a 4% non-union rate and only a 12% rate of evident osteonecrosis after treating 25 young patients (15 – 50 years old) with use of three cancellous screws. Most studies report femoral neck complication rates somewhere between these extremes, usually in the 20% to 40% range [8,9]. The rates of non-union and osteonecrosis have been associated with the time lapse between injury and primary surgery, with most authors indicating a cut-off period of 6 hours as being critical [27,28]. Bonnaire et al [29] identified prognostic factors for non-union and osteonecrosis. Specifically, the rate of non-union was most closely associated with the type of implant used and related complications. Development of femoral head osteonecrosis was associated with the time lapse between injury and primary surgery, the presence of primary dislocation (Garden types III, IV), the type of implant used, and duration of follow-up. Forced reduction maneuvers have also been implicated in the development of osteonecrosis [30]. Regarding the level of injury, some authors report increased rates of non-union and osteonecrosis in subcapital fractures [9,31], but others have found no such correlation [32]. The use of the compression screw has successfully reduced the rate of non-union;
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however, its influence on the rate of osteonecrosis remains a matter of debate [28,29]. Gill et al [33] have proposed a simple and reliable method for intraoperative assessment of femoral head vascularity with the use of a small drill, finding a significant correlation between lack of bleeding after drilling and subsequent development of osteonecrosis. Early MRI performed with a special technique has also been reported as reliable [34]. The development of pseudarthrosic fibrous tissue is itself related with a higher probability of femoral head osteonecrosis [17,35]. Management of non-union and osteonecrosis of femoral neck fractures A review of the literature reveals several studies regarding the management of young patients with femoral neck fractures complicated with non-union or osteonecrosis. A multitude of procedures have been described, ranging from simple reduction and internal fixation to osteotomy to bone grafting, which address either the biomechanical or the biologic factors involved (Fig. 3). Simple reduction and internal fixation has been described as a viable solution in selected patients with femoral neck non-union. Wu et al [12] reported treatment of 11 patients; all non-unions healed after a mean period of 4.6 months, and no osteonecrosis or other complications occurred during a minimum follow-up of 2 years. All patients, however, were
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selected for this procedure after bone scanning had revealed absence of avascular necrosis of the femoral head. Osteonecrosis was present in all five patients in the authors’ series. Furthermore, Wu describes femoral neck shortening as a result of the telescoping effect as a possible complication of this technique. This effect could lead to the development of significant discrepancy in leg length. In 1935 Pauwels [26] described treatment of femoral neck fractures with an abduction intertrochanteric osteotomy, which aims to convert shearing forces at the fracture site into compression. Several authors have reported use of this technique to treat patients with non-union of the femoral neck, especially in the presence of varus deformity. Marti et al [13] treated 50 patients less than 70 years of age with non-union of a femoral neck fracture with a modified Pauwels valgus (abduction) intertrochanteric osteotomy. They reported an 86% union rate. Twenty-two of the patients had radiographic signs of osteonecrosis at the time of the osteotomy. Progression leading to hip arthroplasty was noted in 14% of these patients, and postoperative appearance of osteonecrosis was noted in an additional four patients. An overall 86% hip salvage rate was achieved for a mean follow-up period of 7.1 years. They concluded that for patients under 70 years of age with a non-united fracture of the femoral neck, Pauwels osteotomy may lead to good results, even in the presence of femoral head osteonecrosis, provided there is no serious
Fig. 3. Overview of procedures available for management of young patients with femoral neck non-union and femoral head osteonecrosis.
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collapse. Ballmer et al [14,15] reported a 75% union rate after treating 20 patients with delayed union or non-union of the femoral neck with valgus osteotomy. The presence of osteonecrosis was found to affect clinical outcome, and only a small necrotic area was considered compatible with the procedure. Walcher and Wiesinger [36] stated that radiographic signs of osteonecrosis should be considered a contraindication for osteotomy. Valgus osteotomy has the added advantage of allowing correction of significant leg length discrepancy. Wu et al [12], in treating patients with non-union by reduction and fixation, considered leg shortening of more than 1.5 cm an indication for an additional subtrochanteric valgus osteotomy. Osteonecrosis developed in 2 of the 21 patients in this group. Gerundini et al [37] reported that a valgus osteotomy causes significant distortion of proximal femoral alignment. This distortion could lead to technical difficulties if hip salvage is not achieved and arthroplasty becomes necessary. Valgus osteotomies have also been reported to consist an additional assault to the femoral head blood supply [26]. The subtrochanteric osteotomy used in the authors’ study may avoid such damage. Other osteotomy techniques used in the treatment of idiopathic femoral head osteonecrosis are based on reducing loading forces on segmental necrotic lesions. Posttraumatic osteonecrosis, however, tends to have a more diffuse presentation. Procedures attempting to revascularize the femoral head have been used in the management of patients with posttraumatic osteonecrosis or for primary surgery in patients with a high probability of avascular necrosis. These procedures include nonvascularized bone grafting, muscle-pedicle bone grafting, pedicled vascularized bone grafting, and free vascularized fibular grafting. As early as 1940, Henderson [16] reported the use of a nonvascularized fibular graft for treatment of femoral neck non-union, leading to a 69% union rate. Bonfiglio and Voke [17] reported their experience in treating 77 patients with non-union and avascular necrosis of the femoral head with a Phemister tibial cortical bone graft. Although a 94.5% union rate was achieved, progression of osteonecrosis permitted a satisfactory clinical outcome in only 79% of patients. Nagi et al [18] treated 40 patients with neglected femoral neck fractures with a combination of open reduction, internal fixation with cancellous screw, and a nonvascularized fibular graft serving as a biologic nail. Avascular necrosis was evident in only 8 of these patients preoperatively. They reported union in 95% of cases, accompanied, however, with a high complication rate. Severe osteonecrosis pro-
gression leading to collapse of the femoral head occurred in 12.5% of patients. The hip joint was penetrated in 22.5% of cases (by the screws in 15% and by the fibular graft in the remaining 7.5%). The fibular graft fractured in 10% of patients, indicating insufficient stability and the inferiority of an avascular graft. Osteonecrosis was present in all cases in the authors’ study. Clinical outcome was satisfactory in all cases, and no failure of the implants or fibular grafts was noted. The poor results reported with use of avascular grafts led to the use of vascularized grafts. Meyers et al [19] described the use of a vascularized muscle pedicle bone graft (based on the quadratus femoris) in the treatment of 32 patients with femoral neck nonunion. A union rate of 72% was reported. Baksi et al [20] reported use of a muscle pedicle bone graft for treatment of 56 patients with non-union, neck absorption, and evident avascular necrosis in 34 cases. Their procedure consisted of non-union site takedown, femoral head decompression, internal fixation, and introduction of the muscle pedicle bone graft. They reported satisfactory union in 75% of patients, which reached 82%, if delayed union was included. Femoral head collapse occurred in 6% of the patients with osteonecrosis. Mechanical failure was noted in 16% of cases. Union was achieved in 3 cases with an adjunctive osteotomy, an indication that vascularized bone grafts and osteotomy, used in combination in the authors’ study, may play complementary roles in this clinical situation. The finding that blood supply of muscle pedicle bone grafts is unreliable led to the use of vascularized pedicled bone grafts. Leung [21,22] described use of a pedicled bone graft from the iliac crest in treatment of 15 patients with femoral neck fractures. Of these, only 2 had non-union, 2 had delayed union, and the rest were neglected fractures. None of the patients had evident osteonecrosis preoperatively. The bone graft was placed with press-fit technique in a trough that traversed the fracture site. Union was achieved in all 15 patients. A similar technique, with the addition of screw fixation of the graft, was used by Hou et al [23] to treat five patients with neglected fractures. Of these, only two patients had non-union, and bone scanning revealed no osteonecrosis. Union was achieved in all five patients within 5 months. This procedure provides the advantages of a vascularized bone graft without requiring microsurgical anastomoses. The results of these studies, although satisfactory, cannot be directly compared with the authors’, because they mainly concern primary treatment of neglected fractures, without the complication of avascular necrosis. Schwetlick et al [24], however,
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reported excellent results using a pedicled iliac crest bone graft on six patients with non-union and osteonecrosis. Union was achieved in all cases, and no progression of the osteonecrosis was noted. In 2002 Jackson and Learmonth [38] proposed a treatment algorithm for non-union of femoral neck fractures. Hip arthroplasty was considered indicated in patients over 60 years of age or, if osteonecrosis is present, over 50 years. Younger patients without evidence of avascular necrosis should be treated with osteotomy or refixation, if anatomy had been preserved. A pedicled vascularized bone graft was indicated if avascular necrosis was present. No reports had yet been published of use of free vascularized bone grafts for the treatment of femoral neck nonunions and posttraumatic femoral head osteonecrosis. Later, LeCroy et al [25] published the first report of use of free vascularized fibular grafts in this patient group. They treated 22 consecutive patients with femoral neck non-union and femoral head osteonecrosis after failed internal fixation. Non-union site takedown and correction of neck shaft angle were achieved during reaming and coring of the femoral neck in preparation for the fibular graft. Knowles pins or cannulated cancellous screws provided additional fixation in all cases. They reported satisfactory results, with union being achieved in 91% of cases (20 out of 22) after a mean period of 9.3 months. The remaining two consolidated after a second procedure involving pedicled vascularized grafting. Although osteonecrosis progressed in 59% of patients (13 out of 22), they reported a hip salvage rate of 91% (20 out of 22 patients) throughout a mean follow-up period of 84.7 months. Intra-articular hardware migration requiring reoperation occurred in 18% of cases (4 patients). This study most closely relates to the authors’ own study, in terms of patient population characteristics, presence of osteonecrosis in all patients, and therapeutic interventions. The reported results are comparable to the authors’ results, although the additional valgus osteotomy performed in the authors’ series seems to have reduced the mean time to union. No hardware migration was noted in the authors’ study, indicating increased stability with use of the blade plate. Another common finding in the two studies is the possibility for a satisfactory subjective result despite significant progression of the osteonecrosis. The authors know of no other report in the literature of use of a combined free vascularized fibular grafting and valgus osteotomy. This procedure extends operative time and requires meticulous technique and accuracy during the osteotomy as well as microsurgical expertise. It is therefore probably best
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reserved for patients with a combination of non-union and avascular necrosis. It constitutes a logical approach to this difficult clinical situation, which is complicated by both biomechanical and biologic factors. The efficiency of valgus osteotomy in altering biomechanics at the fracture and non-union site has been well documented [26]. The vascularized fibula, placed subchondrally, provides structural support to the articular surface. Revascularization of the femoral head and bone healing are promoted by trabecular bone formation and by vascular sprouting from the pedicle vessels [39]. Although this series consists of a small number of patients, osteonecrosis of various stages was present preoperatively in every case, unlike most reported series. The follow-up period of 65.2 months is also substantial, permitting significant conclusions. The results compare favorably to those reported in other studies despite the confounding factor of osteonecrosis. An interesting finding was the possibility of a satisfactory subjective result and functional outcome even though progression of the osteonecrosis was evident in two cases. Other authors have reported similar findings [6,13,25,40]. No hardware migration occurred, indicating that the blade plate combined with the fibular graft provides significant stability. No conclusions can be drawn concerning potential complication of hip arthroplasty as a result of the subtrochanteric osteotomy. Hip salvage has so far been achieved in all cases, and no hip arthroplasty has yet been performed on such a patient in our department.
Summary Although the authors recognize that this combined procedure is demanding in expertise, microsurgical technique, and operative time, they believe it provides the logical solution to the complex problem of the young patient with femoral neck non-union and avascular necrosis of the femoral head. It addresses both the biomechanical and the biologic aspects of this situation and has so far yielded promising results. They believe that use of this technique in selected patients, far from being a two-stage arthroplasty, constitutes another step toward solving the unsolved fracture.
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[39] Malizos KN, Quarles LD, Urbaniak JR. Analysis of failures in femoral heads retrieved after osteonecrosis treated with free vascularized fibular graft. Thirtyeighth Annual Meeting of the Orthopaedic Research Society. Washington, DC, February 17 – 20, 1992. [40] Malizos K, Seaber A, Glisson R, Quarles LD, Rizk W, Urbaniak JR. The potential of vascularized cortical graft in revitalizing necrotic cancellous bone in canines. In: Urbaniak JR, Jones Jr JP, editors. Osteonecrosis—etiology, diagnosis, and treatment. Rosemont (IL): American Academy of Orthopaedic Surgeons; 1997. p. 361 – 71.
Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy Alexandros E. Beris, MDa,b,*, Alexander H. Payatakes, MDb, Vassilios K. Kostopoulos, MDc, Anastasios V. Korompilias, MDa,b, Alexandros N. Mavrodontidis, MDb, Marios D. Vekris, MDa,b, Vassilios A. Kontogeorgakos, MDb, Panayotis N. Soucacos, MDd b
a School of Medicine, University of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece Department of Orthopaedic Surgery, University Hospital of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece c Department of Orthopaedic Surgery, NNA Naval Hospital of Athens, 70 Deinokratous Street, Athens, 11 521, Greece d Department of Orthopaedic Surgery, School of Medicine, University of Athens, 2 Nikis Street, Athens, Greece
It is well known that non-union and osteonecrosis of the femoral head frequently complicate intracapsular femoral neck fractures, hence the terms ‘‘unsolved fracture’’ coined by Speed [1], and ‘‘unsolvable fracture’’ later used by Garden [2]. These complications are especially common in young patients, where high-energy trauma is usually involved, leading to increased displacement and shearing forces [3 – 5]. Treatment with reduction and internal fixation in this patient population is associated with a 0 to 59% rate of non-union and a 1% to 86% rate of osteonecrosis [3 – 9]. Although hip arthroplasty provides an acceptable and reliable solution for the aged population, an attempt to salvage the femoral head is warranted in patients younger than 50 years [8,10,11]. A multitude of surgical techniques have been used to deal with the difficult and severe clinical problem of the complicated femoral neck fracture in an attempt to avoid or delay hip replacement. Reduction and internal fixation has been reported to give satisfactory results in selected patients [12]. Several osteotomies have been described, aiming to improve the
* Corresponding author. School of Medicine, University of Ioannina, Panepistemiou Avenue, Ioannina, 45 110, Greece. E-mail address: [email protected] (A.E. Beris).
biomechanics at the non-union site and promote healing by converting shearing into compression [12 – 15]. A variety of procedures have addressed the biologic factor with use of nonvascularized bone grafts, muscle pedicle vascularized bone grafts, pedicled vascularized bone grafts, and free vascularized fibular grafts [16 – 25]. The results reported in the literature with use of the existing techniques have been variable. This article describes the surgical technique and evaluates the results of a new procedure, which consists of subtrochanteric valgus osteotomy, internal fixation, and free vascularized fibular grafting. This combination of pre-existing techniques addresses both the biomechanics and biologic environment of the non-union site while revascularizing the femoral head.
Patients and methods During a period of 3 years (1997 – 1999), five patients (four men and one woman) with non-union of traumatic femoral neck fractures and concomitant osteonecrosis of the femoral head were treated at the University of Ioannina Department of Orthopaedic Surgery with a combination of subtrochanteric valgus osteotomy, internal fixation, and free vascularized fibular grafting. The same procedure was performed on two additional patients who were excluded
0030-5898/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ocl.2004.02.008
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from the present study. The first of these was a 26-year-old man who received a nonvascularized fibular graft because of an anatomic variation (absence of the posterior tibial vessels). The second case was a 22-year-old woman with a pathologic femoral neck fracture secondary to a large aneurysmal bone cyst of the femoral head and neck. The patients included in the study had a mean age of 26.6 years (range, 16 – 37 years). The mechanism of injury was a motor vehicle accident in all five cases. The femoral neck fracture was subcapital in two patients, transcervical fracture in another two, and a basilar neck fracture in one case. All patients had received initial treatment at other centers, which consisted of early open reduction and internal fixation with cannulated screws in three cases, Steinmann pins in one case, and a sliding compression screw in one case. The mean delay between the injury and reoperation was 10.6 months (range, 6 – 16 months). At the time of referral to the authors’ department, all patients presented non-union with various degrees of absorption of the femoral neck. Osteonecrosis of the
femoral head at various stages was also present in all cases (stage II according to the Steinberg classification in two cases, stage III in two cases, and stage IV in one case). Additional bone scanning or MRI scanning was performed in three cases. All patients had significant hip pain and were able to ambulate only with the assistance of crutches.
Operative technique The patients were positioned supine on a fracture table. Two surgical teams were present in every procedure. A Watson-Jones approach of the hip was used in all cases. The ascending branch of the lateral femoral circumflex vessels was identified, prepared, and protected to avoid trauma during later maneuvers. At this point, hardware from the initial procedure, present in three cases, was removed. The origin of the vastus lateralis was reflected to expose the base of the greater trochanter.
Fig. 1. (A) Initial treatment of 16-year-old male with a basilar neck fracture using four Steinmann pins. (B) 12 months later: nonunion, partial absorption of femoral neck, and stage III osteonecrosis. (C) Postoperative radiograph following subtrochanteric valgus osteotomy and free vascularized fibular grafting. (D, E) 4.5 and 9 months postoperatively: satisfactory union. (F) 51 months postoperatively: no progression of osteonecrosis and excellent clinical outcome.
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Closed reduction of the fracture was performed under image intensification. The femoral head was temporarily fixed in a reduced position with two Kirschner wires. A subtrochanteric valgus osteotomy according to the principles described by Pauwels [26] was then performed. The amount of valgus angulation given varied from 20° to 30°. The osteotomy was fixed in its altered position with a 120° to 150° blade plate. The blade was positioned in the inferior portion of the femoral neck to provide adequate space for the subsequent insertion of the fibular graft. The temporary Kirschner wires were then removed, and a femoral tunnel was prepared for reception of the fibular graft. The drilling of the tunnel was followed by de´bridement of the necrotic bone in the femoral head. Autologous cancellous bone graft acquired during the drilling was placed in the femoral head subchondrally. The ipsilateral fibula was harvested by the second surgical team through a lateral approach. The posterior tibial vessels were routinely recognized before the vascular pedicle of the fibular graft was divided.
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The necessity of this practice was proven in a case previously mentioned, in which the posterior tibial vessels were absent. In such a case, the surgeon should consider use of the fibula as a nonvascular graft or use of the contralateral fibula. Division of the vascular pedicle was performed only after the femoral tunnel had been prepared, thus reducing graft ischemia time. The fibular graft was then placed in the femoral tunnel and stabilized with a titanium Kirschner wire to allow for the possibility of future evaluation with MRI scanning after hardware removal. Vascular anastomoses between the vascular pedicle of the graft and the ascending branch were then performed with microsurgical technique. Additional stabilization was provided in two cases with the insertion of a supplementary cancellous screw. Patients were mobilized on the second or third postoperative day. They remained non – weight bearing for 2 months and were allowed only partial weight bearing for an additional 6 to 9 months. All patients were followed with clinical and radiologic evaluation.
Fig. 2. (A) Initial treatment of 20-year-old man with a transcervical neck fracture using two cannulated cancellous screws. (B, C) 6 and 9 months later: non-union, varus deformity, and early stage IV osteonecrosis. (D) Postoperative radiograph following subtrochanteric valgus osteotomy and free vascularized fibular grafting. (E) 6 months postoperatively: satisfactory progress of healing. (F) 54 months postoperatively, following hardware removal: hip salvage and satisfactory clinical outcome despite early arthritic changes.
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Results The mean operative time was 7.2 hours (range, 6.3 – 9.0 hours). Blood loss was not significant, and no patient required a transfusion of more than 1 unit of homologous blood. There were no intraoperative or postoperative complications. Patients were available for follow-up for a mean period of 65.2 months (range, 51 – 74 months). Osseous union was achieved in all five patients after a mean period of 5.6 months (range, 4 – 8 months). No adjunctive procedures were necessary to achieve union. There were no cases of hardware migration. Progression of osteonecrosis was arrested in three cases (Fig. 1). One patient with stage III osteonecrosis progressed to stage IV. The patient with preoperative early stage IV osteonecrosis showed radiologic signs of early arthritis; however, hip movement remains relatively painless (Fig. 2). All hips were therefore salvaged until the most recent follow-up. Two patients underwent a second operation for hardware removal, 26 and 57 months, respectively, after the osteotomy and grafting procedure. The achievement of union was associated with a significant decrease in hip joint pain and an improvement of range of motion. At the most recent evaluation, all patients reported minimal to mild hip pain and were able to walk a considerable distance and climb stairs with little or no support despite femoral head collapse in two patients and radiologic evidence of early arthritis in one of these. Range of motion was nearly normal in three cases and satisfactory in the remaining two. The mean Harris hip score at last follow-up was 88.8 (range, 77 – 97), as compared with a mean score of 61.4 preoperatively. No significant morbidity was associated with the donor site in any of the patients. In the patient who received a nonvascularized fibular graft, union was also achieved after a period of 8 months, with no progression of the osteonecrosis. The result in the patient with the pathologic fracture was excellent as well. Union was achieved within 6 months, with filling out of the cystic space and preservation of the femoral head.
Discussion Because of anatomy of the blood supply to the femoral head and contributing biomechanical factors, femoral neck fractures are associated with high complication rates and present a challenge to the orthopedic surgeon. These complications are especially common in patients younger than 50 years old,
with whom every attempt should be made to avoid or delay hip arthroplasty [8,10,11]. This age group, however, presents the highest rates of non-union and osteonecrosis, because the high-energy trauma involved usually leads to significant displacement and a relatively vertical fracture plane [3 – 5]. Non-union and osteonecrosis after femoral neck fractures The rates reported in the literature for development of non-union and osteonecrosis in young patients with femoral neck fractures vary widely. Protzman and Burkhalter [3] reported rates as high as 59% for non-union and 86% for osteonecrosis in a study of a military population. Significantly lower rates have been reported in other studies. Swiontkowski et al [4] treated 27 patients under 50 years old as vascular emergencies with immediate reduction, internal fixation with compression, and capsulotomy. They reported no non-unions and only 20% osteonecrosis, which, however, caused severe symptoms in most cases. Tooke and Favero [6] treated 32 patients under 50 years old with a similar protocol and reported 3% non-union and 19% osteonecrosis, which reached 5.5% and 33%, respectively, when dealing with significantly displaced fractures. Again, most of the osteonecrosis cases recognized were severe and led to arthroplasty. Gautam et al [7] reported a 4% non-union rate and only a 12% rate of evident osteonecrosis after treating 25 young patients (15 – 50 years old) with use of three cancellous screws. Most studies report femoral neck complication rates somewhere between these extremes, usually in the 20% to 40% range [8,9]. The rates of non-union and osteonecrosis have been associated with the time lapse between injury and primary surgery, with most authors indicating a cut-off period of 6 hours as being critical [27,28]. Bonnaire et al [29] identified prognostic factors for non-union and osteonecrosis. Specifically, the rate of non-union was most closely associated with the type of implant used and related complications. Development of femoral head osteonecrosis was associated with the time lapse between injury and primary surgery, the presence of primary dislocation (Garden types III, IV), the type of implant used, and duration of follow-up. Forced reduction maneuvers have also been implicated in the development of osteonecrosis [30]. Regarding the level of injury, some authors report increased rates of non-union and osteonecrosis in subcapital fractures [9,31], but others have found no such correlation [32]. The use of the compression screw has successfully reduced the rate of non-union;
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however, its influence on the rate of osteonecrosis remains a matter of debate [28,29]. Gill et al [33] have proposed a simple and reliable method for intraoperative assessment of femoral head vascularity with the use of a small drill, finding a significant correlation between lack of bleeding after drilling and subsequent development of osteonecrosis. Early MRI performed with a special technique has also been reported as reliable [34]. The development of pseudarthrosic fibrous tissue is itself related with a higher probability of femoral head osteonecrosis [17,35]. Management of non-union and osteonecrosis of femoral neck fractures A review of the literature reveals several studies regarding the management of young patients with femoral neck fractures complicated with non-union or osteonecrosis. A multitude of procedures have been described, ranging from simple reduction and internal fixation to osteotomy to bone grafting, which address either the biomechanical or the biologic factors involved (Fig. 3). Simple reduction and internal fixation has been described as a viable solution in selected patients with femoral neck non-union. Wu et al [12] reported treatment of 11 patients; all non-unions healed after a mean period of 4.6 months, and no osteonecrosis or other complications occurred during a minimum follow-up of 2 years. All patients, however, were
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selected for this procedure after bone scanning had revealed absence of avascular necrosis of the femoral head. Osteonecrosis was present in all five patients in the authors’ series. Furthermore, Wu describes femoral neck shortening as a result of the telescoping effect as a possible complication of this technique. This effect could lead to the development of significant discrepancy in leg length. In 1935 Pauwels [26] described treatment of femoral neck fractures with an abduction intertrochanteric osteotomy, which aims to convert shearing forces at the fracture site into compression. Several authors have reported use of this technique to treat patients with non-union of the femoral neck, especially in the presence of varus deformity. Marti et al [13] treated 50 patients less than 70 years of age with non-union of a femoral neck fracture with a modified Pauwels valgus (abduction) intertrochanteric osteotomy. They reported an 86% union rate. Twenty-two of the patients had radiographic signs of osteonecrosis at the time of the osteotomy. Progression leading to hip arthroplasty was noted in 14% of these patients, and postoperative appearance of osteonecrosis was noted in an additional four patients. An overall 86% hip salvage rate was achieved for a mean follow-up period of 7.1 years. They concluded that for patients under 70 years of age with a non-united fracture of the femoral neck, Pauwels osteotomy may lead to good results, even in the presence of femoral head osteonecrosis, provided there is no serious
Fig. 3. Overview of procedures available for management of young patients with femoral neck non-union and femoral head osteonecrosis.
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collapse. Ballmer et al [14,15] reported a 75% union rate after treating 20 patients with delayed union or non-union of the femoral neck with valgus osteotomy. The presence of osteonecrosis was found to affect clinical outcome, and only a small necrotic area was considered compatible with the procedure. Walcher and Wiesinger [36] stated that radiographic signs of osteonecrosis should be considered a contraindication for osteotomy. Valgus osteotomy has the added advantage of allowing correction of significant leg length discrepancy. Wu et al [12], in treating patients with non-union by reduction and fixation, considered leg shortening of more than 1.5 cm an indication for an additional subtrochanteric valgus osteotomy. Osteonecrosis developed in 2 of the 21 patients in this group. Gerundini et al [37] reported that a valgus osteotomy causes significant distortion of proximal femoral alignment. This distortion could lead to technical difficulties if hip salvage is not achieved and arthroplasty becomes necessary. Valgus osteotomies have also been reported to consist an additional assault to the femoral head blood supply [26]. The subtrochanteric osteotomy used in the authors’ study may avoid such damage. Other osteotomy techniques used in the treatment of idiopathic femoral head osteonecrosis are based on reducing loading forces on segmental necrotic lesions. Posttraumatic osteonecrosis, however, tends to have a more diffuse presentation. Procedures attempting to revascularize the femoral head have been used in the management of patients with posttraumatic osteonecrosis or for primary surgery in patients with a high probability of avascular necrosis. These procedures include nonvascularized bone grafting, muscle-pedicle bone grafting, pedicled vascularized bone grafting, and free vascularized fibular grafting. As early as 1940, Henderson [16] reported the use of a nonvascularized fibular graft for treatment of femoral neck non-union, leading to a 69% union rate. Bonfiglio and Voke [17] reported their experience in treating 77 patients with non-union and avascular necrosis of the femoral head with a Phemister tibial cortical bone graft. Although a 94.5% union rate was achieved, progression of osteonecrosis permitted a satisfactory clinical outcome in only 79% of patients. Nagi et al [18] treated 40 patients with neglected femoral neck fractures with a combination of open reduction, internal fixation with cancellous screw, and a nonvascularized fibular graft serving as a biologic nail. Avascular necrosis was evident in only 8 of these patients preoperatively. They reported union in 95% of cases, accompanied, however, with a high complication rate. Severe osteonecrosis pro-
gression leading to collapse of the femoral head occurred in 12.5% of patients. The hip joint was penetrated in 22.5% of cases (by the screws in 15% and by the fibular graft in the remaining 7.5%). The fibular graft fractured in 10% of patients, indicating insufficient stability and the inferiority of an avascular graft. Osteonecrosis was present in all cases in the authors’ study. Clinical outcome was satisfactory in all cases, and no failure of the implants or fibular grafts was noted. The poor results reported with use of avascular grafts led to the use of vascularized grafts. Meyers et al [19] described the use of a vascularized muscle pedicle bone graft (based on the quadratus femoris) in the treatment of 32 patients with femoral neck nonunion. A union rate of 72% was reported. Baksi et al [20] reported use of a muscle pedicle bone graft for treatment of 56 patients with non-union, neck absorption, and evident avascular necrosis in 34 cases. Their procedure consisted of non-union site takedown, femoral head decompression, internal fixation, and introduction of the muscle pedicle bone graft. They reported satisfactory union in 75% of patients, which reached 82%, if delayed union was included. Femoral head collapse occurred in 6% of the patients with osteonecrosis. Mechanical failure was noted in 16% of cases. Union was achieved in 3 cases with an adjunctive osteotomy, an indication that vascularized bone grafts and osteotomy, used in combination in the authors’ study, may play complementary roles in this clinical situation. The finding that blood supply of muscle pedicle bone grafts is unreliable led to the use of vascularized pedicled bone grafts. Leung [21,22] described use of a pedicled bone graft from the iliac crest in treatment of 15 patients with femoral neck fractures. Of these, only 2 had non-union, 2 had delayed union, and the rest were neglected fractures. None of the patients had evident osteonecrosis preoperatively. The bone graft was placed with press-fit technique in a trough that traversed the fracture site. Union was achieved in all 15 patients. A similar technique, with the addition of screw fixation of the graft, was used by Hou et al [23] to treat five patients with neglected fractures. Of these, only two patients had non-union, and bone scanning revealed no osteonecrosis. Union was achieved in all five patients within 5 months. This procedure provides the advantages of a vascularized bone graft without requiring microsurgical anastomoses. The results of these studies, although satisfactory, cannot be directly compared with the authors’, because they mainly concern primary treatment of neglected fractures, without the complication of avascular necrosis. Schwetlick et al [24], however,
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reported excellent results using a pedicled iliac crest bone graft on six patients with non-union and osteonecrosis. Union was achieved in all cases, and no progression of the osteonecrosis was noted. In 2002 Jackson and Learmonth [38] proposed a treatment algorithm for non-union of femoral neck fractures. Hip arthroplasty was considered indicated in patients over 60 years of age or, if osteonecrosis is present, over 50 years. Younger patients without evidence of avascular necrosis should be treated with osteotomy or refixation, if anatomy had been preserved. A pedicled vascularized bone graft was indicated if avascular necrosis was present. No reports had yet been published of use of free vascularized bone grafts for the treatment of femoral neck nonunions and posttraumatic femoral head osteonecrosis. Later, LeCroy et al [25] published the first report of use of free vascularized fibular grafts in this patient group. They treated 22 consecutive patients with femoral neck non-union and femoral head osteonecrosis after failed internal fixation. Non-union site takedown and correction of neck shaft angle were achieved during reaming and coring of the femoral neck in preparation for the fibular graft. Knowles pins or cannulated cancellous screws provided additional fixation in all cases. They reported satisfactory results, with union being achieved in 91% of cases (20 out of 22) after a mean period of 9.3 months. The remaining two consolidated after a second procedure involving pedicled vascularized grafting. Although osteonecrosis progressed in 59% of patients (13 out of 22), they reported a hip salvage rate of 91% (20 out of 22 patients) throughout a mean follow-up period of 84.7 months. Intra-articular hardware migration requiring reoperation occurred in 18% of cases (4 patients). This study most closely relates to the authors’ own study, in terms of patient population characteristics, presence of osteonecrosis in all patients, and therapeutic interventions. The reported results are comparable to the authors’ results, although the additional valgus osteotomy performed in the authors’ series seems to have reduced the mean time to union. No hardware migration was noted in the authors’ study, indicating increased stability with use of the blade plate. Another common finding in the two studies is the possibility for a satisfactory subjective result despite significant progression of the osteonecrosis. The authors know of no other report in the literature of use of a combined free vascularized fibular grafting and valgus osteotomy. This procedure extends operative time and requires meticulous technique and accuracy during the osteotomy as well as microsurgical expertise. It is therefore probably best
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reserved for patients with a combination of non-union and avascular necrosis. It constitutes a logical approach to this difficult clinical situation, which is complicated by both biomechanical and biologic factors. The efficiency of valgus osteotomy in altering biomechanics at the fracture and non-union site has been well documented [26]. The vascularized fibula, placed subchondrally, provides structural support to the articular surface. Revascularization of the femoral head and bone healing are promoted by trabecular bone formation and by vascular sprouting from the pedicle vessels [39]. Although this series consists of a small number of patients, osteonecrosis of various stages was present preoperatively in every case, unlike most reported series. The follow-up period of 65.2 months is also substantial, permitting significant conclusions. The results compare favorably to those reported in other studies despite the confounding factor of osteonecrosis. An interesting finding was the possibility of a satisfactory subjective result and functional outcome even though progression of the osteonecrosis was evident in two cases. Other authors have reported similar findings [6,13,25,40]. No hardware migration occurred, indicating that the blade plate combined with the fibular graft provides significant stability. No conclusions can be drawn concerning potential complication of hip arthroplasty as a result of the subtrochanteric osteotomy. Hip salvage has so far been achieved in all cases, and no hip arthroplasty has yet been performed on such a patient in our department.
Summary Although the authors recognize that this combined procedure is demanding in expertise, microsurgical technique, and operative time, they believe it provides the logical solution to the complex problem of the young patient with femoral neck non-union and avascular necrosis of the femoral head. It addresses both the biomechanical and the biologic aspects of this situation and has so far yielded promising results. They believe that use of this technique in selected patients, far from being a two-stage arthroplasty, constitutes another step toward solving the unsolved fracture.
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