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      Treatment of neglected femoral neck fracture

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          Abstract

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

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          Management of femoral neck fractures in young adults

          Femoral neck fractures in young adults are uncommon and often the result of high-energy trauma. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Multiple factors can play a significant role in preventing these devastating complications and contribute to a good outcome. While achieving an anatomic reduction and stable internal fixation are imperative, other treatment variables, such as time to surgery, the role of capsulotomy and the fixation methods remain debatable. Open reduction and internal fixation through a Watson-Jones exposure is the recommended approach. Definitive fixation can be accomplished with three cannulated or noncannulated cancellous screws. Capsulotomy in femoral neck fractures remains a controversial issue and the practice varies by trauma program, region and country. Until there is conclusive data (i.e. prospective and controlled) we recommend performing a capsulotomy. The data available is inconclusive on whether this fracture should be operated emergently, urgently or can wait until the next day. Until there is conclusive data available, we recommend that surgery should be done on an urgent basis. The key factors in treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression and stable internal fixation.
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            Early prediction of femoral head avascular necrosis following neck fracture.

            Femoral neck fracture puts at risk functional prognosis in young patients and can be life-threatening in the elderly. The present study reviews methods of femoral head vascularity assessment following neck fracture, to address the following issues: what is the risk of osteonecrosis? And what, in the light of this risk, is the best-adapted treatment to avoid iterative surgery? Femoral head vascularity depends on retinacular vessels and especially the lateral epiphyseal artery, which contributes from 70 to 80% of the femoral head vascular supply. Fracture causes vascular lesions, which are in turn the prime cause of necrosis. Other factors combine with this: hematoma tamponade effect, reduced joint space and increased pressure due to lower extremity positioning in extension/internal rotation/abduction during surgery. Head deformity is not due to direct cell death but to the repair process originating from the surrounding living bone. In post-traumatic necrosis, proliferation rapidly invades the head, with significant osteogenesis. Pathologic fractures occur at the boundary between the new and dead bone. Many techniques have been reported to help assess residual hemodynamics and risk of necrosis. Some are invasive: superselective angiography, intra-osseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others involve imaging: scintigraphy, conventionnal or dynamic MRI. The future seems to lie with dynamic MRI, which allows a new classification of femoral neck fractures, based on a non-invasive assessment of femoral head vascularity.
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              Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years.

              The incidence of nonunion and osteonecrosis after femoral neck fracture has been well documented. In older patients implant arthroplasty is well established as an acceptable treatment of these problems. However, in the younger population alternatives to implant arthroplasty are favored to preserve the femoral head. Surgical treatments for nonunion of the femoral neck include osteotomy, nonvascularized bone grafting, muscle-pedicle bone grafting, and vascularized bone grafting. The purpose of this study is to examine the results of free vascularized fibular grafting as a treatment of nonunion of the femoral neck in patients younger than fifty years. Twenty-two consecutive patients underwent vascularized bone grafting for nonunion of the femoral neck after failed internal fixation between 1984 and 1998. The mean age of the patients was 28.7 years. There were thirteen male and nine female patients. The mean interval between internal fixation and free vascularized fibular grafting was 18.3 months. The average follow-up to date is 84.7 months (range 29 to 195 months). Twenty of twenty-two nonunions healed. Two patients required an additional procedure to facilitate union; one patient had iliac crest bone grafting at four months postoperatively and another underwent muscle-pedicle grafting at six months postoperatively. The average time to union for all patients was 9.9 months (range 3 to 23 months). Progression of osteonecrosis of the femoral head occurred in thirteen patients. However, successful long-term salvage of the femoral head was achieved in twenty of twenty-two patients, with an average Harris hip score of 78.9. Four patients required hardware removal or exchange for intraarticular migration with no long-term clinical sequelae. Rates of complications, such as nonunion and osteonecrosis, after femoral neck fractures in young patients have been reported to be as high as 86 percent. Treatments such as osteotomy, muscle-pedicle bone grafting, nonvascularized bone grafting, and vascularized bone grafting have reported variable results. Based on the results reported in this study, vascularized fibular bone grafting compares favorably with a high union rate (91 percent initially, 100 percent after secondary procedures) and successful long-term salvage of the femoral head in 91 percent of the patients. Free vascularized fibular bone grafting represents a promising solution for this difficult problem.
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                Author and article information

                Journal
                Indian J Orthop
                Indian J Orthop
                IJOrtho
                Indian Journal of Orthopaedics
                Medknow Publications & Media Pvt Ltd (India )
                0019-5413
                1998-3727
                Jan-Feb 2015
                : 49
                : 1
                : 17-27
                Affiliations
                [1]Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
                Author notes
                Address for correspondence: Prof. AK Jain, Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi - 110 095, India. E-mail: dranilkjain@ 123456gmail.com
                Article
                IJOrtho-49-17
                10.4103/0019-5413.143909
                4292324
                25593354
                91490c64-f3af-4fcf-94fb-6d077eea8b76
                Copyright: © Indian Journal of Orthopaedics

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Symposium-ICL-2014

                Orthopedics
                femoral neck,neglected,nonunion,neglected diseases,fractures ununited
                Orthopedics
                femoral neck, neglected, nonunion, neglected diseases, fractures ununited

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