Failure of fixation of fracture neck of femur and remedies for management

Sameer Mittal; Alok C Agrawal; Bikram K Kar; Harshal Sakale; Bikas Sahoo; Sandeep K Yadav

doi:10.4103/jodp.JODP_10_18

SYMPOSIUM: FRACTURE NECK OF FEMUR

Year : 2018 | Volume : 1 | Issue : 1 | Page : 29-32

Failure of fixation of fracture neck of femur and remedies for management

Sameer Mittal, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Bikas Sahoo, Sandeep K Yadav
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India

Date of Web Publication

28-Dec-2018

Correspondence Address:
Dr. Alok C Agrawal
HOD, Department of Orthopaedics, AIIMS, Raipur, CG
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.JODP_10_18

Abstract

Failure of fixation is common complication of fracture neck of femur, more common in displaced fractures than in undisplaced fractures. Early diagnosis and treatment of fixation failure is very important for good outcome. Physiological age of patient, status of the hip joint, viability of the femoral head, and presence of occult infection are the factors that should be considered before deciding the suitable salvage procedure. In patients younger than 50 years, preservation of the femoral head is preferred as salvage treatment. Hemiarthroplasty or total hip arthroplasty is the choice of salvage for femoral neck fracture nonunions in physiologically older patients.

Keywords: Failure of fixation, fracture neck of femur, remedies for management

How to cite this article:
Mittal S, Agrawal AC, Kar BK, Sakale H, Sahoo B, Yadav SK. Failure of fixation of fracture neck of femur and remedies for management. J Orthop Dis Traumatol 2018;1:29-32

How to cite this URL:
Mittal S, Agrawal AC, Kar BK, Sakale H, Sahoo B, Yadav SK. Failure of fixation of fracture neck of femur and remedies for management. J Orthop Dis Traumatol [serial online] 2018 [cited 2023 Jun 3];1:29-32. Available from: https://jodt.org/text.asp?2018/1/1/29/248899

Introduction

Fracture neck of femur is treated by mainly two methods. First is osteosynthesis with closed or open reduction and second is by some form of hip arthroplasty. The various methods for internal fixation include multiple cannulated cancellous screw fixation, fixation with dynamic hip screw with derotation screw, and proximal femoral locking compression plate. Fracture fixation is preferred over arthroplasty in young active individuals because it is head-preserving surgery. In fresh undisplaced fractures, closed reduction and internal fixation has very good results but in patients with displaced fractures and delayed presentation, there is often high chances of fixation failure and nonunion.

Fixation failure mainly results from inaccurate reduction [Figure 1], inadequate fixation [Figure 2], vascular insufficiency, and occult infection.^[1] These patients present with pain on weight-bearing, persistent groin or buttock pain, pain on hip movement, and difficulty with ambulation.

Figure 1: Inaccurate reduction of fracture neck of femur

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Figure 2: Inadequate fixation of fracture neck of femur

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Early diagnosis of fixation failure is very important. It is carried out mainly by checking X-rays and regular follow-up. It is seen in plain radiograph as loss of reduction, backing out of screws, gaping or radiolucent zone, or collapse at fracture site. Alho et al.^[2] outlined several radiographic signs in patients who have undergone internal fixation of a femoral neck fracture that predict the need for revision at 3 months: change in fracture position by 10mm, change in screw position by 5%, backing out of the screws by 20mm, and perforation of the femoral head. Bone scintigraphy and computed tomography can be used where plain radiographs are equivocal.

Femoral head viability and occult infection should be assessed before decision-making of any salvage procedure. Femoral head viability is primarily assessed by radiographic criteria described for osteonecrosis in plain radiographs. Magnetic resonance imaging and bone scintigraphy can also be used but despite the presence of small avascular areas in young patients without femoral head collapse, every attempt should be made to preserve the femoral head.

Occult infection should be considered as a potential cause of failed internal fixation of a hip fracture. Therefore, every patient presenting with failed internal fixation should be evaluated with complete blood count with differential count, erythrocyte sedimentation rate, and C-reactive protein level. If infection is confirmed with tissue culture, appropriate antibiotic according to culture sensitivity report should be used postoperatively for 6 weeks.^[3]

Usually, in patients with acute failure of fracture fixation, unacceptable fracture alignment, or established fracture nonunion, revision surgery is considered. In most patients, 3-month observation period is a reasonable time to expect signs of fracture union. In patients with radiographic evidence of progressive but incomplete healing, a longer period of observation may be necessary.^[3] Several factors should be considered before deciding appropriate treatment, including the patient’s age and physical status, femoral head viability, the amount of femoral neck resorption, and the duration of the nonunion. Patients older than 60 years may be more likely to be poorer surgical candidates, and extreme osteoporosis decreases the efficiency of any internal fixation.

In general, several operative options are available for failed fixation of fractures of the femoral neck. These include osteosynthesis with a new internal fixation device, valgus intertrochanteric osteotomy, bone grafting, prosthetic replacement (hemiarthroplasty or total hip arthroplasty), and arthrodesis.

In patients younger than 50 years, preservation of the femoral head is preferred as salvage treatment. This may involve either improving the mechanical environment at the fracture site (i.e., valgus intertrochanteric osteotomies) or improving the biologic environment of the nonunion site by bone grafting (nonvascularized, free vascularized, or muscle pedicle–type grafts).^[4]

Valgus Intertrochanteric Osteotomy

In the treatment of femoral neck nonunions, the displacement osteotomy, made just proximal to the lesser trochanter, was first described by McMurray in 1938.^[5] In 1925, Schanz^[6] published an angulation osteotomy made through or just distal to the lesser trochanter. Later, Pauwel^[7] popularized the concept of valgus intertrochanteric osteotomy. He showed that the resultant force through the center of the hip joint was due to the force of gravity on the body supported by the hip and the muscular force of the abductors. He calculated that this force was directed approximately 16degrees from the vertical plane. He then showed the technique of valgus intertrochanteric osteotomy with resection of a laterally based wedge of bone to reorient the nonunited femoral neck fracture so that its plane is nearly perpendicular to the force across the hip joint. This has several effects, by converting the shearing forces parallel to the nonunion to compressive forces, stabilizing the nonunion and promoting healing, and improving abductor mechanics by restoring femoral length and the abductor lever arm.^[7]

The goal of valgus intertrochanteric osteotomy is to convert vertically oriented fracture to a more horizontal plane. The goal is to obtain fracture angle around 30degree to minimize shear forces at the fracture site, maximize compression forces, and promote union. The desired wedge angle is calculated by subtracting 30degree from fracture angle.^[8] Fracture angle should be measured from a line perpendicular to femoral shaft to minimize the effect of change of leg position.^[9] Appropriate pre-op templating is required to determine appropriate angle fixation device, angle of insertion of the fixation device and desired neck shaft angle nonunion site should be secured with Kirschner wires to prevent rotation and change of angles intraoperatively. Osteotomy site should be marked with Kirschner wires. After the appropriate wedge of lateral cortex is resected, the fixation device is placed in the proximal fragment. It is important to note that if the osteotomy exceeds 20degree of correction, the femoral shaft should be lateralized to offset the creation of excessive valgus forces through the ipsilateral knee. To avoid creating a deformity that would be difficult later to convert to a hip arthroplasty, attention should be paid to maintain the alignment of the bone both proximal and distal to the osteotomy on the lateral view.^[10]

Several published series have shown very good results supporting this technique in the salvage situation for femoral neck nonunions. Marti et al.,^[8] in their series of 50 patients with femoral neck nonunions treated with valgus intertrochanteric osteotomies, reported union in 86% of 50 nonunions treated with intertrochanteric osteotomy alone. The subsequent mean union time was 4 months. Although 44% of patients had radiographic evidence of osteonecrosis (without collapse) at the time of osteotomy, only 14% of these patients showed progressive collapse of the femoral head requiring hip replacement.^[8] Anglen^[9] reported on a series of 13 patients followed up for a mean of 25 months after valgus osteotomy for failed internal fixation of a femoral neck fracture and found that all fractures healed and 85% had good to excellent results. Fifteen percent underwent arthroplasty because of osteonecrosis.^[9]

Bone Grafting

Bone grafting is used in an attempt to improve the biologic environment of the nonunion site. Bone graft can be nonvascularized cancellous bone graft, free vascularized bone graft, or muscle pedicle graft. The most widely studied graft is the quadratus femoris—vascularized pedicle graft—first described by Judet and later modified by Meyers et al.^[11] Its clinical indications include loss of bone stock posteriorly or a well-aligned fracture with low shear angle.^[11] Using free vascularized fibular grafting as a treatment of femoral neck nonunion in patients younger than the age of 50 years, LeCroy et al.^[12] reported their results that 20 of 22 nonunions (91%) healed with an average time to union of approximately 10 months. However, progression of femoral head osteonecrosis occurred in 13 patients. The conclusion was that vascularized fibular bone grafting compared favorably with a high union rate and successful long-term salvage of the femoral head.^[12] There are various other methods, which are described for neglected fractures, fixation failure, and well-aligned nonunions with osteonecrosis, such as fibular autograft and vascularized iliac crest bone graft.^[13],[14]However, the current literature does not support the superiority of any particular technique.^[3]

Hip Arthroplasty

Hip arthroplasty, be it either hemiarthroplasty or total hip arthroplasty, is the choice of salvage for femoral neck fracture nonunions in physiologically older patients. The advantages of hemiarthroplasty are that it is a less-extensive surgical procedure and has a lower risk of instability. If there is significant erosion of the articular cartilage of the acetabulum, either from arthritis or from erosion resulting from hardware penetration, total hip arthroplasty is the preferred choice.

When a total hip arthroplasty is planned for failed fracture neck of femur, several technical difficulties should be kept in mind. Residual bony defect on femoral shaft and proximal femur because of removal of old implant may result in intraoperative fracture during canal preparation. Poor acetabular bone quality because of disuse osteopenia and lack of sclerosed subperiosteal bone as seen in degenerative arthritis result in difficult placement of uncemented femoral component. Acetabular reaming should be carried out carefully to preserve the subchondral bone, avoid forceful acetabular component impaction, and augment component fixation with screws.^[15]

Only a few studies are available about salvage arthroplasty in failed treatment of fracture neck of femur. Franzén et al.^[16] studied the rate of revision in 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures and compared it with that for primary arthroplasty for osteoarthritis. The age- and sex-adjusted risk of prosthetic failure was 2.5 times higher after failure of fixation, but all the excess risks were in patients over 70 years of age. They concluded that internal fixation should be the primary procedure, total hip replacement is a safe secondary procedure when osteosynthesis fails.^[16] Tabsh et al.^[17] studied 53 patients who underwent total hip arthroplasty for complications of proximal femoral fractures in their study and compared with 53 patients from the same data bank matched for age, sex, weight, prosthesis type, and length of follow-up but who had not sustained a proximal femoral fracture before total hip replacement. They found that total hip replacement is a satisfactory salvage procedure for failed fracture treatment despite the increased incidence of operative difficulty and increased incidence of complication.^[17] McKinley and Robinson^[18] reported a matched pair series of 214 patients who required an early salvage total hip arthroplasty with cement following failed reduction and internal fixation of a displaced fracture neck of femur (Group I) and patients who had undergone total hip arthroplasty with cement as the primary procedure for the treatment of such a fracture (Group II). In comparison to the primary arthroplasty group, the salvage arthroplasty group showed more superficial infections (P = 0.05) and a significantly higher dislocation rate (21% vs. 8%).^[18] Mabry et al.^[19] reported in their study on the long-term follow-up of 99 patients with femoral neck non unions treated with Charnley hip arthroplasties between 1970 and 1977. At a mean 12-year follow-up of 84 patients, 12 (14%) had undergone revision arthroplasty. Instability occurred in 9% of patients, half of whom had recurrent dislocation.^[19] It is recommended in literature to use large diameter femoral head and surgical approaches with less dislocation risk. In modern literature, dislocation rate in salvage arthroplasty seems to be lower than the older literature.^[3]

Summary

Salvage of failure of fixation of femoral neck fracture depends on many factors such as patient’s physiologic age, the quality of the remaining proximal bone stock, status of the hip joint, and viability of the femoral head. In younger patients, preservation of the hip joint is preferred with internal fixation, osteotomy, or bone grafting. In most of the older patients, prosthetic replacement, whether hemiarthroplasty or total hip arthroplasty, is the preferred salvage option.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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