2-Butoxyethanol Female-Rat Model of Hemolysis and Disseminated Thrombosis: X-Ray Characterization of Osteonecrosis and Growth-Plate Suppression

We recently proposed a chemically induced rat model for human hemolytic disorders associated with thrombosis. The objective of the present investigation was to apply a noninvasive, high-magnification X-ray analysis, the Faxitron radiography system, to characterize the protracted bone damage associated with this 2-butoxyethanol model and to validate it by histopathology. Groups of female Fischer 344 rats were given 0, 250, or 300 mg of 2-butoxyethanol/kg body weight daily for 4 consecutive days. Groups were then sacrificed 2 hours or 26 days after the final treatment. The treated animals displayed a darkened purple-red discoloration on the distal tail. Histopathological evaluation, including phosphotungstic acid-hematoxylin staining of animals sacrificed 2 hours after the final treatment, revealed disseminated thrombosis and infarction in multiple organs, including bones. The Faxitron MX-20 specimen radiography system was used to image selected bones of rats sacrificed 26 days posttreatment. Premature thinning of the growth plate occurred in the calcaneus, lumbar and coccygeal vertebrae, femur, and ilium of the treated animals. Areas of decreased radiographic densities were seen in the diaphysis of the femur of all treated animals. The bones were then examined histologically and showed a range of changes, including loss or damage to growth plates and necrosis of cortical bone. No thrombi were seen in the animals sacrificed at 30 days, but bone and growth plate changes consistent with prior ischemia were noted. The Faxitron proved to be an excellent noninvasive tool that can be used in future studies with this animal model to examine treatment modalities for the chronic effects of human thrombotic disorders.

Avascular necrosis complicating chondral resurfacing techniques

Autologous chondrocyte implantation (ACI) and mosaicplasty have become established operations used to treat full-thickness chondral lesions in the knee and elsewhere. Although complications of both have been documented, there are no previous reports of avascular necrosis (AVN) complicating these procedures. Awareness of AVN as a complication of ACI might have prompted an earlier diagnosis, with possible non-surgical treatment or more minor surgery being possible. At the very least, an appropriate form of management could have been initiated earlier, so shortening the period of disability and suffering for the patient.

Lower-limb MRI in the staging and re-staging of osteonecrosis in paediatric patients affected by acute lymphoblastic leukaemia after therapy

PURPOSE

To assess the diagnostic value of MRI examination in detecting and monitoring osteonecrotic lesions (ON) in childhood acute lymphoblastic leukaemia (ALL) after chemotherapy (CHT) and/or bone marrow transplantation (BMT).

METHODS AND MATERIALS

Seventy-three patients (37 males, mean age 12.4 years old) with ALL after treatment underwent a lower-limb MR examination between November 2006 and March 2012. In 47 there was clinical suspicion of ON, 26 were asymptomatic. Studies were performed with a 1 T and a 1.5 T scanner, acquiring short tau inversion recovery (STIR) and T1-weighted sequences in coronal plane from the hips to the ankles. The average acquisition time was 18 min. Considering baseline and follow-up examinations, the overall number of MRI studies was 195.

RESULTS

Fifty-four of 73 patients showed ON at MRI study, with an overall number of 323 ON (89 involving articular surface, 24 with joint deformity, JD). Twenty-five of 47 symptomatic patients showed subchondral ON lesions, 11 developed JD. Three of 26 asymptomatic patients showed subchondral bone ON at baseline examination but no JD at follow-up. Twenty-two of 28 BMT, 32/45 CHT patients developed ON.

CONCLUSION

Our MRI protocol proved to be feasible in evaluating ON in paediatric patients. Studies should be addressed only to symptomatic patients.

Transphyseal Distal Humerus Fracture

Transphyseal distal humerus fractures typically occur in children younger than 3 years secondary to birth trauma, nonaccidental trauma, or a fall from a small height. Prompt and accurate diagnosis of a transphyseal distal humerus fracture is crucial for a successful outcome. Recognizing that the forearm is not aligned with the humerus on plain radiographs may aid in the diagnosis of a transphyseal distal humerus fracture. Surgical management is most commonly performed with the aid of an arthrogram. Closed reduction and percutaneous pinning techniques similar to those used for supracondylar humerus fractures are employed. Cubitus varus caused by a malunion, osteonecrosis of the medial condyle, or growth arrest is the most common complication encountered in the treatment of transphyseal distal humerus fractures. A corrective lateral closing wedge osteotomy can be performed to restore a nearly normal carrying angle.

Common Errors in the Management of Pediatric Supracondylar Humerus Fractures and Lateral Condyle Fractures

Supracondylar humerus fractures and lateral condyle fractures are the two most common pediatric elbow fractures that require surgical intervention. Although most surgeons are familiar with supracondylar humerus fractures and lateral condyle fractures, these injuries present challenges that may lead to common errors in evaluation and management and, thus, compromise outcomes. It is well agreed upon that nondisplaced supracondylar fractures (Gartland type I) are best managed nonsurgically with cast immobilization. Errors may be made, however, in the treatment of type II fractures because the extent of displacement and instability are difficult to assess. Although some type II fractures are stable after closed reduction, many are not and benefit from closed reduction and percutaneous pinning to prevent late displacement and cubitus varus deformity. Stable fixation must be achieved and errors related to pin placement must be avoided to prevent the failure of type III fractures after closed reduction and percutaneous pinning. Many potential errors and pitfalls also are seen in the management of lateral condyle fractures. Radiographic assessment of displacement can be improved by obtaining an internal oblique view of the elbow. Surgical treatment with closed reduction and percutaneous pinning may be indicated for minimally displaced fractures (2 to 4 mm) that show evidence of increasing displacement over time or demonstrate intra-articular extension on an arthrogram. Displaced fractures are best treated with open reduction and internal fixation. Errors in surgical dissection, fracture reduction, and fixation are common and may result in osteonecrosis, malunion, and nonunion.

Bone disease in post-transplant patients

PURPOSE OF REVIEW

Mineral and bone disorders are common problems in organ transplant recipients. Successful transplantation solves many aspects of abnormal mineral and bone metabolism, but the degree of improvement is frequently incomplete. Posttransplant bone disease can affect long-term outcomes as well as increase the likelihood of fracture. In this article, we reviewed the major posttransplant bone diseases and recent advances in treatment strategies.

RECENT FINDINGS

Pretransplant bone disease and immunosuppressants are important risk factors for posttransplant bone disease. Corticosteroid withdrawal may result in minimal or no protection against fractures, with increased risk for acute rejection. Vitamin D analogue and bisphosphonate are frequently used to prevent and treat posttransplant osteoporosis. Posttransplant hyperparathyroidism increases the risk for all-cause mortality and graft loss, but not major cardiovascular events. Cinacalcet was well tolerated and effectively controlled hypercalcemic hyperparathyroidism; however, it did not improve bone mineral density and discontinuation led to parathyroid hormone rebound. Six-month paricalcitol supplementation reduced parathyroid hormone levels and attenuated bone remodeling and mineral loss in case of posttransplant hyperparathyroidism.

SUMMARY

Posttransplant bone diseases present in various forms, including osteoporosis, hyperparathyroidism, adynamic bone disease, and osteonecrosis. Prophylactic and therapeutic approaches to both pretransplant and posttransplant periods should be considered.

Correlation Between Residual Displacement and Osteonecrosis of the Femoral Head Following Cannulated Screw Fixation of Femoral Neck Fractures

The aim of the study was to introduce a new method for measuring the residual displacement of the femoral head after internal fixation and explore the relationship between residual displacement and osteonecrosis with femoral head, and to evaluate the risk factors associated with osteonecrosis of the femoral head in patients with femoral neck fractures treated by closed reduction and percutaneous cannulated screw fixation.One hundred and fifty patients who sustained intracapsular femoral neck fractures between January 2011 and April 2013 were enrolled in the study. All were treated with closed reduction and percutaneous cannulated screw internal fixation. The residual displacement of the femoral head after surgery was measured by 3-dimensional reconstruction that evaluated the quality of the reduction. Other data that might affect prognosis were also obtained from outpatient follow-up, telephone calls, or case reviews. Multivariate logistic regression analysis was applied to assess the intrinsic relationship between the risk factors and the osteonecrosis of the femoral head.Osteonecrosis of the femoral head occurred in 27 patients (18%). Significant differences were observed regarding the residual displacement of the femoral head and the preoperative Garden classification. Moreover, we found more or less residual displacement of femoral head in all patients with high quality of reduction based on x-ray by the new technique. There was a close relationship between residual displacement and ONFH.There exists limitation to evaluate the quality of reduction by x-ray. Three-dimensional reconstruction and digital measurement, as a new method, is a more accurate method to assess the quality of reduction. Residual displacement of the femoral head and the preoperative Garden classification were risk factors for osteonecrosis of the femoral head. High-quality reduction was necessary to avoid complications.

Post-traumatic osteonecrosis of the proximal humerus

Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.

Avascular Necrosis of Trochlea After Supracondylar Humerus Fractures in Children

Avascular necrosis (AVN) is a rare but important complication after supracondylar humerus fractures. Posttraumatic humerus deformity was first reported in 1948 and sporadically thereafter. AVN deformity has been classified as type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista and a metaphyseal portion). In this article, we present 5 cases of AVN after supracondylar humerus fracture, discuss the importance of late clinical findings, and postulate a mechanism of AVN in nondisplaced fractures. Five cases of AVN after supracondylar humerus fracture were reviewed from the Children's of Alabama database. Four of the 5 patients were female. Four patients sustained a Gartland type III fracture, and 1 patient sustained a nondisplaced Gartland type I fracture. Age at time of injury ranged from 5 years to 10 years. All patients had an asymptomatic clinical period after treatment and re-presented 6 months to 7 years later with elbow pain or loss of motion. All patients were treated symptomatically. AVN of the trochlea has a late clinical presentation. The cause of this complication is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to type A or type B deformity. In nondisplaced fractures, the lateral vessels are interrupted by tamponade because of encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. AVN of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis

BACKGROUND

The risk of post-traumatic humeral head avascular necrosis (AVN), regardless of the treatment, has a high reported incidence. In 2004, Hertel et al. stated that the most relevant predictors of ischemia after intracapsular fracture treated with osteosynthesis are the calcar length, medial hinge integrity and some specific fracture types. Based on Hertel's model, the purpose of this study is to evaluate both its reliability and weaknesses in our series of 267 fractures, assessing how the anatomical configuration of fracture, the quality of reduction and its maintenance were predictive of osteonecrosis development, and so to suggest a treatment choice algorithm.

MATERIALS AND METHODS

A retrospective study, level of evidence IV, was conducted to duly assess the radiographic features of 267 fractures treated from 2004 to 2010 following Hertel's criteria treated with open reduction and internal fixation by angular stability plates and screws. The average age was 65.2 years. The average follow-up was 28.3 ± 17.0 months. The percentage of AVN, the quality and maintenance of reduction obtained during surgery were evaluated.

RESULTS

The AVN incidence was 3.7 %. No significant correlation with gender, age and fracture type was found. At the last follow-up X-ray, only 30 % presented all Hertel's good predictors in the AVN group, 4.7 % in the non-AVN group (p < 0.05). About quality of reduction in the AVN group, it was poor in 50 %; while in the non-AVN group, it was poor in 3.4 % (p < 0.05). Four patients with AVN were symptomatic, and three needed a second surgery.

CONCLUSIONS

Hertel's criteria are important in the surgical planning, but they are not sufficient: an accurate evaluation of the calcar area fracture in three planes is required. All fractures involving calcar area should be studied with CT.

Spontaneous Osteonecrosis of Knee After Arthroscopy Is Not Necessarily Related to the Procedure

Reports in the literature have suggested a causal relationship between knee arthroscopy and spontaneous osteonecrosis of the knee (SONK). We conducted a study to determine if there are imaging characteristics associated with SONK and if there is a relationship between arthroscopy and SONK. In this retrospective review, we compared preoperative and postoperative findings in 11 patients (12 joints) who developed SONK after arthroscopy with findings in 11 age- and sex-matched controls who did not develop SONK after arthroscopy. There were no significant preoperative radiologic differences between the SONK and control groups. All 12 SONK lesions seen on magnetic resonance imaging were in the medial femoral condyle. Six SONK knees developed the lesion after arthroscopy, and 6 had SONK lesions before arthroscopy. Eleven of the 12 SONK knees had a medial meniscal tear, compared with 8 medial meniscal tears and 3 lateral meniscal tears in the control group. Eight SONK knees and 5 control patients had medial meniscal extrusion of more than 3 mm. A causal relationship between knee arthroscopy and SONK is questionable.

Fishtail deformity--a delayed complication of distal humeral fractures in children

BACKGROUND

Concavity in the central portion of the distal humerus is referred to as fishtail deformity. This entity is a rare complication of distal humeral fractures in children.

OBJECTIVE

The purpose of this study is to describe imaging features of post-traumatic fishtail deformity and discuss the pathophysiology.

MATERIALS AND METHODS

We conducted a retrospective analysis of seven cases of fishtail deformity after distal humeral fractures.

RESULTS

Seven children ages 7-14 years (five boys, two girls) presented with elbow pain and history of distal humeral fracture. Four of the seven children had limited range of motion. Five children had prior grade 3 supracondylar fracture treated with closed reduction and percutaneous pinning. One child had a medial condylar fracture and another had a lateral condylar fracture; both had been treated with conservative casting. All children had radiographs, five had CT and three had MRI. All children had a concave central defect in the distal humerus. Other imaging features included joint space narrowing with osteophytes and subchondral cystic changes in four children, synovitis in one, hypertrophy or subluxation of the radial head in three and proximal migration of the ulna in two.

CONCLUSION

Fishtail deformity of the distal humerus is a rare complication of distal humeral fractures in children. This entity is infrequently reported in the radiology literature. Awareness of the classic imaging features can result in earlier diagnosis and appropriate treatment.

Delayed Avascular Necrosis and Fragmentation of the Lunate Following Perilunate Dislocation

Perilunate and perilunate fracture dislocations are high-energy injuries with the wrist loaded in extension, ulnar deviation, and intercarpal supination. The force vector travels from a radial to a ulnar direction and can result in complex carpal instability. The diagnosis is often delayed, which can result in suboptimal outcomes. Nonoperative management can produce inferior results, with patients experiencing pain and weakness. Therefore, early treatment with open reduction and internal fixation is recommended to assess the osteochondral and ligamentous disruption and to achieve anatomic reduction of the carpus. Despite this, these patients can develop radiographic degenerative joint disease, which can be seen in up to 90% of cases. This can be due to difficulty in holding and maintaining carpal reduction. Increased radiodensity of the lunate following these injuries has been observed but is believed to be a transient phenomenon without risk of progression to avascular necrosis. This may be due to the blood supply of the lunate, which has varied patterns of intraosseous and extraosseous vascularity. The authors report a patient who developed avascular necrosis and delayed lunate fragmentation following a May-field Type IV perilunate dislocation. This finding highlights the importance of long-term follow-up with these patients.

Avascular necrosis of bone in childhood cancer patients: a possible role of genetic susceptibility

With the increasing number of paediatric cancer patients and with their prolonged survival, the evidence of a number of serious complications induced by anticancer therapy is rising. Osteonecrosis (ON) of bone is one of these treatment-related effects with a multifactorial pathogenesis. In the past few years, several polymorphisms of candidate genes with possible role in development of this disorder were studied.We summarized potential risk factors leading to increased susceptibility to osteonecrosis of bone development in cancer patients during childhood and to present current knowledge in the field of genetic aspects of this condition (Ref. 86).

The clinical spectrum and pathophysiology of skeletal complications in lysosomal storage disorders

Lysosomal storage disorders affect multiple organs including the skeleton. Disorders with prominent skeletal symptoms are type 1 and 3 Gaucher disease, the mucopolysaccharidoses, the glycoproteinoses and pycnodysostosis. Clinical manifestations range from asymptomatic radiographical evidence of bone pathology to overt bone crises (Gaucher), short stature with typical imaging features known as dysostosis multiplex (MPS), with spine and joint deformities (mucopolysaccharidoses, mucolipidosis), or osteopetrosis with pathological fractures (pynodysostosis). The pathophysiology of skeletal disease is only partially understood and involves direct substrate storage, inflammation and other complex alterations of cartilage and bone metabolism. Current treatments are enzyme replacement therapy, substrate reduction therapy and hematopoietic stem cell transplantation. However, effects of these interventions on skeletal disease manifestations are less well established and outcomes are highly dependent on disease burden at treatment initiation. It is now clear that adjunctive treatments that target skeletal disease are needed and should be part of future research agenda.

[Proximal humerus fractures: clinical assessment and functional outcome in patients with osteonecrosis of the humeral head]

INTRODUCTION

Fractures of the proximal humerus resulting in three or more fragments represent a high risk of necrosis. The former is the second most frequent site of necrosis, only after the femur, due to either traumatic or nontraumatic causes. The former are the most common, with an incidence rate of necrosis of 13-34% in fractures with more than four fragments. The purpose of this study is to assess the functional outcome of patients with a history of fracture of the proximal humerus and osteonecrosis treated conservatively.

MATERIAL AND METHODS

This is a descriptive, retrospective, observational study with a 6-12 month follow-up of patients older than 60 years of age with a diagnosis of fracture of the proximal humerus managed conservatively between January 2004 and November 2009. One hundred and twenty-two patients met the inclusion criteria and 12 were lost to follow-up. Mean age was 71.02 years with a range between 60 and 92 years; 41 males and 69 females. The DASH and CONSTANT scales were applied.

RESULTS

After applying the functional assessment scales and validating the results, the correlation coefficient obtained was 0.80, and it was statistically significant.

CONCLUSION

Conservative treatment should be used only in patients who meet the necessary criteria. Depending on the type of fracture and the patient's characteristics, treatment should always be aimed at stabilization, early mobilization, and early functional recovery. This study found that fractures treated conservatively eventually develop some degree of osteonecrosis of the head, but they have proper function, similar to that of a healthy limb.

Management of osteonecrosis of the jaws induced by radiotherapy in oncological patients: preliminary results

OBJECTIVE

Osteoradionecrosis (ORN) is a bone aseptic necrosis which develops on post-irradiated bone tissue of patients who underwent radiotherapy for head-neck tumors. The mandible presents a higher risk to develop ORN, if compared to the maxillary bone, due to its lower vascularization. The aim of the present study is to clinically assess the regenerative ability by the epithelial and connective tissues, in response to ORN onset.

PATIENTS AND METHODS

Authors have verified the importance of the surgical-pharmacological treatment, as an effective protocol for eliminating the exposed bone sequestration, as well as the teeth eventually damaged by the radiotherapy, assessing that the epithelium can regenerate only on healthy and vital tissues.

RESULTS

The reported patient underwent resection of a portion of the left mandible with an incomplete healing after the surgery. A second curettage was scheduled in order to remove the bands of necrotic tissue and to obtain a clinical remission of symptoms.

CONCLUSIONS

In patients undergoing radiotherapy, the dental surgeon should be able to give an early diagnosis of the dental and maxillofacial related pathologies; he should also detect all the possible infective sources and administer any possible treatment in a short time, before the beginning or the prosecution of radiotherapy.

Osteonecrosis of Interphalangeal Joint of Thumb Two Months after Rattlesnake Bite

This case report details the osteonecrosis of the interphalangeal (IP) joint of the thumb two months after a rattlesnake bite. It describes the clinical presentation, imaging studies, histological review, pathology review, and review of literature. Our patient was a fifty-one year-old male who obtained a poisonous snakebite to the thumb. While in the hospital for acute treatment, a blood blister was debrided. He was seen two weeks after discharge for further debridement of epidermolysis. Patient presented one month later with a hand x-ray demonstrating bony erosions, and a bone scan showing active changes in the IP joint of his right thumb. He was taken to the OR for further debridement and definitive diagnosis. Pathology results confirmed osteonecrosis with negative bone cultures. The clinical presentation, diagnosis, and operative management of osteonecrosis offer a unique challenge, especially in a patient presenting with osteonecrosis from a poisonous snakebite.

Dysbaric osteonecrosis among professional divers: a literature review

AIM

Dysbaric osteonecrosis (DON) continues to be a significant occupational hazard that has significant medical and social consequences for professional divers. This review aims to evaluate the prevalence and risk factors of DON among professional divers and to summarize the scientific knowledge regarding distribution of the lesions as well as disease prognosis and treatment.

METHOD

A literature review using the Medline database.

RESULTS

The prevalence of DON varies between 0 and 70.6% in professional divers, and its prevalence is highest in Turkey, Hawaii, Korea and Japan but is dependent on activity and medical monitoring. The risk of DON is very low for military divers who strictly obey the decompression rules and who undergo periodic medical examination. DON pre- dominately occurs in the proximal part of the femur and humerus. In a majority of cases, DON will progress despite the absence of further dysbaric exposure.

CONCLUSION

The pathophysiology of the disease is incompletely understood and other etiological factors are perhaps being overlooked.

A surgical approach algorithm for transverse posterior wall fractures aids in reduction quality

BACKGROUND

Transverse posterior wall fractures are difficult to treat and historically have been associated with stiffness, posttraumatic arthritis, and pain, which correlate with the reduction. The Kocher-Langenbeck approach is used most often, whereas the extended iliofemoral approach has been reserved for more complex injury patterns. The latter approach has substantially more risks. No data to our knowledge exist on the use of sequential anterior and posterior approaches for this pattern.

QUESTIONS/PURPOSES

The purpose of this study is to evaluate an algorithmic method to determine the choice of surgical approach(es) for transverse posterior wall fractures. The main question is: will this approach-based algorithm allow for adequate reduction and stabilization to union? Our secondary endpoints were Merle d'Aubigne scores, reoperations, and radiographic sequelae including arthritis, avascular necrosis, and heterotopic ossification.

METHODS

A retrospective study was conducted in which patients were drawn from an existing database. The inclusion criterion was transverse posterior wall fractures with adequate imaging treated by one surgeon. All but one patient were treated within 2 weeks of injury. Mean followup was 23 months (range, 3 months to 11 years). Between November 5, 1999, and August 22, 2012, 74 patients were treated with open reduction internal fixation for this injury; nine were excluded as a result of percutaneous treatment or inadequate preoperative imaging. The remaining 65 patients (88%) comprised the study group. All patients were treated by the senior surgeon with an algorithm that consisted of either a Kocher-Langenbeck or sequential approach based on the location, magnitude, and direction of displacement of the ischiopubic segment. Indomethacin was prescribed to all patients for heterotopic ossification prophylaxis for a total of 6 weeks postoperatively. Based on the algorithm, 82% (53 patients) were treated with Kocher-Langenbeck and 18% (12 patients) with the sequential approach. Adequacy of reduction was measured using AP and Judet views of the pelvis; union was determined empirically by pain-free weightbearing and lack of displacement over time. Outcomes were the Merle d'Aubigne score and radiographic findings of avascular necrosis or arthrosis.

RESULTS

The algorithm resulted in 100% reduction within 1 mm on plain radiographs. Initial displacement was greater in the patients undergoing the sequential approach (p=0.01, 7.7 versus 12.4 mm). The average d'Aubigne score was 15.3. Radiographic arthritis scores were 68% excellent/good. Avascular necrosis developed in five patients (8%). Five patients (8%) went on to THA, and four patients (6%) developed superficial or deep infection. Only one patient developed Brooker III heterotopic ossification and this was not symptomatic.

CONCLUSIONS

This algorithm helps guide appropriate selection of the surgical approach and results in accurate reduction with functional and radiographic results that are comparable with existing series while avoiding extended approaches. However, like any operative decision, the choice of approach should not depend entirely on an algorithm; rather, the algorithm is best used as a guide to understand the factors involved in treating these rare and complex injuries and to help make an appropriate choice for an individual patient.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Medical treatment of osteonecrosis of the knee associated with thrombophilia-hypofibrinolysis

In 6 patients with stage II knee osteonecrosis, all 6 with thrombophilia and 4 with concurrent hypofibrinolysis, the authors prospectively determined whether anticoagulation with enoxaparin could prevent collapse and progression to osteoarthritis, ameliorate pain, and restore function. The 6 patients were treated with enoxaparin (40 to 60 mg/d for 3 or more months) as mandated by a US Food and Drug Administration-approved protocol. In post-enoxaparin prospective follow-up, patients were reassessed clinically every 4 to 6 months, and radiographs were obtained every year. The 6 patients followed up at 15.1, 7.5, 3.9, 2.25, 2, and 1 year, respectively. None progressed to joint collapse or severe osteoarthritis. Four became and remained asymptomatic at 2-, 3.9-, 7.5-, and 15.1-year follow-up, respectively. A fifth patient did not progress to collapse or severe osteoarthritis but had residual pain at 2.25-year follow-up. The sixth patient had no symptomatic benefit on enoxaparin but improved on rivaroxaban at 1-year follow-up. Two patients had recurrences of knee pain 1 and 4 years after their initial treatment with enoxaparin. One resolved after a second course of enoxaparin, and the other, with a second recurrence 1 year after the second course, resolved after a third course. Pretreatment, all 6 patients required canes, crutches, or wheelchairs, but after enoxaparin, no patient required them, and walking was unrestricted. Thrombophilia-hypofibrinolysis contributes to the pathogenesis of knee osteonecrosis. Thrombophilic-hypofibrinolytic patients with stage II knee osteonecrosis treated with enoxaparin have had no collapse or progression to severe osteoarthritis, and most have had resolution of pain and restoration of full function. This represents a major improvement compared with the natural history of untreated spontaneous knee osteonecrosis.

Treatment for avascular necrosis of bone in people with sickle cell disease

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 17 March 2014.

SELECTION CRITERIA

Randomised clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomisation eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, relative risk (RR) 0.95 (95% confidence interval (CI) 0.56 to 1.60; vaso-occlusive crises, RR 1.14 (95% CI 0.72 to 1.80; very low quality of evidence); and acute chest syndrome, RR 1.06 (95% CI 0.44 to 2.56; very low quality of evidence)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomised controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

[Second Köhler disease]

Les auteurs rapportent 17 cas de la deuxième maladie de Köhler. Il s'agit de jeunes femmes (13 cas), qui ont consulté pour des douleurs métatarso-phalangiennes unilatérales de type mécanique. La maladie touche la deuxième tête métatarsienne dans 14 cas. Le diagnostic est posé grâce à la radiologie: le stade III est retrouvé dans 11 cas. Nous avons opté pour l'intervention de Gauthier: Ostéotomie de dorsiflexion de la tête métatarsienne par résection cunéiforme à base dorsale de la zone nécrotique. Les suites opératoires sont bonnes et l’évolution est favorable pour nos patients, avec un recul moyen de 3 ans.

Evaluation of bone heating, drill deformation, and drill roughness after implant osteotomy: guided surgery and classic drilling procedure

PURPOSE

This study evaluated and compared bone heating, drill deformation, and drill roughness after several implant osteotomies in the guided surgery technique and the classic drilling procedure.

MATERIALS AND METHODS

The tibias of 20 rabbits were used. The animals were divided into a guided surgery group (GG) and a control group (CG); subgroups were then designated (G0, G1, G2, G3, and G4, corresponding to drills used 0, 10, 20, 30 and 40 times, respectively). Each animal received 10 sequential osteotomies (5 in each tibia) with each technique. Thermal changes were quantified, drill roughness was measured, and the drills were subjected to scanning electron microscopy.

RESULTS

Bone temperature generated by drilling was significantly higher in the GG than in the CG. Drill deformation in the GG and CG increased with drill use, and in the CG a significant difference between G0 and groups G3 and G4 was observed. In the GG, a significant difference between G0 and all other groups was found. For GG versus CG, a significant difference was found in the 40th osteotomy. Drill roughness in both groups was progressive in accordance with increased use, but there was no statistically significant difference between subgroups or between GG and CG overall.

CONCLUSION

During preparation of implant osteotomies, the guided surgery technique generated a higher bone temperature and deformed drills more than the classic drilling procedure. The increase in tissue temperature was directly proportional to the number of times drills were used, but neither technique generated critical necrosis-inducing temperatures. Drill deformation was directly proportional to the number of times the drills were used. The roughness of the drills was directly proportional to the number of reuses in both groups but tended to be higher in the GG group.

A study on dysbaric osteonecrosis in caisson workers

PURPOSE

To study the effects of exposure to compressed air on tunnel workers' health and to investigate the prevalence of dysbaric osteonecrosis (DON) in caisson workers.

METHODS

128 tunnel workers were divided into the exposed group (n = 58) and the control group (n = 70), and their shoulders, hips and knees were examined with X-ray, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

1) 34.5% of the exposed group were diagnosed with DON based on the national diagnostic criteria of decompression sickness. 2) The incidental difference of skeletal cystic changes between the exposed group and the control group was highly statistically significant (p < 0.01). 3) CT and MRI examination could detect early onset of DON lesions, and the cystic changes shown in CT and abnormal signals in MRI were diagnostic indicators in cases.

CONCLUSION

Cystic changes in CT and abnormal signals in MRI are key imaging findings of early DON.

Aseptic necrosis at multiple localisations in a lupus patient with lymphoma

Avascular or aseptic necrosis is a well-defined entity leading to the degradation of cellular elements of the bone. The pathogenesis of osteonecrosis (ON) is still unknown. There are two main types of ON: traumatic or non-traumatic. Several clinical entities could associate with ON, systemic diseases, environmental factors, pregnancy, systemic autoimmune or rheumatic diseases, thrombophilia, corticosteroid therapy, cytotoxic dugs, infections, metabolic and hematologic diseases, etc. Corticosteroids (CS) are still the most frequently used therapeutic options in the early phase and during flares of these diseases. Inflammatory cytokines and antibodies have been described to participate in the pathogenesis of ON. The infiltrative disorders of the bone marrow could also contribute to the development of ON. Hereby, we describe a female patient with NHL followed by SLE in whom ON has developed at least in two localisations. Lupus flare, long-term CS therapy, lymphoma relapse or the presence of antiphospholipid antibodies were excluded. Although the bi-localised ON could be contributed to immunologic factors or trauma, the exact aetiology in this case could not be elucidated.

A case-control study of elective hip surgery among HIV-infected patients: exposure to systemic glucocorticoids significantly increases the risk

OBJECTIVES

This was a cross-sectional study with a nested case-control analysis among a cohort of HIV-infected adults aiming to explore the prevalence of and risk factors for elective hip surgery (total hip arthroplasty and resurfacing).

METHODS

Cases were identified from the out-patient database of HIV-infected adults attending one tertiary hospital service. For each case, five controls from the same database matched by age, gender and ethnicity were identified. From the case notes, information about demographic factors, HIV factors and risk factors for hip surgery attributable to osteoarthritis or avascular necrosis (body mass index, lipids, alcohol, comorbidities and treatment with oral glucocorticoids) was extracted.

RESULTS

Among the cohort of 1900 HIV-infected out-patients, 13 cases (12 male) who had undergone hip surgery [0.7%; 95% confidence interval (CI) 0.3-1.1%] were identified, with a median age of 47 years. Eleven of the 13 cases (85%) were Caucasian and seven of the 13 were in stage 3 of HIV infection. Fewer of the cases were in the asymptomatic stage of infection compared with controls [odds ratio (OR) for stage 2 or 3 infection 4.0; 95% CI 0.8-18.5]. Ever having used oral glucocorticoids was highly significantly associated with elective hip surgery (OR 44.6; 95% CI 5.7-347.7).

CONCLUSIONS

Among this young cohort, the prevalence of elective hip surgery was 0.7%, with the median age at surgery being 47 years. Ever having been exposed to systemic glucocorticoids was highly significantly associated with elective hip surgery, suggesting that the principal mechanism underlying the need for surgery was avascular necrosis. There may be an increased need for elective hip surgery associated with HIV infection.

[Etiologic diagnosis of jaw osteonecrosis, other than bisphosphonate and radiotherapy related osteitis]

Our purpose was to highlight the various etiologies of maxillo-mandibular osteonecrosis, other than radiotherapy and biphosphonate related osteitis that have been abundantly reported. We performed a PubMed search from August 1, 1972 to August 1, 2012 using the following MeSH terms: "osteonecrosis", "bone", "necrosis", "jaw", "maxilla", "mandible", "palate", "oral", "avascular necrosis", NOT "bisphosphonate" NOT "osteoradionecrosis". Most cases of osteonecrosis were iatrogenic. Viral, mycotic, or bacterial infections were less frequent causes. Cocaine abuse, Wegener's granulomatosis, and N/K lymphoma were other etiologies. It is important to identify the various etiologies rapidly to manage this sometimes very mutilating condition adequately.

Sickle cell disease and pulpal necrosis: a review of the literature for the primary care dentist

A case of difficult diagnosis of a patient with sickle cell disease and tooth pain fuelled a literature review by a primary care general dental practitioner. A literature search was conducted to review the relationship between sickle cell disease and pulpal necrosis. The results indicated statistically significant associations of sickle cell disease and tooth pain without any carious or traumatic pathology. It is important for the primary care dentist to be aware of the relationship between sickle cell disease and pulpal necrosis to prevent misdiagnosis and consequently mistreatment.

Osteonecrosis of the jaw in a male osteoporotic patient treated with denosumab

Osteonecrosis of the jaw (ONJ) is a clinical condition associated with long-term exposure to inhibitors of bone resorption, mainly bisphosphonates. Denosumab (DMab) is a human monoclonal antibody of the receptor activator of nuclear factor kappa-B ligand. It prevents osteoclast-mediated bone resorption and is widely prescribed for the management of postmenopausal osteoporosis. Whereas ONJ has already been reported in women treated with DMab, we report for the first time the development of ONJ, following tooth extraction, in a male patient treated for idiopathic osteoporosis with DMab. Due to the constant increase in DMab prescription, for the management of osteoporosis, in both genders, physicians should be made aware of this potential risk.

An update on the recent literature on sickle cell bone disease

PURPOSE OF REVIEW

To summarize the findings of the recent publications on sickle cell bone disease (SBD).

RECENT FINDINGS

Individuals with sickle cell disease (SCD) are living longer and develop progressive organ damage including SBD with age. Recent studies suggest alternative radiological diagnostics such as ultrasound and scintigraphy can detect and differentiate between different forms of SBD. MRI with or without diffusion-weighted sequences remains the gold standard. Case reports of cranio-orofacial SBD highlight the rarity of this presentation. Vitamin D deficiency is highly prevalent at all ages, but may not be an independent risk factor for avascular necrosis (AVN). Gene polymorphisms of the Annexin A gene may predict AVN in SCD. A recent study demonstrated reduced days with pain and improved physical activity quality of life following high-dose vitamin D therapy. The high rates of osteopenia and osteoporosis in SCD support the need for research addressing this rising public health problem. Lastly, results of total hip arthroplasty for AVN in SCD has improved significantly over time with the use of cementless prosthetic material and improved supportive care.

SUMMARY

SBD remains poorly studied. Prospective randomized studies targeting predictors, diagnostics, prevention, and treatment options for SBD are sorely needed.

High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature

Multifocal or multiple osteonecrosis (ON), defined by the involvement of 3 or more anatomic sites, is unusual, being observed in only 3%-10% of patients diagnosed with ON. We report the clinical characteristics of a cohort of 29 patients with multifocal ON from a single center and evaluate the prevalence of associated prothrombotic abnormalities in 26 of these patients. We conducted a retrospective study of all patients diagnosed with multifocal ON evaluated in our institution during the last 20 years. We recorded clinical manifestations and underlying diagnoses. A wide thrombophilic profile was performed, including antithrombin, protein C, protein S, lupus anticoagulant, anticardiolipin antibodies, activated protein C resistance, factor V Leiden, mutation G-20210-A of the prothrombin gene, and factor VIII. Coagulation test results were compared with those in a healthy control group and a group of patients with history of lower-extremity deep venous thrombosis. The mean age of the patients was 49.2 ± 15 years (range, 28-81 yr). The mean number of ON localizations per patient was 5.2 ± 2.3 (range, 3-11). Hips were the most commonly affected joint (82%), followed by knees (58%), shoulders (37%), and ankles (13%). Most patients had an underlying disease process, and 12 of 25 (48%) patients had coagulation test abnormalities. The most common alterations were high factor VIII levels and antiphospholipid antibody (aPL) positivity in 24% and 20% of cases, respectively. These abnormalities were more prevalent in patients with multifocal ON compared with patients in the control groups. Sixty-one percent of patients had a history of corticosteroid treatment. Patients with coagulation abnormalities had a higher number of ON localizations per patient (6.5 ± 2.7 vs. 3.88 ± 0.8; p = 0.002) and a higher prevalence of atypical ON localizations (25% vs. 0%; p = 0.05). In conclusion, in the present cohort of patients with multifocal ON, 48% of the patients had at least 1 prothrombotic factor, especially high levels of factor VIII and aPL. These findings have major implications for the diagnosis and treatment of multifocal ON and clearly indicate the need to perform a thrombophilic profile in these patients.

Histological findings on jaw osteonecrosis associated with bisphosphonates (BONJ) or with radiotherapy (ORN) in humans

OBJECTIVE

To describe the histological features of bone tissue harvested from patients affected by jaw osteonecrosis associated with bisphoshponates (BONJ) or with radiotherapy (ORN), in undecalcified ground sections.

MATERIALS AND METHODS

Sixteen bone tissue samples from 14 patients with BONJ and two patients with ORN were processed in order to obtain both ground, undecalcified sections and decalcified sections. The sections underwent histometric and morphometric analysis.

RESULTS

Bone tissue samples obtained from patients with BONJ or ORN of the jaws shared some histological characteristics. Common histological features included the loss of bone architecture, the absence of a proper Haversian system and proper marrow spaces, the presence of necrotic spots of non-mineralized tissue, areas of empty osteocytic lacunae next to areas of hypercellularity, the presence of resorption pits with rare osteoclast-like cells and the presence of bacteria and of an inflammatory infiltrate. A violet rib of tissue characterized by large resorption pits facing was frequently observed between the mineralized bone and the inflammatory infiltrate.

CONCLUSIONS

The histological features of BONJ and ORN are similar and resemble those of osteomyelitis. Even though it is not clear whether infection is the cause or consequence of bone exposure, inflammatory cells, bacteria or their products may have a massive, direct lytic effect on bone tissue challenged by bisphosphonates.

[Is the Hawkins sign able to predict necrosis in fractures of the neck of the astragalus?]

OBJECTIVE

To assess if the Hawkins sign can predict whether or not astragalus fractures of the neck will develop avascular necrosis. It is also assessed whether the occurrence of this complication is related to the displacement of the fracture, soft tissue injury, or delay in the reduction or surgery. The results were compared with those found in the literature.

MATERIAL AND METHODS

A retrospective study was conducted on 23 talar neck fractures recorded over a a period of thirteen years. The following variables were analysed: displacement of the fracture, soft tissue injury, delay and type of treatment, complications, observation of the Hawkins sign, and functional outcome.

RESULTS

There were 7 type I Hawkins fractures, 11 type II, and 4 type III and 1 type IV. Four cases developed avascular necrosis (2 Hawkins type II and 2 type III). Hawkins sign was observed in 12 cases, of which none developed necrosis. Four cases with negative Hawkins sign developed necrosis. No statistically significant differences were found when comparing the development of avascular necrosis with the displacement of the fracture, soft tissue injury, or delay in treatment. Differences were found when comparing the development of avascular necrosis with the Hawkins sign (P=.03).

CONCLUSION

A positive Hawkins sign rules out that the fractured talus has developed avascular necrosis, but its absence does not confirm it.

An unusual complication of tooth exfoliation and osteonecrosis following herpes zoster infection of trigeminal nerve: a case report and literature review

Osteonecrosis following herpes zoster infection is a rare but severe complication, and clinicians' awareness is important for early detection and management of this condition. A case of herpes zoster of the left maxillary division of the trigeminal nerve is reported in a young female having no concurrent predisposing factors, with accompanying rare complications of alveolar bone necrosis and rapid tooth exfoliation. Acyclovir was used to manage the case effectively. The previously reported similar cases in the literature have been reviewed and the pathophysiology of tooth exfoliation and osteonecrosis by varicella zoster viruses is discussed.

Histologic analysis of postmeniscectomy osteonecrosis

Bone marrow signal changes on magnetic resonance imaging (MRI) after meniscectomy have been reported as evidence of postmeniscectomy osteonecrosis, but this pathology is unclear. We conducted a study to follow-up cases with bone marrow signal changes on MRI after meniscectomy and investigate the pathology of underlying lesions. Of 136 patients with no presurgical evidence of osteonecrosis, 29 had juxta-articular bone marrow signal changes on MRI after arthroscopic meniscectomy and subsequently underwent conservative therapy. In 6 of these 29 patients, clinical symptoms and radiographic changes began deteriorating. Based on the Koshino classification, 4 of the 6 patients had Stage-2 knee osteonecrosis and 2 had Stage-3. Arthroscopic and pathologic examinations were performed. Arthroscopic findings were fibrillation (all 6 cases), fissuring (4), ulceration (2), and eburnation (2). Histologic analysis confirmed subchondral bone fractures in all 6 cases, but osteonecrotic lesions were detected only in 2 cases with obvious radiologic deterioration. Postmeniscectomy osteonecrosis might result from subchondral bone fractures. Fracture healing is worse in patients with comorbidities than in those without it; comorbidities might be a risk factor for osteonecrosis.

Bilateral idiopathic osteonecrosis of the major tubercle of the humerus

Bilateral osteonecrosis of the tuberculum majus has not been reported in the literature. A case of bilateral avascular necrosis of the tuberculum majus is presented associated with smoking and occasional alcohol consumption as risk factors, which was successfully treated with non-operative treatment.

LEVEL OF EVIDENCE

Case report, Level V.

[Lingual mandibular osteonecrosis]

A 47-year-old man was referred to an oral and maxillofacial surgeon by his dentist because ofa painful ulcer with exposed bone at the lingual side of teeth 47 and 48. The lesion was diagnosed as lingual mandibular osteonecrosis. Characteristics of lingual mandibular osteonecrosis are exposed bone in the molar area and sequestration. The disorder can appear spontaneously or following damage to the mucous membrane. Treatment options are surgical smoothening of exposed bone, surgical removal of necrotic bone and awaiting spontaneous sequestration.

Proximal humeral fractures: internal fixation

Fractures of the proximal humerus are common injuries that are increasing in incidence as the population ages. These fractures are often treated nonsurgically; however, surgery is indicated if displacement, concurrent dislocation, or unacceptable alignment is present. Knowledge of the anatomic and physiologic characteristics of the proximal humerus and shoulder joint and familiarity with the available fixation elements will help surgeons make informed and patient-specific decisions regarding treatment. Reduction and internal fixation of proximal humeral fractures has expanding indications in comparison with arthroplasty, in part because of improvements in fixation technology and a better understanding of anatomy and physiology. The outcomes of proximal humeral fractures managed with percutaneous pinning, open reduction and locked-plate fixation, and intramedullary fixation are being actively investigated.

A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration

BACKGROUND

We systematically reviewed etiological factors of Kienböck's disease (osteonecrosis of the lunate) discussed in the literature in order to examine the justification for including Kienböck's disease (KD) in the European Listing of Occupational Diseases.

METHODS

We searched the Ovid/Medline and the Cochrane Library for articles discussing the etiology of osteonecrosis of the lunate published since the first description of KD in 1910 and up until July 2012 in English, French or German. Literature was classified by the level of evidence presented, the etiopathological hypothesis discussed, and the author's conclusion about the role of the etiopathological hypothesis. The causal relationship between KD and hand-arm vibration was elucidated by the Bradford Hill criteria.

RESULTS

A total of 220 references was found. Of the included 152 articles, 140 (92%) reached the evidence level IV (case series). The four most frequently discussed factors were negative ulnar variance (n=72; 47%), primary arterial ischemia of the lunate (n=63; 41%), trauma (n=63; 41%) and hand-arm vibration (n=53; 35%). The quality of the cohort studies on hand-arm vibration did not permit a meta-analysis to evaluate the strength of an association to KD. Evidence for the lack of consistency, plausibility and coherence of the 4 most frequently discussed etiopathologies was found. No evidence was found to support any of the nine Bradford Hill criteria for a causal relationship between KD and hand-arm vibration.

CONCLUSIONS

A systematic review of 220 articles on the etiopathology of KD and the application of the Bradford Hill criteria does not provide sufficient scientific evidence to confirm or refute a causal relationship between KD and hand-arm vibration. This currently suggests that, KD does not comply with the criteria of the International Labour Organization determining occupational diseases. However, research with a higher level of evidence is required to further determine if hand-arm vibration is a risk factor for KD.

Radial inclination and palmar tilt as risk factors for Kienböck's disease

Radial inclination angle (RIA) and palmar tilt (PT) of distal articular surface of radius, are anatomical factors that influence force transmission across the wrist and load transfer to the lunate. The purpose of this study is to evaluate the relationship between these parameters and Kienböck's disease. We measured and compared RIA and PT in standard posteroanterior and lateral wrist x-rays of 55 patients with Kienböck's disease and 60 controls. The mean RIA was 25.5° in Kienböck's disease patients and 23.3° in the control group (P = .002). The mean PT was 11.5° and 9.4° for patients and controls, respectively (P = .005). All of these differences were statistically significant. We concluded that there is an etiological association between higher degrees of RIA and PT with Kienböck's disease.

Non-union and avascular necrosis of delayed reduction and screw fixation in displaced femoral neck fracture in young adults

OBJECTIVE

Management of displaced femoral neck fracture is crucial and vulnerable to develop complications. The present study was performed to evaluate the clinical outcome of delayed reduction with multiple screw fixations in young patients who had displaced femoral neck fracture.

MATERIAL AND METHOD

The authors conducted a retrospective study in young patients, aged less than 50 years old, who underwent delayed fixation for traumatic displaced femoral neck fracture (Garden classification III or IV) at Phetchabun Hospital between 1997 and 2002. Either closed or open reduction was performed to achieve an acceptable alignment and fixed with 2 or 3 cancellous screws. Study factors were age, gender Garden classification, time to reduction, type of reduction, number of screw fixation and Garden alignment index. Non-union and avascular necrosis was assessed by clinical and radiographic findings.

RESULTS

There were 26 eligible patients. The average duration of delayed surgery was 13 days (range 2 to 30 days). Twenty-three patients had completed followed-up at average 28.4 months (range 14-52 months). All patients revealed complete union and independently ambulated within 10-16 months postoperatively. Clinical and radiographic avascular necroses of the femoral head developed in 2 patients (8.7%) at 20 and 24 months after surgery. Three patients who had early fixation failure underwent hemiarthroplasty except one patient refused to re-operate.

CONCLUSION

Within 30-day delayed reduction and screw fixation for the treatment of displaced femoral neck fracture in the young is still good alternative treatment to preserve the femoral head with low rate of avascular necrosis.