DSA observation of hemodynamic response of femoral head with femoral neck fracture during traction: a pilot study

Incidence and Risk Factors for Fracture-Related Infection After Peri-Prosthetic Femoral Fractures: A Multicenter Retrospective Study (TRON Group Study)

Background: Fracture-related infection (FRI) sometimes occurs with peri-prosthetic femoral fracture (PPF) treatment. Fracture-related infection often leads to multiple re-operations, possible non-union, a decreased clinical function, and long-term antibiotic treatment. In this multicenter study, we aimed to clarify the incidence of FRI, the causative organisms of wound infection, and the risk factors associated with post-operative infection for PPF. Patients and Methods: Among 197 patients diagnosed with peri-prosthetic femoral fracture who received surgical treatment in 11 institutions (named the TRON group) from 2010 to 2019, 163 patients were included as subjects. Thirty-four patients were excluded because of insufficient follow-up (less than six months) or data loss. We extracted the following risk factors for FRI: gender, body mass index, smoking history, diabetes mellitus, chronic hepatitis, rheumatoid arthritis, dialysis, history of osteoporosis treatment, injury mechanism (high- or low-energy), Vancouver type, and operative information (waiting period for surgery, operation time, amount of blood loss, and surgical procedure). We conducted a logistic regression analysis to investigate the risk factors for FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. Results: Fracture-related infection occurred after surgery for PPF in 12 of 163 patients (7.3%). The most common causative organism was Staphylococcus aureus (n = 7). The univariable analysis showed differences for dialysis (p = 0.001), Vancouver type (p = 0.036), blood loss during surgery (p = 0.001), and operative time (p = 0.001). The multivariable logistic-regression analysis revealed that the patient background factor of dialysis (odds ratio [OR], 22.9; p = 0.0005), and the operative factor of Vancouver type A fracture (OR, 0.039-1.18; p = 0.018-0.19) were risk factors for FRI. Conclusions: The rate of post-operative wound infection in patients with a PPF was 7.3%. Staphylococcus was the most frequent causative organism. The surgeon should pay attention to infection after surgery for patients with Vancouver type A fractures and those undergoing dialysis.

Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions

Background

Antibiotic-impregnated cement-coated plates (ACPs) have been used successfully for temporary internal fixation between stages in the two-stage treatment of infected non-unions. We describe our approach of using an ACP in the staged treatment of a methicillin-resistant Staphylococcus aureus (MRSA)-infected distal femoral non-union below a total hip prosthesis. In addition, we present the results of an in vitro experiment to provide an in-depth insight into the capacity of ACPs in (i) treating residual biofilm and (ii) preventing bacterial recolonisation.

Materials and methods

In the first stage, we used a titanium LISS plate coated with hand-mixed PALACOS with vancomycin (PAL-V) for temporary internal fixation combined with commercially prepared COPAL with gentamicin and vancomycin (COP-GV) to fill the segmental defect. In the second stage, the non-union was treated with double-plate fixation and bone grafting.A Kirby-Bauer agar disc diffusion assay was performed to determine the antimicrobial activity of both ACPs and a drug-release assay to measure antibiotic release over time. A biofilm killing assay was also carried out to determine if the antibiotic released was able to reduce or eradicate biofilm of the patient's MRSA strain.

Results

At one-year follow-up, there was complete bone-bridging across the previous non-union. The patient was pain-free and ambulatory without need for further surgery. Both ACPs with COP-GV and PAL-V exerted an antimicrobial effect against the MRSA strain with peak concentrations of antibiotic released within the first 24 hours. Concentrations released from COP-GV in the first 24 hours in vitro caused a 7.7-fold log reduction of colony-forming units (CFU) in the biofilm. At day 50, both COP-GV and PAL-V still released concentrations of antibiotic above the respective minimal inhibitory concentrations (MIC), likely contributing to the positive clinical outcome.

Conclusion

The use of an ACP provides stability and infection control in the clinical scenario of an infected non-union. This is confirmed in vitro where the release of antibiotics from ACPs is characterised by an early burst followed by a prolonged sustained release above the MIC until 50 days. The burst release from COP-GV reduces CFU in the biofilm and prevents early recolonisation through synergistic activity of the released vancomycin and gentamicin.

Clinical significance

An antibiotic-impregnated cement-coated plate is a useful addition to the surgeon's armamentarium to provide temporary internal fixation without the disadvantages of external fixation and contribute to infection control in an infected non-union.

How to cite this article

Wagner RK, Guarch-Pérez C, van Dam AP, et al. Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions. Strategies Trauma Limb Reconstr 2023;18(2):73-81.

The effect of skin traction on pain relief in patients with isolated intertrochanteric fractures, a randomized clinical trial

BACKGROUND

Hip fractures are common in elderly patients. The surgery is usually delayed due to underlying conditions, and pain control is crucial while the patient is cleared for surgery. In this randomized controlled trial (RCT) study, we hypothesized that the application of skin traction in patients with intertrochanteric fracture does not significantly change the Visual Analogue Score (VAS) of pain.

METHODS

This is a prospective, single institution, parallel randomized controlled trial. Two hundred and twenty-nine patients with isolated intertrochanteric fractures were enrolled in the study. Patients with neurologic issues, drug addiction, scars or swelling, or vascular issues at the site of skin traction application were excluded from the study. Patients were divided into two groups: group A included 97 patients, and group B included 95 patients. Skin traction was applied for group A, while only a soft pillow was put beneath the patients' knees in the other group. The VAS score was measured after the diagnosis, two hours before the operation, and 24 h after the surgery. The morphine dosage administered per day was documented for both groups.

RESULTS

After excluding patients with postoperative delirium, 154 patients (55 males and 99 females) with isolated intertrochanteric fractures (69 right-sided and 85 left-sided), and a mean age of 70 ± 10 remained in the study. There were no significant differences between the two groups regarding age, gender, and mean time from injury to admission (P > .05). The mean VAS score measures and morphine dosage administered per day were not significantly different between the two groups (P > .05). Both groups experienced significant pain relief 24 h postoperatively (P < .001).

CONCLUSION

Pre-operative skin traction application affected neither the patients' VAS scores nor the mean morphine dosage per day in patients with isolated intertrochanteric fractures. Our data does not support the routine application of pre-operative skin traction in patients with intertrochanteric fractures.

TRIAL REGISTRATION

The project was registered in the Iranian Registry of Clinical Trials (registration reference: IRCT20180729040636N3, registration date: 01/07/2020).

LEVEL OF EVIDENCE: 1

Association between Weitbrecht's Retinaculum Injury and Femoral Head Necrosis in Femoral Neck Fractures

Objective

To investigate associations between femoral head necrosis (FHN) and injury to the retinaculum of Weitbrecht in patients with femoral neck fractures who had undergone initial trials of either closed reduction or direct open reduction.

Methods

This prospective observational study included 110 patients with displaced femoral neck fractures admitted to the Sixth People's Hospital Affiliated to Shanghai Jiaotong University and Shanghai Tongji Hospital between January 2008 and May 2017. Among these, 25 patients underwent initial closed reductions, and 85 patients underwent an open reduction directly. Watson‐Jones anterolateral approach was used during the surgery for injury to the retinaculum of Weitbrecht, and FHN was assessed as a surgical outcome. The severity of injury to the retinaculum of Weitbrecht was evaluated using a scoring system developed by our surgical team. Follow‐up was at least 24 months.

Results

The initial closed reduction treatment group had significantly higher total scores of injury to the retinaculum of Weitbrecht (6.24 ± 2.20 vs 4.62 ± 2.12, p = 0.009) compared to the open reduction group. High total scores were significantly associated with initial trials of closed reduction treatment, especially for the broken and released injury to the superior and anterior retinacula (both p = 0.01). Twenty‐six patients experienced FHN postoperatively, with mean onset time of 19.42 ± 3.87 months. FHN was significantly associated with the severity of injury to the retinaculum of Weitbrecht (p < 0.001) at the superior, anterior, and inferior retinacula. FHN was significantly associated with injury to the retinaculum of Weitbrecht in females.

Conclusions

Femoral neck displacement in patients treated initially with closed reduction is associated with subsequent injury to the retinaculum of Weibrecht, which may lead to FHN. Severity of injury to the retinaculum of Weibrecht may be used as a biomarker to evaluate bone necrosis in patients with femoral neck fractures.

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques

Background

Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use.

Methods

A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible.

Results

A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant.

Conclusion

Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted.

Level of evidence

III.

Intraoperative monitoring of femoral head perfusion in adult femoral neck fractures

Objectives:

To validate a novel intraoperative method of quantifying femoral head perfusion in adult patients with femoral neck fractures and to determine whether the lack of a perfusion waveform correlates with the development of osteonecrosis, nonunion, or reoperation.

Design:

Prospective cohort.

Setting:

Level 1 trauma center.

Patients/Participants:

Nineteen patients with 20 acute femoral neck fractures treated with hip-preserving surgical fixation. All patients underwent intraoperative quantification of femoral head perfusion.

Intervention:

Intraoperative quantification of femoral head perfusion pressure and waveform utilizing an intracranial pressure monitor.

Main outcome measurements:

Radiographic union, avascular necrosis, revision surgery.

Results:

Nineteen patients (8 male, 11 female, average age 56 ± 21 years) with 20 femoral neck fractures were enrolled. Eight fractures were stable (Garden 1-2/OTA B1.1–1.3) and 12 were unstable (Garden 3-4/OTAB2.1–3.3). A waveform was present in 12 of 20 cases. The average pressures were systolic 36.8 mm Hg, diastolic 30.8 mm Hg, pulse pressure 6.0 mm Hg. A perfusion waveform was significantly associated with advanced age (P = 0.02) and accompanied by trend toward stable fracture patterns. There were 4 deaths during the 1-year follow-up period (20%), and there were 5 conversions to total hip arthroplasty (25%). There was no significant association between revision surgery or death with the absence of a waveform.

Conclusions:

Our study demonstrated the feasibility of a relatively low cost, minimally invasive, technique to quantify femoral head perfusion. In our limited sample, the absence of perfusion did not correlate with our main outcomes; however, the trend toward correlation with increased fracture displacement was as expected. A larger cohort of patients will be needed to detect a significant difference between those with and without a perfusion waveform with regards to our primary outcomes. Further study is needed to delineate the role such data may play in medical decision making at the time of index surgery.

Level of Evidence:

Prognostic Level II.

Development and validation of a predictive nomogram for postoperative osteonecrosis of the femoral head with cannulated screws fixation

Background

Osteonecrosis of the femoral head (ONFH) remains a major complication of femoral neck fractures. Early interventions require preliminary prediction and detection. In this study, we aimed to evaluate the perioperative variables of postoperative ONFH in femoral neck fracture patients with closed reduction and cannulated screw fixation. We also established and validated an individualized nomogram for the prediction of postoperative ONFH.

Methods

We included 470 patients with ONFH from two hospitals [First Affiliated Hospital of University of Science and Technology of China (n=360) and Southern Branch of the First Affiliated Hospital of the University of Science and Technology of China (n=110)]. We evaluated the prognostic value of multiple perioperative variables using a Cox regression model in the training cohort. We developed a nomogram for the prediction of ONFH using a logistic regression model. We assessed the performance of this nomogram in a validation cohort and evaluated its clinical value.

Results

Of the 470 patients who met the inclusion criteria, 141 (30.0%) developed postoperative ONFH. We found alcohol use [odds ratio (OR), 1.743, 95% confidence interval (CI), 1.042-2.901, P=0.033], cerebrovascular disease (OR, 5.357, 95% CI, 2.318-13.13, P<0.001), interval to surgery (OR, 5.273, 95% CI, 2.724-10.43, P<0.001), Garden classification (OR, 23.17, 95% CI, 6.812-145.3, P<0.001), Garden index (OR, 5.935, 95% CI, 2.670-14.184, P<0.001), interval to partial weight-bearing (OR, 0.053, 95% CI, 0.006-0.296, P=0.002), and six-month Harris hip score (OR, 0.856; 95% CI, 0.792-0.919, P<0.001) were independent predictors of postoperative development of ONFH. Based on these variables, we developed a nomogram that showed good discrimination in both the training [area under the curve (AUC) =0.865] and the validation cohort (AUC =0.877). The favorable performance of this nomogram was also confirmed in the validation cohort.

Conclusions

We developed and validated an easy-to-use nomogram for predicting postoperative ONFH. This nomogram can aid decision-making of intraoperative interventions and postoperative rehabilitation plans for patients, surgeons, and osteo-rehabilitative physicians.

Detection of vascularity of femoral head using sub-millimeter resolution steady-state magnetic resonance angiography-initial experience

OBJECTIVE

The purpose of this study was to use the steady-state (SS) magnetic resonance angiography (MRA) with a sub-millimeter resolution to detect the arteries supplying to the femoral head (FH).

MATERIALS AND METHOD

SS MRA scanning of hips was performed bilaterally in 15 healthy volunteers. A blood pool contrast agent was used. The scanning protocol included a 0.8-mm³ isotropic T1-fast field echo sequence with spectral fat suppression technique. Two highly qualified radiologists independently evaluated the medial circumflex femoral artery (MCFA), the lateral circumflex femoral artery (LCFA), and the three retinacular arteries including superior retinacular artery (SRA), inferior retinacular artery (IRA), and anterior retinacular artery (ARA). The intraosseous branches of the three retinacular arteries were also evaluated. An orthopaedic surgeon was consulted in case of disagreement. Observation by the two radiologists and support from the orthopaedic surgeon served as the end result. Agreement between the two observer radiologists was evaluated.

RESULTS

Interobserver agreement between the two radiologists was found to be substantial to perfect. Of the 30 hips, the LCFA and MCFA were detected in all hips; the SRA and IRA were detected in most hips (100%, 90%), and the ARA was detected in 13 hips (43%). The intraosseous branches of SRA and IRA were detected in 30 and 22 hips (100%, 73%), respectively, while the intraosseous branches of ARA were detected in 11 hips (37%).

CONCLUSION

The main arteries supplying the FH can be detected by the SS MRA, making it a novel method to detect the vascularity of FH.

An antibiotic cement-coated locking plate as a temporary fixation for treatment of infected bone defects: a new method of stabilization

Background

The induced membrane technique has achieved good clinical results in the treatment of infected bone defects, and external fixation is the main method, but it causes inconvenience and complications in patients. In this study, our objective was to investigate the outcomes of using an antibiotic cement-coated locking plate as a temporary internal fixation in the first stage of the surgical induced membrane technique for treating extremities with infected bone defects.

Methods

We retrospectively analysed patients with lower extremity infected bone defects in our department between January 2013 and December 2017. All patients were treated with the induced membrane technique. In the first stage, the defects were stabilized with an antibiotic cement-coated locking plate as a temporary fixation after debridement, and polymethyl methacrylate cement was implanted to induce the formation of a membrane. In the second stage, bone grafting rebuilt the bone defects after infection control, and the temporary fixation was changed to a stronger fixation.

Results

A total of 183 patients were enrolled, with an average follow-up duration of 32.0 (12–66) months. There were 154 males and 29 females with an average age of 42.8 (10–68) years. The infection sites included 81 femurs, 100 tibias and 2 fibulas. After the first stage of treatment (infection control), 16 (8.7%) patients had recurrence of infection. In terms of the incidence of complications, 4 patients had poor wound healing, 2 patients had fixation failure and 1 patient had femoral fracture due to a fall. After the second stage of treatment (bone reconstruction), there were 24 (13.1%) recurrences of infection, with a mean time of 9.9 months (range 0.5 to 36). Among them, 18 patients underwent bone grafting after re-debridement, 6 received permanent placement of antibiotic bone cement after debridement and 2 patients refused further treatment and chose amputation. Bone healing was achieved in 175 (95.9%) patients at the last follow-up, and the average time to bone union was 5.4 (4–12) months.

Conclusions

Antibiotic cement-coated locking plates have good clinical effects in the control of bone infection, but attention must be paid to the possible difficulty of skin coverage when applied in calves.

Treatment of a periprosthetic femur fracture around an antibiotic spacer with revision and an antibiotic plate

Infection following total hip arthroplasty can be a devastating complication, often necessitating a 2-stage surgery with the temporary placement of an antibiotic spacer. Fracture around this spacer is an uncommon complication that presents serious treatment challenges. Our manuscript details the successful surgical treatment of a previously unreported fracture around an antibiotic spacer, treated with revision to a hemiarthroplasty and placement of an antibiotic plate.

Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases

Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives.

Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives.

Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually.

Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.

Micro Perfusion and Quantitative Analysis of the Femoral Head Intraosseous Artery

The present study investigates the feasibility of micro perfusion of femoral head specimens from femoral neck fracture patients by the inferior retinacular arteries and performing intraosseous artery quantitative analysis of the femoral head. Twelve femoral neck fracture patients who had undergone conventional hip replacement surgery were included in this study. Femoral head specimen arteries were first dissected and exposed and then perfused by the inferior retinacular arteries and all the femoral heads underwent micro-CT scanning. After micro-CT scanning, a digital 3-D model was reconstructed to quantify the femoral head intraosseous arteries for comparison with a normal femoral head. The artery length density, artery volume density, and artery length/volume ratio were calculated separately and compared with normal femoral head parameters. Micro-CT scanning displayed the epiphyseal arterial network structure and their fine vascular branches in all 12 femoral neck fractures. Blood was supplied from the inferior retinacular artery to the epiphyseal arterial network then to all the fine blood vessels within the femoral head. No statistical differences were observed in femoral heads' intraosseous artery length densities or volume densities between the normal and femoral neck fracture specimens, while the artery length/volume ratio showed a statistical difference, and the ratio increased from 19 to 46. Micro perfusion of the femoral head by the inferior retinacular arteries is possible and can present the epiphyseal network and their fine arterial branches in pathologic conditions to provide a morphological basis for the study of femoral head disease.

Histological Observation of the Retinacula of Weitbrecht and Its Clinical Significance: A cadaveric study

BACKGROUND

The retinacular arteries provide major supply to the femoral head, their injuries may lead to the femoral head necrosis (FHN) in femoral neck fractures. Although the femoral neck fracture was seriously displaced in some patients, FHN did not occur, which suggests that the blood supply is not fully blocked. This study was aimed to find the association between the structure of the retinacula of Weitbrecht and the mechanism of protecting retinacular arteries from being injured.

MATERIALS AND METHODS

Fourteen formalin-fixed cadaveric specimens (in 28 hips) with no significant vascular disease were observed. The retinacula were cut longitudinally and then cut into three parts: medial, middle, and lateral. These specimens were stained using hematoxylin and eosin and improved Masson Trichrome stain. The microstructure and tightness of the retinacula fixed to the bone and the distribution of vessels were examined under a stereoscope, an optical microscope, and a scanning electron microscope.

RESULTS

The microstructure and compactness in each part of retinacula were different, and the tightness of the fibers of the retinacula fixed to the bone in each part were different. A particular structure which resembled a Sandwich panels was observed, and it may be an effective mechanism of protecting retinacular arteries.

CONCLUSION

The Sandwich panels structure existed generally in the retinacula of Weitbrecht, and this sandwich panelture may play very important role in protecting the retinaculum artery from being injured, which show the importance of protecting the retinacular artery in the treatment of femoral neck fractures.

Identifying Patients Who Will Most Benefit from Single Photon Emission Computerized Tomography and Computerized Tomography After Femoral Neck Fracture

Background

Single photon emission computerized tomography and computerized tomography (SPECT/CT) is useful for assessing blood supply within the femoral head after femoral neck fracture, but its use in all femoral neck fracture patients is not feasible. Therefore, the present study aimed to identify the patients for whom SPECT/CT examination will be most beneficial.

Material/Methods

Sixty-five patients with a unilateral femoral neck fracture who underwent SPECT/CT examination of the hip and were treated via closed reduction and internal fixation with three screws were enrolled between January 2009 and March 2011. A decision tree model (C 5.0) was used to identify the factors that best reflect blood supply and to build a flowchart for identifying patients who would benefit from SPECT/CT.

Results

Fracture type was most strongly associated with the Fracture/Normal (F/N) ratio, which reflects the blood supply to the fractured femoral head. Age and the time interval from injury to examination were also associated with the F/N ratio. SPECT/CT examination is most beneficial for patients with a displaced fracture, especially if they are over 58 years old and the time interval from injury to examination is less than 10 days.

Conclusions

Our results indicate that elderly people with a displaced fracture are most likely to benefit from SPECT/CT examination, which can show the blood supply to the femoral head within a relatively short window of time after the injury.

Review of Lower Extremity Traction in Current Orthopaedic Trauma

Although methods of traction for temporizing and definitive treatment of orthopaedic injuries are described in dated textbooks, current literature and recommendations on the use of skin and skeletal traction in orthopaedic trauma are lacking. Elaborate traction schemas have been described, but few of them have been retained in practice and even fewer have been supported by scientific data. Several options exist for traction modalities that involve the pelvis and lower extremities, including portable traction devices and traction pins.

The Use of Superselective Arteriography in the Evaluation of the Influence of Intracapsular Hip Joint Pressure on the Blood Flow of the Femoral Head

OBJECTIVE

We aimed to analyze the intracapsular pressure of the hip joint following femoral neck fracture and its relationship to the position of the hip or to traction and (using superselective arteriography) to evaluate the blood supply to the femoral head and the influence of traction and hip position on the blood supply.

SUBJECTS AND METHODS

Twenty-six cases of fresh Garden type I-III femoral neck fractures were enrolled. After being placed in the neutral position, in internal rotation or with traction of 3 and 5 kg, respectively, intracapsular manometric changes were measured. Eight cases underwent superselective arteriography of the medial circumflex femoral artery and its branches under the manometric changes of the hip joint capsule.

RESULTS

Twenty-four to 48 h after the injury, the intracapsular pressure was significantly higher on the fractured side than on the normal side. The mean pressure was 28.41 ± 9.339 mm Hg in fully extended hips in the neutral position, 79.92 ± 12.80 mm Hg in internally rotated hips, 51.39 ± 15.41 mm Hg in hips with 3 kg of traction and 64.81 ± 13.56 mm Hg in hips with 5 kg of traction. The arteriographic findings revealed that traction and internal rotation reduced the perfusion of the femoral head at the medial circumflex femoral artery and its branches, and also negatively influenced venous reflux.

CONCLUSION

Traction and internal rotation both caused the intracapsular pressure of the hip joint to rise considerably, which reduced the femoral head perfusion and impeded venous reflux. This could lead to avascular necrosis of the femoral head.

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.

Efficacy evaluation for the treatment of subcapital femoral neck fracture in young adults by capsulotomy reduction and closed reduction

BACKGROUND

Subcapital femoral neck fracture in young adults has many complications, and the incidence is increasing year-by-year. The selection of the proper operation method to avoid them is an ambiguous matter. This study aimed to evaluate the treatment effect of subcapital femoral neck fracture by the capsulotomy and internal fixation with iliac bone grafting or closed reduction and internal fixation in young adults.

METHODS

From March 2003 to February 2010, 65 young patients with subcapital femoral neck fractures were treated, including 39 males and 26 females with average age of 34.5 years (range, 19-50 years); 29 cases of the left side and 36 cases of the right side. They were randomly divided into Group A with 34 cases treated by closed reduction and internal fixation and Group B with 31 cases treated by the capsulotomy and internal fixation with iliac bone grafting. The two groups had no significant differences in sex, age, body mass index and preoperative Harris Hip Score. The observation criteria involved the length of the incision, blood loss, operation time, nonunion rate, avascular necrosis of the femoral head (ANFH) rate and Harris Hip Score.

RESULTS

Four of 65 patients were lost follow-up, and the follow-up rate was 93.8%, the average follow-up time was 38.7 months (range, 33-47 months). In Group A, the incision length was 5.1 ± 2.2 cm, blood loss was 84.0 ± 13.2 ml, and operation time was 52.9 ± 10.2 min. In Group B, the incision length was 15.4 ± 4.6 cm, blood loss was 396.0 ± 21.3 ml, and operation time was 116.5 ± 15.3 min. Nonunion occurred in 8 patients (25.2%) in Group A and 1 patient (3.3%) in Group B. ANFH occurred in 9 patients (29.1%) in Group A and 2 patients (6.7%) in Group B. Postoperative Harris Hip Score was 89.0 ± 5.6 in Group A and 95.0 ± 4.5 in Group B. The above index of two groups was considered statistically significant (P < 0.05).

CONCLUSIONS

Capsulotomy and internal fixation with iliac bone grafting can improve fracture healing, reduce ANFH in young adults. It is a safe and effective operation for subcapital femoral neck fracture.

Analysis of risk factors for femoral head necrosis after internal fixation in femoral neck fractures

Femoral head necrosis is a rare but devastating complication following femoral neck fracture. The reported incidence of avascular necrosis after femoral neck fracture fixation varies widely, and there is no consensus regarding its risk factors. The aim of this study was to analyze the risk factors for femoral head necrosis after internal fixation in femoral neck fracture. This retrospective study included 166 patients with femoral neck fractures treated with surgical reduction and internal fixation at the authors' institution from January 2004 to December 2008. Eight patients died for reasons unrelated to the surgery, and 12 patients were lost to follow-up. The remaining 146 patients (146 fractures) were followed until union or until conversion to total hip arthroplasty. The patients included 61 males and 85 females with an average age of 47.5 years (range, 18-68 years). The authors analyzed the following factors: age, sex, Garden classification, reduction quality, surgical methods, injury-to-surgery interval, preoperative traction, weight-bearing time, and implant removal. All patients were followed for a mean of 52 months (range, 6-90 months). The incidence of femoral head necrosis was 14.4% (21/146). Garden classification (P=.012), reduction quality (P=.008), implant removal (P=.020), and preoperative traction (P=.003) were significantly associated with femoral head necrosis. Patient age (P=.990), sex (P=.287), injury-to-surgery interval (P=.360), weight-bearing time (P=.868), and surgical methods (P=.987) were not significantly associated with femoral head necrosis. In multivariate logistic regression analysis, implant removal was not a significant risk factor for femoral head necrosis development (P=.498). Garden classification, reduction quality, and preoperative traction had a significant effect on femoral head necrosis development.

Osteonecrosis of femoral head occurred after stent placement of femoral artery

We present a case of osteonecrosis of femoral head (ONFH) that occurred after stent angiography of femoral artery for the treatment of arteriosclerosis obliterans (ASO) of left inferior limb in a 76-year-old woman. No case of late collapse of femoral head as a complication of endovascular procedure such as stent placement has been previously documented. We considered that ONFH occurred after detaining stent at a junction of left deep femoral artery for the treatment of the ischemia of left lateral and medial femoral circumflex artery.

Management of femoral neck fractures in the young patient: A critical analysis review

Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.