TREATMENTT OF NONUNION OF FEMORAL NECK FRACTURE BY VALGUS OSTEOTOMY

1
TREATMENTT OF NONUNION OFFEMORAL NECK
FRACTUREBYVALGUS OSTEOTOMY
Iran University of Medical scienceDr. M.
NorouziAssociated Prof.
2
NONUNION OF FEMORAL NECK FRACTUREIS STILL A BIG
CHALANGE ESPECIALLY INDEVELOPING COUNTRIES
3
- ACCURATE REDUCTION- RIGID INTERNAL
FIXATIONHAVE THE GREATEST INFLUENCE ON UNION
RATE OF FEMORAL NECK FRACTURE
Bames, V.and Donvan K. Ther 67 1987 Rockwood and
Greens 1996
4
THE RATE OF NONUNION IN UNDISPLACEDFEMORAL
NECK FRACTURESWIHCH ARE SECURLY FIXEDIS
RELATIVELY LOW
Bank,H.H Clinic of North America 5 1974
5
THERE IS A HIGH INCIDENCEOF NONUNION OFFEMORAL
NECK FRACTURESAFTER IMPLANT FAILURE
Blount. Wp AAOS instrue. Cours Lect, 9.2, 1952
6
Main causes of nonunion of femoral neck
fractures are

• Inadequate Reduction
• Poor Internal Fixation
• Vascular Insufficiency

Barr , J.S. Clinic Orthop., 92 1973 Rockwood and
Greens
7
THE FRACTURE LINE(Pauwels Angle)has an
important role in the union of femoral neck
fracture
Hafter unfallbleike 45 1953
8
(No Transcript)
9
Increased Pauwels angleIncreased shearing
forcesIncreases risk of nonunion
10
Change of fracture line from vertical to
horizontalby osteotomy will usually result in
healing.
Blount. Wp Mrti RK, J.B. J.S 71-B 1989 Pauwels
F Hafter Unfallbeikd 45 1953
11
Phemister BelievesLACK OF PERIOSTEUM INFEMORAL
NECK DECREASES THE HEALING POTENTIAL AND CREATES
A HIGH RISK OF NONUNION
Phemister, D.B J.B.J.S. 21A 1939
12
SINCE HEALING OF FRACTURE OFFEMORAL NECK IS
INTERAOSSEOUS(Endosteal),THERE IS A MARKED
INCIDENCE OF NONUNION OFFEMORAL NECK IN PATIENT
WITHAVASCULAR NECROSIS
Barnes, R. Brown, J.J Graden R.S. Nicoll F.,
J.B.J.S 5881979
13
BANK NOTED THAT60 OF THE PATIENTS WITH
NONUNION OF FEMORAL NECK HAD COMMINUTION AT THE
FRACTURE SITE,SPICIALLY IN THE POSTERIOR PART
OF THE NECK
J.B.J.S 44A 1962
14
- PATIENTS AGE - POOR MEDICAL CONDITION -
OSTEOPOROSISINCREASE THE RATE OF NONUNION OF
FEMORAL NECK FRACTURE.
Canale S.T. Campbells 1998 Pauwels F
15
TREATMENT DEPENDS ON

• - Age of the patient
• Medical status
• Viability of the femoral head
• Size of the remnant femoral neck
• Osteoporosis
• Duration of the disease
• State of joint space

Canale S.T. Campbells Hammer A,J. J. Orthop.
Trauma 6 1992 Pauwels. F
16
WHEN TO SAVE THEFEMORAL HEAD?
WHEN NOT TO SAVE THE FEMORAL HEAD?
17
IN PATIENTS OVER 60 YEARS OF AGE,WITH
OSTEOPOROSIS AND POOR MEDICAL CONDITIONS,IT IS
BETTER TO PERFORMTOTAL JOINT REPLACEMENT
Coate R.L AND Armour , p Injury 11
1980 Grbhardt J.S et al Clinical Orthop. 1992
18
IN CASE OF INFECTED NONUNION OF FEMORAL
NECK,WHERE IT IS NOT POSSIBLETO DO TOTAL JOINT
REPLACEMENT,IT IS BETTER TO PERFORMRESECTION
ARTHROPLASTY
(Girdlestone Procedure)
Zabihi T Kohanim, M, Amir-Jahed AK J.B.J.S.
55A1993
19
THERE IS NO INDICATION OFARTHRODESIS OF THE HIP
JOINT IN OLD PATIENTS
Cotes.RL Armour,P Injury 1980 Grbhardt Bj.s.
et al Clincal Ortho. 1992
20
PROCEDURE TO SAVE FEMORAL HEAD

• Rigid internal fixation
• with bone graft
• Muscle pedicle graft
• Valgus osteotomy
• with or without bone graft

Chan-Hsiung M.D. Clinic Orthop. No. 206 May
1986 Judet, R Acta Orthop. Scand 321
1962 Judet. R. Tdel, J Lord, G. Roy- Camille, R.
Letournel
21
GOOD CANDIDATE FOR SAVING THE FEMORAL HEAD

• Young patient with
• good medical condition
• No osteoporosis
• Normal joint space

Bank. H.H Chun-Hsiung Huang M.D.
22
OSTEOTOMY FOR NONUNION OF FEMORAL NECK
1. Medial displacement osteotomy (Mc.Murray) at
the level of the trochanter 2. Valgus osteotomy
which is at the level of Intertrochanteric or
Subtrochanter
23
(No Transcript)
24
WE BELIEVE VALGUS OSTEOTOMYWITH OR WITHOUT BONE
GRAFTIS THE BEST METHOD OFTREATING NONUNION
OFFEMORAL NECK
25
IT CONVERTS THE SHEARING FORCE OFA VERTICAL
FRACTUTE LINE TO A TRANSVERS LINEAND THE
COMPRESSION FORCEWILL ENHANCE HEALING
26
ADVANTAGES

• Good chance of success
• Easily performed and fairly stable

DISADVANTAGES

• Predisposing the hip to O.A
• Possible A.V.N

27

• Marti et al
• 88 Union Rate In 50 patients
• JBJS Br. 1989 Nov71(5)782-7.
• Sringari T. et al
• 90 Union Rate In 20 patients
• Injury. 2005 May36(5)630-4.

28
Number of the patients 33Duration of the
follow-up 1990 - 2004
OUR RESULTS

• Age Average 38 years(16 60 y.)
• Sex 19 male 14 female

29
CAUSES OF THE NONUNION

• Implant failure 21
• Osteomalacia 2
• Untreated 10

30
DURATION OF FOLLOW-UP 6 YEARSDURATION OF THE
UNION 5 MONTH (3-8 m)RATE OF UNION In 32
Pts. (96)
31
NECK SHAFT ANGLE
Before operation 109 (78-125) After operation
140 (125-160)
Harris Hip Score
from 31(range 14-38) preoperatively improved to
83(range 59-88) postoperatively
32
A.V.N.
SHORTENING
Before operation 2.5 (0.5 - 4.5) cm Reduced
to 1.0 cm
5 Patients Developed A.V.N (15), Sign of OA
progressed in one ? THA
33
LIMITATION OF MOTION
Improved remarkably
RELIEF OF PAIN
Improved (not to have to use crutches)
34
CONCLUSION

• 1. Valgus osteotomy is an effective method for
  treatment of nonunion of the fmoral neck fracture
  in young patients
• 2. In young patients with resorption of femoral
  neck ? We did femoral neck lengthening just at
  the level of the osteotomy (For improvement of
  ROM and prevention of bone impingement)
• 3. Condylar hip plate is a better option than DHS

35
36 y. Male , Pathologic FX
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
27- year- old F. , Pathologic untreated fx
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
M. 46 y. Neglected fx
46
(No Transcript)
47
M. 23 y. Implant failure
48
M. 28 y. Implant failure
49
(No Transcript)
50
M. 24 y. Implant failure
51
(No Transcript)
52
M. 26 y. nonunion and short neck
53
(No Transcript)
54
M. 43 y. Implant failure
55
M. 34 y. Implant failure
56
M. 34 y. Implant failure
57
M. 16 y. Implant failure, Resorption of femoral
neck
58
(No Transcript)
59
M.23 y.Infected Nonunion
60
(No Transcript)
61
(No Transcript)
62
Mount Damavand
Thank you for your attention
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
(No Transcript)
70
(No Transcript)
71
(No Transcript)