MANAGEMENT OF FAILED

NECK FEMUR FRACTURE

 PRESENTOR- DR SUMU CHOWDHURY

 MODERATOR- DR ASHWANI SONI
INTRODUCTION
 Neck connects head with shaft and is about
3.7cm long
 Neck makes an angle with the shaft 130+/-7
degree
 Non Union is established when a minimum 9
months has elapsed since injury and
fracture shows no visible signs of healing for
3 months
 Femoral Neck fractures defined non-union
after only 3 months of injury
Fracture Neck of Femur

 Delayed presentation – 48hrs – 3 weeks after

injury
 Neglected fracture – delay > 21 days
 Non–union - > 3 months
 Main complications – AVN (12-86%)
Non union (12-40%)
Blood supply of Neck Femur
 Extra capsular arterial ring located at base of femoral
neck , formed by medial and lateral circumflex femoral
artery, superior and inferior gluteal arteries also contribute.
It gives ascending cervical branches

 Artery of ligamentum teres- derived from obturator and

medial circumflex femoral artery

 Ascending cervical branches- divided into anterior,

posterior, medial and lateral. Lateral group provides most
of the blood supply to neck and head. These arteries form
subsynovial intra articular arterial ring. Once they
penetrate femoral head they are termed as epiphyseal
arteries.
Neck of femur non union
causes
 Absent cambium layer of periosteum
 Synovial fluid washing out fracture
hematoma
 Synovial fluid contains fibrinolysin agents
 Shearing effect of fracture site affecting
vascular ingrowth
 Tamponade effect at fracture site due to
intracapsular nature of fracture
Factors contributing to non
union

 Inaccurate reduction
 Loss of fixation
 Vascular insufficiency
 Posterior comminution
 No treatment
Classification of non union neck
femur fracture
 Sandhu described a classification system for non
union/neglected femoral neck fracture incorporating
changes at various stages.
 Based on changes , he classified the neglected femoral
fracture into 3 types (described as stages)
Stage I
 Fracture surface are
still irregular or
jagged
 The size of the
proximal fragment
is 2.5cm or more
 Gap between
fragments is 1 cm
or less
 Head of the femur
is viable with no
sign of AVN on Xray
or MRI
Stage II
 Fracture surfaces are
smooth and sclerosed
 The size of the
proximal fragment is
2.5cm or more
 The gap between the
fragments is more
than 1 cm but less
than 2.5cm
 The head of femur is
viable
Stage III
 Fracture surfaces
are smoothened
out
 The size of the
proximal fragment
is less than 2.5cm
 The gap between
the fragments is
more than 2.5 cm
 The head of femur
shows signs of AVN
Investigations
 Plain x-rays
 Bone scanning – to differentiate between

AVN and non union

 Tomography or high resolution CT scan-

provides the best assessment (bony

appearance, sclerosis, trabecular
resorption, microfractures, subchondral
collapse)
 Mri – to assess the viability of femoral head
Treatment

 Goal – to achieve painless, mobile and

stable hip
 Depends on –
 age and physical status of patients
 Duration of non – union
 Viability and collapse of the femoral head
 Amount of neck resorption
 Potential limb length inequality
Treatment
 Treatment modality vary both in elderly and
in young adults
 Replacement arthroplasty is the treatment

of choice for elderly patients in non union

neck of femur.
 In young adults efforts are focussed on

preserving the femoral head.

Decision making
 Irrespective of vascularity of head, good reduction and
neck shaft angle maintained-
 If presented within 3 weeks – Fix it
 If presented 3 weeks – 3 months – fixation
+BG/MPBG
 If presented after 3 months with shortening and
varus of the head – osteotomy +/- BG
 If there is a segmental collapse –
Replacement arthroplasty
Arthrodesis
Treatment options for
stage I
 Closed reduction and internal fixation
 Closed reduction and internal fixation with one

screw and double fibular graft or two screws and

one fibular graft
 CR or OR and MPBG based on quadratus femoris

or sartorius or tensor fascia

 Abduction osteotomy and osteosynthesis with

DHS or 135 degree angle blade plate or 120

degree double angle plate
Treatment options for
stage 2
 Open reduction followed by freshening of fracture
surfaces and internal fixation with two screws and
one free fibular graft
 ORIF with multiple screws and muscle pedicle

bone graft
 Valgus osteotomy
Treatment options for
stage 3
 Total hip arthroplasty
 Hemiarthroplasty
 Excision Arthroplasty

In sandhu’s stage I and stage II neglected femoral neck fracture

osteosynthesis with open reduction and bone grafting with MPBG or
valgus osteotomy achieves union in almost 90% cases. However in
stage III with or without AVN,osteosyntheis are poor. So the choice
of treatment is replacement arthroplasty (hemi or total)
Closed/open reduction,internal fixation
and single or double fibular graft

 CR/OR with CCS fixation of the fracture is performed after

freshening fracture surfaces
 Fibula being a cortical bone provides mechanical strength
besides stimulating the union acting as autograft
 Once graft revascularized, the osteoblasts stimulated by
bone morphogenic protein replace the resorbed bone
 Non vascularized fibular graft along with cancellous screws is
technically less demanding and dependable procedure
 Vascularized fibular graft give superior results and consists of
microvascular anastomosis,so technically more demanding
Muscle pedicle bone graft +/- fixation

Meyers (1974)-
 Quadratus Femoris MPBG by posterior approach,

lifted with a bone or periosteum and placed across

fracture site posteriorly
 Anatomical reduction not mandatory
 Neck should not be completely absorbed
 Fixation with screw/wire
 90% union rate , 11% collapse at 2 years
Meyer’s graft
Muscle pedicle bone graft +/- fixation

Bakshi (1983,86,92)
 Tensor fascia lata/sartorius MPBG are used in

lateral or supin position by lateral or anterolateral

approach
 Used gluteus minimus with attached bone block

fixed anteriorly
 Used in proven non union with absorbed neck
 75% good results
Valgus osteotomy
 Valgus osteotomy was refined by Pauwels in
1927
 According to his findings showing that non

union NOF was due to high shear forces that

increased with the vertical orientation of the
fracture
 Goal was to redirect shear forces to

compression forces via angulation

osteotomy and fixation with blade plate
device
Valgus osteotomy
Pauwel’s osteotomy
Potential pitfalls
 Excessive valgus orientation :
 Often the calculated angle to convert a pauwels 3 to
pauwels 1 may be as high as 40-50 degrees
 Removal of large wedge leads to distortion of femoral
anatomy and abduction as well as external rotation
deformity
 Valgus > 30 degrees can compromise the blood supply
and increase the risk of AVN
 Excessive valgus could also make a salvage THR
extremely difficult.
Three in one procedure
In this procedure
 With dynamic hip screw
 Valgus osteotomy at lesser trochanteric level
 Non vascularized fibular graft

This procedure is helpful in Sandhu classification

Type 1 and 2
Head sacrificing
procedures

 Bipolar arthroplasty

 Total hip arthroplasty

In the Elderly
 Replacement Arthroplasty is the treatment
of choice for elderly patients in fracture of
neck femur non-unions
 Total hip replacement is the treatment of

choice in a cooperative independent

individual with a normal life span
 Hemiarthroplasty may be done in a patient

with much less demand and leading a

sedentary lifestyle
THR and
HEMIARTHOPLASTY
Valgus osteotomies and
THA
 The advantages of valgus osteotomy are
manifold and include preserving bone stock
and avoiding total hip arthroplasty (THA) in
young patients
 THA in young patients is associated with

higher complication rates such as prosthesis

loosening and infection , as well as higher
revision rates
Uncemented THR in failed valgus osteotomy

 Entry point care should be taken so as to avoid reaming

a false passage
 While broaching care should be taken to negotitae over
the tracts cut by previous implants where a bridge of
bone tends to form
 An uncemented stem should have a distal fit and extend
distal to previous screw holes
 The trochanteric fragment may remain as a non union
and may have to be seperately reattached to femur
 If the proximal femoral anatomy is grossly altered due to
subtrochanteric osteotomy , a corrective osteotomy may
be required.
Cemented THR in failed valgus osteotomy

 Care should be taken during cementation to

pressurise the screw holes externally, as the
cement can track out and cause
devascularisation of the sandwiched bone
 However they have been shown to have

increased complication rates in terms of

survival and infection rates as compared to
primary THR
Failure after Fixation
 Meta-analysis from 41 studies with 1558
fractures were performed
Results of meta-analysis
Incidence Displaced Undisplace Statistical
fracture d fracture significanc
e
Overall 18% 17% 6.9% No
reoperation
AVN 14.3% 14.7% 6.4% Yes
Non-union 9.3% 10% 5.2% No
Implant 9.7% - - -
failure
Discussion
 Incidence of complications experienced by young
femoral neck fracture patients is relatively high
 In isolated femoral neck fractures , displaced fractures
were associated with a substantially higher incidence of
reoperation, AVN and non union
 Reoperation following internal fixation of isolated femoral
neck fracture occurred in nearly 20% cases and AVN
and nonunion were most common complications that
lead to reoperation.
THANK YOU