This book is presented by Trauma Society of India and discusses the anatomy, classification, and assessment of fracture patterns and treatment protocols pertaining to this area. It also discusses in detail the management of complications such as nonunion and a vascular necrosis. Read more at http://www.thieme.in/component/virtuemart/1135/127/indian-original/guidelines-in-fracture-management-fracture-of-the-neck-of-the-femur-detail?Itemid=0

1. Chapter 11
Nonunion Femoral Neck Fracture—
Management
S. C. Goel
● Introduction 132
● Clinical Evaluation 132
● Management 133
● Classification 134
● Stage-Wise Treatment 136
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Chapter 11
11 Nonunion Femoral Neck Fracture—Management
fractures more than 3 weeks old.6
Meyers et al7
arbitrarily
classified fracture of the neck of the femur treated more than
30 days after injury as having delayed treatment. Fractures
being operated more than 3 weeks after injury have remained
displaced for a considerable time, resulting in damage to vas-
cular supply of the head and hence are more prone to avas-
cular necrosis (AVN). As the fracture fragments are not in
contact, reparative process does not start and the fracture
ends tend to become smooth with absorption and sclerosis.
Some of the patients have been walking on this fracture, lead-
ing to formation of a pseudarthrosis and cavitation at frac-
tures ends. These fractures cannot be expected to unite by a
closed reduction and internal fixation due to lack of osteo-
genic potential and avascularity. When the fracture neck of
the femur is of more than 3 weeks’ duration, internal fixation
alone has a very high failure rate. Internal fixation has to be
combined with some type of bone graft or osteotomy, par-
ticularly in young patients below the age of 50 years (or 55
years) in whom it is desirable to preserve the joint.8
In developing countries, many patients are treated under
compromised situations, suboptimal operation theater con-
ditions, and improper implants and they report with nonun-
ion. These patients are treated in the same way as neglected
fractures.
██ Clinical Evaluation
Patients with nonunion of femoral neck fracture usually pre-
sent with painful limp. This pain generally appears within
few months after fracture, whereas pain from AVN generally
presents 1 to 2 years after fracture. Neglected femoral neck
fracture presents with shortening, severe external rotation of
the lower extremity, upward displacement of the trochanter,
with or without soft tissue contracture. Head and neck would
have undergone variable degree of absorption.
██ Introduction
Nonunion is the most common complication of fracture neck
of femur. The incidence of nonunion of femoral neck fracture
is up to18.5% for elderly patients and 8% for young patients.1,2
If patient’s age is more or the displacement is significant,
chances of nonunion may increase.3
The best end result after
a femoral neck fracture is the patient’s own healed femoral
neck and head. Much attention has been paid to the problem
of fracture of the neck of the femur in elderly patients, but
few of the published articles make any comment with regard
to the same lesion in younger patients.
Fracture of the neck of the femur has multiple factors,
leading to difficulties in union. Both biological and mechani-
cal parameters contribute to the development of union com-
plications. On the biological side, the lack of cambium layer of
the periosteum of femoral neck and the presence of synovial
fluid at the fracture site inhibit fracture union. Mechanical
parameters include the amount of vertical inclination of the
fracture line, quality of reduction, stability of fixation, and
integrity of the posterior cortex. These mechanical factors
lead to an unstable fracture.
Time interval between injury and operation is an impor-
tant factor in results of treatment of femoral neck fractures.
It is recommended that early anatomical reduction and rigid
internal fixation should be performed preferably on the day
of injury.4,5
Delayed treatment of the femoral neck fractures is
not as simple as those of fresh fracture. In developing coun-
tries, patients tend to visit first the local bone setter. There
are additional problems of transport, communication, lack of
early diagnosis, and so forth, leading to delay in seeking treat-
ment, which makes it more difficult to achieve osteosynthesis.
There is lot of confusion regarding the definition of unu-
nited fracture. Many authors have suggested against closed
reduction and internal fixation of displaced untreated
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Nonunion Femoral Neck Fracture—Management
Plain X-rays are adequate to make a clinical diagnosis and
stage the neglected femoral neck fracture. Radiographic signs
of nonunion9
present at 3 months that indicate femoral neck
fracture nonunion are as follows:
1. Change in fracture position by 10 mm,
2. Change in screw position by 5%,
3. Backing out of the screws by 20 mm, and
4. Perforation of the screws into the hip joint.
Computed tomography (CT) scanning provides the best
assessment of fracture union. CT can be done even with inter-
nal fixation implant inside. CT scan may be useful to see the
bony appearance of stippled area and bony sclerosis, trabecu-
lar resorption, microfracture and subchondral collapse, and
presence of AVN. Radiographic changes often are not present
with AVN until the disease has reached an advanced stage.
Therefore, bone scintigraphy or magnetic resonance imaging
(MRI) may be considered to assess femoral head viability.
Infection must be ruled out as a cause or differential diagno-
sis for nonunion. History about any constitutional symptoms
should be taken and the skin incision should be inspected for
any signs of infection.
Preoperative evaluation must include white blood cell
count, erythrocyte sedimentation rate, and C-reactive pro-
tein. Intraoperative tissue samples from the nonunion site
should be obtained for frozen section at the time of any surgi-
cal intervention.
██ Management
Many different procedures have been proposed for the treat-
ment of nonunion of fracture of the neck of the femur. Albee10
reported using tibial bone peg graft in ununited femoral neck
fractures. Henderson11
used tibial or fibula grafts at Mayo clinic
in 77 young patients of ununited femoral neck fractures after
making a channel with a drill with good results. King6
and Nagi
et al12
have used fibular graft with internal fixation with good
results. Lindequist13
reported introduction of cancellous bone
graft through a drilled channel in femoral neck without expos-
ing the fracture after fixation by multiple pins.
Various workers have advised use of displacement and
angulation osteotomies in management of nonunion of fem-
oral neck fractures. McMurray14
proposed a displacement
osteotomy in which the femur is placed medially beneath the
femoral head following an oblique osteotomy from the base
of the greater trochanter to the upper end of the lesser tro-
chanter. He used it with good results in nonunion and fresh
fractures of femoral neck. The union occurred between three
fragments and the head remained viable. In a later series,
although the functional results had been good but union at
the fracture site had not been obtained always, shortening
has been a constant feature and incidence of AVN has been
between 18.2 and 22%.15
Pauwels16
demonstrated that the problem is essentially
biomechanical. He described an abduction osteotomy at the
intertrochanteric level, which shifts line of weight bearing
medially and converts the shearing force at the nonunion site
into a compression force as the fracture line becomes horizon-
tal. However, extreme valgus position shortens the lever arm,
thus placing increased pressure on the head of femur during
walking. He fixed the nonunion with graft and removed a
wedge from lateral side to realign the femur in valgus posi-
tion. Muller et al17
modified it and fixed the osteotomy with a
blade-plate. This concept has been popular in Europe.
Dickson18
devised a geometric angulation osteotomy com-
bined with an osteosynthesis. This osteotomy changes the
angle of weight bearing by 45 degrees. Marti et al19
got 76%
good or excellent results in 50 ununited femoral neck frac-
tures after valgus osteotomy. Many other reports have shown
good results with this procedure.20–22
Judet23
in 1962 described quadratus femoris–based muscle
pedicle bone graft for femoral neck fractures. Later, Meyers et
al24
and Baksi25
popularized this method.
Elderly patients with nonunion of femoral neck fracture are
not expected to show union with any osteosynthetic procedure
and they are treated by appropriate arthroplasty procedure.
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Chapter 11
The factors on which the management depends are as
follows:
1. Age of the patient
2. Vascularity
3. Remaining bone quality
4. Status of the articular surface and sphericity of the
femoral head
5. Alignment of the neck and shaft
6. Potential limb length discrepancy
██ Classification
The classifications described for fresh fractures cannot be
used reliably to predict the outcome in cases of nonunion
of femoral neck fracture as there is absorption of femoral
neck; fracture surfaces get smoothened; the fracture gap is
increased; and the head of the femur can develop AVN. These
changes occur in variable severity depending on the length
of neglect. Classifications for fresh fracture like the Pauwels
and Garden classification require proper fracture surfaces to
see the displacement, which is difficult if there is absorption.
To see these changes good-quality X-ray of pelvis including
both hip joints in as identical position as possible should be
taken. The length of the proximal fragment is measured from
upper margin of fovea centralis to the midpoint of the fracture
margin. CT scan or MRI of pelvis can be extremely useful in
accurately measuring the gap between the fragments and the
size of the proximal fragment. Sometimes, the absorption of
the proximal fragment is more marked in the center than on
the periphery, giving it the shape of a cup or a moon. This may
not be clearly seen on routine AP view X-ray of the hip and
can be better appreciated on CT scan or MRI. AVN of the head
of the femur may be seen earlier on MRI/CT scan than on plain
X-ray of the hip.
Based on these changes, Sandhu26
has classified the unu-
nited femoral neck in following three stages.
Stage I (Fig. 11.1)
A. Fracture surfaces are still irregular (Fresh)
B. The size of proximal fragment is 2.5 cm or more
C. Gap between the fragments is 1 cm or less
D. Head of the femur is viable; there is no sign of AVN on
X-ray picture or MRI or CT scan
Stage II (Fig. 11.2)
A. Fracture surfaces are smoothened out
B. The size of the proximal fragment is 2.5 cm or more
C. The gap between the fragments is more than 1 cm but
less than 2.5 cm
D. The head of the femur is viable
If either of the feature a or c is present, it is allocated to
Stage II.
Fig. 11.1 Stage I.
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Nonunion Femoral Neck Fracture—Management
Fig. 11.2 Stage II.
Fig. 11.3 (A) Stage III (B) Head of femur in same
patient after removal, looking only a shell.
Stage III (Fig. 11.3)
A. Fracture surfaces are smoothened out
B. The size of the proximal fragment is less than 2.5 cm
C. The gap between the fragments is more than 2.5 cm
D. The head of the femur shows signs of AVN
If any of the feature b, c, or d is present, the fracture is allo-
cated to Stage III.
A
B
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Chapter 11
██ Stage-Wise Treatment
The goal of treatment in neglected fracture neck of femur
is to achieve a painless, mobile, and stable hip.27
The treat-
ment depends on the age and physical status of the patient,
duration of nonunion, viability and spherocity of the femoral
head, amount of resorption of the femoral neck, and potential
limb length inequality. Early anatomical reduction and stable
internal fixation restore the vascularity and reduce the inci-
dence of AVN.3
Nonunion and AVN of the femoral head are
the main complications following femoral neck fractures.
Unfortunately, in developing countries, patients traditionally
are, often, treated by local bone setters initially and report to
hospital late due to difficulties of finance, communication, and
transport. Even if they seek medical advice, many times the
diagnosis is missed or a poor technique or improper implant is
used, leading to nonunion. The fractures presenting late have
their own problems of management. Even in developed coun-
tries, the diagnosis is missed sometimes especially in elderly
people.28
If the fracture is more than 6 weeks old, accurate
close reduction and firm fixation to achieve union is difficult.
Management options being used currently are grouped as
follows:
1. Osteosynthesis with or without vascularized or non-
vascularized bone grafting
2. Osteotomy, displacement, or angulation type
3. Osteosynthesis with muscle pedicle bone grafting
4. Replacement (hemiarthroplasty, HA or total hip
replacement) (Figs. 11.4 and 11.5)
These are to be used in different stages as follows:29
Stage I
1. Closed reduction and internal fixation
2. Closed reduction and internal fixation with one screw
and double fibular graft or two screws and one fibular
graft
Fig. 11.4 (A) Radiograph of a 50-year-old female showing failure of fixation and nonunion; (B) treated with bipolar arthroplasty.
A B
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Nonunion Femoral Neck Fracture—Management
A B C
Fig. 11.5 (A) Fracture neck of femur in a 45-year-old male; (B) failed internal fixation with nonunion; (C) managed by cemented total hip
arthroplasty.
3. Closed reduction or open reduction and bone muscle
pedicle graft based on quadratus femoris or sartorius
or tensor fascia femoris
4. Abduction osteotomy and osteosynthesis with DHS or
135 degree angled blade plate or 120 degree double-
angle blade plate
Stage II
1. Open reduction, freshening of fracture surfaces, and
internal fixation with two screws and one free fibular
graft
2. Open reduction and internal fixation with multiple
screws and muscle pedicle bone graft
3. Valgus osteotomy
Stage III
1. Total hip arthroplasty
2. Bipolar or HA
3. Valgus osteotomy
These procedures are discussed in detail in later chapters.
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