Eun Sun Moon,M

Revasculariztion of the Femoral Head by Muscle Pedicle Bone Graft in Whole Head Osteonecrosis and Nonunion of the Femoral Neck Fracture

A Case Report

Fachry A Tandjung, Dicky Mulyadi, Hermawan NR.

Department of Orthopedics, RSHS UNPAD Bandung

Corresponding Author:

Fachry A Tandjung

Department of orthopaedic and traumatology surgery

Hasan Sadikin Hospital UNPAD University

Jl. Pasteur no Bandung, Indonesia

Tel: 062 22 - 2035477

Fax: 062 22 - 2035477

E-mail: fachryambia@yahoo.com

Revascularization of the Femoral Head by Muscle Pedicle Bone Graft in Whole Head Osteonecrosis and Nonunion of the Femoral Neck Fracture

-A Case Report-

Abstract

Failures in the treatment of fracture of the femoral neck lead to be many bad condition such as osteonecrosis of the femoral head, and nonunion or malunion of the femoral head. Internal fixation using multiple Knowles pins is an accepted treatment for fractures of the femoral neck in young adult patients, but there has been little recognition of the risk of iatrogenic osteonecrosis of the femoral head and nonunion of the femoral neck during this procedure. We report one case of osteonecrosis of the femoral head and nonunion of the femoral neck in nineteen-year-old women, which was developed after failure treatment of the femoral neck fracture by multiple Knowles pins.

The patient was successfully treated by quadratus femoris muscle pedicle bone graft. Key Words: Femoral neck fracture, Multiple Knowles pins, Osteonecrosis of the femoral head, Nonunion of the femoral neck fracture, Quadratus femoris muscle pedicle bone graft.

Abstrak

Kegagalan penatalaksanaan fraktur dari neck femur berkembang menjadi beberapa kondisi misalnya osteonecrosis dari head femur, dan nonunion atau malunion dari head femur. Fiksasi dalam dengan menggunakan multiple Knoles pins sudah diterima sebagai cara penatalaksanaan fraktur neck femur untuk usia dewasa muda, tetapi hanya sedikit informasi mengenai iatrogenic osteonecrosis dari head femur dan nonounion neck femur yang terjadi setelah prosedur ini. Kami laporkan satu kasus iatrogenic osteonecrosis femoral dan nonunion neck femur pada penderita wanita usia sembilanbelas tahun yang terjadi setelah operasi fraktur neck femur dengan penatalaksanaan menggunakan multiple Knoles pins. Penderita ini dapat kami tangani dengan baik dengan menggunakan teknik operasi quadratus femoris muscle pedicle bone graft. Kata kunci: Neck femur fraktur, multiple Knoles pins, osteonecrosis head femur, nonunion neck femur, quadratus femoris muscle pedicle bone graft.

Introduction

A neglected femoral neck fracture usually presents as malunion or nonunion, with or without osteonecrosis of the femoral head, and is a great challenge to the surgeon (3). Either hemiarthroplasty or total hip arthroplasty is a good solution for delayed femoral neck fractures in the aged (31). However, the treatment becomes very difficult particularly in young adults because arthroplasty is not indicated. This is a complicated case report on the treatment of complete osteonecrosis of the femoral head and nonunion of the femoral neck after fixation failure with Knowles pins in displaced femoral neck fracture in a nineteen-year-old woman, who was successfully treated by quadratus femoris muscle pedicle bone graft. Ten years follow-up result of this patient will be described.

Case Report

A nineteen-year-old woman sustained a displaced left femoral neck fracture in an automobile accident (Figure 1A). Two days after the injury, she was treated by internal fixation with multiple Knowles pins (Figure 1B). The procedure was performed at another hospital and weight bearing was permitted after 3 months.

Five months after the operation, she slipped down and the hip became progressively painful, interfering with the activities of daily living. Radiographs revealed displacement of the fracture site with fixation failure (Figure 2A). She was transferred to our institution at that time. Radiography of the hip revealed a sclerotic femoral head and bone scintigraphic revealed a cold spot in the femoral head indicating complete osteonecrosis of the femoral head (Figure 2B). We decided to perform a quadratus femoris muscle pedicle bone grafting and refixation with multiple cannulated screws.

Under general anesthesia the patient was placed in the lateral decubitus position. The C-arm machine was positioned for anteroposterior and lateral views, and preliminary imaging was made to check the position of the femoral head and neck.

After preparation of the skin and surgical draping, the incision was started using posterolateral modified Gibson approach. The deep fascia and fascia lata were cut in the direction of the skin incision exposing the borders of the quadratus femoris muscle insertion.

A rectangular graft was marked out on the intertrochanteric crest of the femur with a small osteotome. To minimize the chance of breaking the graft, its cephalad end to caudad end was outlined with drilled holes through the posterior cortex of the femur and these drilled holes were connected using an osteotome (Figure 3A). The graft started proximally at a point about three centimeters from the tip of the greater trochanter, including the posterolateral aspect of the intertrochanteric crest along with the insertion of the quadratus femoris muscle, and ended at the level of the lesser trochanter. Its width was 1.5 centimeters and depth was one centimeter. The medial edge of the graft was at the base of the neck of the femur and outside the capsule.

After the bone graft had been undercut with the curved osteotome, the graft with the attached quadratus femoris was freed with a large osteotome and retracted in the direction of the muscles origin on the lateral aspect of the ischial tuberosity.

An H-shaped incision was then made in the posterior part of the femoral head exposing posterior cortex of the fracture site. With abduction and internal fixation rotation of the leg, the fracture site was reduced. Pins were inserted to get strong purchase on the strong bone of the head without parallel insertion. The position of the pins was checked by anteroposterior and lateral views using the C-arm.

A bone slot was made from the posterior aspect of the femoral head to the neck through the fracture site, according to the length and width of the pedicle graft by using a chisel. The proximal end of the pedicle graft was inserted into the prepared slot in the head of the femur and impacted. One screw was placed through the distal portion of the pedicle graft, fixing it to the trochanteric region of the femur (Figure 3B).

Five months after surgery, radiographs revealed the head femur still in a fixed position (Figure 4A). We recommended complete non weight-bearing for one year periode until radiographs shows a signs of bone healing. Bone scintigraphic at 18 months after surgery revealed revascularization of the head of the femur (Figure 5A), and radiographs shows a trabeculation crossing the fracture line (Figure 4B). Three years after quadratus femoris muscle pedicle bone grafting, radiographs (Figure 4C) and bone scintigraphic (Figure 5B) revealed complete healing of the femoral head.

Discussion

Fractures of the femoral neck occur mostly in elderly patients (19). The incidence of femoral neck fractures in patients less than 50 years of age accounts for only 3 % of the total fracture population (3, 9). Although femoral neck fracture is uncommon in young patients, it is usually a serious injury, and should be treated as soon as possible (12, 27).

Several authors, in reporting femoral neck fractures treated by closed reduction and internal fixation in elderly patients, presented incidences of nonunion of 10% to 35%, and incidences of osteonecrosis of 30% to 42% (2, 8, 23, 30). In young adults (20-40 years old), the incidences of nonunion and osteonecrosis were higher compare to the elderly. Protzman and Burkhalter (28) reported a 59% incidence of nonunion and an 89% incidence of osteonecrosis. Concerning the correlation between osteonecrosis and nonunion, Baksi (6) state, osteonecrosis is a familiar complication of intracapsular fractures of the femoral neck, whether or not the fracture unites.

Femoral neck fractures can be treated with either immediate closed or open reduction followed by internal fixation or prosthetic replacement of the femoral head. Arthroplasty was not indicated for femoral neck fracture in young patients, except for severe comminution femoral neck fractures (23).

Neglected cases or delayed treatment of the femoral neck fracture are very rare, in developed country especially for young adults; there are only a few reports on femoral neck fracture. Huang (19) reported their series of sixteen young adults with neglected femoral neck fractures treated with internal fixation or angulation osteotomy with or without bone graft. He achieved good to excellent results in 81% of the cases, with a 25% incidence of osteonecrosis and no cases of nonunion. In the report by Meyers et al (23) on muscle pedicle bone graft in addition to osteotomy in treating delayed femoral neck fractures, 20% of the cases treated within 30 days after injury developed nonunion, while the failure rate increased up to 75% if the treatment was started more than 90 days after injury.

In the review of English literature we found that only two similar cases in patient less then 20 years of age. Baksi (6) reported the treatment of post-traumatic avascular necrosis by muscle pedicle bone grafting. Our case presented at the worst conditionthe with displaced nonunion and fixation failure combined with whole head osteonecrosis.

Muscle pedicle bone grafts have been shown in animal experiments to preserve vascularity and viability of the bone (16, 21, 22). Judet (21) and Meyers et al. (23) reported muscle pedicle grafts in humans for accelerating the union of intracapsular fractures of the femoral neck. Because the muscle pedicle bone graft is vascular, radiological density is not different from that of normal bone (6). In our case we performed quadratus femoris bone graft combined with multiple cannulated screws for fixation.

Restriction of weight bearing seemed to be very important in order to have a good clinical result. Baksi (6) did not allow full weight bearing for a five to eight months after operation. In our case the patient was not allowed for full weight bearing for one year after surgery and then six months after radiographs evidence of complete bony union and recirculation of the femoral head.

We recommend rigid fixation with multiple cannulated screws and combine with quadratus femoris pedicle bone graft for the rare and difficult case like ours for neglected nonunion of femoral neck fracture combined with osteonecrosis of the femoral head in young adults.

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