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Treatment Modality
of Non-Union in
Fracture of Neck of
Femur
Dr.Avik Sarkar
KB Bhabha Municipal General Hospital,
Bandra (...
Causes of Non-Union in Fracture
Neck of Femur
• FAILURE TO REDUCE OR MAINTAIN REDUCTION
• ABSENCE OF CAMBIUM LAYER OF PERI...
INVESTIGATIONS
• X-RAYS
AP
LATERAL
PBH
• CT SCAN
• MRI
• BONE SCAN WITH PIN COLOMETER (TO
DIFFERENTIATE BETWEEN AVN AND NO...
Femoral neck non-union occurs in 20–30%
of displaced femoral neck fractures.
Femoral neck fractures should unite by 6
mont...
TREATMENT
Treatment modalities vary both in elderly and
in young adults (less than 40 years)
IN THE ELDERLY
 Replacement Arthroplasty is the treatment of
choice for elderly patients in fracture of neck
femur non-un...
IN YOUNG ADULTS (BELOW 40 YEARS)
 The type of femoral neck non-union determines
the treatment needed.
 Hence a classific...
Leighton's Classification of
Femoral Neck Non-union [1]
TYPE I - INADEQUATE FIXATION OR NON-ANATOMIC
REDUCTION
TYPE II - L...
Type I (Inadequate fixation or non-anatomic reduction)
The surgical plan
(a) removal of fixation
(b) realignment of the fe...
a. Fracture neck femur non-union – AP view
b. 2 year follow-up – AP view
c. 2 year follow-up – Lateral view
TYPE II (Loss of fixation with fracture displacement)
 The Surgical Plan
(a) removal of initial fixation
(b) deformity co...
PREPLANNING
 Identification and documentation of the vascular
status of the femoral head
 A preoperative drawing to dete...
TYPE III (Fibrous non-union with no displacement and intact fixation)
 The Surgical Plan
(a) drill out the non-union
(b) ...
 By placing numerous drill holes (4.5 to 8.0 mm in
diameter) from the lateral cortex into the head,
through the femoral n...
REHABILITATION
 The patient is generally mobilized at 25% weight-
bearing over the first 6 weeks.
 Once adequate healing...
OSTEOTOMY
An Osteotomy is a surgical corrective procedure
used to obtain a correct biomechanical alignment
of the extremit...
PROXIMAL FEMORAL OSTEOTOMY
PROXIMAL FEMORAL OSTEOTOMIES can be classified
according to
(A) Anatomic Location
High Cervical...
PRINCIPLES OF OSTEOTOMY IN
NONUNION FRACTURE NECK FEMUR
 Line of weight bearing is shifted medially.
 Shearing force at ...
Types of Osteotomies
 McMurray’s Displacement Osteotomy
 Schanz Angulation Osteotomy
 Dickson’s High Geometric Osteotom...
PAUWEL’S VALGUS OSTEOTOMY
 Valgus Intertrochanteric Femoral Osteotomies
transfer the centre of hip rotation medially from...
Treatment modality of non union fracture neck of femur
Treatment modality of non union fracture neck of femur
Treatment modality of non union fracture neck of femur
Treatment modality of non union fracture neck of femur
Treatment modality of non union fracture neck of femur
Treatment modality of non union fracture neck of femur
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Treatment modality of non union fracture neck of femur

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Treatment Modality of Non-Union fracture neck of femur

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Treatment modality of non union fracture neck of femur

  1. 1. Treatment Modality of Non-Union in Fracture of Neck of Femur Dr.Avik Sarkar KB Bhabha Municipal General Hospital, Bandra (West), Mumbai
  2. 2. Causes of Non-Union in Fracture Neck of Femur • FAILURE TO REDUCE OR MAINTAIN REDUCTION • ABSENCE OF CAMBIUM LAYER OF PERIOSTEUM (CAMBIUM LAYER PRODUCES CALLUS) • CUTTING OFF OF BLOOD SUPPLY OF HEAD • DEVELOPMENT OF SHEERING FORCE AT FRACTURE SITE AFTER FRACTURE, CAUSING VERTICAL INCLINATION • TAMPONADE EFFECT AT FRACTURE SITE DUE TO INTRACASPULAR NATURE OF FRACTURE • SECRETION OF INHIBITORY SUBSTANCES AT FRACTURE SITE
  3. 3. INVESTIGATIONS • X-RAYS AP LATERAL PBH • CT SCAN • MRI • BONE SCAN WITH PIN COLOMETER (TO DIFFERENTIATE BETWEEN AVN AND NON-UNION)
  4. 4. Femoral neck non-union occurs in 20–30% of displaced femoral neck fractures. Femoral neck fractures should unite by 6 months. If there is no evidence of healing, or the patient continued to have pain at 3 to 6 months after surgery, then a delayed union (3 months) or non-union (6 months) should be suspected.
  5. 5. TREATMENT Treatment modalities vary both in elderly and in young adults (less than 40 years)
  6. 6. 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.
  7. 7. IN YOUNG ADULTS (BELOW 40 YEARS)  The type of femoral neck non-union determines the treatment needed.  Hence a classification of femoral neck non-unions was established to elucidate treatment protocols
  8. 8. Leighton's Classification of Femoral Neck Non-union [1] TYPE I - INADEQUATE FIXATION OR NON-ANATOMIC REDUCTION TYPE II - LOSS OF FIXATION WITH FRACTURE DISPLACEMENT TYPE III - FIBROUS NON-UNION WITH NO DISPLACEMENT AND INTACT FIXATION [1] CLASSIFICATION AND TREATMENT OF FEMORAL NECK NONUNIONS IN YOUNG PATIENTS. Leighton R. J Bone Joint Surg Br 2008 vol. 90-Bno. SUPP I 124
  9. 9. Type I (Inadequate fixation or non-anatomic reduction) The surgical plan (a) removal of fixation (b) realignment of the femoral head on the neck A Meyer's bone graft is used with a vascular Quadratus Femoris muscle pedicle. This muscle pedicle may be added to support the posterior comminution and provide a vascularized graft to ensure union. Fixation is performed with multiple screws or a combination of sling hip screw with a superior de-rotation screw. Meyer’s Technique
  10. 10. a. Fracture neck femur non-union – AP view b. 2 year follow-up – AP view c. 2 year follow-up – Lateral view
  11. 11. TYPE II (Loss of fixation with fracture displacement)  The Surgical Plan (a) removal of initial fixation (b) deformity correction by osteotomy with an osteotomy plate using a compression device GOAL To change a shear force on the neck fracture into a compression force.
  12. 12. PREPLANNING  Identification and documentation of the vascular status of the femoral head  A preoperative drawing to determine the change that will occur in leg lengths  A preoperative drawing to determine the position of the femoral head after the osteotomy (this drawing should be present in the OR while the surgery is performed)
  13. 13. TYPE III (Fibrous non-union with no displacement and intact fixation)  The Surgical Plan (a) drill out the non-union (b) fix the fracture with a fixed angled device (sliding hip screw or blade plate). (c) add bone graft (optional) The primary aim of this procedure is to drill out or open the endosteal canal to allow revascularization and endosteal healing in a previous fibrous non-union. There is thick fibrous union between the two ends of the femoral neck and will prevent osseous union if canal is not freshened.
  14. 14.  By placing numerous drill holes (4.5 to 8.0 mm in diameter) from the lateral cortex into the head, through the femoral neck, the canal is revascularized. These are inserted over guide pins, using cannulated drills.  A Meyer's vascularized graft should be added, to stimulate bone union of the femoral neck, posteriorly. Application of a four-hole osteotomy plate, placed under compression. Subtrochanteric osteotomy was done and subsequently a secondary Meyer's graft was performed later to achieve fracture union.
  15. 15. REHABILITATION  The patient is generally mobilized at 25% weight- bearing over the first 6 weeks.  Once adequate healing is evident, full weight- bearing can be allowed, initially with crutches for 2 weeks, a single crutch for 2 weeks, and then weight-bearing with a cane. PHYSIOTHERAPY Abductor strengthening should be initiated at week 6 to prevent development of Trendelenburg gait
  16. 16. OSTEOTOMY An Osteotomy is a surgical corrective procedure used to obtain a correct biomechanical alignment of the extremity, so as to achieve equivocal load transmission, performed with or without removal of a portion of the bone. PRINCIPLE o Increases the contact area o Restores Biomechanical advantage o Moves normal articular cartilage into weight bearing zone o Improves coverage of head
  17. 17. PROXIMAL FEMORAL OSTEOTOMY PROXIMAL FEMORAL OSTEOTOMIES can be classified according to (A) Anatomic Location High Cervical Intertrochanteric Subtrochanteric Greater Trochanteric (B) Displacement of Distal Fragment Transpositional Osteotomy Angulation Osteotomy Sagittal Plane Coronal Plane Adduction Osteotomy (Varus) Abduction Osteotomy (Valgus)
  18. 18. PRINCIPLES OF OSTEOTOMY IN NONUNION FRACTURE NECK FEMUR  Line of weight bearing is shifted medially.  Shearing force at the non-union is decreased, because the fracture surface has become more horizontal
  19. 19. Types of Osteotomies  McMurray’s Displacement Osteotomy  Schanz Angulation Osteotomy  Dickson’s High Geometric Osteotomy  Pauwel’s Y Osteotomy
  20. 20. PAUWEL’S VALGUS OSTEOTOMY  Valgus Intertrochanteric Femoral Osteotomies transfer the centre of hip rotation medially from the superior aspect of the acetabulum to decrease the weight bearing area of femoral head.  Normally 15o of correction is required INDICATIONS  Trendelenburg Limb  Adduction Deformity  Motion in adduction beyond adduction deformity  Painful abduction CONTRAINDICATIONS  Flexion of less than 60 o  Knock Knees (It will increase the deformity)
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Treatment Modality of Non-Union fracture neck of femur

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