Treatment Modality of Non-Union fracture neck of femur

1. Treatment Modality
of Non-Union in
Fracture of Neck of
Femur
Dr.Avik Sarkar
KB Bhabha Municipal General Hospital,
Bandra (West), Mumbai

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. INVESTIGATIONS
• X-RAYS
AP
LATERAL
PBH
• CT SCAN
• MRI
• BONE SCAN WITH PIN COLOMETER (TO
DIFFERENTIATE BETWEEN AVN AND NON-UNION)

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. TREATMENT
Treatment modalities vary both in elderly and
in young adults (less than 40 years)

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. 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. 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. 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. a. Fracture neck femur non-union – AP view
b. 2 year follow-up – AP view
c. 2 year follow-up – Lateral view

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. 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. 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.  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. 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. 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. 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. 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. Types of Osteotomies
 McMurray’s Displacement Osteotomy
 Schanz Angulation Osteotomy
 Dickson’s High Geometric Osteotomy
 Pauwel’s Y Osteotomy

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)