Treatment of pathologic femoral neck fractures

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9.5.1 Treatment of pathologic neck fractures due to bone cysts

Our subsequent discussion will be directed towards Our treatment approach is documented by clinical the treatment of various pathologic fractures and examples (Figs. 226-228). our surgical treatment aiming at the preservation of the femoral head in a sequence outlined in Sect. 2.3.

Pathologic Game

Fig. 226. Pathologic fracture caused by a juvenile bone cyst.

This 10-year-old boy fell during a soccer game; his right leg was in external rotation, he was unable to walk; a, b. Radiographs taken the next day showed a right-sided neck fracture in the presence of a large juvenile bone cyst involving neck and trochanter; c, d. During surgery a massive angle-stable Deyerle plate and three wires having threads at their tips were used. In addition, the epiphysis was fixed with two Kirschner wires. The cyst was curetted, exposing a large defect in the bone wall. The cavity was later filled twice with cancel-lous bone from the bone bank; e. One and a half year later, we observed a loss of head sphericity at the weight bearing area. We transferred to the neck and head a pedicled bone graft attached to the quadratus femoris muscle and stabilized it with a Kirschner wire; f. After 19 years the remodeling of the femoral head, its anatomic contour and the multiple small cysts and/or resorption cavities in head and neck are well seen. A shortening of the femoral neck by 3 cm is evident when comparing the neck length to the opposite side; it was compensated by the growth in length of the femur leading only to a 1 cm leg length discrepancy. The function is almost normal, due to the cranial migration of the trochanter a slight Trendelenburg sign is present. The patient played basketball for years. Today, 25 years after the initial accident, he is symptom-free and is completely able to function as a judge e

Fig. 226. Pathologic fracture caused by a juvenile bone cyst.

This 10-year-old boy fell during a soccer game; his right leg was in external rotation, he was unable to walk; a, b. Radiographs taken the next day showed a right-sided neck fracture in the presence of a large juvenile bone cyst involving neck and trochanter; c, d. During surgery a massive angle-stable Deyerle plate and three wires having threads at their tips were used. In addition, the epiphysis was fixed with two Kirschner wires. The cyst was curetted, exposing a large defect in the bone wall. The cavity was later filled twice with cancel-lous bone from the bone bank; e. One and a half year later, we observed a loss of head sphericity at the weight bearing area. We transferred to the neck and head a pedicled bone graft attached to the quadratus femoris muscle and stabilized it with a Kirschner wire; f. After 19 years the remodeling of the femoral head, its anatomic contour and the multiple small cysts and/or resorption cavities in head and neck are well seen. A shortening of the femoral neck by 3 cm is evident when comparing the neck length to the opposite side; it was compensated by the growth in length of the femur leading only to a 1 cm leg length discrepancy. The function is almost normal, due to the cranial migration of the trochanter a slight Trendelenburg sign is present. The patient played basketball for years. Today, 25 years after the initial accident, he is symptom-free and is completely able to function as a judge

Pathologic Fracture Femur

Fig. 227. Pathologic fracture due to a bone cyst in an adult.

This 32-year-old woman felt a cracking of her right hip without a fall. Thereafter, she was unable to walk; a. Right pathologic neck fracture with an extensive bone cyst that reaches into the neck and trochanter; b, c. The cyst is particularly well seen after reduction and traction; d. The intraosseous venography showed a good drainage. The cavity in the head area is also filled with the contrast agent. It is evident that the femoral head consists only of a small half-moon shaped remnant; e. We stabilized the fracture with two Pugh nails and attached a plate to the cranial nail. The intraosseous venography after internal fixation remained positive; f, g. After one year we removed the caudal nail and implanted a bone graft from the bone bank. Later on, the second Pugh nail was replaced by a Smith-Petersen nail and the plate removed; h, i. Twenty-three years later we replaced the migrated nail by a titanium screw as a precaution. Her entire period of disability during all surgeries combined was less than one year. She is now symptom-free. The leg is 2 cm shorter, but the hip function is almost complete

Fig. 227. Pathologic fracture due to a bone cyst in an adult.

This 32-year-old woman felt a cracking of her right hip without a fall. Thereafter, she was unable to walk; a. Right pathologic neck fracture with an extensive bone cyst that reaches into the neck and trochanter; b, c. The cyst is particularly well seen after reduction and traction; d. The intraosseous venography showed a good drainage. The cavity in the head area is also filled with the contrast agent. It is evident that the femoral head consists only of a small half-moon shaped remnant; e. We stabilized the fracture with two Pugh nails and attached a plate to the cranial nail. The intraosseous venography after internal fixation remained positive; f, g. After one year we removed the caudal nail and implanted a bone graft from the bone bank. Later on, the second Pugh nail was replaced by a Smith-Petersen nail and the plate removed; h, i. Twenty-three years later we replaced the migrated nail by a titanium screw as a precaution. Her entire period of disability during all surgeries combined was less than one year. She is now symptom-free. The leg is 2 cm shorter, but the hip function is almost complete

Femoral Neck Plates

Fig. 228. Pathologic fracture due to a bone cyst during puberty.

This 17-year-old girl fell from a horse; a. Extensive bone cyst in the left neck area, comminuted neck fracture and displacement of the head in varus. At the day of accident, internal fixation with two cannulated screws and double DCD plate under image intensification;

b. This postoperative film demonstrates a stable internal fixation in slight valgus. The patient used walking aids with partial weight bearing for three months; weight bearing was gradually increased to a point after 6 months when she could walk with full weight bearing;

c. Two years after the accident the fracture has remodeled, the femoral head is spherical and shows a normal trabecular structure. The joint is intact and the patient walks without a cane. When comparing to the opposite side the function of both hip joints is nearly identical. For the treatment of extensive bone cysts the choice of the DCD double plate has proved to be ideal

Fig. 228. Pathologic fracture due to a bone cyst during puberty.

This 17-year-old girl fell from a horse; a. Extensive bone cyst in the left neck area, comminuted neck fracture and displacement of the head in varus. At the day of accident, internal fixation with two cannulated screws and double DCD plate under image intensification;

b. This postoperative film demonstrates a stable internal fixation in slight valgus. The patient used walking aids with partial weight bearing for three months; weight bearing was gradually increased to a point after 6 months when she could walk with full weight bearing;

c. Two years after the accident the fracture has remodeled, the femoral head is spherical and shows a normal trabecular structure. The joint is intact and the patient walks without a cane. When comparing to the opposite side the function of both hip joints is nearly identical. For the treatment of extensive bone cysts the choice of the DCD double plate has proved to be ideal

9.5.2 Compression fracture in osteomalacia

Rickets in adults (osteomalacia) and the resulting Milkman's pseudo-fractures are nowadays rare (Magilligan and Dulligan, 1952). Bones that have lost part of their mineral content and thus their strength buckle at the medioposterior aspect of the neck resulting in a varus position under load (similar to Looser lines in children suffering from rickets). According to Devas (1965) compression fractures due to osteomalacia belong to the group of stress fractures; they heal spontaneously with a large endosteal callus (Fig. 229).

9.5.3 Femoral neck fractures in osteopetrosis (Albers-Schonberg disease, marble bones)

The etiology is a congenital defect of the osteoclast function. The malignant osteopetrosis is a recessive autosomal disease that is seen in children and that usually leads to a demise during the first two decades of life (Hinkel and Beiler, 1955; Hasenhuttl, 1962). Progression is rapid mainly due to anemia secondary to the replacement of red marrow by bone and due to infection. A very dense, hard and brittle bone is the consequence of the hyperactivity of osteoblasts. Bone is also inelastic and fragile. The foramina where the cranial nerves exit at the base of the skull narrow and are responsible for visual and acoustic disturbances (Fig. 230).

Pathologic Compression Fractures

Fig. 229. Compression fracture of femoral neck in osteomalacia.

52-year-old woman. Complaints about both hips and other joints started six years ago. Radiographs, MRI and tests of metabolism confirmed the diagnosis of osteomalacia; a, b. At the level of the left neck caudal to the Adam's arch a broad bone density is seen surrounding a Looser's line (arrow). Coxa vara; c. MRI shows a low signal intensity at the level of the left Adam's arch and caudally at the neck. We started treatment with vitamin D and followed the patient regularly. After one year the zone of the pseudofracture narrowed; d. After three years the zone has remodeled spontaneously, no complaints were voiced anymore

Fig. 229. Compression fracture of femoral neck in osteomalacia.

52-year-old woman. Complaints about both hips and other joints started six years ago. Radiographs, MRI and tests of metabolism confirmed the diagnosis of osteomalacia; a, b. At the level of the left neck caudal to the Adam's arch a broad bone density is seen surrounding a Looser's line (arrow). Coxa vara; c. MRI shows a low signal intensity at the level of the left Adam's arch and caudally at the neck. We started treatment with vitamin D and followed the patient regularly. After one year the zone of the pseudofracture narrowed; d. After three years the zone has remodeled spontaneously, no complaints were voiced anymore

Osteopetrosis Leg

Fig. 230. Femoral neck fracture in osteopetrosis.

This 12-year-old boy is unable to walk and deaf on account of a known osteopetrosis. He fell at home; a. This radiograph shows a smooth, vertical fracture of a radiodense right femoral neck; b. The fracture had been operated twice elsewhere; c. No consolidation ensues, to the contrary a loss of reduction occurred; d. The third operation was done in our institute and consisted of an internal fixation with cannulated titanium alloy screws and two Kirschner wires; e. After one month we observed a breakage of the wire and a renewed loss of reduction. Based on the positive angiogram we decided in favor of a repeat internal fixation; f. For internal fixation we employed two cannulated titanium alloy screws and a cancellous bone screw; g. h. Two years later the fracture had remodeled, the implants were removed with the exception of one cannulated screw; i. Three years later head contour and joint space are preserved. The patient is pain-free. His condition is similar to that present before the accident

Fig. 230. Femoral neck fracture in osteopetrosis.

This 12-year-old boy is unable to walk and deaf on account of a known osteopetrosis. He fell at home; a. This radiograph shows a smooth, vertical fracture of a radiodense right femoral neck; b. The fracture had been operated twice elsewhere; c. No consolidation ensues, to the contrary a loss of reduction occurred; d. The third operation was done in our institute and consisted of an internal fixation with cannulated titanium alloy screws and two Kirschner wires; e. After one month we observed a breakage of the wire and a renewed loss of reduction. Based on the positive angiogram we decided in favor of a repeat internal fixation; f. For internal fixation we employed two cannulated titanium alloy screws and a cancellous bone screw; g. h. Two years later the fracture had remodeled, the implants were removed with the exception of one cannulated screw; i. Three years later head contour and joint space are preserved. The patient is pain-free. His condition is similar to that present before the accident

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