Valgus osteotomy for nonunion and neglected neck of femur fractures

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics.The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomyoptimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.     

Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults

Twenty cases of neglected (more than 1 month old) displaced femoral neck fractures in young adults were treated with a valgus intertrochanteric osteotomy. A fracture union rate of 85% (17 cases) was achieved. Two of the healed cases developed avascular necrosis. After 30 months 15 patients (75%) had achieved good to excellent results. We believe that intertrochanteric osteotomy provides good alternative management for neglected femoral neck fractures.     

First metatarsal osteotomy nonunion and malunion

The purpose of this article is to review our experience with malunion and nonunion of proximal and distal first metatarsal osteotomies and to outline the treatment options when such complications occur.     

Valgus intertrochanteric osteotomy for non-union of femoral neck fracture

In spite of improved surgical techniques and fixation devices, non-union still reportedly occurs in 10-30% of cases of femoral neck fracture. A variety of methods of treatment that preserve the femoral head have been described, yet there are few reports on the results of valgus intertrochanteric osteotomy in cases of femoral neck non-union. We treated 11 such cases with valgus intertrochanteric osteotomy performed at one centre and using a single surgical technique. The cases were evaluated clinically and radiographically at a mean of 4.9 years. All of the non-unions were shown radiographically to have healed by an average of 12.5 weeks. Functional outcome was excellent for nine patients and poor for two who underwent subsequent total hip arthroplasty for avascular necrosis of the femoral head. We conclude that valgus intertrochanteric osteotomy is an effective treatment for femoral neck non-union, but avascular necrosis of the femoral head is a possible complication.     

Treatment of nonunion and malunion following hand fractures

Hand fractures account for about 1.5% of all emergency room visits and 40% of upper extremity fractures. Unfortunately, complications occur following these injuries. When the underlying osseous structure is affected with nonunion or malunion, it can further compromise hand function, therefore diagnosis and treatment of these complications is an important part of caring for patients with hand fractures. The decision to intervene must be based on the likelihood of achieving the desired correction, and improving the function, of the hand. This article reviews principles of diagnosis and treatment of nonunions and malunions, including conditions affecting the thumb and pediatric patients.     

Intraarticular osteotomy for malunion of metacarpal head fractures

Three cases of intraarticular osteotomy of malunited intraarticular fractures of the metacarpal head are described. The patients, all young males, had significant improvement in the articular anatomy and function. Rigid internal fixation was used in each case.     

股骨粗隆间骨折术后骨不连的治疗现状

股骨粗隆间骨折术后骨不连是一种少见而严重的并发症.手术治疗是主要的临床选择.手术方案包括保留股骨头和髋关节置换两大类,前者包括股骨粗隆外翻截骨术和更换内固定术,后者包括全髋和半髋关节置换术.选择治疗方案需考虑多种因素,尤其是首次内固定治疗失败一定程度上破坏了股骨近端结构,这都增加了治疗难度.本文总结了近年来国内外股骨粗...     

Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures

Insufficiency fractures are often overlooked, particularly when associated with greater trochanteric avulsion fractures. Here, we report magnetic resonance imaging (MRI) findings of insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures treated by internal fixation. We identified 8 patients (3 men and 5 women; age range, 58–92 years old). All cases used internal fixation devices. Operations were performed within 30 min with a total recorded blood loss within 50 ml. We studied MRI findings, hospital stay (number of days), the ambulatory status at hospital discharge, and complications. We were able to identify intertrochanteric fractures using MRI which we could not identify with radiographs. The average hospital stay was 28 days. Seven patients could walk with support and one patient could walk without support. There were no complications regarding the operation itself. Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures were often overlooked. We successfully treated these fractures by internal fixation.     

Calcaneus malunion and nonunion

Though the debate continues between operative interventions versus conservative therapy, there is significant evidence that the deformity that results from calcaneus malunions causes significant disability for the patient. Knowledge of the fracture patterns in the original calcaneal fracture aids in both understanding the deformity of the malunion and the necessary steps for correction of the deformity. Increased heel width, subfibular impingement, tibiotalar impingement, varus/valgus deformity of the hindfoot, peroneal tendon dysfunction, and subtalar arthrosis are well established consequences of calcaneal malunion. Different surgical options have been postulated either trying to address all the deformities or concentrating on certain aspects that are most clinically pressing. The simplest form of treatment is isolated lateral wall decompression, and if applied to a patient who has minimal subtalar arthrosis and no hindfoot deformity, good results are produced. The more complex surgical interventions aim to correct the lateral ankle symptoms, subtalar arthrosis, and hindfoot varus. These surgeries result in a more functional foot but should be considered a salvage procedure because there is still considerable disability as indicated by lower functional scores on the Short Form 36 and American Orthopaedic Foot and Ankle Society hindfoot surveys. Nonunion in calcaneal fractures has limited incidence within the literature for both operative and nonoperative management. Thus, any conclusion as to why there would be such a low incidence can only be made on speculation that the vascularity of the calcaneus and ability to immobilize both the subtalar and calcaneocuboid joints allow the fracture to heal.     

The value of trochanteric displacement in a varus producing intertrochanteric osteotomy

Surgical Principles In order to maintain or increase the abductor lever arm during a varus producing intertrochanteric osteotomy, distal displacement of the greater trochanter is often needed. Without displacing the trochanter, a significant weakness of the abductors would occur [4, 5]. With greater trochanter osteotomy, access to the hip joint is improved, permitting better visualization of the upper part of the femoral head and the roof of the acetabulum (ie, for a simultaneous shelf procedure). When a flexion component is added to the osteotomy, the trochanteric osteotomy increases the range of correction in the sagittal plane and reduces mechanical pressure on the anterosuperior surface of the femoral head [3]. The aim of an isolated greater trochanteric osteotomy is to advance distally and to lateralize the abductors. To achieve fixation, the preserved soft tissue layer, screws, or a tension wire cerclage are used [4–6, 10]. The indication of a trochanteric osteotomy combined with an intertrochanteric osteotomy has increased [1, 4, 10, 11]. The technique described in detail below is part of a varus osteotomy performed as previously described by M. E. Müller [7, 8, 10] and relies on the use of AO osteotomy plates [9]. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 211–218 (German Edition).     

Anterior trochanteric slide osteotomy for primary total hip arthroplasty. Review of nonunion and complications

The radiographic results of 73 anterior trochanteric slide osteotomies were retrospectively reviewed at an average of 36 months after primary hip arthroplasty to determine the incidence of nonunion of the trochanter and complications related to trochanteric hardware. In each case, the trochanter was retracted anteriorly, with the gluteus medius and vastus lateralis muscle insertions left intact. Reattachment was performed with 2 monofilament wires or cables passed through the lesser trochanter in each case. Ninety-two percent of the trochanters healed; nonunion was associated with anterior displacement of the trochanteric fragment with external rotation of the femur. The incidence of repeat surgery for hardware-related problems was 28%. Although the slide osteotomy prevented proximal migration of the trochanteric fragment, the incidence of hardware complications was too high to justify the routine use of this approach in primary hip arthroplasty.     

全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的治疗

目的 探讨在全髋关节翻修术中采用张力带方法治疗大转子粉碎性骨折或截骨不愈便的临床效果。方法 1992年1月～1998年10月，对295例行全髋关节翻修术中大转子粉碎性骨折或截骨不愈合的19例(20髋)患者进行治疗，男7例．女12例；年龄63～76岁，平均69岁。20髋中，16髋为假体松动伴骨溶解在翻修术中发生股骨大转子骨折，4髋为全髋关节置换时采用股骨转子截骨入路。因转子截骨不愈合致髋外展肌力不足而行翻修术。采用多枚克氏针加张力带钢丝固定的方法进行治疗。结果 术后随访12～118个月,平均30个月。Harris髋关节评分从术前的平均45分恢复至随访时的平均89分。19髋达一期愈合，1髋固定失败后再次行大转于张力带固定后愈合。19髋平均愈合时间为166周。所有病例术后均无髋关节脱位。结论 在全髋关节翻修术中使用多枚克氏针加张力带钢丝固定的方法治疗股骨大转子骨折或截骨不愈合，可以提高愈合率，维持正常的髋关节外展肌功能。该方法也适用于大转子粉碎性骨折或骨质疏松的患者。     

Pivot osteotomy for the correction of malunion of metacarpal neck fractures.

A new configuration of osteotomy has been developed which combines the principles and benefits of opening and closing wedge osteotomies without the degree of shortening associated with the closing wedge osteotomy and the tension imposed on the soft tissues by the opening wedge osteotomy. It is ideally suited to the correction of angular malunions in the long bones of the hands. Ten osteotomies of malunions of the metacarpals have been performed in nine hands giving good correction of the malunion in all cases.     

大转子后半截骨在髋臼骨折手术显露中的应用

目的 探讨大转子后半截骨在涉及臼顶后上部的髋臼骨折手术显露中的作用.方法 2000年1月至2008年1月收治32例涉及臼顶后上部的髋臼骨折患者,其中28例获得随访,男16例,女12例;平均年龄39.9岁(16～73)岁;新鲜骨折19例,陈旧性骨折9例.所有患者均采用大转子后半截骨入路进行显露,采用髋臼三维记忆内固定系统固定髋臼骨折及大转子截骨块.结果 28例患者术后获平均48.9个月(19～95个月)随访.根据Matta标准:解剖复位17例,满意复位10例,不满意复位1例.所有髋臼骨折均一期愈合,未出现骨折移位.所有截骨块均获骨性愈合,平均愈合时间为14周.无骨不连、截骨块近端移位、内固定松动、断裂及深部感染等并发症发生.其中1例患者髂腹股沟切口发生浅表感染,经定期换药后切口二期愈合;2例患者骨折愈合后出现内固定刺激征,术后6个月取出大转子部位内固定.外展肌力根据美国医学研究委员会分级系统评定:4级3例,3级1例,其余患者肌力末受明显影响.采用d'Aubigne & Postel 临床分级标准评定髋关节功能:优10例,良15例,可2例,差1例,优良率为89.3%.结论 大转子后半截骨入路能够提供可靠的臼顶后上部显露,可以满足髋臼骨折的复位要求.

Abstract：

Objective To explore whether posterior trochanteric osteotomy can provide adequate exposure to facilitate surgery for acetabular fractures.Methods From January 2000 to January 2008, 32 cases of acetabular fracture involving the acetabular dome underwent posterior trochanteric osteotomy for a better exposure to facilitate internal fixation with acetabular tridimensional memory fixation system(ATMFS).Of the 32 cases, 28 were followed up.They were 16 men and 12 women, with a mean age of 39.9 years (16 to 73) .There were 19 fresh fractures and 9 old ones.Results Twenty-eight cases were followed up for an average of 48.9( 19 to 95) months .According to Matta criteria, anatomical reduction was achieved in 17 cases, satisfactory reduction in 10 cases, and unsatisfactory reduction in one old fracture.All the fractures got direct bony union with no displacement or deep infection.All the osteotomy fragments healed within 14 weeks without any nonunion, proximal migration, loosening or breakage of hardware or deep infection.Superficial infection occurred in one patient but healed after regular dressing.Two patients had to sustain removal of the implants from greater trochanter because of irritation.According to the Medical Research Council (MRC) grading system, the strength of the abductors was of Grade 4 in 3 patients, of Grade 3 in one patient and normal in the rest.By the modified d'Aubigne & Postel scoring system, the excellent to good rate was 89.3%.Conclusion Posterior trochanteric osteotomy can provide an adequate exposure of the acetabular dome without such complications as nonunion, proximal replacement or weakness of the abductors which often occur after the conventional oblique osteotomy.     

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

To explore the clinical efficacy of thetreatment of comminuted trochanteric fractures andtrochanteric osteotomy non-union in revision total hiparthroplasty with tension-band f‘Lxation.     

AO微型钢板螺钉固定治疗掌指骨骨折骨不连或畸形愈合

目的探讨AO微型钢板螺钉治疗掌指骨骨折术后骨不连或畸形愈合的应用价值。方法对11例14个掌指骨骨折克氏针固定术后骨不连或畸形愈合者采用手术治疗,其中指骨骨不连7个,掌骨骨不连5个,掌骨畸形愈合2个。术中骨折端修整,取自体髂骨植骨12个,畸形愈合行截骨矫正2个。11例均应用AO微型钢板螺钉内固定,同期行肌腱或关节囊松解术,术后早期行关节功能锻炼。结果术后随访4～12个月,11例均于术后6～8周达到骨折临床愈合,无畸形愈合。根据TAFS评分,2例为优,9例为良,3例差,优良率为78.5 %。结论AO微型钢板螺钉内固定,自体骨植骨,同期行肌腱和关节囊松解以及术后早期关节功能锻炼,是掌指骨骨不连或畸形愈合的治疗原则。