Date: Thu, 16 Nov 2000 15:39:50 -0500

Subject: Femoral neck nonunion with ipsilateral subtrochanteric fracture

From: Praveer Srivastava, UK Lexington

May I request suggestions and comments on treatment options from members of the List.

This 27 y/o lady sustained a closed right Sub-trochanteric fracture, with a spiral extension extending into the femoral neck, in a traffic accident. Concomitant injuries included a grade III A fracture dislocation of the right ankle, a right talar body fracture, and extensive crushing and degloving of the left thigh. Initial injury films of the right femur and hip are attached.

Open reduction of the neck was needed, and a DHS plate and a derotational screw were used. Six months later, she has healed all her injuries, but has a painful right hip, with tomographic confirmation of an ununited neck fracture. Xrays at 6 months are attached (apologies for the scratch!)

I am in favor of a valgus intertrochanteric osteotomy with a 120 degree plate, to achieve a correction of the Pauwel's angle from 65 to 35 degrees. However, this jeopardizes the sub-troch fracture with the plate's stressor effect, and I am (reluctantly) considering an overlapping anterior plate just distal to the osteotomy, spanning the fracture. Other local opinions include a free/vascularized fibula, minimalism by simply changing to a 150 degree DHS side plate, and Myer's muscle pedicle.

Thank you for your attention.

From: J.C. Goslings

Sent: Thu, 16 Nov 2000 22:19:56 +0100

Dear colleague,

Did the threads of the (DHS-) screws reach beyond the fracture line in the femoral neck?

Goslings, Amsterdam

Date: Thu, 16 Nov 2000 17:06:53 -0500

From: Kevin Pugh

If the neck and shaft are not healed, I would go with your first impression. Valgus osteotomy of the neck, and extend the plate to cover the shaft fracture. Or....put on another plate in another plane on the femur. I would bone graft the shaft at this time as well.

KP

Date: Fri, 17 Nov 2000 16:10:55 -0800

From: Thomas A. DeCoster

This 27 yo female has a delayed/nonunion of a femoral neck fracture above a healing subtrochanteric fracture initially treated with compressing hip screw. My suggestion is to wait.

Perhaps add electrical stimulation, crutches and reduced activity. The subtrochanteric fracture is not yet completely healed and removing the plate and or doing an osteotomy here will be complicated. The films do not show any loss of fixation in the femoral head nor any great displacement of the femoral neck fracture. 3-6 months from now, if she hasn't healed, you could perform osteotomy etc with a much higher success rate.

Tom DeCoster