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Acetabular and Femoral Neck Fracture Nonunion and Malunion

  • Robert C. JacobsEmail author
  • Craig S. Bartlett
  • Michael Blankstein
Chapter
Part of the Fracture Management Joint by Joint book series (FMJJ)

Abstract

Nonunion and malunion are uncommon complications following femoral neck fracture and even more rarely reported after a fracture of the acetabulum. These complications can be difficult to diagnose but can be successfully treated with a large number of patients experiencing good to excellent outcomes. Algorithmic approaches for each are included including the conversion to total hip arthroplasty after unsuccessful open reduction internal fixation of an acetabular fracture.

With respect to the acetabulum, malunion is likely more common than previously thought. Case examples for conversion to total hip arthroplasty after acetabular malunion and open reduction internal fixation after acetabular nonunion are included. Due to their bimodal demographics of young and old, fractures of the femoral neck have significant differences with respect to both their etiology and treatment. A case example for conversion of nonunion to total hip arthroplasty is included.

Keywords

Acetabular Acetabulum Nonunion Malunion Fracture Femoral neck 

References

  1. 1.
    Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106.Google Scholar
  2. 2.
    Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78:1632–45.CrossRefGoogle Scholar
  3. 3.
    Mayo KA. Open reduction and internal fixation of fractures of the acetabulum. Results in 163 fractures. Clin Orthop Relat Res. 1994;305:31–7.Google Scholar
  4. 4.
    Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res. 2003;407:173–86.CrossRefGoogle Scholar
  5. 5.
    Mohanty K, Taha W, Powell JN. Non-union of acetabular fractures. Injury. 2004;35:787–90.CrossRefGoogle Scholar
  6. 6.
    Briffa N, Pearce R, Hill AM, et al. Outcomes of acetabular fracture fixation with ten years’ follow-up. J Bone Joint Surg Br. 2011;93:229–36.CrossRefGoogle Scholar
  7. 7.
    Hull JB, Raza SA, Stockley I, et al. Surgical management of fractures of the acetabulum: the Sheffield experience 1976-1994. Injury. 1997;28:35–40.CrossRefGoogle Scholar
  8. 8.
    Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res. 1994;305:10–9.CrossRefGoogle Scholar
  9. 9.
    Moed BR, Willsoncarr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84-A:752–8.CrossRefGoogle Scholar
  10. 10.
    Murphy D, Kaliszer M, Rice J, et al. Outcome after acetabular fracture. Prognostic factors and their inter-relationships. Injury. 2003;34:512–7.CrossRefGoogle Scholar
  11. 11.
    Saterbak AM, Marsh JL, Nepola JV, et al. Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns. J Orthop Trauma. 2000;14:230–7.CrossRefGoogle Scholar
  12. 12.
    Starr AJ, Watson JT, Reinert CM, et al. Complications following the “T extensile” approach: a modified extensile approach for acetabular fracture surgery-report of forty-three patients. J Orthop Trauma. 2002;16:535–42.CrossRefGoogle Scholar
  13. 13.
    Stockle U, Hoffmann R, Sudkamp NP, et al. Treatment of complex acetabular fractures through a modified extended iliofemoral approach. J Orthop Trauma. 2002;16:220–30.CrossRefGoogle Scholar
  14. 14.
    Wright R, Barrett K, Christie MJ, et al. Acetabular fractures: long-term follow-up of open reduction and internal fixation. J Orthop Trauma. 1994;8:397–403.CrossRefGoogle Scholar
  15. 15.
    Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am. 1964;46:1615–46.CrossRefGoogle Scholar
  16. 16.
    Johnson EE, Matta JM, Mast JW, et al. Delayed reconstruction of acetabular fractures 21-120 days following injury. Clin Orthop Relat Res. 1994;305:20–30.Google Scholar
  17. 17.
    Morshed S. Current options for determining fracture union. Adv Med. 2014;2014:708574.CrossRefGoogle Scholar
  18. 18.
    Giannoudis PV, Grotz MR, Papakostidis C, et al. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005;87:2–9.CrossRefGoogle Scholar
  19. 19.
    Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94:1559–67.CrossRefGoogle Scholar
  20. 20.
    Sagi HC, Jordan CJ, Barei DP, et al. Indomethacin prophylaxis for heterotopic ossification after acetabular fracture surgery increases the risk for nonunion of the posterior wall. J Orthop Trauma. 2014;28:377–83.CrossRefGoogle Scholar
  21. 21.
    Berry DJ, Halasy M. Uncemented acetabular components for arthritis after acetabular fracture. Clin Orthop Relat Res. 2002;405:164–7.CrossRefGoogle Scholar
  22. 22.
    Schreurs BW, Zengerink M, Welten ML, et al. Bone impaction grafting and a cemented cup after acetabular fracture at 3-18 years. Clin Orthop Relat Res. 2005;437:145–51.Google Scholar
  23. 23.
    Sen RK, Veerappa LA. Long-term outcome of conservatively managed displaced acetabular fractures. J Trauma. 2009;67:155–9.CrossRefGoogle Scholar
  24. 24.
    Mcnamara AR, Boudreau JA, Moed BR. Nonoperative treatment of posterior wall acetabular fractures after dynamic stress examination under anesthesia: revisited. J Orthop Trauma. 2015;29:359–64.CrossRefGoogle Scholar
  25. 25.
    Clarke-Jenssen J, Wikeroy AK, Roise O, et al. Long-term survival of the native hip after a minimally displaced, nonoperatively treated acetabular fracture. J Bone Joint Surg Am. 2016;98:1392–9.CrossRefGoogle Scholar
  26. 26.
    Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures in an older population. J Orthop Trauma. 2010;24:637–44.CrossRefGoogle Scholar
  27. 27.
    Mayo KA, Letournel E, Matta JM, et al. Surgical revision of malreduced acetabular fractures. Clin Orthop Relat Res. 1994;305:47–52.Google Scholar
  28. 28.
    Bellabarba C, Berger RA, Bentley CD, et al. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am. 2001;83-A:868–76.CrossRefGoogle Scholar
  29. 29.
    Makridis KG, Obakponovwe O, Bobak P, et al. Total hip arthroplasty after acetabular fracture: incidence of complications, reoperation rates and functional outcomes: evidence today. J Arthroplast. 2014;29:1983–90.CrossRefGoogle Scholar
  30. 30.
    Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am. 1998;80:1295–305.CrossRefGoogle Scholar
  31. 31.
    Lizaur-Utrilla A, Sanz-Reig J, Serna-Berna R. Cementless acetabular reconstruction after acetabular fracture: a prospective, matched-cohort study. J Trauma Acute Care Surg. 2012;73:232–8.CrossRefGoogle Scholar
  32. 32.
    Salama W, Ditto P, Mousa S, et al. Cementless total hip arthroplasty in the treatment after acetabular fractures. Eur J Orthop Surg Traumatol. 2017;28:59.CrossRefGoogle Scholar
  33. 33.
    Sermon A, Broos P, Vanderschot P. Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003. Injury. 2008;39:914–21.CrossRefGoogle Scholar
  34. 34.
    Von Roth P, Abdel MP, Harmsen WS, et al. Total hip arthroplasty after operatively treated acetabular fracture: a concise follow-up, at a mean of twenty years, of a previous report. J Bone Joint Surg Am. 2015;97:288–91.CrossRefGoogle Scholar
  35. 35.
    Morison Z, Moojen DJ, Nauth A, et al. Total hip arthroplasty after acetabular fracture is associated with lower survivorship and more complications. Clin Orthop Relat Res. 2016;474:392–8.CrossRefGoogle Scholar
  36. 36.
    O’toole RV, Hui E, Chandra A, et al. How often does open reduction and internal fixation of geriatric acetabular fractures lead to hip arthroplasty? J Orthop Trauma. 2014;28:148–53.CrossRefGoogle Scholar
  37. 37.
    Brinker MR, O’connor DP, Monla YT, et al. Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma. 2007;21:557–70.CrossRefGoogle Scholar
  38. 38.
    Lindstrom D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248:739–45.CrossRefGoogle Scholar
  39. 39.
    Paprosky WG, O’rourke M, Sporer SM. The treatment of acetabular bone defects with an associated pelvic discontinuity. Clin Orthop Relat Res. 2005;441:216–20.CrossRefGoogle Scholar
  40. 40.
    Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6-year follow-up evaluation. J Arthroplast. 1994;9:33–44.CrossRefGoogle Scholar
  41. 41.
    Solomon LB, Studer P, Abrahams JM, et al. Does cup-cage reconstruction with oversized cups provide initial stability in THA for osteoporotic acetabular fractures? Clin Orthop Relat Res. 2015;473:3811–9.CrossRefGoogle Scholar
  42. 42.
    Sternheim A, Backstein D, Kuzyk PR, et al. Porous metal revision shells for management of contained acetabular bone defects at a mean follow-up of six years: a comparison between up to 50% bleeding host bone contact and more than 50% contact. J Bone Joint Surg Br. 2012;94:158–62.CrossRefGoogle Scholar
  43. 43.
    Veerappa LA, Tripathy SK, Sen RK. Management of neglected acetabular fractures. Eur J Trauma Emerg Surg. 2015;41:343–8.CrossRefGoogle Scholar
  44. 44.
    Mcgrory AC, Replogle L, Endrizzi D. Ultrasound gel minimizes third body debris with partial hardware removal in joint arthroplasty. Arthroplast Today. 2017;3:29–31.CrossRefGoogle Scholar
  45. 45.
    Paprosky WG, O’Rourke M, Sporer SM. The treatment of acetabular bone defects with an associated pelvic discontinuity. Clin Orthop Relat Res. 2005;441:216–20.CrossRefGoogle Scholar
  46. 46.
    D’Antonio JA. Periprosthetic bone loss of the acetabulum. Classification and management. Orthop Clin North Am. 1992;23(2):279–90.PubMedGoogle Scholar
  47. 47.
    Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. A meta-analysis of 18 published studies involving 564 fractures. Injury. 2005;36:131–41.Google Scholar
  48. 48.
    Slobogean GP, Sprague SA, Scott T, et al. Complications following young femoral neck fractures. Injury. 2015;46:484–91.CrossRefGoogle Scholar
  49. 49.
    Slobogean GP, Stockton DJ, Zeng B, et al. Femoral neck fractures in adults treated with internal fixation: a prospective multicenter Chinese cohort. J Am Acad Orthop Surg. 2017;25:297–303.CrossRefGoogle Scholar
  50. 50.
    Collinge CA, Mir H, Reddix R. Fracture morphology of high shear angle “vertical” femoral neck fractures in young adult patients. J Orthop Trauma. 2014;28:270–5.CrossRefGoogle Scholar
  51. 51.
    Thorngren KG, Hommel A, Norrman PO, et al. Epidemiology of femoral neck fractures. Injury. 2002;33(Suppl 3):C1–7.CrossRefGoogle Scholar
  52. 52.
    Egol KA, Koval KJ, Zuckerman JD. Handbook of fractures. Philadelphia: Wolters Kluwer Health; 2015.Google Scholar
  53. 53.
    Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86-A:1711–6.CrossRefGoogle Scholar
  54. 54.
    Seeley MA, Georgiadis AG, Sankar WN. Hip vascularity: a review of the anatomy and clinical implications. J Am Acad Orthop Surg. 2016;24:515–26.CrossRefGoogle Scholar
  55. 55.
    Pauwels F. Der Schenkelhalsbruch. Ein mechaizisches problem: Grundagen des Heilungsvorganges Prognose und kausale Therapie. Beilagheft Z. Orthop. Chir. 63 Stuttgart, Enke. 1935.Google Scholar
  56. 56.
    Muller M. Intertrochanteric osteotomy: indications, preoperative planning, technique. In: Schatzker J, editor. The trochanteric osteotomy. Berlin: Springer; 1984.Google Scholar
  57. 57.
    Garden R. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961;48-B:647–63.CrossRefGoogle Scholar
  58. 58.
    Fixation Using Alternative Implants for the Treatment of Hip Fractures Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017;389:1519–27.CrossRefGoogle Scholar
  59. 59.
    Stockton DJ, Lefaivre KA, Deakin DE, et al. Incidence, magnitude, and predictors of shortening in young femoral neck fractures. J Orthop Trauma. 2015;29:e293–8.CrossRefGoogle Scholar
  60. 60.
    Bhandari M, Chiavaras M, Ayeni O, et al. Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures. J Orthop Trauma. 2013;27:e213–9.CrossRefGoogle Scholar
  61. 61.
    Bhandari M, Chiavaras MM, Parasu N, et al. Radiographic union score for hip substantially improves agreement between surgeons and radiologists. BMC Musculoskelet Disord. 2013;14:70.CrossRefGoogle Scholar
  62. 62.
    Chiavaras MM, Bains S, Choudur H, et al. The Radiographic Union Score for Hip (RUSH): the use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopedic surgeons. Skelet Radiol. 2013;42:1079–88.CrossRefGoogle Scholar
  63. 63.
    Frank T, Osterhoff G, Sprague S, et al. The Radiographic Union Score for Hip (RUSH) identifies radiographic nonunion of femoral neck fractures. Clin Orthop Relat Res. 2016;474:1396–404.CrossRefGoogle Scholar
  64. 64.
    Bhattacharyya T, Bouchard KA, Phadke A, et al. The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am. 2006;88:692–7.PubMedGoogle Scholar
  65. 65.
    Liporace F, Gaines R, Collinge C, et al. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008;90:1654–9.CrossRefGoogle Scholar
  66. 66.
    Upadhyay A, Jain P, Mishra P, et al. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004;86:1035–40.CrossRefGoogle Scholar
  67. 67.
    Lu-Yao GL, Keller RB, Littenberg B, et al. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am. 1994;76:15–25.CrossRefGoogle Scholar
  68. 68.
    Swiontkowski MF. Intracapsular fractures of the hip. J Bone Joint Surg Am. 1994;76:129–38.CrossRefGoogle Scholar
  69. 69.
    Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg. 2005;13:101–9.CrossRefGoogle Scholar
  70. 70.
    Beam HA, Parsons JR, Lin SS. The effects of blood glucose control upon fracture healing in the BB Wistar rat with diabetes mellitus. J Orthop Res. 2002;20:1210–6.CrossRefGoogle Scholar
  71. 71.
    Alho A, Benterud JG, Ronningen H, et al. Prediction of disturbed healing in femoral neck fracture. Radiographic analysis of 149 cases. Acta Orthop Scand. 1992;63:639–44.PubMedGoogle Scholar
  72. 72.
    Blomfeldt R, Tornkvist H, Ponzer S, et al. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am. 2005;87:1680–8.PubMedGoogle Scholar
  73. 73.
    Berry DJ, Von Knoch M, Schleck CD, et al. The cumulative long-term risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am. 2004;86-A:9–14.CrossRefGoogle Scholar
  74. 74.
    Burgers PT, Van Geene AR, Van Den Bekerom MP, et al. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop. 2012;36:1549–60.CrossRefGoogle Scholar
  75. 75.
    Hailer NP, Garellick G, Karrholm J. Uncemented and cemented primary total hip arthroplasty in the Swedish Hip Arthroplasty Register. Acta Orthop. 2010;81:34–41.CrossRefGoogle Scholar
  76. 76.
    Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: a randomised controlled trial in 400 patients. J Bone Joint Surg Br. 2010;92:116–22.CrossRefGoogle Scholar
  77. 77.
    Swart E, Roulette P, Leas D, et al. ORIF or arthroplasty for displaced femoral neck fractures in patients younger than 65 years old: an economic decision analysis. J Bone Joint Surg Am. 2017;99:65–75.CrossRefGoogle Scholar
  78. 78.
    Rodriguez-Merchan EC, Gomez-Castresana F. Internal fixation of nonunions. Clin Orthop Relat Res. 2004;419:13–20.CrossRefGoogle Scholar
  79. 79.
    Marti RK, Schuller HM, Raaymakers EL. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br. 1989;71:782–7.CrossRefGoogle Scholar
  80. 80.
    Magu NK, Singla R, Rohilla R, et al. Modified Pauwels’ intertrochanteric osteotomy in the management of nonunion of a femoral neck fracture following failed osteosynthesis. Bone Joint J. 2014;96-B:1198–201.CrossRefGoogle Scholar
  81. 81.
    Mayo K, Kuldjanov D. Generic preoperative planning for proximal femoral osteotomy in the treatment of nonunion of the femoral neck. J Orthop Trauma. 2018;32(Suppl 1):S46–54.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Robert C. Jacobs
    • 1
    Email author
  • Craig S. Bartlett
    • 1
  • Michael Blankstein
    • 1
  1. 1.University of VermontBurlingtonUSA

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