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Archives of Orthopaedic and Trauma Surgery
Published in: Archives of Orthopaedic and Trauma Surgery 11/2017

01-11-2017 | Trauma Surgery

Focal osteonecrosis in the femoral head following stable anatomic fixation of displaced femoral neck fractures

Authors: Lionel E. Lazaro, Jonathan P. Dyke, Ryan R. Thacher, Joseph T. Nguyen, David L. Helfet, Hollis G. Potter, Dean G. Lorich

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 11/2017

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Abstract

Introduction

Femoral head (FH) osteonecrosis (ON) and subsequent segmental collapse is a major concern following displaced femoral neck fractures (FNF). We aimed to quantify residual perfusion to the FH following FNF and evaluate the viability of the FH overtime after surgical fixation.

Materials and methods

Twenty-three patients with FNF underwent dynamic contrast-enhanced (DCE)-MRI to estimate bone perfusion in the FH, using the contralateral side as control. Following open anatomic reduction and a length/angle-stable fixation, a special MRI sequence evaluated the FH for ON changes over time at 3 and 12 months after surgery.

Results

We found significant compromise of both arterial inflow [83.1%—initial area under the curve (IAUC) and 73.8%—peak) and venous outflow (243.2%—elimination rate (K el)] in the FH of the fractured side. The supero-medial quadrant suffered the greatest decrease in arterial inflow with a significant decrease of 71.6% (IAUC) and 68.5% (peak). Post-operative MRI revealed a high rate (87%—20/23) of small ON segments within the FH, and all developed in the anterior aspect of the supero-medial quadrants. Fracture characteristics, including subcapital FNF, varus deformity, posterior roll-off ≥20° and Pauwel’s angle of 30°–50° demonstrated a greater decrease in perfusion compared to contralateral controls.

Conclusion

FNF significantly impaired the vascular supply to the FH, resulting in high incidence of small ON segments in the supero-medial quadrant of the FH. However, maintained perfusion, probably through the inferior retinacular system, coupled with urgent open anatomic reduction and stable fixation resulted in excellent clinical and radiographic outcomes despite a high rate of small ON segments noted on MRI.

Level of evidence

Level I: Prognostic Investigation.
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Metadata
Title
Focal osteonecrosis in the femoral head following stable anatomic fixation of displaced femoral neck fractures
Authors
Lionel E. Lazaro
Jonathan P. Dyke
Ryan R. Thacher
Joseph T. Nguyen
David L. Helfet
Hollis G. Potter
Dean G. Lorich
Publication date
01-11-2017
Publisher
Springer Berlin Heidelberg
Published in
Archives of Orthopaedic and Trauma Surgery / Issue 11/2017
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI
https://doi.org/10.1007/s00402-017-2778-8

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