Orthopedics

Feature Article 

Prospective and Comparative Analysis of Internal Fixation of Femoral Neck Fractures With or Without Vascularized Iliac Graft in Young Adults

Xiao-bing Yu, MD; De-wei Zhao, PhD, MD; Shi-zhen Zhong, MD; Bao-yi Liu, MD; Ben-jie Wang, MD; Yu-peng Liu, MD; Yao Zhang, MD; Da-ping Cui, MD; Da-peng Fu, MD; Hui Xie, MD

Abstract

The purpose of this study was to compare the effectiveness of 2 surgical approaches for femoral neck fractures in young adults: internal fixation with or without a vascularized iliac graft. Between January 1998 and December 2008, seventy-eight patients presented with a Garden type III (n=38) or IV (n=40) femoral neck fracture. Thirty-eight patients were women and 40 were men, with an average age of 28 years (range, 16–38 years). Fractures were caused by fall injury (n=24), motor vehicle accident (n=36), and heavy weight lifting (n=18). Patients were randomly divided into 2 groups. Group A underwent internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery (n=44), and group B underwent internal fixation with 3 cannulated compression screws (n=34). Average follow-up was 4.5 years (range, 2–8 years), and mean Harris Hip Score was 92 (range, 62–100) in group A and 84 (range, 40–100) in group B. Average fracture healing time at final follow-up was 4.4 months in group A and 6 months in group B. Two (4.5%) cases of osteonecrosis of the femoral head occurred in group A, and 8 (23.5%) cases occurred in group B. Internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery is an effective surgical approach for treating femoral neck fractures in young adults to minimize the occurrence of fracture nonunion and osteonecrosis of the femoral head and to facilitate bone healing and functional recovery of the hip.

The authors are from the Department of Clinical Anatomy (X-BY, S-ZZ, B-YL), Nanfang Medical University, Guangzhou; and the Department of Orthopaedics (D-WZ, B-JW, Y-PL, YZ, D-PC, D-PF, HX), Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China.

The authors have no relevant financial relationships to disclose.

This work was supported by the China National Natural Science Foundation grant 30970699 and National Science and Technology Support Program 2012BAI17B02.

The authors acknowledge the patients and their families and thank Da-chuan Xu for his discussion and technical advice.

Correspondence should be addressed to: De-wei Zhao, PhD, MD, Department of Orthopaedics, Zhongshan Hospital of Dalian University, No. 6 Jiefang St, Dalian, Liaoning Province, 116001, China (dldxyxb@163.com).

Abstract

The purpose of this study was to compare the effectiveness of 2 surgical approaches for femoral neck fractures in young adults: internal fixation with or without a vascularized iliac graft. Between January 1998 and December 2008, seventy-eight patients presented with a Garden type III (n=38) or IV (n=40) femoral neck fracture. Thirty-eight patients were women and 40 were men, with an average age of 28 years (range, 16–38 years). Fractures were caused by fall injury (n=24), motor vehicle accident (n=36), and heavy weight lifting (n=18). Patients were randomly divided into 2 groups. Group A underwent internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery (n=44), and group B underwent internal fixation with 3 cannulated compression screws (n=34). Average follow-up was 4.5 years (range, 2–8 years), and mean Harris Hip Score was 92 (range, 62–100) in group A and 84 (range, 40–100) in group B. Average fracture healing time at final follow-up was 4.4 months in group A and 6 months in group B. Two (4.5%) cases of osteonecrosis of the femoral head occurred in group A, and 8 (23.5%) cases occurred in group B. Internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery is an effective surgical approach for treating femoral neck fractures in young adults to minimize the occurrence of fracture nonunion and osteonecrosis of the femoral head and to facilitate bone healing and functional recovery of the hip.

The authors are from the Department of Clinical Anatomy (X-BY, S-ZZ, B-YL), Nanfang Medical University, Guangzhou; and the Department of Orthopaedics (D-WZ, B-JW, Y-PL, YZ, D-PC, D-PF, HX), Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China.

The authors have no relevant financial relationships to disclose.

This work was supported by the China National Natural Science Foundation grant 30970699 and National Science and Technology Support Program 2012BAI17B02.

The authors acknowledge the patients and their families and thank Da-chuan Xu for his discussion and technical advice.

Correspondence should be addressed to: De-wei Zhao, PhD, MD, Department of Orthopaedics, Zhongshan Hospital of Dalian University, No. 6 Jiefang St, Dalian, Liaoning Province, 116001, China (dldxyxb@163.com).

Femoral neck fractures constitute 3% of all fractures.1 They occur most frequently in elderly patients with osteoporosis and occasionally in young adults. They result from high-energy injuries and are accompanied by multisystem injuries.2 Although total hip arthroplasty is an option for elderly patients, it is not a good choice for young adults.2–6 It is challenging for orthopedic surgeons to work on this area due its the complexity in anatomical structure, blood circulation, biomechanical and functional characteristics, fracture union features at the upper part of the femur, and nature of the treatment. It is difficult to manage because of the special blood circulatory system of the femoral neck and the fragmentation condition.7–9 The typical current treatment for patients with femoral neck fractures is internal fixation with 3 screws, in which case nonunion and osteonecrosis of the femoral head are unavoidable.10,11 Gozen12 reported that blood supply is key when treating femoral neck fractures. Chang et al13 used the deep circumflex iliac artery intraoperatively as the blood supply. However, a vascularized iliac graft combined with internal fixation to treat a femoral neck fracture has not been previously reported.

To prevent fracture nonunion and osteonecrosis of the femoral head in young adults with femoral neck fractures, the current authors compared the effectiveness of 2 surgical approaches: group A underwent internal fixation using 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery and group B underwent internal fixation with 3 cannulated compression screws.

Materials and Methods

Seventy-eight young adults (38 women and 40 men) with an average age of 28 years (range, 16–38 years) were admitted between January 1998 and December 2008 for a Garden type III (n=38) or IV (n=40) femoral neck fracture. Of these patients, 36 had a subcapital fracture and 42 had a transcervical fracture caused by fall injury (n=24), motor vehicle accident (n=36), and heavy weight lifting (n=18). Patients were randomly divided into 2 groups: group A underwent internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery (n=44), and group B underwent internal fixation with 3 cannulated compression screws (n=34). The interval between presentation and surgery was 1 to 3 days. All patients were followed for 2 to 8 years (average, 4.5 years) postoperatively.

Each patient underwent a detailed pre-operative physical examination and routine supporting examinations. Anteroposterior and lateral hip radiographs were obtained to determine the fracture type and displacement and to achieve an easier closed reduction. No excessive traction or excessive inner rotation of the ipsilateral limb was allowed to minimize the occurrence of nonunion and osteonecrosis of the femoral head due to injuries of the remaining blood vessels under the exterior–posterior support ligament of the femoral head.

Surgical Technique

Internal fixation with 3 cannulated compression screws was performed in group B. After epidural anesthesia, the patient lay on the traction bed with the ipsilateral limb in 90° of abduction and 15° of inward rotation. Mean operative time was 65±12 minutes. Under surveillance in the C-arm radiograph machine, 2 spots (2 and 4 cm, respectively) below the highest point at the lateral trochanter along the femoral axis were chosen as the upper and lower puncture sites, respectively. The middle puncture site was set 1 cm posterior to the femoral axis, along the line 3 cm below the higher puncture site and vertical to the femoral axis. Three induction needles were inserted into each site, laid in parallel with the femoral neck, and evenly positioned in a triangular position. Skin surrounding the puncture sites was properly incised and separated with a clamp to expose the periosteum, after which 3 cannulated screws were placed along each induction needle. The puncturing depth was strictly controlled at 0.5 to 1 cm under cartilage (0.5 cm in subcapital fractures). The induction needles were then removed, and the incision was closed with sutures and dressing.

Patients in group A underwent internal fixation with 2 cannulated screws in combination with an iliac graft supported by the ascending branch of the circumflexa femoris lateralis. Mean operative time was 68±14 minutes. The puncture of 2 cannulated screws was conducted as described for group B, with 1 screw immobilizing the rear of the femoral head and the other screw immobilizing the upper part of the femoral calcar to spare enough space for the pedicle graft. A double-curved, 12-cm-long incision was generated along the line connecting the anterosuperior iliac spine and the posterior patella, and the proximal end of the incision traveled along the iliac crest 4 cm beyond the anterosuperior iliac spine (Figure 1). The incision was properly extended upward or downward when necessary.

Illustration showing that a 12-cm double-curved incision was generated anterolaterally, starting 4 cm proximal to the spina iliaca anterosuperior.

Figure 1: Illustration showing that a 12-cm double-curved incision was generated anterolaterally, starting 4 cm proximal to the spina iliaca anterosuperior.

After partial transection of the musculus sartorius and the starting part of the rectus femoris, the musculus tensor fasciae latae was stretched outward to expose the ascending branch of the circumflexa femoris lateralis. Separation was performed toward the iliac crest to the starting point of the musculus tensor fasciae latae; the thinner branch of the iliac crest was brought together by a branch of gluteal muscle. An iliac graft was then taken from the lateral anterosuperior iliac spine, which was approximately 5 cm long and 3 cm wide, with a vascular pedicle long enough for transfer. The authors then incised an approximately 3-cm-long and 2-cm-wide vascularized bone graft from the iliac crest, where a volume of 1 cm3 to 2 cm3 of cancellous bone was collected. The capsule of the femoral head and neck was incised in a T shape. An osteotome was used to create an approximately 2×2-cm bone window at the femoral head–neck junction laterally, supported by a previously harvested vascularized bone graft and specially designed impaction instruments of different sizes. Specific attention was paid to prevent squeezing the soft tissue cuff containing the vessels of the bone graft. The iliac graft was then transferred to the window on the affected femoral head and embedded into the bone (Figure 2).

Illustration showing a vascularized iliac graft supported by the ascending branch of the circumflexa femoris lateralis taken from the anterosuperior iliac crest. It was approximately 5 cm long and 3 cm wide, with a vascular pedicle long enough for transfer. An attempt was made to elevate the collapsed segment of the femoral head intraoperatively with impaction instruments through a 233-cm bone window created at the femoral head–neck junction and supported by the autologous vascularized iliac graft.

Figure 2: Illustration showing a vascularized iliac graft supported by the ascending branch of the circumflexa femoris lateralis taken from the anterosuperior iliac crest. It was approximately 5 cm long and 3 cm wide, with a vascular pedicle long enough for transfer. An attempt was made to elevate the collapsed segment of the femoral head intraoperatively with impaction instruments through a 233-cm bone window created at the femoral head–neck junction and supported by the autologous vascularized iliac graft.

Skin traction was performed on the ipsilateral limb to maintain 30° of abduction in a neutral position. Antibiotics were given to prevent infection, and nonsteroidal anti-inflammatory drugs were given to patients with severe pain. Active contraction–extension quadriceps exercises were initiated 24 hours postoperatively. In general, patients could sit or half-sit in bed and start active abduction and adduction exercises for 20 to 30 times each round, 3 rounds per day. Three weeks postoperatively, patients could walk on crutches. At follow-up 4 to 6 months postoperatively, patients underwent examinations, including radiographs and hip function assessment, and paired crutches were changed to a single crutch based on the healing status of the fracture as demonstrated by the radiographs. The screws were removed after the bone-healing condition was stabilized for an average of 1.5 years. Mean length of stay was 17±5 days for patients in group A and 15±3 days for patients in group B.

Descriptive statistics, Fisher’s exact test, and Student’s t test were used to analyze categorical data. Continuous data were analyzed with descriptive statistics and unpaired t test. A P value less than .05 was considered statistically significant.

Results

Average follow-up was 4.5 years (range, 2–8 years). Average healing times were 4.4 and 6 months for groups A and B, respectively. Based on the standard features of the Harris Hip Score14 and radiology, osteonecrosis of the femoral head occurred in 2 (4.5%) patients in group A and 8 (23.5%) patients in group B. Two osteonecrosis cases were caused by fracture nonunion. Nonunion was observed in no patient in group A and 2 patients in group B, whereas hip varus was observed in 1 patient in each group. No dislocation or deep venous thrombosis was observed in either group, whereas shortened limbs were observed in 2 patients in group A and 6 patients in group B. No difference existed between the 2 groups in operative time and length of stay (P=.125 and .214, respectively) (Tables 1, 2; Figure 3).

Patient Data

Table 1: Patient Data

Postoperative Complications

Table 2: Postoperative Complications

Postoperative radiographs showing a Garden type III fracture. The fracture was fixed with 2 cannulated screws and an iliac graft (A); 18-month postoperative VIEW radiograph showing the fracture healing (B); 18-month postoperative VIEW radiograph showing that the internal fixation system was removed (C); 4 years after removing the internal fixation system, digital subtraction angiography VIEW showing that the ascending branch of lateral circum-flex artery were successfully grafted to the femoral head and neck (D); after removing the internal fixation system, VIEW 3-dimensional computed tomography scan showing that the femoral neck fracture was healed, with the screw tunnel and autologous vascularized iliac graft (arrow) (E); no vascular necrosis or screw tunnel was observed on the coronal view (F) and the transverse section (G). [AQ 25]

Figure 3: Postoperative radiographs showing a Garden type III fracture. The fracture was fixed with 2 cannulated screws and an iliac graft (A); 18-month postoperative VIEW radiograph showing the fracture healing (B); 18-month postoperative VIEW radiograph showing that the internal fixation system was removed (C); 4 years after removing the internal fixation system, digital subtraction angiography VIEW showing that the ascending branch of lateral circum-flex artery were successfully grafted to the femoral head and neck (D); after removing the internal fixation system, VIEW 3-dimensional computed tomography scan showing that the femoral neck fracture was healed, with the screw tunnel and autologous vascularized iliac graft (arrow) (E); no vascular necrosis or screw tunnel was observed on the coronal view (F) and the transverse section (G).

Discussion

Reduction of blood flow in the femoral head occurs in 83% of patients with a subcapital fracture and 52% of patients with a transcervical fracture.15 Subcapital fracture has the highest incidence of osteonecrosis of the femoral head, followed by transcervical fracture. Therefore, subcapital, transcervical, and previous fractures are considered surgical indications in young adults16 for treatment with internal fixation with 2 cannulated screws combined with an iliac graft or internal fixation with 3 cannulated screws. Osteonecrosis of the femoral head is a complication of an intracapsular femoral neck fracture and is associated with age, injury severity, cortical bone defect, fracture grade, time between initial injury and surgery, reduction accuracy, evacuation of the intracapsular hematoma, and position of the fixation devices.17–19 Surgical treatment should be performed as soon as possible in the absence of contradictive evidence.20–24 Intraoperatively, the affected joint capsule should be opened and fully decompressed, and blood deposits should be thoroughly rinsed and eliminated, with sufficient decompression to prevent bleeding.25–29 Nonunion and osteonecrosis of the femoral head are major postoperative complications of femoral fractures in young adults.30–33 The incidence of osteonecrosis in young adults is higher than in that elderly patients because a stronger force is required to cause the fracture with severe displacement in young adults than in elderly patients.

Ensuring that sufficient blood flows to the damaged bone is the key to avoiding nonunion and osteonecrosis of the femoral head because fracture severity is associated with the degree of blood supply damage.34–38 Bone grafting is a reliable method for treating fractures with good functional outcomes in the long term. The current authors prefer a free fibular graft with 2 cannulated screws and early mobilization (osteonecrosis of the femoral head, 0%–6.5%; nonunion, 9%–12%).39–41 Sufficient blood supply reduces the risk of osteonecrosis of the femoral head and nonunion.17,42

In the current study, reduction was successfully achieved by internal fixation with an iliac graft supported by the ascending branch of the circumflexa femoris lateralis. Using the ascending branch of the circumflexa femoris lateralis graft had advantages: (1) it was easy to harvest; (2) with sufficient care, it caused minimal morbidity at the donor site; and (3) the vascular pedicle was sufficiently long. The procedure provided good blood supply to the fractured bone, facilitated the healing process, and prevented the femoral bone from becoming necrotic.43–47 The current procedure is an efficient approach for treating femoral neck fractures.

The advantages of a cannulated compression screw are its small size, hollow cavity, and compression function. Screw threads can significantly buffer the cutting force, fulfill the compression actions, and significantly decrease the volume of the inner fixers, therefore decreasing the damage to the bone callus in some patients.48–50 Although 3 fixation screws placed in a triangular position and evenly distributed in the femoral neck can increase the stability of the fractured femoral neck in accordance with biomechanics, 2-screw fixation also sufficiently retains the triangular position and increases the stability more efficiently.51–54

Ninety-five percent of the circumflexa femoris lateralis and its extensions branch from the deep femoral artery, whereas 5% branch directly from the femoral artery. The ascending branch of the circumflexa femoris lateralis ascends upward after it leaves the trunk and then travels upward along the deep surface of the rectus femoris to the port of the musculus tensor fasciae latae, where it delivers a spina iliaca branch, a gluteus medius branch, and a musculus tensor fasciae latae branch. Among these branches, the spina iliaca branch travels upward and stops at the spina iliaca. This ascending branch is a mean of 8.5±3.1 cm long, with a mean outer diameter of 3.2±0.9 mm at the starting site. An iliac graft supported by the ascending branch of the circumflexa femoris lateralis is rich in blood supply and has a longer blood vessel pedicle.55,56 Two sampling methods exist: iliac grafts supported by the spina iliaca branch or by the anteroinferior spina iliaca branch. Both branches belong to the ascending branch of the circumflexa femoris lateralis. Although these 2 sampling methods have similar advantages (ie, rich in bone content, easy to process, and do not affect functional hip recovery), the latter method is more convenient. However, when the anteroinferior spina iliaca branch was not found intraoperatively in the current study, the incision was extended upward to sample an iliac graft supported by the blood vessel pedicle of the circumflexa ilium profunda.57,58

In the current study, ischemic femoral head necrosis occurred in 8 patients in group B. Two of these cases were caused by fracture nonunion, and the interval between consultation and surgical treatment in 1 of the 2 patients was 3 weeks. It was possible that abnormal action of the fractured bone caused the aggravation of the impaired blood supply to the femoral head. Both patients underwent total hip arthroplasty. Another 2 patients sustained subcapital fractures, which healed 11 months postoperatively as proved by radiographs. However, the density of the femoral head increased with complications, such as cystic fibrosis and partial collapse of the exterior–posterior femoral head. This could be caused by the more severely impaired blood supply. Both patients showed amelioration of pain and improved function of the ipsilateral hip after removal of the cannulated screws and receiving the iliac graft supported by the ascending branch of the circumflexa femoris lateralis. Two patients (aged 34 and 36 years, respectively) with a subcapital fracture in group A sustained ischemia of the femoral head, and their poor postoperative prognosis was associated with their ages and the severity of the damaged blood supply in this type of subcapital fracture. Patients with osteonecrosis were followed with intravenous digital subtraction angiography, which confirmed that the blood supply in patients in group A was significantly better than that in patients in group B.

Conclusion

Internal fixation of a fractured femoral head using 2 cannulated screws combined with an iliac graft supported by the ascending branch of the circumflexa femoris lateralis is an effective approach for treating femoral neck fractures in young adult patients. It can improve the blood supply in fractured bone and the femoral head, accelerate healing, and prevent bone osteonecrosis.

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Patient Data

Variable Surgical Approach
Group Aa (n=44) Group Bb (n=34)
HHS (range), pointsc 92 (62–100) 84 (40–100)
Mean bone healing, mod 4.4 6
ONFH, No. (%)e 2 (4.5) 8 (23.5)

Postoperative Complications

Postoperative Complication No.
Group Aa (n=44) Group Bb (n=34)
Infection 1 0
Nonunion 0 2
Avascular necrosisc 2 8
Hip varus 1 1
Dislocation 0 0
Deep venous thrombosis 0 0
Lower limbs shortened 2 6

10.3928/01477447-20130122-12

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