Avascular necrosis of the femoral head following trochanteric fractures in adults: a systematic review.

INTRODUCTION: Avascular necrosis of the femoral head (ANFH) following trochanteric fractures (TFx) is infrequent. The causal relationship between ANFH and TFx remains controversial. Although several major risk factors for ANFH have been proposed, most of them remain under discussion. In this study we undertook a systematic review of the literature to investigate the incidence of AVN, risk factors and outcomes following Tfx fixation. MATERIALS AND METHODS: A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of ANFH and series of TFx with or without cases of ANFH published between inception of journals to December 2013 were eligible for inclusion. Relevant information was divided in two sections. Part I: included the analysis of detailed case reports of ANFH, either published isolated or included in series of TFx, with the objective of establishing potential risk factors, clinical and radiological presentation, time to development, treatment and outcome of this complication. Part II: analyzed series of TFx, which included cases of ANFH with or without details of aetiology, treatment modalities and outcomes, with the objective of assessing the incidence of ANFH in TFx. RESULTS: Overall 80 articles with 192 cases of ANFH after TFx met the inclusion criteria. The most probable developmental pathway appears to be a disruption of the extra osseous arterial blood supply to the femoral head. Suggested risk factors included high-energy trauma with fracture comminution and displacement, and an atypical course of the fracture line, more proximal, at the base of the neck. Most cases were diagnosed within the first two years after fracture. The clinical and radiological features appear to be similar to those of idiopathic avascular necrosis of the femoral head. The incidence of AVFH with a minimum of 1-year follow-up was calculated 0.95%, and with a minimum 2-year follow-up it was 1.37%. Total hip replacement was the mainstay of treatment. CONCLUSION: The incidence of AVFH after Tfx fixation is small 1.37% within the first 2 years of injury. Risk factors for the development of this complication are related to the severity of trauma, fragment geometry and fracture displacement. Optimum surgery of these fractures cannot guarantee prevention of ANFH.

The treatment of subtrochanteric nonunions with the long gamma nail: twenty-six patients with a minimum 2-year follow-up.

OBJECTIVE: To assess the efficacy of the long Gamma nail in the treatment of subtrochanteric nonunions. DESIGN: Retrospective. SETTING: Multicenter (university teaching hospital, private centers). PATIENTS: Twenty-nine consecutive patients with noninfected sub-trochanteric nonunions following fractures previously treated with different methods of internal fixation. INTERVENTION: Implant removal, corrective osteotomy as needed (3 cases), fixation with a long Gamma nail, and cancellous bone grafting where bone loss (5 cases), all done in a 1-stage procedure. MAIN OUTCOME MEASUREMENTS: Analysis of clinic and radiologic results. Outcome assessment comparing the preinjury status with the status at a minimum follow-up of 24 months. RESULTS: At 2 years, 2 patients had died and another patient was lost to follow-up. Thus, 26 patients completed a median follow-up of 27 months (range 24-41 months). Twenty-three of these patients achieved union after 1 procedure (88% effective initial treatment), and 2 patients achieved union after 1 additional procedure each (exchange of a broken nail and bone grafting, respectively), rising the rate of union to 25 of the 26 patients (96%) in a mean of 7 months (range 4-11 months). The other patient remained ununited at the time of her final follow-up. In addition to the broken nail, breakage of the distal bolts occurred in 2 patients with less than 10 mm shortening. Twenty-one of the 26 patients (80.7%) were restored to their preinjury status. CONCLUSION: Subtrochanteric nonunion can be treated effectively using the long Gamma nail for skeletal stabilization, following removal of previously implanted devices.