CASE REPORT OPEN ACCESS

International Journal of Surgery Case Reports 3 (2012) 529532

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Pseudarthrosis of femoral neck stress fracture treated with open reduction, sliding hip screw and bone morphogenic protein
D. Dargan , D. McCaffrey, W.D.C. Kealey
Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, Northern Ireland BT12 6BA, United Kingdom

a r t i c l e

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a b s t r a c t
INTRODUCTION: Pseudarthrosis of femoral neck stress fractures in young adults are associated with a high incidence of complications and revision surgery. The majority are treated urgently with closed reduction and internal xation. PRESENTATION OF CASE: We describe a displaced tension-type femoral neck fatigue fracture presenting late. Pseudarthrosis formation prior to surgery resulted in resorption and shortening of the femoral neck. Open reduction and internal xation was performed, with adjuvant recombinant human bone morphogenic protein-7 therapy. Radiological union was achieved by twelve weeks and by one year the patient was asymptomatic. DISCUSSION: Reports of successful management of femoral neck fatigue fracture non-unions are rare. Meyers muscle pedicle graft, valgus subtrochanteric osteotomy, and cannulated screw xation with autologous iliac crest bone graftare alternative procedures. CONCLUSION: This extremely rare fracture type merits open reduction to enable accurate fracture reduction. Supplementing sliding hip screw xation with an orthobiological agent was successful in this challenging situation. 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Article history: Received 1 March 2012 Received in revised form 30 May 2012 Accepted 22 June 2012 Available online 7 July 2012 Keywords: Femur neck fractures Stress fractures Pseudarthrosis Bone morphogenic protein Nonunion Internal xation

1. Introduction Fatigue fractures differ from insufciency or pathological stress fractures as they occur in healthy bone which has been exposed to localised, repetitive sub-threshold loading. This causes microtrauma to the crystalline structure in excess of the ability to repair, resulting in fracture if the activity persists. Often, an imbalance in muscular effort results in an abnormal force distribution.1 The femoral neck is predisposed to non-union for several reasons. As it is within the joint capsule, it is exposed to synovial uid and enzymes. Shear stresses due to the anatomical position of the femoral neck provide a biomechanical challenge, and a tenuous blood supply from retinacular vessels adjacent to bone is often disrupted in the event of fracture. High risk activities for fatigue fractures include long-distance running and military training,2 particularly with a weighted backpack. Footwear modications and altering training patterns help prevent these fractures in athletes and military personnel.2 Gradual onset of pain is the main early symptom with leg length discrepancy occurring on displacement. Continued weight bearing is often possible despite displacement, as demonstrated in the case below.

Only 15% of fatigue fractures of the femoral neck show early changes on plain radiographs3 and 50% may show no changes at any stage if serial radiographs are used.4 Magnetic resonance imaging has been proven to be more sensitive, specic and accurate than both plain radiography and scintigraphy, and is now regarded as the gold standard for the investigation and diagnosis of suspected fatigue fractures.5

2. Case report A 37-year-old healthy male presented with a ten-month history of increasing right hip pain on active hip movements, and a six week history of leg length discrepancy. He had no history of trauma, no co-morbidities and had never taken corticosteroids, but took non-steroidal anti-imammatory medication for analgesia. As a milkman, he carried a crate of milk, invariably in his right hand, on a daily basis. He ran with this load from the milk delivery vehicle to the customers front door. As a crewman on a lifeboat at weekends, he would jump and land from short heights in urgent situations. No contact sport or recreational physical exercise was implicated. Plain radiographs demonstrated a displaced fracture at the base of the right femoral neck (Fig. 1). Painful fracture mobility was clinically evident. A differential of osteomyelitis, insufciency fracture, primary bone neoplasia or metastatic deposit were considered. Haematological investigations were normal. Computed tomography and an isotope bone scan failed to demonstrate an occult malignancy.

Corresponding author at: Apartment 31, St. Johns Wharf, Laganbank Road, Belfast, Northern Ireland BT1 3LT, United Kingdom. Tel.: +44 7815863493. E-mail address: dallan [email protected] (D. Dargan).

2210-2612/$ see front matter 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2012.06.006

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Fig. 1. Plain anteroposterior X-ray of pelvis on presentation.

Magnetic resonance imaging excluded avascular necrosis of the femoral head. The appearance suggested bone failure in tension rather than compression (Fig. 2). The neck fracture was carefully mobilised and reduced via a SmithPetersen approach. Bone morphogenic protein was added to the fracture site, and the fracture was compressed with a variable angle sliding hip screw. Intra-operative bacteriology specimens showed no growth and curettage sent for histopathological analysis excluded malignancy. A post-operative dual energy X-ray absorptiometry (DEXA) scan excluded osteoporosis. The fracture achieved radiological union by twelve weeks (Figs. 3 and 4) and by one year the patient was pain free, walking normally with no evidence of avascular necrosis (Fig. 5), with a Harris Hip score6 of >90.

Fig. 3. Anteroposterior X-ray of right hip twelve weeks after surgery.

3. Discussion Femoral neck fatigue fractures may be classied initially according to prognosis and risk of displacement from plain radiographs of the proximal femur. Compression fractures involve the calcar, and tension fractures involve the superior cortex. Tension fractures have a higher likelihood of displacement than compression fractures,7 and may necessitate prophylactic xation to prevent displacement, depending on patient factors such as pre-morbid mobility, body habitus, compliance and co-morbidities. However, bicortical, undisplaced fractures have been treated non-operatively with excellent outcomes in young, compliant military recruits.8,9 Magnetic resonance imaging can further differentiate the severity of fatigue injury,10 if a displaced fracture is not apparent from plain radiographs. Displaced stress fracture xation is known to have a high complication rate with revision required in up to 47% of patients,11,12 particularly if there is a delay in the diagnosis. Acutely displaced femoral neck fatigue fractures may be managed with a sliding hip screw. However, reports of successful management of femoral neck fatigue fracture non-unions are rare. Muscle pedicle graft (Meyers procedure),13 valgus subtrochanteric osteotomy,14 and autologous bone graft harvesting from the iliac

Fig. 2. Coronal T2 weighted image of the right proximal femur, demonstrating pseudarthrosis of the fatigue fracture.

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crest, with cannulated screw xation,15 are alternative procedures. In each of the above individual cases, good to excellent results were described. Meyers published successful results of muscle pedicle grafting in acute traumatic displaced femoral neck fractures in seventeen adults under forty years, although none were for non-union. Marti et al.16 followed up 44 of 50 femoral neck non-unions treated with Pauwels abduction osteotomy. Excepting seven revisions to arthroplasty, the average Harris Hip score was 91. Subtrochanteric osteotomy allows an average lengthening of 1.01.5 cm.17 LeCroys free vascularised bula grafting of femoral neck non-unions resulted in long term preservation of the femoral head in 20 of 22 patients, but average Harris score of 78.18 Arthroplasty is generally reserved for revision in young individuals. Recently, the role of autologous iliac crest bone graft as the gold standard for non-union has been questioned.19 Graft harvest carries a risk of chronic donor site pain, and rhBMP-7 has demonstrated similar efcacy to autologous bone graft in long bone non-unions.20 The rarity of femoral neck pseudarthrosis prevents a singleinstitution trial of adjunctive bone morphogenic protein use. Whether angiogenic properties of rhBMP reduce the incidence of avascular necrosis in a population is unclear. Complications such as heterotopic ossication raise concerns regarding the appropriate dosage of rhBMP. Although expensive, the initial cost of rhBMP-7 is considerably less than that of multiple operations for persistent non-union,20 and therefore has been advocated if complex or persistent non-union is anticipated. 4. Conclusion
Fig. 4. Lateral X-ray of hip twelve weeks after surgery.

Fatigue fracture of the femoral neck is rare but should be considered in any patient with hip pain and either a recent or prolonged history of intense or repetitive activity. As plain radiographs lack sensitivity, physician education regarding presentation and the value of MRI is important to prevent delay in diagnosis and progression to displacement. We recommend early MRI to investigate potential femoral neck fatigue fractures if symptoms persist despite rest, or recur with activity, in any patient with no other obvious cause such as osteoarthritis. In the case of non-union of displaced femoral neck fatigue fractures the use of rhBMP-7 or other biological adjuvant therapies may improve the rate of union following surgical xation and justify their expense by avoiding revision surgery. Conict of interest statement I conrm that there are no conicts of interest with nancial or personal relationships with other people, or organisations that could inappropriately inuence this work. Funding No grant or funding was received in support of this study. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Author contributions All authors contributed to writing, data acquisition, critical review and nal approval.

Fig. 5. Anteroposterior X-ray of right hip one year after surgery.

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532 D. Dargan et al. / International Journal of Surgery Case Reports 3 (2012) 529532 male adults. Journal of Bone and Joint Surgery British Volume 2006;88(12): 15749. Kiuru MJ, Pihlajamaki HK, Ahovuo JA. Fatigue stress injuries of the pelvic bones and proximal femur: evaluation with MR imaging. European Radiology 2003;13(3):60511. Pihlajamaki HK, Ruohola JP, Kiuru MJ, Visuri TI. Displaced femoral neck fatigue fractures in military recruits. Journal of Bone and Joint Surgery 2006;88(9):198997. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Archives of Orthopaedic and Trauma Surgery 2003;123(10):52733. Mendez AA, Eyster RL. Displaced nonunion stress fracture of the femoral neck treated with internal xation and bone graft. A case report and review of the literature. American Journal of Sports Medicine 1992;20(2):2303. Diwanji SR, Kong IK, Cho SG, Seon JK, Yoon TR. Displaced stress fracture of the femoral neck treated by valgus subtrochanteric osteotomy: 2 case studies. American Journal of Sports Medicine 2007;35(9):156770. Haddad FS, Bann S, Hill RA, Jones DH. Displaced stress fracture of the femoral neck in an active amenorrhoeic adolescent. British Journal of Sports Medicine 1997;31(1):702. Marti RK, Schuller HM, Raaymakers E. Intertrochanteric osteotomy for nonunion of the femoral neck. Journal of Bone and Joint Surgery British Volume 1989;71(5):782. Wu C-C, Shih C-H, Chen W-J, Tai C-L. Treatment of femoral neck nonunions with a sliding compression screw: comparison with and without subtrochanteric valgus osteotomy. The Journal of Trauma and Acute Care Surgery 1999;46(2):3127. LeCroy CM, Rizzo M, Gunneson EE, Urbaniak JR. Free vascularized bular bone grafting in the management of femoral neck nonunion in patients younger than fty years. Journal of Orthopaedic Trauma 2002;16(7):46472. Sen MK, Miclau T. Autologous iliac crest bone graft: should it still be the gold standard for treating nonunions? Injury 2007;38(Suppl. 1):S7580. Garrison KR, Shemilt I, Donell S, Ryder JJ, Mugford M, Harvey I, et al. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database of Systems Review 2010:6.

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