Study: remodeling seen years after femoral neck fracture

Children with transepiphyseal fractures and AVN had good function at long-term follow-up.

Indian orthopedic investigators reported that children with intertrochanteric fractures have good remodeling potential and can remodel years after malunion.

Anil Arora, MD, and colleagues followed 76 children with femoral neck fractures for up to 24 years. The study included operative and nonoperative treatments on patients with transepiphyseal, transcervical, basal and intertrochanteric fractures. Of the group, 21 patients also underwent primary defunctioning osteotomy.

The long-term follow-up revealed that 23 patients had premature epiphyseal fusion and 21 developed avascular necrosis. Other complications included delayed union (seven), nonunion (four) and coxa valga (two). Ratliff's criteria showed that 65 patients had good or fair results, according to the study abstract.

Potential for good

"Transepiphyseal fractures, though very rare, are known for sinister complications," Arora said during his presentation at the 15th Triennial Congress of the Asia Pacific Orthopaedic Association. "But, there is something very good. The younger the child is [with the fracture], even if there is a complication, there is more remodeling potential and a better prognosis."

In patients with transepiphyseal fractures and avascular necrosis (AVN), the investigators found remodeling and good function at long-term follow-up.

"Transcervical fractures need to be fixed in a stable manner and one should not hesitate to cross the physis if it is required to achieve stable fixation," Arora said. Surgeons should also fix displaced basal fractures as they may repeatedly displace following closed reduction, he noted in the study abstract.

The investigators discovered that children with intertrochanteric fractures have good remodeling potential and can remodel years after malunion.

AVN signs

While signs of AVN can appear on X-rays as early as 3 months postop, he noted that surgeons should be alert to changes. The investigators found that surgically treated patients with AVN had better results and the natural history of the condition can lead to flattening and arthritic changes in children, according to the study abstract.

The study also revealed that patients with coxa vara >110° showed remodeling at long-term follow-up. However, those with <110? did not, Arora said. Twenty-three patients in the study developed premature epiphyseal fusion.

"It has been seen in even conservatively-treated patients," Arora said. "It is not fair to blame the implant solely."

He noted that leg-length difference in these cases was roughly 2 cm.

For more information:
Anil Arora, MD, can be reached at University College of Medical Sciences, Shahdara, Delhi 110095, India; 91-11-22582972-74.
Arora A. Long-term outcome in childhood femoral neck fractures: The lessons learned. #F053-1. Presented at the 15th Triennial Congress of the Asia Pacific Orthopaedic Association. Sept. 9-13, 2007. Seoul.