Transfracture abduction osteotomy: A solution for nonunion of femoral neck fractures

Background: Nonunion and avascular necrosis (AVN) of the femoral head remains one of the major complications following femoral neck fractures. Despite various surgical techniques and internal fixation devices, the incidence of nonunion and AVN has remained unsolved. Neglected nonunion of femoral neck fracture is common in the developing world. Treatment options include rigid internal fixation with or without bone grafting, muscle pedicle bone graft, valgus osteotomy of the proximal femur with or without bone graft, valgus osteotomy or hip arthroplasty. We conducted a retrospective analysis of cases of nonunion of femoral neck fracture treated by transfracture abduction osteotomy (TFAO). Materials and Methods: Over a period of 35 years (1974-2008), 30 patients with nonunion of femoral neck fractures were treated with TFAO over a period of 35 years (1974-2008), All patients were less than 50 years of age. Absence of clinical and radiological signs of union after four months was considered as nonunion. Patients more than 50 years of age were excluded from the study. Union was assessed at 6 months radiologically. Limb length was measured at six months. The mean duration of femoral neck fracture was 19 months (range 4 months 10 years). Results were analyzed in terms of radiological union at six months. Average followup was five years and six months. Results: Consistent union was noted at the followup after six months in 29 cases. One case was lost to followup after five and one-half months postoperatively. However, the fracture had united in this case at the last followup. Average shortening of the limb at six months was 1.9 cm. Average neck shaft angle was 127 (range 120-145). Five cases went into AVN but were asymptomatic. Two cases required reoperation due to back out of Moore's pins. These were reopened and cancellous screws were inserted in the same tracks. Conclusions: Consistent union of nonunion femoral neck fracture was noted at the followup after six months in 29 cases. The major drawback of the procedure is immobilization of the patient in the hip spica for eight weeks.