Prediction of femoral head avascular necrosis following femoral neck fracture: "pin-tract sign" of 99mTc-HDP pinhole bone scan after metallic fixation.

OBJECTIVE: To evaluate the predicting value of 99mTc-hydroxydiphosphonate (HDP) pinhole bone scan in development of osteonecrosis of femoral head (ONFH) in patients with femoral neck fracture after cannulated screw fixation. METHODS: Pinhole bone scan of patients with metallically fixed femoral neck fracture from 2001 to 2015 were retrospectively reviewed. Initial pinhole bone scan was obtained within 2-3 weeks after surgery. Findings of initial pinhole bone scan were divided in to 4 groups. Group CU included cold defect in affected femoral head, group HU with no cold defect. Group PP with increased uptake along the inserted screws and group PN with no increased uptake along the inserted screws. More than 6 months of follow-up with pinhole bone scan and clinico-radiological evidence for ONFH was reviewed. RESULTS: 72 patients (mean age 54.01 years, male 22, female 50) were included. 19 patients were in group CU, 53 in group HU. 60 patients were in group PP, 12 in group PN. During the follow-up, 13 patients were diagnosed as ONFH. 9 (47.36%) patients in group CU developed ONFH and 4 (7.5%) in group HU. 4 (6.66%) patients in group PP developed ONFH and 9 (75%) in group PN. CONCLUSIONS: To predict ONFH of femoral head followed by neck fracture, many imaging techniques with variable results were known. In this study, cold defect in early postoperative pinhole bone scans could predict ONFH, and loss of increased uptake along screw inserted site could be a strong indicative sign of ONFH. Further evaluation with a larger population is necessary.

Is rigid fixation of the greater trochanter necessary for arthroplasty of intertrochanteric fractures?

INTRODUCTION: Stable fixation of the greater trochanter fracture fragments is necessary in arthroplasty of intertrochanteric hip fractures, as nonunion of the greater trochanter fracture comminution may result in impaired function or dysfunction of the abductor lever arm. HYPOTHESIS: The ethibond suture technique is an efficient method for fixation of the greater trochanter fracture fragments. MATERIALS AND METHODS: A total of 47 cases were studied. The mean age of the patients was 80.6 years, and the minimum follow-up was 6 months. Radiologic evaluation was done by examination of greater trochanter healing and measurement of migration of the greater trochanter fragment. Functional evaluation was done by comparison of pre-injury and postoperative ambulation status. RESULTS: The mean migration of the greater trochanter fragment with ethibond sutures was 5.98mm. Union was achieved in 76.6%, and the nonunion rate was 23.4%. 86.9% of patients had no difference in ambulation or had a difference of only 1 level by the Koval score after treatment compared to their pre-injury status. DISCUSSION: The ethibond suture technique provides good fixation of the greater trochanter fragments in arthroplasty of intertrochanteric hip fractures. LEVEL OF EVIDENCE: IV, Case series.

Treatment of Proximal Femur Osteomyelitis Occurred after Proximal Femoral Nail Antirotation Fixation, with Antibiotic Cement-coated Tibia Intramedullary Nail: A Case Report.

Antibiotic cement-coated intramedullary nails maintain a locally high antibiotic concentration while contributing to bone stability. We present a case of femoral subtrochanteric fracture in a patient with an infected nonunion who was successfully treated for an infection and nonunion using an antibiotic cement-coated tibial intramedullary nail. A 79-year-old woman with a right femoral subtrochanteric fracture underwent internal fixation using proximal femoral nail antirotation (PFNA). She developed osteomyelitis with nonunion at the surgical site 10 months postoperatively. We decided to insert an antibiotic cement-coated tibial intramedullary nail. After coating the nail with bone cement mixed with antibiotics, bone fixation was achieved by inserting the nail at the site of the PFNA. The patient's symptoms improved, symptoms from the infection disappeared, and bone union was confirmed. Osteomyelitis occurred because of postoperative infection following a proximal femoral fracture. Antibiotic cement-coated tibial intramedullary nails are an effective option to treat patients with osteomyelitis of the femur and achieve bone union where nonunion persists with shallow a intramedullary femoral canal.