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Osteonecrosis of the Femoral Head After Retrograde Intramedullary Nailing of a Femoral Shaft Fracture in an AdolescentA Case Report
Darren A. Frank, MD1; Robert A. Gallo, MD1; Gregory T. Altman, MD1; Daniel T. Altman, MD1
1 Department of Orthopaedic Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212. E-mail address for R.A. Gallo: august_gallo@yahoo.com
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Sep 01;87(9):2080-2085. doi: 10.2106/JBJS.D.02774
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Extract

Osteonecrosis of the capital femoral epiphysis following antegrade intramedullary nailing of femoral shaft fractures has been generally described as occurring in adolescent and pediatric patients1-10. However, a limited number of cases have been reported in adults11,12. The condition appears to represent an iatrogenic injury resulting from the proximity of the medial femoral circumflex artery to the piriformis fossa, which is the typical starting point for intramedullary nailing13. To our knowledge, there have been no previously published reports of osteonecrosis of the femoral head following retrograde intramedullary nailing of a femoral shaft fracture. Retrograde insertion techniques are applicable to adults and older adolescents, after closure of the distal femoral physis. We present the case of an adolescent male with osteonecrosis of the femoral head following retrograde femoral intramedullary nailing, and we review the osteonecrosis risk factors that may be present in patients who sustain polytrauma. Our patient and his legal guardian were informed that data concerning the case would be submitted for publication.
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    Hee Joong Kim, M.D.
    Posted on October 10, 2005
    Subchondral Stess Fracture--An Alternative Diagnosis?
    Department of Orthpaedic Surgery, Seoul National University Hospital, Seoul, KOREA

    To The Editor:

    We read with interest "Osteonecrosis of the Femoral Head after Retrograde Intramedullary Nailing of a Femoral Shaft Fracture in an Adolescent" (2005;87:2080-85), by Darren, et al. The authors reported a rare case of osteonecrosis of the femoral head (ONFH) that occurred after retrograde intramedullary nailing for a femoral shaft fracture in a 17-year-old boy with polytrauma. We would suggest that the diagnosis of the authors might be incorrect because the figures suggest to us a possible diagnosis of subchondral stress fracture of the femoral head (SSFFH).

    SSFFH is an infrequent condition that was first reported to occur as an insufficiency type stress fracture in people with poor bone quality(1-9). Recently, we reported that SSFFH occurred as a fatigue type stress fracture in military recruits(10).

    The authors found collapse of the femoral head on plain radiographs and subchondral collapse and edema within the femoral head on T2- weighted MR image and felt that these findings confirm a diagnosis of ONFH. However, we believe there are two findings against a diagnosis of osteonecrosis on the MR image. The first MR finding of ONFH is reported to be the abnormal signal intensity band (low signal intensity on T1) that represents the reactive zone between necrotic and living bones(11-14). In ONFH, subchondral fracture occurs inside of the necrotic area(15). Therefore, together with the subchondral fracture line, there should be an abnormal signal intensity band surrounding the fracture line. The second finding against ONFH is the extent of BME. Edema cannot occur in dead tissue and in ONFH, the BME pattern is observed outside of the necrotic area(10,14,16). However, in the present case, the BME pattern is observed in whole femoral head and it suggests that the head is alive.

    The patient seemed to be kept in bed for a long time because of polytrauma and it might lead to disuse osteoporosis. We think it is likely to expect a subchondral insufficiency fracture of the femoral head in this patient.

    Kwang Woo Nam, M.D.

    Jeong Joon Yoo, M.D.

    Hee Joong Kim, M.D.

    References:

    1. Bangil M, Soubrier M, Dubost JJ, Rami S, Carcanagues Y, Ristori JM, Bussiere JL. Subchondral insufficiency fracture of the femoral head. Rev Rheum Engl Ed. 1996;63:859-61.

    2. Buttaro M, Gonzalez Della Valle A, Morandi A, Sabas M, Pietrani M, Piccaluga F. Insufficiency subchondral fracture of the femoral head: report of 4 cases and review of the literature. J Arthroplasty. 2003;18:377-82.

    3. Motomura G, Yamamoto T, Miyanishi K, Shirasawa K, Noguchi Y, Iwamoto Y. Subchondral insufficiency fracture of the femoral head and acetabulum: a case report. J Bone Joint Surg Am. 2002;84:1205-9.

    4. Raffi M, Mitnick H, Klug J, Firooznia H. Insufficiency fracture of the femoral head: MR imaging in three patients. AJR. 1997;168:159-63.

    5. Uetani M, Hashmi R, Ito M, Okimoto T, Kawahara Y, Hayashi K, Enomoto H, Shindo H. Subchondral insufficiency fracture of the femoral head: magnetic resonance imaging findings correlated with micro-computed tomography and histopathology. Comput Assist Tomogr. 2003;27:189-93.

    6. Vande Berg BC, Malghem J, Goffin EJ, Duprez TP, Maldague BE. Transient epiphyseal lesions in renal transplant recipients: presumed insufficiency stress fractures. Radiology.1994;191:403-7.

    7. Yamamoto T, Bullough PG. Subchondral insufficiency fracture of the femoral head: A differential diagnosis in acute onset of coxarthrosis in the elderly. Arthritis Rheum. 1999;42:2719-23.

    8. Yamamoto T, Schneider R, Bullough PG. Insufficiency subchondral fracture of the femoral head. Am J Surg Pathol. 2000;24:464-8.

    9. Yamamoto T, Schneider R, Bullough PG. Subchondral insufficiency fracture of the femoral head: histopathologic correlation with MRI. Skeletal Radiol. 2001;30:247-54.

    10. Song WS, Yoo JJ, Koo KH, Yoon KS, Kim YM, Kim HJ. Subchondral fatigue fracture of the femoral head in military recruits. J Bone Joint Surg Am. 2004;86:1917-24.

    11. Nakamura T, Matsumoto T, Nishino M, Tomita K, Kadoya M. Early magnetic resonance imaging and histologic findings in a model of femoral head necrosis. Clin Orthop. 1997;334:68-72.

    12. Kubo T, Yamasoe S, Sugano N, Fujioka M, Naruse S, Yoshimura N, Oka T, Hirasawa Y. Initial MRI findings of non-traumatic osteonecrosis of the femoral head in renal allograft recipients. Magn Reson Imaging. 1997;15:1017-23.

    13. Sakamoto M, Shimizu K, Iida S, Akita T, Moriya H. Osteonecrosis of the femoral head. A prospective study with MRI. J Bone Joint Surg Br. 1997;79:213-219.

    14. Kim YM, Oh HC, Kim HJ. The pattern of bone marrow oedema on MRI in osteonecrosis of the femoral head. J Bone Joint Surg Br. 2000;82:837-41.

    15. Glimcher MJ, Kenzora JE. The biology of osteonecrosis of the human femoral head and its clinical implications (3 parts). Clin Orthop. 1979;138:284-309; 139:283-312; 140:273-312.

    16. Vande Berg BE, Malghem JJ, Labaisse MA, Noel HM, Maldague BE. MR imaging of avascular necrosis and transient marrow edema of the femoral head. RadioGraphics. 1993;13:501-20.

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