The authors have not given the figures for the case 1; They have not given the lateral view of the second case. From what appears in the AP view of the second case, the reduction seems to be in the valgus mode. Such "hat on hook" reductions are well proven to aid union because of the settling that might occur, provided, the implant is holding. The 6 month follow up xray shows this settling rather than varus. There is no sign of avascularity in the femoral head. It is well probable that the neck may still have proceeded to union. A 3D CT reconstruction done at this time would have made us wiser.
It would be interesting to know whether a similar situation occured in the first case as well.
Nonunions of the femoral neck in the young adult is a very difficult problem to tackle. The question as to when to go for a second procedure in a case of established nonunion is a dilemma. No dogmas exist. Waiting for more than 6 months in an ununited neck reduces the chance of obtaining a vascular head. Though union occurs vascularity can still be a problem resulting in early degenerative arthrosis. Waiting too long can unnecessarily jeopardise vascularising procedures like muscle pedicle grafting. However, it remains to be said that there is no clear cut time frame as to when a muscle pedicle grafting can be performed with high rate of success
The above case report has to be seen in this light. An option of supervised neglect should be given only to those whose xrays show a doubtful union and those who refuse a second surgery.
As long as these questions are not answered, fracture neck of femur will still remain as the "unsolved fracture".
Clarification needed
29 July 2008
The authors have not given the figures for the case 1; They have not given the lateral view of the second case. From what appears in the AP view of the second case, the reduction seems to be in the valgus mode. Such "hat on hook" reductions are well proven to aid union because of the settling that might occur, provided, the implant is holding. The 6 month follow up xray shows this settling rather than varus. There is no sign of avascularity in the femoral head. It is well probable that the neck may still have proceeded to union. A 3D CT reconstruction done at this time would have made us wiser.
It would be interesting to know whether a similar situation occured in the first case as well.
Nonunions of the femoral neck in the young adult is a very difficult problem to tackle. The question as to when to go for a second procedure in a case of established nonunion is a dilemma. No dogmas exist. Waiting for more than 6 months in an ununited neck reduces the chance of obtaining a vascular head. Though union occurs vascularity can still be a problem resulting in early degenerative arthrosis. Waiting too long can unnecessarily jeopardise vascularising procedures like muscle pedicle grafting. However, it remains to be said that there is no clear cut time frame as to when a muscle pedicle grafting can be performed with high rate of success
The above case report has to be seen in this light. An option of supervised neglect should be given only to those whose xrays show a doubtful union and those who refuse a second surgery.
As long as these questions are not answered, fracture neck of femur will still remain as the "unsolved fracture".
Competing interests
None declared