|Year : 2015 | Volume
| Issue : 6 | Page : 797-800
Single-stage osteosynthesis and augmented muscle pedicle bone grafting in pathological fracture neck femur with fibrous dysplasia
Basant Kumar Bhuyan
Department of Orthopaedics and Trauma, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan University, Kandagiri Square, Bhubaneswar, Odisha, India
|Date of Web Publication||19-Nov-2015|
Basant Kumar Bhuyan
Professor and Unit Head, Department of Orthopaedics and Trauma, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan University, Khandagiri Square, Bhubaneswar - 751 030, Odisha
Source of Support: None, Conflict of Interest: None
The present report is a case of fibrous dysplasia of the proximal femur with pathological fracture neck of femur treated by single-stage surgery of curettage, internal fixation, nonvascularized fibular grafting and tensor fascia latae-based muscle pedicle bone grafting. At latest (2.6 years) follow-up, fracture is united without any evidence of local recurrence and patient is pain free with good clinical and functional results.
Keywords: Fracture neck of femur, muscle pedicle bone grafting, pathological fracture, tensor fascia latae
|How to cite this article:|
Bhuyan BK. Single-stage osteosynthesis and augmented muscle pedicle bone grafting in pathological fracture neck femur with fibrous dysplasia. Med J DY Patil Univ 2015;8:797-800
|How to cite this URL:|
Bhuyan BK. Single-stage osteosynthesis and augmented muscle pedicle bone grafting in pathological fracture neck femur with fibrous dysplasia. Med J DY Patil Univ [serial online] 2015 [cited 2020 Nov 26];8:797-800. Available from: https://www.mjdrdypu.org/text.asp?2015/8/6/797/169937
| Introduction|| |
Fibrous dysplasia is a developmental disorder of bone that can present in a monostotic or polyostotic form. Polyostotic fibrous dysplasia is a rare disease described in 1938 by Lichtenstein and in a later publication with Jaffé, who also described the monostotic form of the disease.  Fibrous dysplasia has been associated with multiple endocrine and nonendocrine disorders and with McCune-Albright and Mazabraud's syndromes. Primarily affecting adolescents and young adults (85% between the second and third decade of life), it accounts for 7% of benign bone tumors.  Many of the asymptomatic lesions are found incidentally; the remainder presents with symptoms of swelling, deformity, or pain.
| Case Report|| |
An 18-year-old adult male presented to the casualty department with acute pain in the left groin area. There was an episode of trivial trauma which leads to pain and inability to bear weight on the affected left lower extremity. On clinical examination, the left lower limb was shortened and externally rotated. There was the presence of marked anterior hip joint tenderness and all movements of the hip joint were restricted due to pain. There were no signs of an acute infection or general disease symptoms such as fever, night sweat, and loss of weight or appetite.
On radiological examination, an osteolytic lesion was located in the area of the proximal femur with pathological fracture neck of femur [Figure 1]a.
Generalized skeletal survey shows no similar lesions elsewhere and bone morphology appears normal apart from the lesion. Both computed tomography and magnetic resonance imaging scan of pelvis showed a cystic lesion at neck and trochanteric region associated with pathological fracture neck of femur [Figure 1]b and c.
|Figure 1: (a) X-ray of left hip joint antero-posterior view shows an osteolytic lesion with pathological fracture neck of femur; (b) computed tomography scan showed a cystic lesion at neck and trochanteric region associated with a pathological fracture neck of femur; (c) magnetic resonance imaging scan shows a large, cystic space occupying lesion of the neck and proximal femur with displaced pathological fracture neck of femur|
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Patient was thoroughly evaluated clinically and by laboratory examination studies. Differential diagnosis of cystic lesions such as simple bone cyst, aneurismal bone cyst, fibrous dysplasia, or a giant cell tumor was taken into consideration.
Patient was planned for tissue diagnosis by core biopsy which was suggestive of fibrous dysplasia. Due to its benign nature of the lesion, patient was planned for a single-stage surgery consists of curettage, primary osteosynthesis, nonvascularized fibular grafting, cortico-cancellous bone grafting, and augmented tensor fascia latae (TFL)-based muscle pedicle bone grafting.
Patient was operated under regional anesthesia in the supine position over a fracture table. Hip joint was exposed through anterior Smith-Petersen's approach. Thorough curettage of the lesion was done with curette and powered burrs. Fracture reduction and primary osteosynthesis were performed with two 6.5 mm AO cannulated screws under image intensifier control and it was supplemented with ipsilateral nonvascularized fibular graft [Figure 2]a. The remaining defect space was filled with cortico-cancellous bone graft and artificial bone graft substitutes [Figure 2]b.
|Figure 2: (a) Fracture fi xation with Fibular graft and cannulated screws; (b) curettage of the lesion and corticocancellous bone grafting; (c) tensor fascia latae (TFL)-based muscle pedicle bone graft harvested from the iliac crest; (d) TFL muscle pedicle fi xed over the anterior surface of the neck with two cancellous lag screws|
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The surgical technique for TFL muscle pedicle bone grafting was as described by Bhuyan.  The origin of TFL muscle from the outer border of the iliac crest was identified, and a rectangular graft was marked out with a small osteotome. With straight and curved osteotome a graft of 5 cm length, 1 cm width, and 1 cm depth was gently cut out [Figure 2]c. One end of the graft was trimmed, and a slot was made in the femoral head and anterior aspect of the neck across the fracture site. The graft along with the muscle pedicle was mobilized, then placed into this slot and after impaction firmly secured with two 4 mm cancellous lag screw and washers [Figure 2]d. The wound was closed in layers over vacuum suction drain.
Postoperative X-ray showed good fracture reduction with implant in the proper position and adequate filling of the boney lesion. One-lag screw appears to impinge the hip joint at weight bearing area of the femoral head, but the patient did not complain of any pain or grating sensation during movement of the hip joint [Figure 3]a and b. Hence, it was not revised and left behind for later removal after union of the fracture.
|Figure 3: X-rays including (a and b) immediate postoperative X-ray, antero-posterior (A-P) and lateral view; (c and d) follow-up X-ray (2.6 years) A-P and lateral view shows fracture union|
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Postoperatively active quadriceps, mobilizing exercises of hip and knee joint started after 48 h. Nonweight bearing and crutch walking started after 5 days, partial weight bearing (toe touch) was allowed after 6 weeks. Full weight bearing was permitted 6 months after surgery by evidence of radiological union at the fracture site. At latest follow-up (2.6 years), fracture is well united with disappearance of fracture line and well-maintained calcar with a normal hip joint [Figure 3]c and d. There is no recurrence of the osteolytic lesion and the bone grafts showing gradual incorporation to the surrounding bone. The clinical results were analyzed by using the Musculoskeletal Tumor Society functional evaluation and which found to be excellent  [Figure 4]a and b.
|Figure 4: (a and b) Functional result of the patient; able to squat and sit cross-legged|
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Histopathological examination of the biopsy material taken intraoperatively further confirms the diagnosis of fibrous dysplasia [Figure 5].
|Figure 5: Histopathology report suggestive of fibrous dysplasia (H and E, ×40 magnifi cation shows abundant fi broblast in matrix)|
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| Discussion|| |
Clinically, the disease of fibrous dysplasia manifests itself in the form of more or less painful bone deformities, growth disorders, and in part extensive osteolysis with transformation zones including spontaneous fractures. Monostotic disease mostly presented with a circumscribed lesion with rate of distribution affecting the skeleton are femur (36%), tibia (19%), calvaria (17%), and ribs (10%), respectively.  Malignant transformations into high-grade fibro or osteosarcomas are very rare.
In the case of fibrous dysplasia, the strength of the bone is weaker than normal. If no fracture or danger of fracture of the bone exists, as a rule conservative therapy is carried out.  In the polyostotic form of disease, predominantly bisphosphonate therapy is used. Several case studies with pamidronate showed positive effects exerted on bone mineral density and the reduction of pain. ,
Close monitoring is required in asymptomatic lesions, but symptomatic circumscribed lesions; curettage and the filling up of individual foci have gained importance as the definitive choice of treatment. ,,, In the case of bony deformity, corrective osteotomies and rigid internal fixation are performed in addition to curettage and bone grafting. Single or staged procedure (curettage and bone grafting followed by corrective osteotomy) is also advocated by some authors for severe femoral neck deformity. ,
Pathological femoral neck fracture is difficult to treat and it requires surgical treatment.  Magu et al. showed good to excellent results by modified Pauwel's intertrochanteric osteotomy in pathologic femoral neck fractures.  Perea-Tortosa et al. also showed good results by using vascularized bone graft from the iliac crest and osteosynthesis.  Kundu et al. showed good results by sartorius muscle pedicle bone grafting in benign lytic lesions involving the femoral neck. 
Muscle pedicle bone grafting has been successfully used for the management of fresh or neglected fracture neck of femur.  It enhances the local vascularity by providing additional blood supply; hence, it accelerates fracture healing process, prevents avascular necrosis, and collapse of the femoral head. In this case report of pathological fracture, neck femur was treated by single-stage surgery (curettage, bone grafting, nonvascularized fibular grafting, and 6.5 mm AO cannulated screw fixation) augmented with TFL-based muscle pedicle bone grafting. This is an extensive and unique surgical technique with excellent clinical outcome. Surgical expertise and strict technical considerations are required for a successful outcome of surgery.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]