Research Article

Geriatric Orthopaedic Surgery

& Rehabilitation
Avascular Necrosis of Femoral Head: 4(3) 74-77
ª The Author(s) 2013
Reprints and permission:
A Rare Complication of a Common Fracture sagepub.com/journalsPermissions.nav
DOI: 10.1177/2151458513507771
in an Octogenarian gos.sagepub.com

Ravi Mallina, MRCS1, and Feroz Dinah, FRCS1

Abstract
Avascular necrosis (AVN) of the femoral head is a relatively uncommon complication following an extracapsular hip fracture.
Although it can occur following fixation of unstable 3-part or 4-part intertrochanteric fractures with significant posteromedial and
posterolateral comminution, it remains a rare complication. We present a case of AVN of the femoral head following fixation of a
stable 2-part intertrochanteric fracture in spite of good healing at the hip fracture site. This is a rare but eminently treatable cause
of persisting hip pain after hip fracture surgery, and primary or secondary care physicians should be aware of this possibility.

Keywords
avascular necrosis, femoral head, extracapsular hip fracture, dynamic hip screw

Introduction osteoarthritis. However, there was softening and destruction

Avascular necrosis (AVN) of the femoral head following a
stable extracapsular hip fracture is a rare complication, with
isolated case reports in the English literature. We describe an
unusual case of AVN of the femoral head in an octogenarian
following dynamic hip screw (DHS) fixation for a stable
2-part intertrochanteric fracture.
of the femoral head cartilage and underlying bone suggestive
of AVN. Following removal of the DHS, an uncemented THR
with metal-on-polyethylene bearing was implanted. After
appropriate rehabilitation, the patient was discharged without
any postoperative complications. At the last clinical review,
6 months following the THR, the patient remained pain free
and independently mobile, with check radiographs confirming
a well-seated uncemented THR (Figure 4).

Case Report
An 80-year-old female presented with a left hip fracture fol-
lowing a fall. She had no significant medical comorbidities.
Radiological examination confirmed a simple extracapsular hip
fracture (type 31 A1 fracture) devoid of any posteromedial and
posterolateral comminution (Figure 1). The fracture was
stabilized with DHS fixation within 24 hours of admission.
Intraoperative images confirmed accurate fracture reduction
and hardware placement (Figure 2).
There were no intraoperative complications, and the patient
made an uneventful recovery. She was discharged home 8 days
after the surgery.
Two years later, the patient was referred to the orthopedic
service with increasing left groin and knee pain and difficulty
mobilizing. Clinically, the patient had groin tenderness, painful
restricted range of hip movements, particularly internal rotation
of the hip. Although knee radiographs were normal, sequential
radiographs of the left hip confirmed superolateral AVN of the
femoral head (Figure 3A and B). The patient was therefore
offered a total hip replacement (THR), which she agreed to.
Intraoperatively, there was no evidence of posttraumatic
Discussion
A detailed review of the English literature puts the incidence of
AVN following fixation of extracapsular intertrochanteric
fractures at 0.3% to 1.16%.1-6 Although 48 cases of AVN of the
femoral head were reported in 9725 patients with intertrochan-
teric fractures, this rare complication was more prevalent in
unstable extracapsular hip fractures (type 31 A2 and 31 A3
fractures). In patients with stable fractures (type 31 A1), AVN
was reported only sporadically: the 48 cases of AVN identified,
consisted of only 3 cases of stable 2-part intertrochanteric frac-
tures. In our patient, the fracture was only minimally displaced,
was reduced satisfactorily by closed method, and was stabilized
1
The South West London Elective Orthopaedic Centre, Epsom, United
Kingdom
Corresponding Author:
Ravi Mallina, The South West London Elective Orthopaedic Centre, Dorking
Road, Epsom KT18 7EG, United Kingdom.
Email: ravi.mallina@nhs.net
Mallina and Dinah 75

Figure 1. A and B, The anterior–posterior (AP) and lateral radiograph of the left hip showing extracapsular fracture.

Figure 2. A and B, Intraoperative radiographs displaying optimal position of lag screw and neck shaft angle.

Figure 3. A and B, The anterior–posterior (AP) left hip showing early and late superolateral avascular necrosis (AVN) of the left femoral head.
76
Figure 4. The anterior–posterior (AP) pelvis demonstrating unce-
mented total hip replacement (THR).
by an experienced surgeon within 24 hours of admission to the
hospital. There were thus no risk factors for AVN of the
femoral head.
Anatomical variations in extracapsular and intraosseous
vascular anastomoses have been extensively debated in the
literature.7 This suggests that disruption of blood supply to
the femoral head via posterior retinacular branches of
profunda medial circumflex artery may still appear to be the
primary etiology of the present complication. Some authors
have postulated that with advancing age blood vessels are
less resistant to overstretching during fracture reduction
maneuvers, which may jeopardize the already precarious
blood supply to the femoral head. The AVN of the femoral
head has been reported to occur in patients treated with ante-
grade intramedullary nail when the entry point of the nail is
medial to the greater trochanter around the piriform fossa,
thereby causing iatrogenic injury to the deep branch of med-
ial circumflex artery.8 Inadvertent placement of guide wire or
multiple attempts of passing the guide wire across the
femoral neck are theoretical risk factors for AVN of the
femoral head. However, none of these is thought to be
responsible for AVN in our patient.
Several studies have been reported in the literature on the
management of complications of proximal femoral fracture
by hip arthroplasty.9-12 The majority of the complications are
mechanical in nature and related to hardware failure. Cut out
and migration of the lag screw are the commonest, followed
by plate failure and intramedullary nail or lag screw fracture.
Posttraumatic osteoarthritis, nonunion, and AVN of the
femoral head, although infrequent, can be successfully man-
aged by THR even in the elderly patients. In a recent large
series of 102 THRs performed for complications of internal
fixation of proximal femoral fractures, 39 of them were for
failed intertrochanteric hip fractures.9 Of these 39 cases (33
treated with a DHS and 3 with an intramedullary nail), the
authors reported AVN of the femoral head in 11 cases.
However, the review does not mention the AVN rates in stable
2-part intertrochanteric fractures. A review focussing on THR
Geriatric Orthopaedic Surgery & Rehabilitation 4(3)
(n ¼ 32) following failure of DHS fixation of fractures of the
proximal femur does not report the clear incidence of AVN
of the femoral head.11
The THR performed for reasons other than primary
osteoarthritis is associated with higher complication rates, and
THR secondary to failed intertrochanteric fractures is no
exception. In the most recent reviews, a dislocation rate of
2% to 5% and a periprosthetic fracture rate of 3% to 6% are
quoted when a THR is performed for complications of
intertrochanteric hip fracture.9-12 Elderly patients should be
adequately counseled about this when offered a major proce-
dure such as THR.
The current case highlights the possibility of AVN of the
femoral head after fixation and healing of a stable 2-part inter-
trochanteric hip fracture. As most elderly patients with osteo-
porotic proximal femoral fractures are not followed up on
discharge and do not seek medical attention, this complication
may perhaps be underestimated. Once diagnosed appropriately,
with the help of multidisciplinary support, we were able to
offer our patient an uncemented THR thereby improving her
quality of life. Although AVN is a rare occurrence after extra-
capsular hip fractures, persisting hip or leg pain should alert the
treating physician or surgeon to this unusual complication,
which can be easily treated to improve the patient’s pain,
mobility, and quality of life.
Declaration of Conflicting Interests
The author(s) declared no conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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