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Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures

Large, Thomas M. MD; Adams, Mark R. MD; Loeffler, Bryan J. MD; Gardner, Michael J. MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: November 1, 2019 - Volume 27 - Issue 21 - p 794-805
doi: 10.5435/JAAOS-D-18-00225
Review Article
SDC
CME

Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.

From the Orthopaedic Trauma Services, Mission Hospital, Asheville, NC (Dr. Large), the Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ (Dr. Adams), the Atrium Health Department of Orthopaedic Surgery, OrthoCarolina Hand Center, Charlotte, NC (Dr. Loeffler),and the Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA (Dr. Gardner).

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Large, Dr. Adams, Dr. Loeffler, and Dr. Gardner.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jaaos.org).

Copyright 2019 by the American Academy of Orthopaedic Surgeons.
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