Methods of Assessment
After treating the patients with FD by internal fixation only, they were followed up through clinical and radiologic evaluation, at 1.5, 3, 6, 12, and 24 months postoperatively. Postoperative complications were recorded. The Musculoskeletal Tumor Society (MSTS) score15 was used for the evaluation of functional outcomes.
Statistical analysis of data focused on epidemiologic data and functional outcome. Continuous variables such as age and follow-up period were expressed as mean and range. Complications were described as a percentage rate.
The study included 12 male patients (63.16%) and 7 female patients (36.84%). The mean age of the patients was 20.74 years (range, 7 to 40 years). Eighteen patients had a monostotic FD and one patient had a polyostotic disease. One patient had previous curettage and nonvascularized fibular grafting elsewhere and complicated with graft resorption (Figure 2). Eight patients (42.11%) presented with hip pain, two patients (10.53%) presented with limping, five patients (26.32%) presented with hip pain and limping, two patients (10.53%) presented with pathologic fractures, and two patients (10.53%) presented with shepherd's crook deformity (Table 1). Of the 19 patients, 2 patients (10.53%) underwent core biopsy for confirming diagnosis.
All the 19 patients with manifesting FD underwent internal fixation only without grafting. The choice of implant used for fixation depended on the location of the lesion and the bone quality. Fixation by intramedullary (IM) nail was done in four patients (21.05%), dynamic hip screw (DHS) in eight patients (42.11%), cannulated screws in four patients (21.05%), broad dynamic compression plate (DCP) in two patients (10.53%), and narrow DCP in one patient (5.26%). Valgus osteotomy was done in two patients (10.53%) with shepherd's crook deformity.
The mean follow-up period was 53.58 months (range, 24 to 159 months). The mean MSTS score was 27.63 points (range, 21 to 30 points) (Table 1). With the exclusion of the two patients with shepherd's crook deformity, who underwent valgus osteotomy and internal fixation, the mean MSTS score of the remaining 17 patients would be 28.41. At the final follow-up, none of our patients had hip pain, refracture, or progression of deformity. All osteotomy sites showed complete union. No patients in our study developed internal fixation failure.
Four patients (21.05%) had postoperative complications. One patient (5.26%) developed mild limping, which required shoe lift of 1 cm. One patient (5.26%) experienced superficial wound infection, which was managed with antibiotics efficiently. One patient (5.26%) had residual varus deformity and mild limping, which required shoe lift of 1 cm. One patient (5.26%) had residual varus deformity and 3 cm limb length discrepancy, which required also shoe lift.
FD of bone is characterized by the presence of fibro-osseous tissue in the bone with cortical widening and thinning.2 , 16 FD of proximal femur has a wide spectrum of clinical presentations, ranging from hip pain, limping, to deformity, or may present as a pathologic fracture.2 , 7 , 11
In our study of 19 patients with FD of proximal femur, 12 were male and 7 female, which coincided with the numbers in Tong et al,17 who reviewed 15 patients, of which 9 were male and 6 female, and also in Kushare et al,18 who reviewed 23 patients, of which, 14 were male and 9 female. In our study, the mean age of the patients was 20.74 years, which was slightly lower than that of the patients in Tong et al17 (mean age of patients was 25 years) and Majoor et al19 (mean age of patients was 23 years).
The main problem in FD is the resultant weak bone that becomes so evident in the proximal femoral location. So, the treatment is always directed to augment or restore the strength and integrity of bone.2 , 6 The goal of surgery in FD of proximal femur is to eliminate the symptoms resulted from repeated fissures or fractures caused by the lesion, to correct the deformity if present, and to prevent future morbidities such as pathologic fractures or deformities.6
Some authors believe that restoring the integrity of bone requires grafting.17 , 19 However, we do believe that only internal fixation would achieve this goal without associated morbidities of bone grafting. So, this study assesses whether doing internal fixation for these patients would alleviate their symptoms and prevent future morbidities. Moreover, one might think that doing internal fixation without grafting would put the patient under the risk of fixation failure by time. However, in our study, none of the fixations failed with a mean follow-up period of 53.58 months (range, 24 to 159 months). The reason for this was that bone integrity was already present and failure of fixation would happen if bone continuity was lost or ununited fractures were present, which was not the case. Moreover, the complications that occurred in our patients are not related to the nonuse of grafting.
In Nakashima et al20 and Onoda et al,21 intralesional curettage and bone grafting was the treatment option. Majoor et al19 performed cortical strut allografting for impending or actual proximal femoral fractures in 30 patients with FD. In Tong et al,17 15 patients were treated by internal fixation with DHS and anatomic plates following curettage and bone grafting with valgus osteotomy in shepherd’s crook deformity. In Nishida et al,22 eight patients with proximal femoral FD were treated with fibular strut grafting and compression hip screw fixation. Jung et al23 treated eight patients with shepherd's crook deformity by multiple osteotomies and IM nailing.
In our study, all the patients were treated by internal fixation only without grafting using variable implant options depending on the lesion site and bone quality. IM nailing was done in four patients (21.05%), which is a good fixation option for proximal femur, especially in subtrochanteric lesions.24 Long IM nailing traversing the neck and having a firm purchase in the head can prevent loss of neck shaft angle.23 In our study, DHS was used in eight patients (42.11%), cannulated screws in four patients (21.05%), broad DCP in two patients (10.53%), and narrow DCP in one patient (5.26%); and valgus osteotomy was performed in two patients with shepherd's crook deformity.
In our study, with the use of internal fixation implants, the mean MSTS score was 27.63 points, which was considered satisfactory. This score was slightly lower than that in Lang et al,25 where the mean MSTS score was 28.42 points. Also, this score was worse than that in Rosario et al,26 where the mean MSTS score was 29.6 points. This may be attributed to using a minimally invasive surgical approach by Rosario et al26 and relatively low MSTS score, 21 of 30, in two patients with shepherd's crook deformity in our study in whom valgus osteotomy was performed but unlikely with under correction of the varus deformity.
Yang et al27 obtained satisfactory results with valgus osteotomy, curettage, impaction allograft, and IM nail with neck cross-pinning. Li et al13 reported good results and improved functions with valgus osteotomy and DHS fixation. Stephenson et al12 suggested that only curettage and bone grafting of proximal femoral FD is able to obtain a favorable outcome. Contrarily, Enneking and Gearen28 reported that after curettage and bone grafting, lesions were likely to be recurrent and it was not possible to obtain a satisfactory result.
Regarding complications, four patients (21.05%) in our study had postoperative and late complications. One patient had superficial wound infection, which was healed with antibiotics. One patient had mild limping, which required shoe lift of 1 cm. And two patients had residual varus deformity, one of them with 3 cm limb length discrepancy and required also shoe lift. These complications would not be prevented if grafting was used. No internal fixation loosening occurred in any of the patients in our study. Complications in our study were slightly lesser than those in Kushare et al,18 with a complication rate of 21.7%. In Majoor et al,19 the complication rate was 3.3%, with only one patient having a refracture after surgery, which was treated and healed conservatively. In Rosario et al,26 none of the patients developed complications.
In our study, follow-up loss of neck shaft angle did not occur, which was better than O'Sullivan and Zacharin29 and Jung et al23 who reported loss of neck shaft angle in five and two patients, respectively. Our better results were attributed to good stabilization of the femoral neck, which was crucial to prevent the progression of deformity.
The limitations of our study are its retrospective design and single-center site. Also, we had a relatively small number of patients with variable internal fixation implants.
The optimal management option for FD of proximal femur remains debatable. Internal fixation only without grafting has satisfactory functional outcome that alleviates the patient's symptoms, improves the limb function, and prevents future morbidities such as deformities and pathologic fractures. This method eliminates the addition of extra morbidity, longer surgical time, and extra cost caused by bone grafting.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons
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