Journal of Pediatric Orthopaedics - 2026-01-01 - Journal Article; Multicenter Study
Fixation Procedures of The Proximal Third Femur in Patients With Osteogenesis Imperfecta: Location, Location, and High Revision Rates.
Nguyen CV, Makarewich CA, Akula S, Poon SC, Cho RH
Topics
Key Takeaway
Femoral neck fractures in OI carry a 72.2% complication rate, 33.3% nonunion rate, and 55.6% revision rate, with Pauwels type 3 morphology in 72.2% of cases driving the majority of failures.
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Summary
This multicenter retrospective study evaluated outcomes of proximal femur fracture and osteotomy fixation in OI patients, applying Pauwels classification to femoral neck fractures and analyzing risk factors for complications. Femoral neck fractures (n=18) had a 72.2% complication rate, 33.3% nonunion rate, and 55.6% revision rate; higher Pauwels class (p=0.044) and lower reduction quality (p=0.037) were independent risk factors. Intertrochanteric/subtrochanteric procedures (n=35) had lower nonunion rates (5.4%) but still required revision in 32.4% of cases, most after initial healing.
Key Limitation
Small sample size (n=18 femoral neck fractures) limits statistical power to detect additional risk factors and prevents subgroup analysis by OI type or bisphosphonate use.
Original Abstract
BACKGROUND
Fractures and osteotomies of the proximal femur and femoral neck in patients with osteogenesis imperfecta (OI) can be challenging to reduce and stabilize. The purpose of this study was to evaluate the results of surgical fixation of proximal femur fractures and osteotomies, use modern classification to describe femoral neck fractures in OI, and identify risk factors for complications.
METHODS
This was a multi-center retrospective study of patients with OI who had proximal femur fixation and at least 12 months follow up. Patient demographics, radiographic classifications, clinical data, and details of each procedure and follow up visit were obtained. Radiographs were examined and graded for reduction quality and healing. Risk factors for complications were analyzed using Mann-Whitney U for continuous variables and Fisher Exact test for categorical variables.
RESULTS
Fifty-five fracture or osteotomy fixation procedures in 43 patients were included (18 femoral neck, 35 intertrochanteric or subtrochanteric femur). Most femoral neck fractures were Pauwels type 3 (72.2%). For femoral neck fractures, the complication rate was 72.2%, the nonunion rate was 33.3%, and the overall revision surgery rate was 55.6%. Lower reduction quality was associated with higher rate of nonunion ( P =0.037), and higher Pauwels class was associated with higher complication rates ( P =0.044). For intertrochanteric/subtrochanteric osteotomies and fractures, combined complication rate was 35.1% and nonunion rate was 5.4%. Revision surgery rate was 32.4%, with most of these arising after initial healing. All patients in the study eventually went on to union.
CONCLUSION
Femoral neck fractures in patients with OI have high rates of complications, nonunion, and reoperation. Risk factors for complications include higher Pauwels type and lower initial reduction quality. Intertrochanteric and subtrochanteric fractures and osteotomies have a lower nonunion rate but their overall rate of revision surgery is still almost 1/3, with most complications occurring after initial healing. Patients with OI should be counseled that proximal femur fractures and osteotomies have high rates of revision surgery.
LEVEL OF EVIDENCE
Level IV-retrospective case control study.