Treatment of Pathologic Femoral Neck Fractures with Modified Pauwels’ Osteotomy N. K. Magu, MS*†; Roop Singh, MS*†; Ashwini Sharma, MS*†; and Rajeev Sen, MD‡ Treatment of pathologic femoral neck fractures secondary to extensive lesions of fibrous dysplasia and simple bone cysts has been controversial. We think that modified Pauwels’ in- tertrochanteric osteotomy and osteosynthesis can result in sound healing of the lesion and of the fracture, with no re- currence, low complication rates, and good functional re- sults. Seven patients were treated with a uniform approach consisting of biopsy (Stage I) and osteotomy with osteosyn- thesis (Stage II). Curettage of the lesion and bone grafting were not done. The average followup was 79.28 months (range, 32–142 months). All of the fractures and osteotomy sites healed in means of 14 weeks (range, 12–16 weeks) and 9.1 weeks (range, 8–10 weeks), respectively. All fibrous dys- plasia lesions healed radiologically. Grade IV radiographic healing was seen in both patients with simple bone cysts after 35 and 92 months. Using the Musculoskeletal Tumor Society functional evaluation and Toronto Extremity Salvage Score, all the patients had good to excellent results. Complications such as infection, local recurrence, refracture, femoral neck deformity, osteonecrosis of the femoral head, and growth arrest of capital femoral physis were not seen. In addition to biomechanical advantages, the procedure seems to have had a biologic role in healing of the fracture and of the lesion by initiating osteogenesis to replace the defect with new bone. Level of Evidence: Therapeutic study, Level IV (case series— no, or historical control group). See the Guidelines for Au- thors for a complete description of levels of evidence. Benign lesions of bone, including developmental defects, frequently are seen in the proximal femur. Two of these lesions, fibrous dysplasia and simple bone cyst, often oc- cur in adolescents and young adults with a normal life expectancy. 38 Treatment of femoral neck fractures second- ary to symptomatic benign lesions is difficult because of the size and nature of the lesion, the resulting bony defect, the recurrence, the associated deformity, and osteonecrosis (ON). 25,34,38 Numerous treatment modalities have been reported for treatment of pathologic fractures of the proximal femur secondary to benign lesions. 9,13,17,18,20,29,32,34–36,38 Popular methods of corticosteroid or bone marrow injections can- not be relied on to heal the cyst. 4,21,23,33 An unsatisfactory outcome in 25% of patients and a complication rate of 45%, which includes avascular necrosis, coxa vara, refrac- tures, and short femur, have been observed after treatment with traction or traction and hip spica as initial treatment in pathologic fractures through unicameral bone cysts. 27 Persistence of the cystic cavity with nonoperative methods poses an additional risk of recurrent fractures, recurrence of the lesion requiring repeat procedures, deformity, os- teonecrosis of the femoral head, infection, coxa vara, epiphyseal arrest and shortening of the limb, and resorp- tion of the cancellous bone grafts. The risks associated with commonly used methods 13,17,18,20,25,27,29,32,34–36,38 need to be satisfactorily addressed. The classic treatment of simple bone cysts with curettage of the lining mem- brane and grafting with homogenous or autogenous bone has been associated with a high risk of recur- rence. 2,6,14,24,36 It often is difficult to fix fractures inter- nally through unicameral cysts in the neck or intertrochan- teric or subtrochanteric regions of the femur because of the extensive loss of bone. 15,23,31,34 Fibrous dysplasia of bone is an enigma with no known cure. 17 Recurrence rates of 66.6% and 13.3% have been reported in two series of fibrous dysplasia treated by cu- rettage and cancellous 13 or cortical bone grafting. 17 Grafts are incorporated quickly after autologous cancellous bone grafting and eventually are replaced by dysplastic tissue. 11 Received: February 22, 2004 Revised: September 4, 2004; February 8, 2005 Accepted: March 14, 2005 From the Departments of *Orthopaedics, †Physical Medicine and Rehabili- tation and ‡Pathology, Pt. B.D. Sharma PGIMS, Rohtak (Haryana) India. Each author certifies that he or she has no commercial association that might pose a conflict of interest in connection with submitted article. Each author certifies that his institution has approved the human protocol for this investigation and that all experimentation was conducted in conformity with ethical principles of research. Informed consent was taken for partici- pation in the study. Correspondence to: N. K. Magu, MS, 22/8 FM, Medical Enclave, Rohtak- 124001 (Haryana), India. Phone: 91-1262-213967; Fax: 0091-1262-211889; E-mail: nkmagu@rediffmail.com. DOI: 10.1097/01.blo.0000164355.99795.79 CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 437, pp. 229–235 © 2005 Lippincott Williams & Wilkins 229