TRAUMARECONSTRUCTION

Management of neglected/ununited fractures of thefemoral neck in young adultsO.N.Nagi and M. S.Dhillon

Department of Orthopaedics, Post Graduate Institute of Medical Education and Research,Chandigarh, India

INTRODUCTIONProximal femoral fracturesmay be extra or intra-capsu-lar injuries, and they occur with about the same fre-quency in the elderly population. They are morecommon in women, with the inter-trochanteric extra-capsular injuries occurring in a relatively older segmentof thepopulation.1Intra-capsular femoralneck fractures,known since the advent of medicine, are still a manage-ment enigma, in spite of increased understandingof the technology, diagnostic methods and treatment. Inthe last century, treatment protocols have evolvedconsiderably fromWhitman’s protocols of spica applica-tion, andhave nowbecomebetter def|ned.2 This injury ismost frequently encountered in the elderly population,where aminor slipmaybe the cause, and is relatively un-common in young adults.Themodern literature reflectsa disturbing trend of more injuries occurring in theyounger age groups, and these are usually the result ofhigh-energy trauma. At whatever age they present,complications are frequent, with union rates beingrelatively low; a combination of factors is responsiblefor this.

TERMINOLOGYBasically, all femoral neck fractures, where the fractureline is primarily within the joint capsule, are called ‘Intra-capsular’ fractures of the hip. Fractures that involve thearticular surface should be considered a more complexvariety and some authors even consider them separately.A host of names has been given to intra-capsular pat-terns, varying from‘transcervical’ to ‘Subcapital’ injuries,and the prognosis in these cases is much worse.On theother hand, those at the base of the neck, are primarilyextra-capsular and are separate entities, requiring

different forms of stabilisation, and having much betterunion rates.

EPIDEMIOLOGYKoval andZuckerman,1reported that in1994, 250 000 fe-moral neck fractures occurred in the USA (projected1.3million fractures worldwide). This rate is expected todouble by 2025. Martin et al. found increasing incidenceof fractures of the proximal femur, which could not beexplained by changing demographics alone.3 Approxi-mately half of the fractures reported in all studies are in-tra-capsular, and the average age of these cases isapproximately 80 years, with 75% being females. Con-versely, when the injury occurs in young adults, most ofthese cases are healthy adults, with no super-addedpathology, and good bone stock.The velocity of traumais also higher, with a larger number of associated injuries.

ARTERIALBLOODSUPPLYA lot of detail has now been gleaned about the bloodsupply to the proximal end of the femur, which has someunique features. The arterial supply becomes tenuousafter injury, endangering the femoral head, risking subse-quent avascular necrosis and collapse. The arterial ar-cades which supply the blood to the head and neckmaybe divided into three major groups; these wereclearly described by Crock.4

(1) An extra capsular arterial ring, located at the baseof the femoral neck, and encircling it.

(2) Ascending cervical branches arise from this arterialring on the surface of the femoral neck.

(3) The arteries of the ligamentum teres, which alsosupply a signif|cant part of the blood supply.

The extra-capsular arterial ring is formed posteriorlyby a largebranch of themedial femoral circumflex artery

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Current Orthopaedics (2003) 17, 394--402�c 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S0268-0890(03)00046-X

and anteriorly by a branch from the lateral femoral cir-cumflex artery.The ascending cervical branches or reti-nacular vessels ascendon the surface of the femoralneckin anterior, posterior, medial, and lateral groups; thelateral vessels are the most important. Their proximityto the surface of the femoral neck makes them vulner-able to injury in femoral neck fractures. As the articularmargin of the femoral head is approachedby the ascend-ing cervical vessels, a second, less distinct ring of vesselsis formed, referred to by Chung5 as the subsynovial in-tra-articular arterial ring. It is from this ring of vesselsthat vessels penetrate the head and are referred to asthe epiphyseal arteries, the most important being thelateral epiphyseal arterial group supplying the lateralweight-bearing portion of the femoral head. Theseepiphyseal vessels are joinedby inferiormetaphyseal ves-sels and vessels from the ligamentum teres.

MECHANISMOF INJURYIn contrast to the elderly population, femoral neck frac-tures in young adults can only occur with signif|cantforce. Kocher suggested two mechanisms of injury in allage groups. In the elderly, the injury is more commonlydue to a direct blow over the greater trochanter duringa fall. Inyoung adults, themore common injury is a lateralrotation force applied to the extremity, with or withouta proximally directed force. With deforming force, thehead is held f|xed by the anterior capsule and iliofemoralligaments while the hip rotates externally. By this rota-tion, the posterior cortex of the neck impinges on thelip of the acetabulum, and the neck buckles. This leadsto a complete break in the anterior cortex, and alsocauses buckling of the posterior cortex (Fig. 1a and b).This also explains the marked posterior comminution ofthe neck often seenwith this injury.

RADIOLOGYThe radiological examination6 should include the routineviews (AP, and lateral), and in the cases of fractures withneglect, some special views maybe benef|cial. The APview should be taken in maximum internal rotation ofthe limb to evaluate the extent of neck resorption; itmay alsobe a good idea, in caseswithproximalmigrationof the neck, to take X-rays using the ‘push pull’ method,to see how much the trochanter can be brought downwithmanual traction. In special cases, itmaybe advanta-geous to use CT scans to determine the extent ofcomminution of theposterior cortex;MRI couldbe donefor assessment of the vascular status of the femoralhead, as bone marrow changes may give indirectevidence of presence or lack of vascularity.

Figure1 (a) Line diagramshowingmechanismof femoralneckfracturewith external rotation force.The anterior aspect of thefractureisopenedout (A),whilethereisbucklingoftheposteriorcortex (B). The anterior blood vessels are invariably torn (C)while the posterior vessels may potentially be intact (D).(b) X-ray photograph (lateral view) showing break in anteriorcortex (A) andbuckling of posterior cortex (B).

FEMORALNECKINYOUNGADULTS 395

CAUSESOFDELAYEDHEALING/NON-UNIONIn all intra-capsular fractures, the synovial fluid bathingthe fracturemay interfere with the healing process. An-giogenic-inhibiting factors in synovial fluid can also inhibitfracture repair. Additionally, as the femoral neck has es-sentially no periosteal layer, all healing must be endo-steal. These factors, along with the precarious bloodsupply to the femoral head, make healing unpredictableand non-unions fairly frequent.In the developing countries, we still see patients with

delays in treatmentdue to poormedical facilities, misseddiagnosis (especially in polytraumatised young adults), orimproper surgical techniques.The factors known to con-tribute to non-union of the femoral neck includevascularinsuff|ciency, inaccurate reduction, and loss of f|xation.The f|rst one is usually not in our control, but the lattertwo, along with delayed diagnosis, make up a signif|cantnumber of cases still encountered in the developingworld.In the recent past, improved treatment, earlier diag-

nosis, and an understanding of the treatment regimensof femoral neck fractures has drastically reduced theincidence of non-union after these injuries. Inspite of this,non-unions are still estimated to occur in 10--20% ofpatients in the developed world in all age groups.Withanatomical reduction and stable f|xation, the incidenceof non-union should be acceptably low. However, in ameta-analysis of 106 reports of displaced femoral neckfractures (seen at all ages) by Lu-Yao et al., non-union oc-curred in a cumulative 23--37% of fractures.7

The appropriate treatment depends on several fac-tors, including the age and physical status of the patient,the viability of the femoral head, the amount of resorp-tion of the femoral neck, and the duration of the non-union.8 Most patients with femoral non-unions are over60 years of age; these cases are poor surgical candidatesfor repeated surgical interventions, and extreme osteo-porosis decreases the eff|ciency of any internal f|xation.The answer in this age group is simple, and a replacementarthroplasty as a primary procedure gives reliableresults. In the younger age group, however, where it isimportant to save the femoral head, and in children,where some potential for growth is still present, theoperation should be devised so as to make all attemptsto save the head of the femur.This is not always possible,as delays in treatment invariably lead to problems.

PROBLEMS WITHDELAYThe effect of surgical delay on the incidence of avascularnecrosis andnon-union afterdisplaced femoralneck frac-ture has been reviewed by several investigators. Massie9

demonstrated a direct relationship between delay of

fracture reduction and incidence of avascular necrosis(AVN): fractures reduced within12h of injury had a 25%incidence of AVN, whereas for fracture reduced morethan 7 days after injury, the ratewas100%.Manninger et al.10 reported a signif|cantly lower inci-

dence of segmental collapse in patients treated within6h of injury,when theycompared two subsetswhoweretreated early and late. At 1-year follow-up, 1.9% of frac-tures in the early treatment group and 19.3% of cases inthe delayed treatmentgroup had segmental collapse; fol-low-up at 6 --10 years revealed segmental collapse ratesof 36.8% in the early treatment group and 63.9% in thedelayed treatment group. Additionally, more patients inthe delayed treatment group developed non-union. It isalso interesting to note that in the early treatmentgroup, segmental collapse often involved only a portionof the femoral head, whereas total head involvementwas much more common in the delayed treatmentgroup.This shows how the treatmentbecomesmore dif-f|cult in cases who have a signif|cant period of delay priorto surgery.

EVOLUTIONOF TREATMENTMETHODSHistorically, most of these casesweremanagedby differ-entkinds of osteotomies, inwhich the femur was dividednear the lesser trochanter and was either angulated toprovide a line of weight bearing more directly beneaththe femoral head, or was displacedmedially.11These werenot universally successful, as they were operations doneaway from the fracture site, and did not ensure fractureunion, or re-vascularisation of the head.Two types of os-teotomy or modif|cations of them have been used totreat non-unions of the femoral neck: the displacementosteotomy (McMurray), made just proximal to or at thelesser trochanter, and the angulation osteotomy(Schanz), made through or just distal to the lesser tro-chanter.The displacementosteotomyofMcMurray12heldcentre-stage for a long time, and in our country was onlydiscontinued in the late 1970s as the primary treatmentmodality, whenmore reliablemethods of osteosynthesisbecame available.The mechanical advantages of an osteotomy are that

the line of weight bearing is shiftedmedially and that theshearing force at the non-union is decreasedbecause thefracture surface tends tobecomemorehorizontal.Theseadvantages are greater after the angulation osteotomythan after the displacement osteotomy. A serious disad-vantage is produced if the femoral neck and head areplaced in an extreme valgus position, and this positionmust be avoided if possible because it shortens the leverarm between the trochanter, on which the abductormuscles pull, and the head, which is the fulcrum. In1936,Pauwels13 called attention to thismechanical problem.

396 CURRENTORTHOPAEDICS

In treating non-unions with a viable head, the angula-tion osteotomy was not intended to provide a partialpelvic supportbutrather to shift the line of weight bear-ingmedially and to change the inclination of the fracturesurfaces.Blount14 devised a bladeplate that held the frag-ments securely without external support. The angula-tion osteotomy is currently f|xed with variable angledhip screws and side plates, and several more recentreports have indicated its usefulness. Marti et al.15

reported union in 86% of 50 non-unions treated withinter-trochanteric osteotomy alone; three non-unionshealed after revision procedures.Another operation, arthrodesis, involves different

procedureswhere the hip is fused, and ismentionedonlyfor the sake of completion. Some authors advocate it asan option in children and adults less than 21years of agewho have frank non-unions in which the femoral head isnot viable. The advantages of an arthrodesis for non-union of the femoralneck are freedom frompain and sta-bility during weight bearing; this may lead to a useful ex-tremity that allows ambulation and weight bearing,albeitwith a limp.This can occasionallybe recommendedin adults under the age of about 50 years whosework isheavy manual labour, or after the failure of previoussurgery with an infection in the hip. A major disadvan-tage is the delayed onset of severe degenerative changesin the spine and contralateral hip, as well as signif|cantdiff|culty in subsequent conversion to an arthroplasty.In the present day scenario, the best option perhaps is

to obtain union in these fractures by the best possiblemethod, and to avoid the development of AVN and theensuing collapse of the head. In 1984, the senior authorpublished the results of cases with delayed or neglectedfractures which were treated by a combination of inter-nal f|xation, accurate reduction and f|bular osteosynth-esis.16 The good results seen in those cases lead us tomake this the primary treatment method in all cases offemoral neck fracture seen in young adults, after signif|-cant periods of delay in treatment (6 weeks or more).Consistently reproducible union rates and a loweredincidence of AVN allowed us to expand our indicationsto include those cases in which previous surgical proce-dures had failed, 17and even in children.18

LITERATUREREVIEWThe few reports that have been published concerningneglected fractures of the femoral neck in young adultsemphasise that the outcome is usually poor.19 Early accu-rate reduction and f|xation under compression has givengoodresults, but in developing countries early operationis not always possible. This can lead to problems ofmanagement.It is desirable to try to salvage the femoral head in

young adults, and this often calls for some form of bone

graft. The literature reports many techniques,20--22

ranging from of the use of Phemister grafts,23 vascu-larised24 or muscle pedicle grafts,25,26 and f|bular graftswith or without osteotomy,27--29 but none of these stu-dies has been prospective or large enough to allow anyconclusion about the best form of treatment. Lifeso andYoung,30 concluding that non-union in young adults wasdiff|cult to treat, felt thatvalgus osteotomygave accepta-ble results. However, displacement osteotomy is nolonger popular, as it interferes with subsequent arthro-plasty procedures if there are any complicationswith theprimary operation.31 The best results come from someform of bone graftwith stable f|xation.Baksi25 has popu-larised the use of the muscle pedicle graft proceduredescribed by Meyers,26 and it has been used for ne-glected cases as well as for cases with established AVN.This procedure basically uses the posterior approach,which in the authors’opinion damages whatever residualblood vessels remain in this area after the injury. Thereare now some reports in the literature which cautionagainst the use of the posterior approach.17 In cases inwhich a Meyers muscle pedicle graft had been delayedfor more than 3 months after injury, Johnson and Brockreported up to a 75% rate of non-union.32 On the otherhand, excellent results have been obtainedwith open re-duction and vascularised iliac-crest grafting, using ananterior approach.24 However, the procedure involvesthe use of specialised instrumentation and is technicallydemanding, and since only a few cases have been re-ported the long-term acceptability has yet to be proven.

Operative technique

This involves open reduction of the fracture, whichshould be accurate and stable, special modif|cations inthe anterior capsular incision to try and save anteriorvessels, and the use of a f|bular graft to supplement thef|xation achieved by an AO cancellous screw.

Anterolateral approach (modif|ed fromWatson--Jones)Since the inception of themethodology of f|bular osteo-synthesis, the approach used at our institute has beenone modif|ed from the standard Watson--Jonesapproach.This positions the patient in a semi-supine po-sition, with a sandbag under the buttock, and allowsgoodradiological imaging aswell asmakingmanipulationof the leg easier.This approach allows an easy exposureof the anterior aspect of the hip through the inter-mus-cular interval between the sartorius and the gluteusmedius muscles, by splitting the iliotibial band and thetensor fascia lata muscle.The skin incision is about15 cmlong; instead of the straight, longitudinal incision centredover the greater trochanter, we employ a curved inci-sion, starting from an inch posterior to the anteriorsuperior iliac spine, to the greater trochanter, and thendistally for about 6 cm parallel to the lateral shaft of the

FEMORALNECKINYOUNGADULTS 397

femur (Fig. 2).The deep fascia of the thigh is incised in linewith the skin incision, just posterior to the border of thetensor fasciae lataemuscle; this clearly shows the vastuslateralis muscle distally and the gluteus medius muscleproximally. The interval between the tensor, sartoriusand the gluteus medius muscle is then developed usingblunt dissection, and there may be a few troublesomevessels encountered (branches of the superior of glutealartery).We do not routinely detach the vastus lateralismuscle from its origin at the lateral ridge on the femur.The anterior aspect of the hip capsule is carefully ex-posed; this is facilitated by laterally rotating the leg.Thereflectedhead of the rectus femoris is separated from itsattachments on the hip joint capsule and a clear expo-sure of the anterior capsule is achieved and maintainedby three bone levers, placed above and below the neckof femur, and one over the anterior brim of the acetabu-lum (Fig. 3). A T-shaped incision in the capsule is nowmade by using a cutting cautery, with the longitudinallimb of theT stopping short of the sheath of vessels atthebase of the femoralneck (Fig.4).The capsular incisionis then extended superiorly and inferiorly, and the frac-ture site is exposed. By externally rotating the limb, thefracture can be cleaned of all soft tissues, and freshened;reduction is now achievedby longitudinal traction, inter-nal rotation andmaximal abduction. AK-wire is insertedinto the centre of the femoral head, by which the femor-al head can be manipulated to assist fracture reduction.The position of this wire also gives a rough estimate ofthe length of the cancellous screw required. Once thefracture is reduced andverif|edradiographically, fracturestabilisation is performed by drilling two K-wires across

it.The lag screw is then inserted after drilling a holewitha 4.5mm AO cancellous drill. Using an 8mm DHS drillbit, a hole ismade for the prepared f|bular graft distal tothe screw. The graft is then inserted by gentle tappingwith a mallet, and once the f|bula is flushwith the lateralsurface, the screw is re-tightened, and the f|nal hammer-ing of the graft is done. The fracture reduction andpositioning of the screw and graft are checked radiogra-phically and the wound is closed in layers over a suctiondrain.

Method of harvesting f|bulargraftA separate team can harvest the f|bula from the contral-ateral side, or the same teammay do so from the ipsilat-eral side prior to the hip exposure. Using a 12 cm longincision over the postero-lateral aspect of the f|bula,

Figure 2 Line diagram showing the incision in the skin and iliotibial band.

Figure 3 Line diagram showing the exposed fracture afteradequate retraction ofmuscles.

Figure 4 Line diagram showing theT-shaped cut in the ante-riorcapsule.Theverticallimbofthiscut (A) stopswellshortofthearterial arcade atthe base ofthe femoralneck (B).

398 CURRENTORTHOPAEDICS

the lateral border of the bone is palpated and themobilemuscles are pushed anteriorly, developing the intervalbetween themuscle groups on either side of this border.The periosteum over the border is now cut, and a10 cmlong segment of bone is exposed.We do not routinelystrip the periosteum from the medial aspect to avoidtroublesome bleeding.We also remove only the lateraltwo-third of the bone, ensuring that we stay subperios-teally, and leave behind a tube of soft tissue and perios-teum that can be stitched back.The bone is cut with anoscillating saw, leaving the inter-osseous border intact.Careful resuturing of the periosteal tube and leavingbehind the intact inter-osseous border, allows a betterregrowth of the bone, does not affect ankle stability(especially in children) and minimises bleeding from ves-sels in the area of the inter-osseous membrane. Bone(10 cm in length) is taken out, and drill holes aremade atregular intervals on its surfaces.We believe that theseaid in the incorporation of thebone in theneck.The lead-ingedge of thegraftmaybebevelled for about1cm to aidin the insertion.This graft is now kept aside pending use.

AUTHORS EXPERIENCEOver a 20-year period,more than150 caseswith varyingdegrees of neglect have been treated by the above regi-men (Figs. 5 and 6).The twomain problems encounteredwere resorption

and compromise of the vascularity of the femoral head.It is not possible to achieve accurate reduction ofneglected fractures by closed methods, and repeatedattempts atmanipulation further harm the blood supplyto the head of the femur.Careful open reduction causesonly minimal additional insult to the blood supply. A T-shaped incision in the anterior capsule will ensure thatthe arcade of vessels at the base of the neck is not da-maged (Fig. 4). This approach gives suff|cient exposurefor removal of the interposed f|brous tissue and allowsaccurate reduction. It is important to note that most ofthese fractures are external rotation injuries, with theanterior cortex ruptured. The vessels along this are in-variably torn, and theremaybe a chance that the poster-ior vessels are intact (Fig. 1). By approaching the neckposteriorly, these are almost always damaged. Addition-ally, in cases with posterior comminution, the anteriorcortex acts as a hinge for reduction of the fragments.Our choice of a cortical graft has certain advantages.

The f|bula is easy to harvest and, provided that suff|cientcare is taken, leads to minimal morbidity at the donorsite. The trif|n shape of the f|bula stabilises the fracturebypreventingrotation, and the drilledholes in its surfacemay promote bony in-growth.The graft acts as a biolo-gical Smith--Petersen nail.The subchondral placement ofthe bone in avascular or osteopenic femoral heads mayminimise structural collapse until re-vascularisation

takes place (Fig. 7).Where there is radiological evidenceofAVNwe deferredweightbearinguntilunionhad takenplace, which in some patientsmeant for up to 6 months.The use of the cortical graft may stabilise the neck ifit is comminuted and allow reconstruction in cases ofresorption (Fig. 8), which can be supplemented by addi-tional use of cortico-cancellous bone from the iliac crest.We believe that this is a biological f|xation and that thebond between the implant and the femur strengthenswith time. In all our patients, after a suff|ciently longfollow-up period (in some instancesmore than19 years),serial radiographs showed incorporation of the f|bulargraft into the femoral neck andhead.Thiswas notedpar-ticularly in the distal part of the neck.This incorporationis variable, and is not dependant upon any specif|cfactors, as we have observed fully incorporated and fullyvisible f|bulae at long-term follow-up.This resorption orincorporation can occur only if the host bone in contactwith the graft is vascularised.

Figure 5 (a) AP radiograph of the femoral neck showing a 4-week-old femoralneck fracture. (b) Samecase (AP) view,8 yearsafter open reduction and osteosynthesis using a f|bular graftand cancellous screw.Note someresidualvarus, butgood union.(c) Lateral viewof same case, showing graft incorporation.

FEMORALNECKINYOUNGADULTS 399

In our experience, we encountered f|bular graft frac-tures in four cases.One of them went on to uneventfulunion, while three developed signif|cant complicationsneeding secondary intervention.The central part of thef|bula in the case that united ultimately became part oftheprimarycompressive trabeculae of the femoralneck.The incidence of AVNreported in the literature is be-

tween 8% and 35% after fracture of the femoral neck,and is probably higher in neglected displaced cases. Theradiological features of developing AVN are well known,but without performing a bone scan it is diff|cult to saywith certainty whether re-vascularisation of the femoralhead is occurring.We took the following signs to be indir-ect evidence of re-vascularisation of the femoral head:reconstitution of the trabecular pattern, incorporationof the f|bula into the femoral head proximal to the frac-ture line, and little or no progression of structural col-lapse after a suff|ciently long period of follow-up. Thesefeatures correlated well with the clinical f|ndings,although over time minor radiological changes may be

Figure 6 (a) AP viewof a casewithmultipleprevious failed sur-geries. (b) AP view 5 years after f|bular osteosynthesis, showinggood union and no avascular necrosis. (c) Lateral view of thesame case.

Figure 7 (a) AP view of a 9-month-old femoral neck fracturewithmottling of the head indicative of avascular changes. (b) APviewofthe same case,6 years after f|bularosteosynthesis.Thereisgoodunion, andheadhasrevascularised. (c) Lateralviewofthesame case showing how subchondral placement of the graft hasprevented excessive collapse of the femoral articular surface.Note graft incorporation (arrows).

400 CURRENTORTHOPAEDICS

seen. Our f|ndings suggest that the f|bular graft, byproviding structural support and promoting union,indirectly contributes to re-vascularisation of thefemoral head.Another aspect to note is the fate of the f|bular graft

inside the femoral neck. Long-term evaluation of thesegrafts in extra-osseous situations for reconstruction ofcortical defects after excision of tumours, etc., hasshown the hypertrophy of these grafts. However, nolong-term assessment of the intra-osseous fate of thef|bular graft in cancellous bone exists.The authors haveanalysed a few cases after periods ranging from 8 to 19years, and have found that the rate of incorporation isvariable. Some f|bulae get incorporated completely,while the others may be seen as almost complete scarsof the original bone (data on f|le, submitted for publica-tion).The reasons for this variability are not known, andmaybe dependent on local vascularity and other hostfactors.

SUMMARYOur experience shows that preservation of the femoralhead in young patients with neglected fractures of thefemoral neck is achievable.The f|bular graft acts as a bio-logical implant, and its incorporation into host bone isevident after suff|cient follow-up. Avascular heads mayre-vascularise after union.Reviewof specimens removedin cases undergoing THA showed excellent incorpora-tion of the f|bular autograft in the cancellous bone ofthe femoral neckThis underlines the fact that the bondof the bone graft with the host bone strengthens withtime, making the f|bula a reliable combination of f|xationdevice and bone graft.Open reduction ensures good alignment of the frac-

ture: the anterior approach minimises vascular insult. Apostoperative spica, which can easily be tolerated inthese young individuals, maybe needed in cases with ex-cessive resorption of the neck, or perceived instability ofthe reconstruction. Despite being cortical, the f|bula

serves as a good bone graft which is almost completelyincorporated into the host. The complications includeleg-length discrepancy and coxa vara, which are a smallprice to pay for a united femoral neck and a vascular fe-moral head; these may also be treated by adduction os-teotomy once the fracture has united.

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