Nuclear Medicine and Molecular Imaging

, Volume 51, Issue 1, pp 49–57 | Cite as

Risk Stratification for Avascular Necrosis of the Femoral Head After Internal Fixation of Femoral Neck Fractures by Post-Operative Bone SPECT/CT

  • Sangwon Han
  • Minyoung Oh
  • Seokho Yoon
  • Jinsoo Kim
  • Ji-Wan Kim
  • Jae-Suk Chang
  • Jin-Sook RyuEmail author
Original Article



Avascular necrosis (AVN) of the femoral head is a major complication after internal fixation of a femoral neck fracture and determines the functional prognosis. We investigated postoperative bone single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing the risk of femoral head AVN.


We retrospectively reviewed 53 consecutive patients who underwent bone SPECT/CT within 2 weeks of internal fixation of a femoral neck fracture and follow-up serial hip radiographs over at least 12 months.


Nine patients developed femoral head AVN. In 15 patients who showed normal uptake on immediate postoperative SPECT/CT, no AVN occurred, whereas 9 of 38 patients who showed cold defects of the femoral head later developed AVN. The negative predictive value of immediate postoperative SPECT/CT for AVN was 100 %, whereas the positive predictive value was 24 %. Among 38 patients with cold defects, 1 developed AVN 3 months postoperatively. A follow-up bone SPECT/CT was performed in the other 37 patients at 2–10 months postoperatively. The follow-up bone SPECT/CT revealed completely normalized femoral head uptake in 27, partially normalized uptake in 8, and persistent cold defects in 2 patients. AVN developed in 3.7 % (1/27), 62.5 % (5/8), and 100 % (2/2) of each group, respectively.


According to the time point of imaging, radiotracer uptake patterns of the femoral head on postoperative bone SPECT/CT indicate the risk of AVN after internal fixation of femoral neck fractures differently. Postoperative bone SPECT/CT may help orthopedic surgeons determine the appropriate follow-up of these patients.


Bone SPECT/CT Avascular necrosis Femoral neck fracture Internal fixation 


Compliance with Ethical Standards

Conflict of Interest

Sangwon Han, Minyoung Oh, SeokhoYoon, Jinsoo Kim, Ji-Wan Kim, Jae-Suk Chang, and Jin-Sook Ryu declare that they have no conflicts of interest.

Ethical Statement

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by our Institutional Review Board (IRB no. 2016–0231). The Institutional Review Board waived the need to obtain informed consent. This manuscript has not been published before or is not under consideration for publication anywhere and has been approved by all co-authors.


  1. 1.
    Ehlinger M, Moser T, Adam P, Bierry G, Gangi A, de Mathelin M, et al. Early prediction of femoral head avascular necrosis following neck fracture. Orthop Traumatol Surg Res. 2011;97:79–88.CrossRefPubMedGoogle Scholar
  2. 2.
    Sambrook P, Cooper C. Osteoporosis. Lancet. 2006;367:2010–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Shah AK, Eissler J, Radomisli T. Algorithms for the treatment of femoral neck fractures. Clin Orthop Relat Res. 2002;28–34.Google Scholar
  4. 4.
    Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. Instr Course Lect. 2009;58:69–81.PubMedGoogle Scholar
  5. 5.
    Coleman SS, Compere CL. Femoral neck fractures: pathogenesis of avascular necrosis, nonunion and late degenerative changes. Clin Orthop. 1961;20:247–65.PubMedGoogle Scholar
  6. 6.
    Nikolopoulos KE, Papadakis SA, Kateros KT, Themistocleous GS, Vlamis JA, Papagelopoulos PJ, et al. Long-term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures. Injury. 2003;34:525–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Lowell JD. Results and complications of femoral neck fractures. Clin Orthop Relat Res. 1980;162–72.Google Scholar
  8. 8.
    Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg Am. 1994;76:1793–803.CrossRefPubMedGoogle Scholar
  9. 9.
    Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am. 1994;76:15–25.CrossRefPubMedGoogle Scholar
  10. 10.
    Rogmark C, Flensburg L, Fredin H. Undisplaced femoral neck fractures—no problems? A consecutive study of 224 patients treated with internal fixation. Injury. 2009;40:274–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Cherian SF, Laorr A, Saleh KJ, Kuskowski MA, Bailey RF, Cheng EY. Quantifying the extent of femoral head involvement in osteonecrosis. J Bone Joint Surg Am. 2003;85:309–15.CrossRefPubMedGoogle Scholar
  12. 12.
    Bachiller FG-C, Caballer AP, Portal LF. Avascular necrosis of the femoral head after femoral neck fracture. Clin Orthop Relat Res. 2002;399:87–109.CrossRefGoogle Scholar
  13. 13.
    Plancher KD, Razi A. Management of osteonecrosis of the femoral head. Orthop Clin N Am. 1997;28:461–77.CrossRefGoogle Scholar
  14. 14.
    Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg (Br). 2000;82:679–83.CrossRefGoogle Scholar
  15. 15.
    Ramesh Kumar S, Tripathy SK, Gill SS, Verma N, Singh P, Radotra BD. Prediction of posttraumatic femoral head osteonecrosis by quantitative intraosseous aspirate and core biopsy analysis: a prospective study. Acta Orthop Belg. 2010;76:486–92.Google Scholar
  16. 16.
    Strömqvist B, Brismar J, Hansson LI, Palmer J. Technetium-99m-methylenediphosphonate scintimetry after femoral neck fracture a three-year follow-up study. Clin Orthop Relat Res. 1984;182:177–89.Google Scholar
  17. 17.
    Alberts KA. Prognostic accuracy of preoperative and postoperative scintimetry after femoral neck fracture. Clin Orthop Relat Res. 1990;250:221–5.Google Scholar
  18. 18.
    Lucie RS, Fuller S, Burdick DC, Johnston RM. Early prediction of avascular necrosis of the femoral head following femoral neck fractures. Clin Orthop Relat Res. 1981;161:207–14.Google Scholar
  19. 19.
    Holmberg S, Thorngren K-G. Preoperative 99mTc-MDP scintimetry of femoral neck fractures. Acta Orthop. 1984;55:430–5.CrossRefGoogle Scholar
  20. 20.
    Sonne-Holm S, Nordkild P, Dyrbye M, Jensen JS. The predictive value of bone scintigraphy after internal fixation of femoral neck fractures. Injury. 1987;18:33–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Broeng L, Hansen LB, Sperling K, Kanstrup I-L. Postoperative Tc-scintimetry in femoral neck fracture: a prospective study of 46 cases. Acta Orthop. 1994;65:171–4.CrossRefGoogle Scholar
  22. 22.
    Lausten GS, Hesse B, Thygesen V, Fogh J. Prediction of late complications of femoral neck fractures by scintigraphy. Int Orthop. 1992;16:260–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Ryu J-S, Kim JS, Moon DH, Kim SM, Shin MJ, Chang JS, et al. Bone SPECT is more sensitive than MRI in the detection of early osteonecrosis of the femoral head after renal transplantation. J Nucl Med. 2002;43:1006–11.PubMedGoogle Scholar
  24. 24.
    Collier BD, Carrera GF, Johnson RP, Isitman AT, Hellman RS, Knobel J, et al. Detection of femoral head avascular necrosis in adults by SPECT. J Nucl Med. 1985;26:979–87.PubMedGoogle Scholar
  25. 25.
    Frandsen PA, Andersen E, Madsen F, Skjodt T. Garden’s classification of femoral neck fractures. An assessment of inter-observer variation. J Bone Joint Surg (Br). 1988;70:588–90.Google Scholar
  26. 26.
    Ficat RP. Idiopathic bone necrosis of the femoral head. J Bone Joint Surg (Br). 1985;67:3–9.Google Scholar
  27. 27.
    KuMar MN, BElEhalli P, Ramachandra P. PET/CT study of temporal variations in blood flow to the femoral head following low-energy fracture of the femoral neck. Orthopedics. 2014;37:e563–70.CrossRefPubMedGoogle Scholar
  28. 28.
    Trueta J, Harrison MHM. The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg (Br). 1953;35-B:442–61.Google Scholar
  29. 29.
    Boraiah S, Dyke JP, Hettrich C, Parker RJ, Miller A, Helfet D, et al. Assessment of vascularity of the femoral head using gadolinium (Gd-DTPA)-enhanced magnetic resonance imaging A Cadaver Study. J Bone Joint Surg (Br). 2009;91:131–7.CrossRefGoogle Scholar
  30. 30.
    Tucker FR. Arterial supply to the femoral head and its clinical importance. J Bone Joint Surg (Br). 1949;31:82–93.Google Scholar
  31. 31.
    Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg (Br). 1991;73:73–5.Google Scholar
  32. 32.
    Sevitt S. Avascular necrosis and revascularisation of the femoral head after intracapsular fractures. J Bone Joint Surg (Br). 1964;46:270–96.Google Scholar
  33. 33.
    Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg (Br). 1976;58:2–24.Google Scholar
  34. 34.
    Brown JT, Abrami G. Transcervical femoral fracture. A review of 195 patients treated by sliding nail-plate fixation. J Bone Joint Surg (Br). 1964;46:648–63.Google Scholar
  35. 35.
    Banks HH. Factors influencing the result in fractures of the femoral neck. J Bone Joint Surg Am. 1962;44:931–64.CrossRefGoogle Scholar
  36. 36.
    Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am. 2002;84:1605–12.CrossRefPubMedGoogle Scholar
  37. 37.
    Swiontkowski MF, Winquist RA, Hansen Jr ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837–46.CrossRefPubMedGoogle Scholar
  38. 38.
    Cho M-R, Lee S-W, Shin D-K, Kim S-K, Kim S-Y, Ko S-B, et al. A predictive method for subsequent avascular necrosis of the femoral head (AVNFH) by observation of bleeding from the cannulated screw used for fixation of intracapsular femoral neck fractures. J Orthop Trauma. 2007;21:158–64.CrossRefPubMedGoogle Scholar
  39. 39.
    Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults a prospective, randomised study comparing closed and open reduction. J Bone Joint Surg (Br). 2004;86:1035–40.CrossRefGoogle Scholar
  40. 40.
    Butt MF, Dhar SA, ul Gani N, Farooq M, Mir MR, Halwai MA, et al. Delayed fixation of displaced femoral neck fractures in younger adults. Injury. 2008;39:238–43.CrossRefPubMedGoogle Scholar

Copyright information

© Korean Society of Nuclear Medicine 2016

Authors and Affiliations

  • Sangwon Han
    • 1
  • Minyoung Oh
    • 1
  • Seokho Yoon
    • 1
  • Jinsoo Kim
    • 2
  • Ji-Wan Kim
    • 3
  • Jae-Suk Chang
    • 2
  • Jin-Sook Ryu
    • 1
    Email author
  1. 1.Department of Nuclear Medicine, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  2. 2.Department of Orthopedic Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  3. 3.Department of Orthopedic Surgery, Haeundae Paik HospitalInje UniversityBusanRepublic of Korea

Personalised recommendations