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TRAUMATOLOGY Table of Contents   
Year : 2004  |  Volume : 38  |  Issue : 2  |  Page : 88-91
Valgus osteotomy for nonunion fracture neck femur


Department of Orthopaedics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

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   Abstract 

Background: Non union of femoral neck fracture in young patients is still a problem as they are too young to have hip replacement and other salvage procedures are usually unsatisfactory. Pauwels described valgus osteotomy for nonunion of femoral neck which was used by later surgeons also.
Methods: We report a series of 22 patients of nonunion of femoral neck fracture which were taken up for valgus osteotomy and fixed with 120° double angled dynamic hip screw. Average age of patients was 36.5 yrs. Injury operation interval ranged from 4wks- 32wks. Average follow up was 18 months (12 mths­38 mths).
Results: Femoral neck fractures united in 18 patients (82%). Excellent to good results were seen in 70% patients.
Conclusion: 120° double angled dynamic screw plate assembly provides rigid internal fixation after valgus osteotomy and being a more familiar fixation device simplifies the procedure and gives good results.

Keywords: Nonunion neck of femur; Valgus osteotomy; 120° double angled dynamic hip screw plate

How to cite this article:
Sharma M, Sood L K, Kanojia R K, Sud A. Valgus osteotomy for nonunion fracture neck femur. Indian J Orthop 2004;38:88-91

How to cite this URL:
Sharma M, Sood L K, Kanojia R K, Sud A. Valgus osteotomy for nonunion fracture neck femur. Indian J Orthop [serial online] 2004 [cited 2019 Dec 6];38:88-91. Available from: http://www.ijoonline.com/text.asp?2004/38/2/88/40907

   Introduction Top


In young patients with femoral neck non-union it is desirable to preserve the femoral head. Various treatment modalities have been described to preserve the head e.g. vascularised bone grafts [1],[2] , muscle pedicle grafts [3],[4] , fibular grafts with or without osteotomy [5],[6] but still the best form of treatment remains inconclusive as these procedures are technically demanding and have not given consistently reproducible results. Pauwels [7] postulated that in non-union of femoral neck the problem is both biological and mechanical.

He suggested that by changing the fracture inclination the fracture site can be brought under compression, thereby resulting in union of fracture. These principles still hold true, most authors have used blade plate for fixation after osteotomy [6],[7],[8],[9],[10] . As dynamic hip screw is a more familiar fixation device in use today and has replaced condylar blade plate for most indications, we used a 120° double angled dynamic hip screw barrel plate assembly for fixation which we believe will further simplify the procedure and decrease the complication rate.


   Materials and Methods Top


From November 1999 to Dec 2001, 22 cases of non-union of femoral neck fractures in young patients were taken up for valgus osteotomy and fixed using 120° double angled dynamic hip screw and barrel plate assembly. Patients were divided into two categories -neglected cases where no previous surgery was done and those with previous failed internal fixation device.

There were 17 patients in first group with average injury operation interval of 12 wks (4wks-24 wks) The second group had 5 patients with an average injury operation interval of 24 wks (20 wks- 32 wks). Anteroposterior radiographs of both hips in internal rotation were taken to assess for neck length and classify fracture according to Pauwels criteria and to detect avascular necrosis of femoral head. No special studies were done to detect precollapse avascular necrosis of femoral head as this was not considered to be a contraindication for valgus osteotomy [8],[9],[10] .

Preoperative tracing of proximal femur and both hips were taken. The goal of osteotomy was to achieve a Pauwels angle of 30° or less and hence to bring fracture site under compression. The inclination of fracture line to horizontal was measured. We planned a wedge of 30° in all cases as it is difficult to precisely measure the size of wedge [9] [Figure 1] and in 2 cases with fracture inclination >70° we planned a Y­osteotomy with removal of 50° wedge[Figure 2].

The osteotomy was planned at the level of lesser trochanter as described by Pauwel [7] and later modified by Muller [11] . The entry point of dynamic hip screw was 2 cm above the osteotomy site. The procedure was performed with patient on fracture table under general or spinal anaesthesia and under C-arm image intensifier. The skin incision was directly lateral and straight over greater trochanter and proximal femur. Vastus lateralis was cut in L-shaped manner and elevated subperiosteally. All previous internal fixation devices were removed. The fracture site was not exposed in any patient. After identifying the level of osteotomy a guide wire was inserted above it to make entry point for lag screw. Appropriate sized lag screw was inserted after drilling and tapping. At the level of osteotomy proximal transverse cut and distal angled cut were made and predetermined sized wedge (usually 30°) was removed. The lower limb was swung into abduction to align the femur to plate and reduction clamps were applied. The barrel plate was fixed to femur using 4.5 mm cortical screws. The removed bone wedge was used as bone graft at osteotomy site.

Postoperatively active exercises of hip and knee were started and non-weight bearing crutch walking began after 2-3 days. Weight bearing was delayed till healing was seen at osteotomy site on radiographs and then progressed gradually to full weight bearing.


   Results Top


Average age of patients was 36.5 yrs (range 17 yrs to 52 yrs). Right side was involved in 9 cases and left side in 13 cases. There were 14 males and eight females. Although precollapse avascular necrosis was not considered to be a contraindication for osteotomy, none of our patients had signs of precollapse avascular necrosis on plain radiograph. There were 14 Pauwel type 2 and 8 Pauwel type 3 fractures in our series.

Assessment of union was done by both clinical and radiological criteria. Clinically healing was defined as pain free full weight bearing without assistance. Radiographically healing was determined by presence of bridging trabeculae of bone crossing the non-union site on plain radiographs [Figure 3],[Figure 4]. Average follow up was 18 mths (12 mths-38 mths). All osteotomy sites healed in an average of 14 weeks (8 wks- 20 wks). Non union healed in 18 patients (82%). Fifteen of the seventeen non-union in patients where no previous surgery was done united while three of the five patients with previous failed internal fixation united. Average time to healing of non­union was 20 weeks (12 wks - 40wks). Average change in radiographic fracture inclination after osteotomy was 25 0 . In all patients there was improvement in leg length discrepancy (average 1.5 cm) after osteotomy. Two patients developed avascular necrosis with collapse of femoral head after union of fracture 12 months and 16 months postoperatively. Two patients with pre-existing osteoarthritis of knee with mild pain had no change in pain or deformity at knee after osteotomy. There was no infection, thromboembolic complications or implant failure in our series.

Functional outcome was judged according to Askin­ Bryan [12] criteria

Excellent - Full range of movements and strength, little or no pain and essentially normal appearing radiographs.

Good - Some limitation of motion, mild discomfort and mild joint space narrowing.

Fair-Some limitation of motion and moderate pain with degenerative changes or aseptic necrosis.

Poor - Severe restriction of function and pain requiring salvage procedure.

Excellent results were seen in four patients, good in 10 patients and fair results in two patients. Poor outcome was seen in six patients. Four patients had non-union at fracture site and two patients had avascular necrosis with collapse of head after union of fracture. In one case the position of lag screw was not central, this led to cut through of screw once patient started weight bearing. Two patients had non-union as threads of lag screw were at the fracture site which prevented collapse of fracture. In one patient due to small size of wedge removed the fracture site did not come under compression. Of six patients with poor results, four patients were taken up for bipolar arthroplasty. The remaining two patients refused further surgical treatment and were lost to follow up.


   Discussion Top


Femoral neck fractures in young active adult patients should be treated by early closed reduction and stable internal fixation. Despite improvement in results of internal fixation due to better understanding of reduction of fracture and positioning of implants and improvement in radiography, non­union results in 4%-30% cases [13],[14],[15],[16] . In our country late and neglected presentation of femoral neck fractures is common as initial treatment is usually done by local bone setters. Reports in literature suggest that if neck fracture is more than 2-3 weeks old then primary osteosynthesis with cancellous screw alone does not give good results [17],[18] . Meyers [4] also classified acute fractures of neck of femur as those treated upto 30 days after injury and those beyond 30 days as delayed or non-union.

It is well accepted that aim of treatment in young adult patients with non-union of femoral neck without avascular necrosis is preservation of femoral head. Pauwel [7] showed that placing the non-union of fracture neck under compression by resecting a laterally based wedge resulted in union of fracture. Pauwels carried out a simple lateral closing valgus osteotomy for non-union and if head had slipped down he did a Y-osteotomy [7] . For post operative immobilisation patients were placed in hip spica. This type of osteotomy resulted in shortening and marked medialisation of femoral shaft which usually led to genu valgum. To overcome these problems Muller suggested condylar blade plate for fixation after valgus osteotomy.

The largest series in literature is that of Marti et al [7] . They presented results of valgus osteotomy in 41 patients of non­union of femoral neck, with union rate of 86%. They experienced technical difficulties in six patients requiring a second surgery for refixation. Seven other patients required replacement due to persistent non-union, late segmental collapse or implant failure at the shaft. Angelen [8] reported 13 patients with failed internal fixation of femoral neck treated with valgus osteotomy achieving a union rate of 100%.

Studies comparing blade plate with compression screw for fixation have reported a higher rate of suboptimal position of implant, cut through and implant failure with blade plate [19] . In using blade plate hammer impact can displace the fragments. In dynamic hip screw the implant is not hammered. This assembly also gives compression at fracture site by application of compression screw. It also allows some play for fixation as the assembly can be rotated so that plate rests on outer surface of femur while doing the same in blade plate results in anterior or posterior angulation at osteotomy site. Wu et al [20] used a sliding hip screw to compress the non­union and to realign the proximal femur.

The mechanics of hip joint shows that in one leg stance phase a load of at least three times body weight will transfer 21° inferolaterally [21] . We routinely planned a wedge of 30° as it is difficult to precisely calculate the size of wedge [8] . Pauwels recommended placing the final fracture inclination to 25°. This can be explained on the basis of biological as well as mechanical reasons for effectiveness of osteotomy in promoting union [8] .

Avascular necrosis without head collapse has not been considered to be a contraindication for valgus osteotomy. Calandruccio and Anderson [22] considered that vascular damage at the time of fracture decides whether or not necrosis will develop. However Stromquist and Harrison [23] used tetracycline and isotope studies to show that vascular damage may be increased during the fixation of fracture. In fresh femoral neck fractures overcorrection to more than 20° to 30° valgus or malrotation will affect the remaining vessels and increase the chance of developing necrosis but whether this holds true in old cases with resorption of neck is debatable. It is also well documented that revascularisation of head is possible both by artery of ligamentum teres and by vessels crossing the uniting fracture [24] . Precollapse avascular necrosis is not a contraindication for valgus osteotomy in ununited fracture neck of femur. We believe further studies by non­invasive means are required to evaluate effect of osteotomy on vascularity of femoral head.

 
   References Top

1.Huang CH. Treatment of neglected femoral neck fracture in young adults. Clin Orthop. 1986; 206: 117-126  Back to cited text no. 1    
2.Lueng PC, Shen WY. Fractures of femoral neck in young adults : a new method of treatment for delayed and non-union. Clin Orthop. 1993: 295: 156-160.  Back to cited text no. 2    
3.Baksi DP. Internal fixation of ununited femoral neck fracture combined with muscle - pedicle bone grafting . J Bone Joint Surg (Br). 1986; 68:239-245.  Back to cited text no. 3    
4.Meyers MH, Harvy JP Jr, Moore TM. Treatment of displaced subcapital and transcervical fracture of femoral neck by muscle pedicle bone graft and internal fixation. J Bone Joint Surg (Am). 1933:55:257-274.  Back to cited text no. 4    
5.Dooley BJ, Hooper J. Fibular bone grafting for non-union fracture neck of femur. Aust NZ J Surg. 1982: 52: 134 -140  Back to cited text no. 5    
6.Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular auto grafting for neglected fracture of femoral neck. J Bone Joint Surg (Br). 1998:80:798-804  Back to cited text no. 6    
7.Pauwels F. Der Schenkelhalsbruch ein mechanisches Problem : Grundlagen des Heilungsvorganges, Prognose and kausale Therapie. Stuttgart; Ferdinand Enke Verlag 1935.  Back to cited text no. 7    
8.Marti RK, Schuller HM, Raymakers ELFB. Intertrochantric osteotomy for non-union of femoral neck. J Bone Joint Surg (Br). 1989: 71:782-787  Back to cited text no. 8    
9.Angelen JO. Intertrochantric osteotomy for failed internal fixation of femoral neck fractures.Clin Orthop. 341:1997 :175-182  Back to cited text no. 9    
10.Ballmer FT et al. Pauwel osteotomy for nonunion of femoral neck. Orthop Clin North Am. 1990; 21:759-767.  Back to cited text no. 10    
11.Muller ME, Allgower M, Schneider R, Willeneger H. Manual of internal fixation: 2nd ed Berlin etc:Springer - Verlag.1979.  Back to cited text no. 11    
12.Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop. 1976.114:259-264.  Back to cited text no. 12    
13.Garden RS. Low angle fixation in fractures of femoral neck. J Bone Joint Surg (Br). 1961; 43: 647-663.  Back to cited text no. 13    
14.Kofoed H, Alberts A. Femoral neck fractures. Acta Orthop Scand. 1980; 51:, 127-136.  Back to cited text no. 14    
15.Asnis SE et al. Intracapsular fractures of femoral neck: Results of cannulated cancellous screw fixation. J Bone Joint Surg (Am). 1994; 76: 1793-1803.  Back to cited text no. 15    
16.Garden RS. Reduction and fixation of subcapital fracture of femoral neck. Orthop Clin North Am. 1974, 5, 683-712.  Back to cited text no. 16    
17.CA Bout et al. Percutaneous cannulated cancellous scre fixation of femoral neck fractures: Three point principle. Injury. 1997; 28:135-139  Back to cited text no. 17    
18.Sud A et al. Closed reduction and percutaneous cannulated cancellous screw fixation of femoral neck fractures. Ind J Orthop. 2000; 34:151-152.  Back to cited text no. 18    
19.Doppelt SH. The sliding compression screw : Todays best answer for stabilisation of intertrochantric hip fractures. Orthop Clin North Am. 1980:11: 507-523.  Back to cited text no. 19    
20.Wu et al. Treatment of femoral neck nonunion with a sliding compres­sion screw: Comparison with and without subtrochantric valgus os­teotomy. Injury. 1999; 46:312-317.  Back to cited text no. 20    
21.Pring D. Biomechanics of hip. In: Barrett D. Essential basic sciences for orthopaedics Oxford: Butterworth - Heinemann. 1994:62-93  Back to cited text no. 21    
22.Calandruccio RA, Anderson WE. Post fracture AVN of femoral head: Correlation of experience and clinical studies. Clin Orthop. 1980; 152: 49-84.  Back to cited text no. 22    
23.Stromquist B, Harrison LJ. Femoral head vitality after femoral neck fractures- Comparison between pre and perioperative tetracycline labelling. Arch Orthop Trauma Surg. 1983; 101: 251.  Back to cited text no. 23    
24.Catto M. A histological study of femoral head AVN after transcervical fractures. J Bone Joint Surg [Br]. 1965; 47: 749-776.  Back to cited text no. 24    

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Correspondence Address:
Manish Sharma
B2/ 65 Safdarjung Enclave, New Delhi -110029
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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