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TRAUMATOLOGY Table of Contents   
Year : 2004  |  Volume : 38  |  Issue : 2  |  Page : 92-95
Repositioning osteotomy with dynamic hip screw with 120° double angled barrel plate fixation in fracture neck femur


Department Of Orthopaedics, SN Medical College, Agra, India

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   Abstract 

Background: Nonunion of femoral neck fracture has remained a major complication in spite of advances in treatment.
Methods: Twenty eight patients of femoral neck fracture with viable femoral head were treated with repositioning osteotomy with dynamic hip screw and 120° double angled barrel plate fixation. Patients were followed for an average of 26.5 months.
Results: Radiological signs of union in 26 cases were observed in an average period of 5.2 months; On the basis of functional assessment by Larson's method 26 patients were graded as good results with Larson's score>90 and one patient with a score of 88 as fair result and one patients with a score of 63 as poor result.
Conclusion: Repositioning osteotomy with dynamic hip screw and 120°double angled barrel plate fixation is a useful method in treatment of fracture neck femur with viable femoral head.

Keywords: Repositioning osteotomy; Dynamic hip screw and 120° double angled barrel plate fixation; Fracture neck femur.

How to cite this article:
Pruthi K K, Chandra H, Goyal R K, Singh V P. Repositioning osteotomy with dynamic hip screw with 120° double angled barrel plate fixation in fracture neck femur. Indian J Orthop 2004;38:92-5

How to cite this URL:
Pruthi K K, Chandra H, Goyal R K, Singh V P. Repositioning osteotomy with dynamic hip screw with 120° double angled barrel plate fixation in fracture neck femur. Indian J Orthop [serial online] 2004 [cited 2019 Dec 11];38:92-5. Available from: http://www.ijoonline.com/text.asp?2004/38/2/92/40908

   Introduction Top


The fracture of femoral neck has been called the "unsolved fracture" [1] . Extensive studies of the biomechanics [2] of the femur and pelvis and development of new methods of fixation [3],[4] have led to well defined primary treatment directives [5] . Factors known to pose problems in the management of fracture neck femur are intracapsular location, precarious blood supply of head of femur, difficulty in reduction, strong muscle forces, flow of synovial fluid and osteoporosis. Nonunion and avascular necrosis of femoral head have nevertheless remained major complications. The non-union rate of all femoral neck fracture is still in the range of 10% to 20% [6],[7] despite modern treatment modalities. In old people the fracture neck can be treated by prosthetic replacement arthroplasty but in young people below the age of 60 years it is desirable that the patient's own hip joint should be preserved.

Pauwels [8] exclusively followed biomechanical principles changing the shear and tension forces of a nonunion into compression forces. In internal fixation of repositioning osteotomy by double angled blade plate, at times blade may displace the fracture fragments and minimal change in the direction of blade may change the direction of plate anterior or posterior to the shaft of femur.


   Materials and methods Top


Twenty eight patients of fracture neck femur were treated with repositioning osteotomy with dynamic hip screw 120 o double angled barrel plate fixation from March 2001 to March 2004. Their average age was 42 years (18-58 years). According to anatomical type, six patients were sub capital, 14 patients were transcervical and eight patients were basal fractures. Viability of femoral head was decided on the basis of radiological examination.

Indications for the surgery were

1. Non union of fracture neck femur with viable head of femur

2. Late cases of fracture neck femur with viable head of femur.

3. Fresh Pauwels' type III fracture neck femur.

According to Pauwels' classification of fracture neck femur, six were type II and 22 fractures were types III fracture neck femur. Two patients were operated within 3 weeks of injury, 19 patients between 3 to 12 weeks and 7 patients operated more than 12 weeks after fracture, 15 patients exhibited absorption of femoral neck.

Pre - Operative Planning

Quality skiagrams of pelvis with both hip-anteroposterior view in full internal rotation and lateral view of affected hip were taken. Pre- operative planning was done by measurement of repositioning angle by subtracting 25° from Pauwel's angle. We have taken 30° wedge from below the lesser trochanter and rest amount of wedge (>30°) was resected from above the lesser trochanter. Grading of osteoporosis was done as per Singh's index [9] from the sound hip.

Operative Technique

Under spinal anaesthesia patient was laid supine on orthopaedic table and image intensifier positioned for AP and lateral views. Closed reduction of fracture was done by Whitman's method and in difficult cases by Leadbetter or Flynn methods. After preparation of skin and surgical draping of extremity proximal femur was exposed by lateral incision .Ante version of femoral neck was determined by placing the guide wire along the front of femoral neck. DHS guide wire was inserted from the lateral cortex through 120° DHS angle guide to the posteroinferior quadrant of femoral head up to subchondral bone parallel to the previously inserted anteversion wire and triple reaming was done up to 5-10 mm less than inserted guide wire. Dynamic hip screw of selected size was inserted after tapping, 120 o double angled barrel plate placed over DHS and the site of osteotomy decided. The linear osteotomy was done just above the lesser trochanter leaving some medial cortex then calculated laterally based wedge was resected. A wedge of 30 o was cut distal to the osteotomy and rest amount of wedge was resected proximal to the osteotomy, then osteotomy was completed medially and guide wire was removed. Gap after osteotomy was reduced by abduction of lower limb; 120 o double angled barrel plate was fixed with cortical screws and wound was closed in layers after leaving suction drain. The tube of suction drain was taken out 48 hours after the operation and skin stitches were taken out at 12 th day after operation.

Quadriceps drill was encouraged as soon as patients were in a position to tolerate it. Patients were allowed to sit next day. Partial weight bearing was allowed at 5-7 weeks after operation and full weight bearing was permitted according to the progress of union at osteotomy as well as the fracture sites. Follow up was done on the basis of clinical and radiological assessment, post operatively at monthly interval for three months and then after at the interval of two months.


   Results Top


The patients were followed for an average period of 26.5 months. Functional results were assessed clinically by Larson's method of clinical assessment. Quality of reduction of fracture neck femur was assessed by the Garden's alignment index.

Reduction was good in 25 patients and fair in three cases (good reduction + 10°). The duration of surgery (from skin incision to skin closure) was 60-90 minutes in 25 cases. In one patient dynamic hip screw did cut through the head of femur. In our series average post operative hospital stay of the patients was approximately 16 days. Post operatively we achieved 25° Pauwel's angle in 14 cases in other 14 cases it was 26°-30°. Partial weight bearing with the help of walker was allowed at an average period of 6 weeks after the operation and full weight bearing was allowed at an average period of 10 weeks after operation. There was pre-operative shortening in all cases. At final outcome in 19 cases there was no limb length discrepancy of lower limb, in 4 cases the shortening was under corrected and in other 2 cases there was gain in length of 0.5-1 cm due to over correction. In all cases union at osteotomy site occurred with an average of 2.6 months [Figure 1].

Radiological union was determined by the presence of continuation of trabeculi across the osteotomy and fracture sites. In 26 cases union at fracture site occurred with an average of 5.2 months and two cases had non-union of which one showed fair and the other case showed poor results. Average Larson's score was 91.8 [Table 1]. All the 14 cases of transcervical fracture showed good results. Out of six cases of sub capital fracture, five cases showed good results while one case showed poor result, out of eight cases of basalcervical fracture seven cases showed good results and one case showed fair result. Six patients of Pauwel's Type II fracture showed good results and 20 out of 22 patients of Pauwel's type III fracture showed good results and one case showed fair and another one case had poor result. All 14 cases in which post operatively we achieved Pauwel's angle of 25° showed good results and in other 14 cases in whom we achieved Pauwel's angle between 26°-30°,12 cases showed good results while one case each showed fair and poor result. Two cases operated within three weeks after injury and 19 cases operated between 3-12 weeks after injury, results of all these cases were graded as good results, five out of seven cases operated after 12 weeks of injury showed good results and result of one patient graded as fair and of another one graded as poor result. Complications are given in [Table 2],[Table 3].


   Discussion Top


The femoral neck fracture is probably the fracture for which there exists the larger number of methods of osteosynthesis. Internal fixation of femoral neck fracture is followed by certain incidence of fixation failure. Nonunion may occur in one third of patients with higher rate in vertical or displaced fractures [10] . Number of methods of internal fixation when used alone have failed to achieve the desired end result. Osteoporosis directly influences the degree of displacement and quality of internal fixation. The deficient bone stock and posterior communiation plays a significant role in its biological failure to unite the fracture. The age and sex of patient, ostreoporosis, degree of displacement and quality of fracture reduction are the factors that have found to affect the end result [11],[12] .

Since the first report of internal fixation of femoral neck fracture by von Langen Beck [13] in 1850, multitude of devices for internal fixation of femoral neck fractures have been designed and popularized. Surgical treatment of femoral neck fractures include arthroplasty, non vascularised bone grafting, arthrodesis and osteotomy. Arthroplasty is an acceptable treatment in older patient, in younger patients alternative methods aimed to preserve the patients own femoral head should be favored, cortical bone grafts have been associated with disimpaction or angulations of the head leading to failure [14] . The initially reported success of Meyer's procedure has not been reproduced in a large series and the procedure has been considered unreliable[15 . Arthrodesis has a high failure rate but when successful it leads to a functional hip.

Pauwels recognized that a non- union of femoral neck fracture would consolidate with in few months if shearing force acting on non union fracture site were transformed into compression forces [8] . Repositioning osteotomy with dynamic hip screw and 120° double angled barrel plate fixation plays two folds role. It converts the shearing forces into the compression forces by placing the fracture site perpendicular to the resultant of body weight forces. It buttresses the head of femur from below to improve the stability provided by the internal fixation. Good results had been reported in femoral neck fracture treated with primary osteosynthesis and valgus intertrochantric osteotomy [16],[17]. Avascular necrosis may develop following surgery. Marti et al while making observations on avascular necrosis mention that partial or complete collapse of head of the femur can occur up to 3 or 4 years later [18] . Soto-Hall et al observed that incidence of aseptic necrosis was not raised when treatment for fracture neck femur was neglected because patients inevitably assumed the positions of the greatest joint capacity (flexion, abduction and external rotation) [19] . This posture would relieve the intra articular temponade and lessen the possibility of avascular necrosis. This probably explains why avascular necrosis was not seen in our patients.

In conclusion repositioning osteotomy with dynamic hip screw and 120° double angled barrel plate fixation is a useful method in treatment of fracture neck femur with viable femoral head.

 
   References Top

1.Dickson JA. The "Unsolved" fracture: A protest against defeatism: J Bone Joint Surg (Am). 35:805, 1953.  Back to cited text no. 1    
2. Linton P. On the different types of intracapsular fractures of the femo­ral neck: A surgical investigation of the origin, treatment, prognosis, and complications in 365 cases. Acta Chir Scand. 1990 (suppl 86 ) : 1 , 1944.  Back to cited text no. 2    
3. Blount WP. Blade Plate internal fixation for high femoral osteotomies. J Bone Joint Surg. 25: 319, 1943.  Back to cited text no. 3    
4. Muller ME, Allgower M, Willenegger H. Manual Der Osteosynthese. Berlin; Springer. 1977:360.  Back to cited text no. 4    
5. DeLee JC. Fractures and dislocations of the hip. In Rockwood CA, Green DP (eds): Fractures in adults, ed 2. Philadelphia; JB Lippincott. 1984: 1211.  Back to cited text no. 5    
6. Holmberg S, Kalen R, Thorngren KG. Treatment and outcome of femoral neck farctures . An analysis of 2418 patients admitted from their own homes. Clin Orthop. 218: 42, 1987.  Back to cited text no. 6    
7. Garden RS. Low- angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br). 1961; 43:647.  Back to cited text no. 7    
8. Pauwels F. Der Schenkelhalsbruch ein mechanisches Problem : Grundlagen des Heilungsvorganges, Prognose and kausale Therapie. Stuttgart; Ferdinand Enke Verlag 1935.  Back to cited text no. 8    
9. Singh M, Nagrath AR, Maini PS. Changes in the trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg (Am). 1970;52: 457- 467.  Back to cited text no. 9    
10.Lu-Yoa GL, Keller RB , Littenberg B, Wenliberg 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: 15­23  Back to cited text no. 10    
11.Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg (Br). 1964; 46: 630-47  Back to cited text no. 11    
12. Dalen N. Jacobson B. Rarefied femoral neck trebecular patterns,fractures displacement and femoral head vitality in femoral neck fractures. Clin Orthop. 1986; 207: 97-8.  Back to cited text no. 12    
13. Von Langen Beck B. Gvar Deen . Ges Chri 7:40: J Trauma. 27:291, 1987  Back to cited text no. 13    
14. 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. 14    
15. Zukerman JD, Koval KJ. Hip trauma. In Frimoyer JW {ed} Orthopaedic knowledge update 4. Rosemont; American Academy of Orthopaedic surgeons. 1993:525-538.  Back to cited text no. 15    
16. Rinaldi E, Marengh P, Negri V. Osteosynthesis with vulgus osteotomy in the primary treatment of subcapital fractures of the neck of the femur. Ital J Orthop Traumatol. 1984, 10{3}: 313 -320.  Back to cited text no. 16    
17. Lifeso R, Younge D. The neglected hip fractures . J Orthop Trauma. 1990 ; 4: 287 -292.  Back to cited text no. 17    
18. Marti RK, Schuller HM, Raaymakers ELFB. Intertrochanteric os­teotomy for nonunion of the femoral neck. J Bone Joint Surg (Br). 1989; 71: 782-787.  Back to cited text no. 18    
19. Soto-Hall R , Johnson LH, Johnson RA. Variations in intraaticular pressure of the hip joint in injury and disease . A probable factor in avascular necrosis. J Bone Joint Surg (Am). 1964; 46;509.  Back to cited text no. 19    

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Correspondence Address:
K K Pruthi
Department Of Orthopaedics, SN Medical College, Agra
India
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Source of Support: None, Conflict of Interest: None


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    Figures

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    Tables

  [Table - 1], [Table - 2], [Table - 3]



 

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