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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 2  |  Page : 90-93
Ununited fracture neck of femur treated with closed reduction and internal fixation with cancellous screw and fibular strut graft


Department of Orthopaedic Surgery, SMS Medical College, Jaipur, India

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   Abstract 

Background: Ununited fracture neck of femur in young adults has been tackled in various ways.
Methods: Twenty five patients of ununited fracture neck of femur in age group 21-55 years were treated by closed reduction, cancellous screw fixation and fibular strut graft and followed up for 2-6 years. Time gap between injury and operation was 6 weeks to 58 weeks. Five cases were previously fixed with various fixation devices.
Results: Osseous union was achieved in 24 cases with average time of 18.16 weeks. Main complication encountered in follow-up was avascular necrosis of femoral head, others were joint stiffness and shortening. Functional end results were good to excellent in 24 cases.
Conclusion: Closed reduction with internal fixation by cancellous screw and fibular strut grafting is easy and useful procedure.

Keywords: Ununited fracture neck of femur; Closed reduction; Internal fixation; Fibular strut graft.

How to cite this article:
Singh D, Sharma C S, Bansal M, Meena D S, Asat R P, Joshi N. Ununited fracture neck of femur treated with closed reduction and internal fixation with cancellous screw and fibular strut graft. Indian J Orthop 2006;40:90-3

How to cite this URL:
Singh D, Sharma C S, Bansal M, Meena D S, Asat R P, Joshi N. Ununited fracture neck of femur treated with closed reduction and internal fixation with cancellous screw and fibular strut graft. Indian J Orthop [serial online] 2006 [cited 2018 Oct 16];40:90-3. Available from: http://www.ijoonline.com/text.asp?2006/40/2/90/34447

   Introduction Top


In developing countries like India, ununited femoral neck fracture is a common due to deficient medical facilities, ignorance on the part of patient due to illiteracy and poverty. Femoral neck fracture if not treated within 90 days is called nonunion [1] whereas fracture untreated beyond 3 weeks [2] and 6 weeks [3] have been called as ununited fractures. Various procedures such as osteotomies, muscle pedicle grafts, bone graft, hip replacement arthroplasty etc. are advocated in the literature for ununited fracture of femoral neck in adult but results are still unpredictable [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11]

Henderson [4] proved that ununited fracture neck of femur can be reduced by closed technique without jeopardising precarious blood supply of femoral head as in open reduction. Cancellous screw provides a reasonable good fixation and occupies less space in femoral neck. Bone graft is a good measure to deal with problem of ununited fracture of femoral neck. Fibular graft is easy to obtain, does not leave behind any functional or cosmetic problem at donor site and it provides mechanical and biological fixation. It gets incorporated into surrounding bone. It also prevents subchondral collapse if avascular necrosis is already taking place.


   Material and methods Top


Criteria for selection of patients : Twenty five patients between 21-55 years who were either not treated for 6 weeks following injury or were treated by various internal fixation methods and failed to unite within a reasonable period of time, with viable femoral head as seen on plain roentgenogram were selected for this procedure.

Pre-operatively patients were systemically examined and evaluated radio- graphically regarding viability of femoral head, overriding of trochanter, quality of bone, details of femoral neck etc. and shortening. CT or MRI was not done. If trochanter was high riding and shortening was more than 1 cm, we used pre-operative skeletal traction to equalize the limb length and to aid in closed reduction during surgery.

Operative procedure : Under regional anaesthesia or general anaesthesia the procedure was carried out on standard orthopedic fracture table in supine position.

Under C-arm image intensifier control, the fracture was reduced by closed gentle manipulation technique and limb was tied in internal rotation which also provided easy access for fibula. We were not very keen to obtain 100% reduction which is very difficult also, rather we accepted reduction having good neck length and minimum rotation and maximum contact of fracture fragments which was checked in antraposterior and lateral views.

After reduction, fracture was fixed with two cancellous screw (6.5mm thick, 16mm threaded) leaving behind a space between two screws for fibular strut graft. D.C.S. triple reamer was used to make channel for the fibular graft. About 4" long fibular shaft obtained from middle 1/3 of ipsilateral leg (under tourniquet control, using posterolateral approach, leaving behind periosteum). Graft thus obtained was prepared by chiselling and petalling with the help of osteotome. Interosseos border was blunted and one end tapered. The graft was then inserted through previously made tunnel and hammered into place. After wound closure limb was immobilised into hip spica cast. The sutures were removed through window after 2 weeks.

Follow-up

  • Quadriceps exercise and toe movement from the start
  • At 2 weeks, suture were removed
  • At 6 weeks, spica changed
  • Spica cast continued till radiological sign of union were found
  • Then spica cast removed and mobilisation exercise started


Then after one month of quadriceps strengthening and mobilisation exercise, patient was allowed partial weight bearing with crutches. When sound bony union achieved as also ensured by skiagram full weight bearing allowed.

Criteria for evaluation of results

For evaluation of functional end results, we have used criteria laid down by Mishra [5] which is as follows:

(1) Excellent:

  • Able to walk without support
  • Able to sit in the chair
  • 50-60% of painless movement


(2) Good:

  • Able to walk without support
  • Able to sit in the chair
  • 40% movement possible with minimum pain


(3) Fair:

  • Able to walk with crutches
  • Not able to sit in chair with hip flexed
  • 30% of movement possible and painful


Failure was defined when union was absent.


   Results Top


Patients were followed up to 2-6 years. Union was achieved in 24 cases [Figure - 1],[Figure - 2] in an average time of 18 weeks (range 12-32 weeks) [Table - 1]. Functional end results [5] were excellent in 21, good in 3, and poor in one patient.

The main complication was avascular necrosis of femoral head (5 cases; [Figure - 2]d). Among these 5 new cases of AVN one patient developed frank arthritis, had hinged abduction (range of abduction ~ 20 0 ), 90 0 flexion and walking without support with minimal pain while walking. He may require a total replacement arthroplasty later on. Other two patients with AVN had more than 40% of range of movement with minimum pain. They have not developed arthritis yet; they were treated initially with abduction and extension exercise and stick in opposite hand till the pain disappeared. Now they are walking without support and able to sit in chair.

Remaining 2 patients with AVN are having more than 60% range of movement without pain, able to sit in chair and now walking without support. These two patients were also treated with abduction and extension exercise and stick in opposite hand initially.

Other main complications were knee and hip joint stiffness (2 cases) and shortening-1" in 4 cases.


   Discussion Top


Treatment of femoral neck fracture still remains an "unsolved problem", specially for young, active adults where preservation of femoral head is desired. For active young adult, replacement arthroplasty is not indicated because of long, active productive life ahead, while arthrodesis is not performed because of Indian customs of squatting and sitting cross legged. The problem is further compounded when treatment is delayed and avascular necrotic changes occur in femoral head.

Baksi [6] with muscle pedicle bone graft obtained union rate of 82%, non union 9%, for 6% of cases re-operations were required while failure rate was 3%. Muscle pedicle bone graft procedure are technically more demanding and such expertise and facilities are not available everywhere.

Goel et al [7] reported 66 cases of nonunion neck femur treated with McMurray's osteotomy. They have treated 28 cases in plaster while 38 cases with Wain-Wright plate fixation. Among the plaster group union was 71.4% while in plate group union was 52.6%, incidence of AVN was 18.2%. Ballmer [8] reported a series of 17 cases treated by Pauwel's osteotomy. Union rate in Ballmer series was 88%, however, revision of osteotomy was required in 3 cases and incidence of AVN was 30%. All osteotomies create one more fracture which may fail to unite and salvage surgeries like, THR is difficult afterwards.

With open reduction and fibular strut grafting as reported by Nagi et al [9] and Mishra et al [5] union rate was 96% and rate of AVN was nil. While in our series rate of union is 96% and rate of AVN is 20%.

We were not very keen to obtain 100% reduction because it is diffficut in old cases by closed means with which we are dealing. We have not done open reduction because open reduction is extensive procedure, increases tissue trauma and surgical complication, further disturbs already compromised vascularity, space available for manipulation of fragments under direct vision is extremely limited [10] , end results are similar to closed reduction [4] .

There are biomechanical and biological factor responsible for non union of fracture neck of femur [12],[13] . Osteosynthesis is an ideal way to deal with fracture which needs immobilization. Cancellous screw provides reasonably good fixation and occupies less space in neck. Being a simple implant they are easy to insert and readily available. We are quite satisfied with 6.5mm, 16mm threaded, non-cannulated cancellous screws as they also provided good compression at fracture site.

To counter biological factor we need bone graft. We preferred free fibular cortical graft because, it provides mechanical support and fixation, have satisfactory osteoconductive and inductive potential, prevents subchondral fracture and collapse of head, later gets incorporated into surrounding bone so implant loosening does not occur [Figure - 2]d, is very easy to obtain, there is no donor site morbidity, is also established method to deal with AVN of femoral head, vascular fibular graft is technically demanding operation.

To conclude, closed reduction with internal fixation by cancellous screw and fibular strut grafting is easy and useful procedure can be done by an average orthopaedic surgeon, can be done at district level with good results and acceptable rate of complication in comparison to various osteotomies and muscle pedicle bone graft procedure [1],[6],[7],[8],[10],[11] .

 
   References Top

1.Meyers MH, Harvey JP, Moore TM. Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle pedicle bone graft and internal fixation. J Bone Joint Surg (Am). 1973; 55: 257-274.  Back to cited text no. 1    
2. King T. The closed operation for intracapsular fracture of neck of the femur : final results in recent and old cases. Br J Surg. 1939; 26 : 721-­ 48.  Back to cited text no. 2    
3.Reich RS. Ununited fracture of the neck of the femur treated by high oblique osteotomy. J Bone Joint Surg. 1941; 23 : 141-158.  Back to cited text no. 3    
4. Henderson MS. Ununited fracture of neck of the femur treated by the aid of the bone graft. J Bone Joint Surg. 1940; 22 : 97-106.  Back to cited text no. 4    
5.Mishra D. Femoral neck fractures open reduction; Asnis screw fixation and fibular grafting. Ind J Orthop 1998; 32: 32-35.  Back to cited text no. 5    
6.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. 6    
7.Goel SC, Srivastava AN, Goel MK, Kacker JN, Singh OP. Role of McMurray's osteotomy in the treatment of intracapsular fracture of the femoral neck. Ind J Orthop. 1980; 14: 32-37.  Back to cited text no. 7    
8.Ballmer FT, Ballmer PM, Baumgaertel F, Ganz R, Mast JW. Pauwels osteotomy for nonunion of femoral neck. Orthop Clin North Am. 1990; 21 (4): 759-767.  Back to cited text no. 8    
9.Nagi ON, Gautam VK, Marya SKS. Treatment of femoral neck frac­tures with a cancellous screw and fibular graft. J Bone Joint Surg (Br). 1986; 68: 387-391.  Back to cited text no. 9    
10.Pati BN, Gupta AK, Paruthi M. Cannulated cancellous screw and muscle pedicle bone graft in fracture neck femur. Ind J Orthop. 1998; 32 (2):97-102.  Back to cited text no. 10    
11. Char RD. The sartorius muscle pedicle bone graft for nonunion of basal femoral neck fractures. Ind J Orthop. 1991; 25 (2): 96-98.  Back to cited text no. 11    
12.Bonfiglio M, Voke EM. Aseptic necrosis of the femoral head and nonunion of the femoral neck. J Bone Joint Surg (Am). 1968; 50 : 48-66.  Back to cited text no. 12    
13.Frangakis EK. Intracapsular fracture of the neck of the femur: factor influencing nonunion and ischemic necrosis. J Bone Joint Surg (Br). 1966; 48: 17-30.  Back to cited text no. 13    

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Correspondence Address:
Daria Singh
J II/9 Sector-2, LIC flats, Vidhyadhar Nagar, Jaipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34447

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    Tables

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    Abstract
    Introduction
    Material and methods
    Results
    Discussion
    References
    Article Figures
    Article Tables
 

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