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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 2  |  Page : 94-96
Fibular grafting with cannulated hip screw fixation in late femoral neck fracture in young adults


Department of Orthopaedics, SN Medical College, Agra, India

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   Abstract 

Background: We reviewed the operative results of fibular bone graft with cannulated hip screw fixation in femoral neck fracture in young adults.
Method: Sixteen young adults with femoral neck fracture were treated by fibular bone graft with cannulated hip screw fixation. All the fractures were more than 3 weeks old.
Results: Results were assessed in 15 patients while one patient died due to complications not related to surgery. Union occurred in all 15 patients. One patient had intra-operative complication in the form of screw cut out with graft in the joint space. The average fallow up was 24.4 months. Out of 15 patients assessed clinico­radiologically 11 showed good results, 3 had fair while 1 had poor result.
Conclusion: We conclude that this is a simple and cost effective procedure for late femoral fleck fracture in young adults with good results.

Keywords: Late fracture neck femur; Young adults; Fibular graft; Cannulated hip screw.

How to cite this article:
Goyal R K, Chandra H, Pruthi K K, Nirvikalp. Fibular grafting with cannulated hip screw fixation in late femoral neck fracture in young adults. Indian J Orthop 2006;40:94-6

How to cite this URL:
Goyal R K, Chandra H, Pruthi K K, Nirvikalp. Fibular grafting with cannulated hip screw fixation in late femoral neck fracture in young adults. Indian J Orthop [serial online] 2006 [cited 2020 Jan 19];40:94-6. Available from: http://www.ijoonline.com/text.asp?2006/40/2/94/34448

   Introduction Top


Intracapsular femoral neck fracture has always presented great challenges to orthopaedic surgeons and still continues to be a burning problem, thus it is often called as The Unsolved Fracture [1]. It is probably the fracture for which there exists the largest number of methods for osteosynthesis. Femoral neck fracture in young adults differs in many respects from the same fracture in older age group. Firstly, it is relatively uncommon injury, secondly, there is considerable difference in the severity of trauma and thirdly, these fractures occur through relatively normal strong bone in young adults [2] . Only a few published reports have dealt with femoral neck fractures in young adults and even fewer with late cases [3],[4] .

In under developed countries because of poverty, ignorance and lack of facilities these fractures are often seen only after a delay or improper treatment. These cases are associated with a high incidence of non-union and avascular necrosis.

Fibular bone graft with cannulated hip screw fixation is a recognized method of treatment for late femoral neck fractures even with early stages of avascular necrosis. The cannulated hip screw provides reasonably good fixation and placement of fibular graft has many advantages as it acts as biological implant, prevents subchondral collapse, act as channel for revascularisation and because of its trifine shape adds to the stability of fracture reduction.

The main aim of our study was to salvage the natural femoral head and to provide stable, mobile and painless hip to the patient.


   Material and methods Top


Between April 2001 to September 2003, 16 patients with late femoral neck fractures (>3 weeks) were operated at our institution. There were 10 male and 6 female patients with mean age at surgery as 36.8 (21-50) years. The interval from injury until surgery was 3 to 8 (av 5.5) weeks. All patients were contacted for clinical and radiological follow-up and had standard radiographs of pelvis with both hip AP view in internal rotation and lateral hip radiographs.

After necessary preoperative investigations all patients were operated under spinal/epidural or combined anaesthesia using the traction table. Acceptable reduction was achieved in all the patients by traction and closed manipulation under image intensifier. Two surgical teams were formed, while one team harvested the ipsilateral fibular graft using standard posterolateral approach from the middle third of the leg and drill holes were made on the two surfaces leaving the interosseous border intact. The second team exposed the hip through lateral approach. Three guide wires introduced from the base of the trochanteric flare passing through the fracture site under image guidance. Over the central guide wire the medullary canal was reamed using 8 mm part of triple reamer while cannulated hip screws were introduced over the remaining two guide wires after drilling and tapping. Fibular graft was gently hammered in to the reamed area and after final impaction of the graft both the screws were tightened to provide compression at the fracture site. Closure was done in layers over a suction drain.

After stitch removal our patients were followed at monthly interval for initial three months and thereafter at bi monthly interval. All patients were kept non-weight bearing for an average period of 10 weeks (range 8-12 weeks) but mobilisation was started on the 3rd postoperative day depending on pain tolerance of the patient by using 4-post walker. Partial weight bearing with walker and then with a stick was started after 8 to 17 (average 12.5) weeks while full weight bearing was started after 12 to 21 (average 16.5) weeks depending on the clinical and radiological evidence of union.


   Result Top


All the patients showed union with in six months with an average union time of 3.86 months [Table 1]. The average follow up of our patients was 24.4 (range 20-32) months. Functional evaluation was done by Larson's Method [5] , which showed good results in 11, fair in 3 and poor results in one patient. According to Larson's Method of functional evaluation out of 15 patients assessed l4 patients were pain free and had flexion-extension range 90 0 -120 0 , adduction­abduction range 60 0 -80 0 and external-internal rotation range 60 0 -80 0 [Figure - 1]. Postoperative shortening was seen in 6 patients ranging from 0.5-1.5 cm. During the postoperative period 2 patients had superficial infection that was managed conservatively while one patient had intraoperative complication in the form of graft in the joint space with cut out of the screw and had pain and limited range of motion in all directions [Figure - 2]. We had not observed avascular changes in the femoral head in any of our patients till our follow up.


   Discussion Top


In most of the published reports the free fibular graft was used either to treat non-union of the femoral neck fracture or to treat early stage of avascular necrosis. Henderson [6] at Mayo clinic treated 77 cases of femoral neck fracture by open reduction and free fibular grafting followed by hip spica for 3 months. Dooley and Hooper evaluated retrospectively 26 patients of non-union treated with fibular bone graft with or without valgus subtrochanteric osteotomy, 24 of these cases united [7] . They concluded that an osteotomy did not improve the union rate but rather added a possible further site for complications. Inclan and Patrick [8],[9] used free fibular graft in conjunction with Smith-Petersen nail for treating femoral neck fracture. They reported non-union and avascular necrosis at the rate of 10-l5%. Nagi et al reported a series of 26 cases (10 fresh and l6 old) treated by open reduction and one cancellous screw with free fibular graft followed by single hip spica to all his patients [1],[10] . Slater et al reported a single case study of femoral neck fracture treated by closed reduction and fibular grafting with two cannulated hip screw fixation [11] . In our series of 16 patients, we achieved closed acceptable reduction under image intensifier and put fibular graft with two cannulated hip screws providing reasonably secure fixation. We had not applied hip spica postoperatively; rather we achieved ambulatory status much earlier. In none of our cases complications related to donor site morbidity [12] were reported and the complications that occurred were preventable by good technical judgement. Recently described reconstructive procedures like total hip replacement and surface replacement arthroplasty have a high incidence of failure in younger age group and also life expectancy of patients with late femoral neck fracture is much longer than that of the prosthetic implant. Further more joint preserving surgery improves the quality of life in short and medium term while still leaving the possibility of total hip replacement at an older age.

We conclude that treatment of late femoral neck fracture in young adults is a valuable, simple and cost effective option of salvaging the natural femoral head while simultaneously providing stable, painless and mobile hip leaving the option of reconstructive procedures open at an older age.

 
   References Top

1.Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fractures of femoral neck. J Bone Joint Surg (Br). 1998; 80: 798 -804.  Back to cited text no. 1    
2.Portzman RR, Burkhalter WE. Femoral neck fractures in young adults. J Bone Joint Surg (Am). 1976; 58: 689-695.  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.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. 4    
5.Larson CB. Rating scale for hip disabilities. Clin Orthop . 31:85, 1963.  Back to cited text no. 5    
6.Henderson MS. Un-united fracture of the neck of the femur treated by the aid of the bone graft. J Bone Joint Surg (Am). 1940; 22: 9l -106.  Back to cited text no. 6    
7. Dooley BJ, Hooper J. Fibular bone grafting for non-union of fracture of the neck of the femur. Aust NZ J Surg. 1982; 52 (2): 134 - 40.  Back to cited text no. 7    
8.Inclan A. Late complications in fracture of the neck of the femur treated by nailing, bone grafting or both. J Int Col Surg. 9(l): 36 -50  Back to cited text no. 8    
9.Patrick J. Jntracapsular fractures of femur treated with a combined smith-peterson nail and fibular graft. J Bone Joint Surg (Am). 1949; 31: 67-80.  Back to cited text no. 9    
10.Nagi ON, Gautam VK, Matya SKS. Treatment of femoral neck frac­tures with a cancellous screw and a fibular graft. J Bone Joint Surg (Br). 1986; 68: 387-91.  Back to cited text no. 10    
11.Slater RNS, Gore R, Slater GJR. Free fibular bone grafting for femoral neck fractures-technique. J R Co. Surg. Edinb. 1993; 38: 376 -77.  Back to cited text no. 11    
12.Nagi ON, Dhillon MS, Sharma S et al. Donor site morbidity and regeneration after harvesting of the fibula as free graft. Contemp Orthop. 1992; 24: 535 -40.  Back to cited text no. 12    

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


DOI: 10.4103/0019-5413.34448

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    Figures

  [Figure - 1], [Figure - 2]

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