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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 2  |  Page : 97-99
Fibular osteosynthesis in neglected femoral neck fractures


Department of Orthopaedic Surgery, MLB Medical College, Jhansi, India

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   Abstract 

Background: Neglected fractures of femoral neck present a problem in management.
Method: Twenty five cases of neglected femoral neck fracture in young and middle age were treated by closed reduction and internal fixation by three peripherally placed cannulated cancellous screws, with centrally placed free fibular bone graft.
Results: Union occurred in all the 25 cases, one case had avascular necrosis. There was no residual disability at donor site. Twenty four cases had excellent and one case had satisfactory result.
Conclusion: Free fibular bone graft with multiple cancellous screws gives good results in treatment of neglected intracapsular fracture neck femur.

Keywords: Neglected femoral neck fracture; Fibular osteosynthesis; Free fibular bone graft

How to cite this article:
Gupta D K, Agarwal P. Fibular osteosynthesis in neglected femoral neck fractures. Indian J Orthop 2006;40:97-9

How to cite this URL:
Gupta D K, Agarwal P. Fibular osteosynthesis in neglected femoral neck fractures. Indian J Orthop [serial online] 2006 [cited 2020 Jan 26];40:97-9. Available from: http://www.ijoonline.com/text.asp?2006/40/2/97/34449

   Introduction Top


Fractures of the femoral neck have always been a great challenge to orthopaedic surgeons. Innumerable methods of treatment are available, but none of them gives uniformly good results [1],[2],[3],[4],[5],[6] . The problem is further aggravated by presentation of large percentage of cases after a significant delay, a problem peculiar in developing countries like ours. Established methods of treatment for neglected fracture elsewhere do not hold good for femoral neck fracture because of its complexity in anatomy and biomechanical circumstances. The recent advances in the treatment have remarkably changed the outcome but the optimum results are still not achieved and hence none of the method has been universally accepted as standard method of treatment [6] .

The present work was undertaken to study the role of free fibular bone graft with multiple cancellous screws in treatment of neglected intracapsular fracture neck femur.


   Material and methods Top


Twenty five cases of ununited fracture neck femur between Jan 1998 to Dec 2001 were studied. The duration of injury was 3 weeks to 24 weeks, average being 10 weeks and majority of patient were between 22-60 years of age. Mean age being 48 years.

The patients were kept on bilateral A/K skin traction preoperatively till the two limbs were equal or the injured limb was slightly longer. Patients were taught quadriceps drill on day one.

Operative technique

The surgery was done, under general or regional anaesthesia on fracture table under C arm image intensifier. Close reduction was done with the usual method, position of the fragments was confirmed in AP and lateral views by image intensifier. Fracture was fixed by peripherally placed 3 cannulated cancellous screws in usual manner taking care that at least 1.5×1.5cm of lateral cortex was intact in the middle for fibular graft. A guide wire was placed in almost center of femoral head and neck under the control of image intensifier, length of the guide wire helped to assess the required length of the fibular graft, pre calculated length of fibula was removed by Gigli saw from the middle of ipsilateral leg. Introsseous border of fibula was chiseled off to have almost rounded fibula. 9.0mm hole was drilled around the centrally placed guide wire by the drill bit used for lag screw of DHS. Multiple drill holes using 2.5mm drill bit were made in the whole length of fibular graft already removed. The graft so prepared was hammered over the guide wire upto the subchondral part of the femoral head under C-arm control. Wounds are closed in layer over suction drain.

Post operatively no external splintage was given. Isometric quadriceps exercise were started preferably on the first post operative day as per pain tolerance and cooperation of patient. Knee bending exercises were started on 2 nd or 3 rd post operative day. Crutch walking was allowed after 6 weeks. Patient were followed at 6 weeks interval and examined clinically and radiologically. Full unsupported weight bearing was not allowed till radiological consolidation of fracture. The average follow up period has been 2 years.


   Results Top


Union occurred in all the 25 cases within 12-24 weeks, average being 16 weeks [Figure - 1],[Figure - 2]. Old fractures with absorption of neck took longer than relatively fresh fractures. There was no residual disability at donor site, except transient lateral popliteal nerve involvement in one case. Avascular necrosis was observed in one case, which had persistent pain and restriction of movements at the affected hip. Rest all the patients had full range of movements at hip and knee and were able to resume routine activities. Infection, superficial or deep, did not occur in any case. Results were graded on excellent in 24 cases and satisfactory in one case.


   Discussion Top


Neglected fractures of the femoral neck >3 weeks old pose a challenging problem in management in regards to rate of union and complication like avascular necrosis. Many methods of treatment [5] such as osteotomy displacement/ angulation, replacement arthroplasty (Hemi/total) [4],[6] & osteosynthesis using vascularized corticocancellous graft (Meyer's procedure) [7] or fibular osteosynthesis [8],[9],[10],[11],[12] have been advocated. Osteotomies whether displacement/angulation changed the normal anatomy as well as biomechanics of the hip, result in residual shortening and make future replacement procedure if needed difficult a part from added risk of nonunion at the osteotomy site.

Replacement arthroplasties whether hemi or total involve replacement of natural head by prosthetic head and the best results after arthroplasty, whether hemi or total, can't be compared to the united femoral neck fracture in anatomical or near anatomical position. Successful osteosynthesis overcomes all these problems. Many methods of osteosynthesis using vascularized corticocancellous graft i.e. muscle pedicle or fibular grafting have been advocated. Muscle pedicle grafting needs open reduction which further jeoparadizes vascularity of femoral head and is associated with high incidence of avascular necrosis and hence, has lost its popularity.

Henderson [7] treated nonunion of the femoral neck fracture by open reduction and free fibular grafting with POP hip spica for 3 months. Nagi et al [10],[11] reviewed young patient treated by ORIF with one cancellous screw with free fibular graft and supplemented it with external immobilization using Thomas knee splint or a foam gutter splint or POP hip spica and reported encouraging results.

In modification of Nagi's technique, authors have successfully treated 25 cases of neglected fracture neck femur by closed reduction and internal fixation by three peripherally placed cannulated cancellous screws and centrally placed free fibular graft. The three cancellous screws provide rigid fixations to the fracture, parallel lag screws permits collapse at fracture site still retaining the fixation and thus bringing in union. Bone dust resulting from drilling by 9mm drill bit works as internal bone graft. Fibular strut supports osteoporosed, poorly vascular or avascular femoral head, assist in fixation as well as have osteoinductive potential.

Rigid fixation thus achieved does not necessitate any external immobilization. Close reduction doesn't disturb the retinacular vessels and hence do not add to poor blood supply, so vital for fracture healing.

 
   References Top

1.Deyerle WM. Mulitple pin peripheral fixation in fractures of the two femoral neck of the femur- immediate weight bearing. Clin Orthop. 1965;39: 135-56.  Back to cited text no. 1    
2.Deyerle WM. Impacted fixation over resilient multiple pins. Clin Orthop 1980; 152: 102-22.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Frandersen PA, Jorgensen F. Osteosynthesis of medial fractures of the femoral neck by sliding nail plate fixation. Acta Orthop Scand. 1977; 48: 57-62.  Back to cited text no. 3    
4.Gingras MB, Clarke J, Evarts CM. Prosthetic replacement in femoral neck fractures. Clin Orthop. 1980;152: 147-157.  Back to cited text no. 4    
5.Halpin PJ, Nelson CL. A system of classification of femoral neck fractures with special reference to choice of treatment. Clin Orthop. 1980; 152: 44-48.  Back to cited text no. 5    
6.Sim FH, Stuffer NR. Management of fractures by total hip arthroplasty. Clin Orthop. 1980;152: 191-98.  Back to cited text no. 6    
7.Meyers MH, Harwey JP, Moore TM. Delayed treatment of subcapital and transcervical fractures of the neck of the femur with internal fixa­tions and a muscle pedical bone graft. Orthop Clin N Am. 1974; 5: 779-­792.  Back to cited text no. 7    
8.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. 8    
9.Henderson MS. Ununited fracture of the neck of the femur treated by the aid of bone graft. J Bone Joint Surg (Am). 1940; 22: 91-106.  Back to cited text no. 9    
10.Nagi ON, Gautam VK, Marya 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.Nagi ON, Dhillon MS, Gill SS. Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children. J Orthop Trauma. 1992; 6(3): 306-13.  Back to cited text no. 11    
12.Slater RNS, Gore R, Slater GJR. Free fibular bone grafting for femoral neck fractures- techniques. J R Coll Surg Edinb. 1003; 38: 376-77.  Back to cited text no. 12    

Top
Correspondence Address:
D K Gupta
Type IV/17, MLB Medical College, Jhansi –284 128
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34449

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    Figures

  [Figure - 1], [Figure - 2]

This article has been cited by
1 Meta analysis of different methods used for joint preserving procedures in the management of delayed, neglected and non-united femoral neck fractures in young adults
Mohamed Mansour ELzohairy,Abdel Salam Eid
Trauma. 2016; 18(4): 245
[Pubmed] | [DOI]



 

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    Abstract
    Introduction
    Material and methods
    Results
    Discussion
    References
    Article Figures
 

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