Neurobionplus
Home About Journal AHEAD OF PRINT Current Issue Back Issues Instructions Submission Search Subscribe Blog    
Login 

Users Online: 3915 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
 


 
TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 4  |  Page : 232-234
Reposition osteotomy for fracture neck of femur - A simplified technique of surgery and assessment of results


Department of Orthopaedics, GSVM Medical College, Kanpur, India

Click here for correspondence address and email
 

   Abstract 

Background : Delayed presentation of femoral neck fracture poses problem of management. Methods: Sixteen patients of fracture neck femur were treated with repositioning osteotomy and osteosynthesis with a 120 o double angle blade plate. Ten patients had Pauwel's type II and 6 had type III fracture.
Results : The average period for fracture healing was 14.87 weeks. No patient developed avascular necrosis. The average duration of follow up was 25 months. A new scoring system has been described. The results were excellent in four; good in nine; satisfactory in two and poor in one case.
Conclusion : Reposition osteotomy provides stability and union in femoral neck fractures.

Keywords: fracture neck femur; Repositioning osteotomy; Double angle blade plate.

How to cite this article:
Nath R, Rastogi S, Gupta A K, Prasad N. Reposition osteotomy for fracture neck of femur - A simplified technique of surgery and assessment of results. Indian J Orthop 2006;40:232-4

How to cite this URL:
Nath R, Rastogi S, Gupta A K, Prasad N. Reposition osteotomy for fracture neck of femur - A simplified technique of surgery and assessment of results. Indian J Orthop [serial online] 2006 [cited 2020 Jan 17];40:232-4. Available from: http://www.ijoonline.com/text.asp?2006/40/4/232/34501

   Introduction Top


Fracture neck femur is still a major orthopaedic problem and the treatment in many situations remains controversial. Results depend on extent and mode of injury, amount of displacement and comminution at fracture site, adequacy of reduction and rigidity of fixation, vascularity of the head fragment and timing of surgery.

Garden[1] originally described alignment index as a guide to adequacy of reduction. McMurray's displacement osteotomy[2] with valgus position has been used but it results into significant shortening and genu valgum; and appropriate implant is not available for its fixation. More so the osteotomy was conceived for weight transmission and it does not ensure union of the fracture. Further, displacement is considered a disadvantage for any subsequent total or hemiarthroplasty.

Abduction osteotomy has given consistently good results[3],[4],[5],[6]. Blount's osteotomy at or just distal to the lesser trochanter is preferable to the displacement osteotomy, for the position of the greater trochanter is more satisfactory, function of the abductor muscles is re-established more effectively and shortening is diminished. Dickson's geometric osteotomy has also not been very popular because it too needed exact calculation and execution of angle of osteotomies.[7]

A simplified technique of repositioning osteotomy used in this study is being presented. The technique is suitable for fresh as well as old and neglected fractures without avascular necrosis.


   Material and Methods Top


Sixteen fractures of neck of femur of varied duration were treated by reposition osteotomy. The fracture was reduced as accurately as possible by gentle traction in external rotation on the fracture table followed by internal rotation and abduction by about 20 o . Gentle manipulation at fracture site was also used. In most of the cases accurate reduction was achieved which was checked by X-ray. Image intensifier was not used.

A guide wire was inserted using the 90 o angle guide through the greater trochanter and neck in to the inferior portion of the head of femur and checked with X-ray. Using this wire as guide, blade portion of the 120 o double angle blade plate was inserted leaving the plate projecting out laterally. A cortical screw was fixed into the calcar region through the most proximal hole of the plate stabilizing the blade plate firmly to the head neck trochanter fragment. Now at the level of the elbow of the plate which was usually at or just proximal to the level of the lesser of the elbow of the plate which was usually at or just proximal to the level of the lesser trochanter, a transverse femoral osteotomy was performed by saw and the shaft of femur abducted and fixed to the plate by means of cortical screws. At the site of osteotomy the bone collapsed on the lateral aspect and angulated in valgus position and provided adequate stability.

Additional cancellous lag screws could be used into the neck of femur proximal to the blade, if space permitted, for extra stability and compression of fracture, before performing the osteotomy. Post operatively the fixation was so stable that the patient did not need any immobilization. Patient could be ambulatory non-weight bearing as soon as the pain subsided.

Instead of the blade plate a modified version has also been used in this series where the blade portion of the plate has been replaced by a sliding dynamic hip screw with its additional advantage of dynamic compression at fracture site and simplicity in three-dimensional orientation. It avoided hammering as required for insertion of blade plate and also powered instruments could be used that saved time.


   Results Top


The procedure has been done in adults ranging from 16yrs to 60yrs. Nine patients were males and the rest 7 were females. Mean duration of fracture was 12.43 weeks (range 2 weeks - 2yrs, median 3 weeks and mode 3 weeks). Nine patients had transcervical fractures and ten were Pauwel's type II. Internal fixation and position of the implant were satisfactory in all except one. All the patients united in average time of 14.87 weeks except one who had less than satisfactory reduction of fracture and had delayed union at fracture site even after 20 weeks of follow up. It was observed that patients who had better reduction of fracture and optimum position of implant ultimately had better result.

No patient developed avascular necrosis. Average follow up was 25 months. According to the scoring system developed by the first author, grading of results has been done considering four major and four minor criteria as detailed here.

Nath Scoring System:

Major criteria (65 points):

1. Pain 20 points

2. Avascular necrosis 15 points

3. Union 15 points

4. Shortening 15 points

Minor criteria (35 points):

1. Walking ability 10 points

2. Limp 10 points

3. Movements 08 points

4. Neck shaft angle 07 points

Score of 90-100 points was required for excellent result, 80-89 for result, 70-79 for satisfactory, and below 70 the result was graded as failure. Excellent results were achieved in four patients, good nine and satisfactory results in two patients. In one patient the procedure was considered to be a failure. Details of the new scoring system (NSS) are:

  1. Pain: No pain 20 points, mild tolerate-15, moderate limiting daily activities - 5 and severe pain - zero point
  2. Avascular necrosis (AVN): no AVN 15 points, increased density of head - 10, segmental collapse - 5, and severe with arthritic changes - zero point
  3. Fracture union: union present - 15 points, upto 2.5 cm ; 2.6 cm to 5 cm - 5, > 5 cm zero.
  4. Shortening: No shortening 15 points; upto 2.5 cm - 10; with single stick - 7; with crutches -4, and no weight bearing zero point.
  5. Walking ability: without aid - 10 points ; with single stick - 7; with crutches - 4 '; and no weight bearing - zero point.
  6. Limp: No limp -10 points, mild 8 ; mild to moderate - 6, severe 2 and inability to walk - zero point.
  7. Movements: Hip flexion > 130o - 8 points110-130o - 6 points , 90-110o - 4 points, < 90o - 2 points, and fixed hip - zero point.
  8. Neck shaft angle: >120o - 7 points, 110-120o - 5 points, 100-110o - 3 points, 90-100o - 1 point, and <90o - zero point.



   Discussion Top


There are many methods described in the literature for managing patients of fracture neck femur in the young and middle-aged population. These are various kinds of osteosynthesis with or without intertrochanteric osteotomy [7],[8] or osteosynthesis with some kind of bone grafting. Meyer's study of 32 patients had 74% rate of union and that of Baksi of 56 had 84.4% rate of union[9],[10]. McMurray had performed primary osteotomy for 23 patients and had obtained union of osteotomy and fracture in all of them. However in the different series the results of fracture union varied from 36 to 73.8% and that of avascular necrosis from 2 to 22%. Shortening was reported in all the cases.

It was observed that excellent results by this procedure could be ensured if the fracture was well reduced, implant was well positioned and absorption of neck of femur, if any, was minimal. However, even in old fractures with varying degree for neck absorption the results were reliable if other parameters were satisfactory. The surgeon must be careful to fix the osteotomy in neutral rotation otherwise a rotational deformity would result. This happened in one of our patients with 15 o external rotation deformity, which did not give significant trouble and was compensated. Similarly the abduction osteotomy initially resulted at times into significant compensatory downward pelvic tilt and apparent lengthening, but this also was well compensated by physiotherapy.

The need for a separate scoring system was felt because there was none in the literature especially devoted to fracture neck of femur. Harris Hip scoring was mainly a functional assessment and was lengthy and complicated. Large series of fracture neck femur reported in the literature have assessed their results by noting rate of union, AVN and other complications separately without a comprehensive grading of result. The present scoring system (NSS) has been developed to be a comprehensive system that includes all the aspects of fracture neck of femur i.e. anatomical, radiological and functional as well as complications like AVN.

This simplified technique of double angle blade plate or its modification using a lag screw instead of blade plate used in the present series has many advantages. The stability provided by the implant is adequate and lasting, thus obviating the need for external support. Early mobilization, ambulation and weight bearing is possible. It provides compression at fracture site resulting in early union. The procedure is not very difficult and the changes of avascular necrosis are not increased.

However, the procedure requires an excellent fracture reduction as a pre-requisite for excellent result. The need for image intensification or good radiological support cannot be over emphasized. The availability of a power saw is preferable for osteotomy. A relative disadvantage is that this procedure is difficult to perform in cases where the neck is absorbed especially in sub capital type of fractures and that it does not offer any solution to the vexed problem of avascular necrosis. The new scoring system (NSS) for assessment of comprehensive results of fracture neck femur is easy to understand and simple to use.

 
   References Top

1.Garden RS. Reduction and fixation of sub capital fracture of the femur. Orthop Clin North Am.1974; 5:683.  Back to cited text no. 1    
2. Mc Murray TP. Fracture of the neck of femur treated by oblique os teotomy. Br Med J. 1938; 1: 330.  Back to cited text no. 2    
3. Marti RK, Schuller HM, Raaymakers EF. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg (Br). 1989; 71: 782787.  Back to cited text no. 3    
4. Lifeso R, Young D.The neglected hip fracture. J Orthop Traumatol. 1990; 4: 287- 92.  Back to cited text no. 4    
5. Ballmer FT, Ballmer PM et al. Pauwells osteotomy for non-union of the femoral neck. Orthop Clin North Am. 1990; 21 : 4.  Back to cited text no. 5    
6. Fontanesi G, Costa P et al. Abduction osteotomy for non-union of femoral neck fractures. Ital J Orthop Traumatol. 1991; 17 (3): 293-294.  Back to cited text no. 6    
7. Blount WP. Proximal osteotomy of the femur. American Academy of Orthopaedic Surgeons Instructional Course Lecture. Ann Arbor, JW Edwards 1952; vol. 9.  Back to cited text no. 7    
8. Dickson JA. The right geometric osteotomy with rotation and bone graft for ununited fractures of neck of femur. J Bone Joint Surg (Br). 1947; 29: 1005-1018.  Back to cited text no. 8    
9. Meyers MH, Harvey JP Jr, Moore TM. The Muscle pedicle bone graft in the treatment of displaced fractures of the femoral neck: indications, operative technique, and results. Orthop Clin North Am. 1974 ; 5: 799.  Back to cited text no. 9    
10. Baksi DP. Internal fixation of ununited femoral neck fractures combined with muscle pedicle bone grafting. J Bone Joint Surg (Br).]. 1986; 68: 239-245.  Back to cited text no. 10    

Top
Correspondence Address:
Rajendra Nath
New Type 4, Medical Campus, GSVM Medical College, Kanpur
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34501

Rights and Permissions




 

Top
 
 
  Search
 
   
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    References
 

 Article Access Statistics
    Viewed5448    
    Printed106    
    Emailed1    
    PDF Downloaded357    
    Comments [Add]    

Recommend this journal