|Year : 2015 | Volume
| Issue : 2 | Page : 35-44
Long term outcomes of neglected intracapsular fracture neck in young adults managed by modified double angle barrel plate (DABP) with intertrochanteric valgusosteotomy
S. P. S. Gill1, Manish Raj2, Pulkesh Singh3, Dinesh Kumar3, Jasveer Singh3, Prateek Rastogi4
1 Associate Professor and HOD, Department of Orthopaedics, U.P. Rural Institute of Medical Science and Research, Saifai, Etawah, Uttar Pradesh, India
2 Lecturer, Department of Orthopaedics, U.P. Rural Institute of Medical Science and Research, Saifai, Etawah, Uttar Pradesh, India
3 Assistant Professor, Department of Orthopaedics, U.P. Rural Institute of Medical Science and Research, Saifai, Etawah, Uttar Pradesh, India
4 Resident, Department of Orthopaedics, U.P. Rural Institute of Medical Science and Research, Saifai, Etawah, Uttar Pradesh, India
|Date of Web Publication||22-Mar-2016|
Dr. S. P. S. Gill
Associate Professor and HOD, Department of Orthopaedics, U.P. Rural Institute of Medical Science and Research, Saifai, Etawah, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Clinical trial registration D-3437-2015
Introduction: Fracture neck of femur in young adult have relatively higher incidence of complications such as nonunion, avascular necrosis (AVN) of femoral head, loss of fixation, screw cut-out, and delayed secondary osteoarthritis. Delayed presentation of these cases in developing countries such as India further compromises the outcome of these fractures. Situations like this in young adult lead to difficulty in fixation by simple cancellous screw because of lack of compression surface area. Replacement surgeries in these cases are a difficult choice in these patients; it is difficult to restrict squatting for lifelong due to social culture and lack of toilets. Now, days also preferences are given to head sparing surgeries and osteosynthesis.
Materials and Methods: Cases were selected from the patients attending orthopedics outpatient department and emergency trauma center from August 2006 to August 2012. During this period, total 56 cases of neglected fracture neck femur came to our department. Of these 56 cases, 36 cases qualify for inclusion into this study. Of 36 cases, 22 were female and 14 were male with an age range from 22 years to 48 years and average age of 42 years. Average duration from injury to operative procedure was 4.9 weeks (34 days) and range from 2 weeks to 18 weeks. These cases were operated by modified double angle barrel plate (DABP) with intertrochanteric valgus osteotomy with one cannulated cancellous screw (CCS).
Results: Total 36 cases were operated using DABP and trochanteric osteotomy. Final outcomes were evaluated using modified Askin and Bryan criteria. Of these 36 cases, 32 (88.8%) cases gave good to excellent results and completed their full follow-up. Rest four cases were unable to continue with same implant fixation. These were kept in failure group. These four cases showed failure due to loss of reduction, screw cut-out, and secondary collapse of femoral head after AVN. These cases further managed by replacement surgeries.
Discussion: Neglected fracture neck femurs are not rare presentation in developing countries. Various modalities of treatment are fibular graft, iliac bone graft, multiple screws with fibular graft, muscle pedicle graft. In our case series, we had done combination of DABP with trochanteric osteotomy with CCS and achieved excellent to good results and this method can be used a primary method for management of neglected femoral neck fracture.
Keywords: Double angle barrel plate, femoral neck fracture, neglected femoral neck fracture, trochanteric valgus osteotomy
|How to cite this article:|
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Long term outcomes of neglected intracapsular fracture neck in young adults managed by modified double angle barrel plate (DABP) with intertrochanteric valgusosteotomy. Afr J Trauma 2015;4:35-44
|How to cite this URL:|
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Long term outcomes of neglected intracapsular fracture neck in young adults managed by modified double angle barrel plate (DABP) with intertrochanteric valgusosteotomy. Afr J Trauma [serial online] 2015 [cited 2019 Jan 19];4:35-44. Available from: http://www.afrjtrauma.com/text.asp?2015/4/2/35/179212
| Introduction|| |
Femoral neck fracture at any age is of concern to most of the orthopaedic surgeon. There is great diversity in the management of femoral neck fracture. Probably, this is only fracture that has the most number of controversies regarding management. In developing countries such as India and majority of rural population, late presentation of these femoral neck fractures is not uncommon mainly due to lack of awareness. Femoral neck fracture also has relatively higher incidence of complications such as nonunion  and avascular necrosis (AVN) , of femoral head. These complications are due to precarious blood supply, difficulty in reduction, flow of synovial fluid and washout of fracture hematoma by synovial fluid, and lack of cambium layer in periosteum are some of the reasons for the nonunion and AVN. Delayed presentation and with history of manipulation and massage by local bone setter in developing country further jeopardize the final outcome. This manipulation often leads to neck resorption, smoothening of fracture margin, sclerosis  and gives unfavorable outcome. Replacement surgeries ,, in these cases are also difficult choice as this is very difficult to restrict squatting for lifelong in rural population due to social culture habits. At present, preference are given to head sparing surgeries and osteosynthesis.
Various surgical techniques for neglected femoral neck fracture in young adult includes vascularized iliac bone graft. , Nonvascularized (free) fibular grafting, ,, nonvascularized fibular grafting , with or without cannulated cancellous screw (CCS), muscle pedicle grafting, , and various osteotomy around hip ,, such as McMurry displacement osteotomy and Pauwels osteotomy. Nevertheless, there is no standard guideline for choosing one over another for a particular fracture.
In this study, we used fixed double angle barrel plate (DABP) supplemented with trochanteric valgus osteotomy and CCS for fixation of femoral neck fracture in young adults and operative procedure modified to calculate the amount of wedge to be removed. This is a prospective study and final outcome evaluated and compared with literature.
| Materials and Methods|| |
This study conducted in the Department of Orthopaedics of a 1000-bedded multispecialty tertiary level medical college situated in rural setup in the North India. These cases were selected from the patients attending in orthopedics outpatient department and emergency trauma center from August 2006 to August 2012. During this period, total 56 cases of neglected fracture neck femur came to our department. Of these 56 cases, 36 cases qualify our inclusion criteria of the current study. Noncollapse stage of AVN treated with various rotational osteotomies itself, and there is also evidence of reversal of AVN after fracture union. Radiologically noncollapse stage of AVN was also included in the study as early AVN are not a contraindication to osteosynthesis procedures. ,
Inclusion criteria of the current study are as follows:
- Fracture neck femur, intracapsular fracture
- Fracture duration >2 weeks (with history of massage and manipulation), without any history of massage and manipulation fracture up to 3 weeks taken as fresh fracture
- Age of patients ≤55 years
- Medically fit for anesthesia point of view.
Exclusion criteria are as follows:
- Fracture neck femur of <2 weeks, these cases were managed by CSS fixation
- Age >55 years, managed by fibular grafting with cancellous hip screw and age >65 managed by primary arthroplasty
- Previous any surgery around hip area also excluded
- Radiologically collapse of femoral head excluded.
Of 36 cases, 22 were female and 14 were male with an age range from 22 years to 48 years and average age of 42 years. Average duration from injury to operative procedure was 4.9 weeks (34 days) and range from 2 weeks to 18 weeks. The patients were kept on skin traction and preoperative radiological assessment done with X-ray pelvis with bone hip in internal rotation anteroposterior (AP) view and lateral view of the fractured site. All these cases were investigated in routine manner and posted for elective procedure as soon as possible depending on anesthesia fitness.
Informed consent was taken from every patient with proper explanation of the procedure and probable short-term and long-term complications. Ethical clearances for the procedures were taken from the Ethical Committee of our institute. Fractures were classified using Pauwels' classification , and angle of fracture line recorded according to the classification.
Operative procedure (modified)
All cases were operated on fracture table with the help of image intensifier. Indirect reduction done by traction and rotation of the lower limb combined with manual lateral traction at upper thigh in some cases. Reduction checked on C-arm and maximal possible reduction accepted in all cases without going for open reduction. This reduction is temporarily fixed with thick K-wire passed percutaneously from proximal part of trochanter to femoral head missing the neck of femur. Now, trochanter exposed from lateral incision and a guide wire for Richard screw inserted from most prominent part of the trochanter to inferior part of the head of femur and position checked in AP and lateral view. The second guide wire for CCS was inserted parallel to the first guide wire 1.5 cm superior to the first guide wire to superior part of the neck to head of the femur to give the space for Richard screw. Cannulated drill passed over the second superior guide wire and then proper size cannulated cancellous 6.5 mm screw passed over the guide wire to superior part of head and partially tightened to proximate the both fragments. Double reamer passed over the first guide wire and Richard screw of proper length passed so that is remains 5 mm inside the lateral wall of trochanter to allow the coupling screw to give compression. DABP was passed over Richard screw and coupling screw tightened to give compression at the fracture site. Partially loosen the coupling screw so that it allows rotation of the plate. Plate rotated along the long axis of femur. At this point, distal end of the plate will be at distance from the femur and plate proximal to angle will be in contact of the trochanter. At the angle of plate, femur is marked by drill bit under direct vision and also with the help of C-arm. This mark was taken as proximal horizontal osteotomy site of femur. Plate now rotated upward so that osteotomy site can be exposed and with the help of oscillating saw horizontal cut were taken from marked area up to medial cortex. Medial cortex left intact. The length of the wedge is not fixed in all cases. This depends on the diameter of the femur of that case. To determine the wedge length, plate rotated back along the long axis of femur. With the help of depth gauge or scale, the horizontal diameter of the femur at the site of horizontal osteotomy is taken (X mm). Plate is marked at X mm from the angle of the plate to distally. From this marked point on plate, the gap between plate and femur lateral cortex noted (Y mm). This Y mm is the length of the wedge we have to take from proximal horizontal osteotomy site. Oblique osteotomy carried out Y mm distal to the proximal osteotomy upward so that wedge closed over medical cortex [Figure 1]. Medical cortex left intact during osteotomy. Now, wedge of the bone removed by osteotome or Kocher forcep. Lowman's clamp applied between distal end of plate and femur. Gradual closure of the Lowman's screw done to proximate the plate toward femur and closing of wedge checked on image intensifier. Traction is released, and CCS and coupling screw tightened. Plate fixed to lateral surface of femur with cortical screws using dynamic compression method to give compression at osteotomy site. One 6.5 mm cancellous screw passed through proximal most hole of plate proximal to angle of plate toward inferior part of neck parallel to Richard screw. Wound closed in layers over the drain. We corrected 30° of Pauwels' angle in most of our cases. If more or less degree of angle correction is required that can be achieved by bending the angle of the plate by plate bender up to desired angle. By this method, amount of angle correction is equal to angle at the side plate of barrel plate [Figure 2].
|Figure 1: Pauwels' classification used for this study. (a) Preoperative Pauwels angle determined. (b) Fracture site fixed with K-wire and Richard screw and cannulated cancellous screw passed over guide wire. (c) Operative procedure - proximal horizontal osteotomy done at the site of bend of side plate, wedge height determined by diameter of femur at this site. (d) Operative procedure - Osteotomy site closed and plate fixed to femur - Pauwels' angle comes to <30°|
Click here to view
|Figure 2: (a) Osteotomy site marked by drill bit at the bend of side plate. (b) Wedge of bone removed and osteotomy site closed by using Lawman's clamp. (c) Plate fixed to femur. (d) Final view after osteotomy|
Click here to view
During the postoperative period, intravenous antibiotics given for 3 days followed by oral antibiotics if required depends on dressing condition until removal of stitches. Drain removed after 24-48 h. Postoperative radiograph taken once postoperative pain permits X-ray pelvis with both hip in inter-rotation and lateral view of operated hip. Postoperative radiograph assessed and compared with preoperative radiograph with relation to change in angle of fracture line and again classified according to Pauwels' classification. Patient kept on nonweight bearing and nonweight bearing physiotherapy of knee and hip joint was advised for 6-8 weeks depends on radiograph. Partial weight bearing allowed using walker after 6-8 weeks, gradual increase in weight bearing allowed. Radiologically fracture site and osteotomy site assessed at regular interval any loss of reduction, varus collapse, screw cut-out, nonunion, and AVN were recorded. Cases were followed up every 4 weeks for 3 months followed by every 6 weeks for nest 6 months and then every 8 weeks for 3 years. During follow-up, the functional outcome of cases were recorded and outcome assessed using modified Askin and Bryan criteria.  Final outcome recorded after 3 years of follow-up and the result recorded as excellent, good, and fair group.
| Results|| |
Surgical procedure duration in our cases ranges from 70 min to 90 min from the skin to skin with average duration of 82 min. Average blood loss during surgical procedure was 300 ml as osteotomy site tends to bleed. Amount of blood loss measured by change in weight of surgical sponges used. Blood transfusion did when postoperative hemoglobin had come below 10 g/dl on the 2 nd postoperative day.
These cases were evaluated at every follow-up clinically and radiologically. During follow-up passive and active movement at hip joint, pain during movement, radiological signs of union, and signs of AVN of femoral head and gait during later stage of follow-up recorded. During follow-up, Pauwels' angle again recorded on radiograph and any change noted. The final outcome of these cases assessed using modified Askin and Bryan's criteria [Table 1]. 
In accordance to these criteria, cases evaluated with respect to presence of pain, gait of the patient, need of walking aid, range of motion of hip joint, and activity of daily life.
We achieved 100% osteotomy site union in our cases. Even in 4 cases of failure, osteotomy site was united. Time duration taken for osteotomy site union was ranges from 8 weeks to 15 weeks and average duration was 10 weeks. Fracture site union was achieved in 32 of our cases. Fracture site union was taken when there are three cortical continuations on AP and lateral radiograph of the hip. Average duration taken for fracture site union in our cases was 12 weeks and duration range from 10 to 18 weeks [Figure 3].
|Figure 3: Case 1 - (a) Preoperative radiograph. (b) Follow-up radiograph at 6 weeks. (c) Follow-up radiograph 12 weeks. (d) Follow-up at 20 weeks. (e) Final follow-up - 36 weeks|
Click here to view
Guarded or partial weight bearing allowed only after some radiological sign of fracture union seen during follow-up. Average duration was 7 weeks. This delayed partial weight bearing were just to prevent any late varus collapse or screw cut-out, as these cases were already osteoporotic. Full weight bearing were allowed once radiological full signs of union seen in both AP and lateral view. Average duration of full weight bearing was 12 weeks and range from 10 to 20 weeks. Squatting and cross-legged sitting allowed only 4-6 weeks after complete weight bearing [Figure 4].
|Figure 4: Case 2 - (a) Six-month-old neck fracture with avascular necrosis. (b) Postoperative follow-up radiograph - 6 weeks. (c) Follow-up radiograph at 24 weeks with reversal of avascular necrosis. (d) Final follow-up radiograph - showing complete union with reversal of avascular necrosis. (e) Clinical snaps of the case|
Click here to view
Total 36 cases were operated using DABP and trochanteric osteotomy. The final outcome was evaluated using modified Askin and Bryan criteria.  Of these 36 cases, 32 (88.8%) cases gave good to excellent results and completed their full follow-up. Of these 32 cases, 13 (36%) cases showed excellent result and 19 (53%) cases showed good result. Rest four cases were unable to continue with same implant fixation. These were kept in failure group [Table 2].
|Table 2: Average Pauwels' angle recorded radiologically preoperative, postoperative and during follow-up|
Click here to view
According to Pauwels' classification, out of 36 cases, 10 cases were fallen into Pauwels' Group I, 11 cases into Group II, and 15 cases were of Group III preoperatively. Postoperative assessment of angle was done and noted that out of 36 cases, now, 28 cases fallen in Group I, 8 cases were in Group II, and none in Group III. Good to excellent result is seen in cases that fall in Pauwels' Grade I postoperatively. Cases fallen in Grade II even after osteotomy showed more failure compared to cases those fallen in Pauwels' Grade I postoperatively.
Four cases were shown failure due to loss of reduction, screw cut-out, and secondary collapse of femoral head after AVN. These failure cases were from the Pauwels Grades II and III to start with. Of four failure cases, two cases had history of massage and manipulation by local bone setter that might be the cause of head collapse due loss of vascularity and AVN of femoral head. Two other failure cases had severe osteoporosis that lead to screw cut-out and loss of reduction. These all four cases were further managed by replacement surgeries.
Various complications seen during follow-up were AVN in seven cases. AVN assessed using plain radiograph only. Increased radio sclerosis and crescent sign were taken as sign of AVN and compared with normal opposite side. Of these seven AVN cases, four cases gave poor result as these were also shown loss of reduction, head collapse combined with AVN. Rest three cases of AVN shows union at fracture site and during follow-up, they show reversal of AVN of femoral head seen radiologically as reversal of osteosclerosis. These cases were managed with delayed weight bearing. Of 36 cases, 30 cases were able to perform squatting after 3 years of follow-up. Furthermore, there were no radiological sign AVN of femoral head at any of these cases at the end of follow-up Over all Demographic distribution of femoral Neck Fracture cases with final outcome shown in [Table 3].
| Discussion|| |
Delayed presentations of fracture neck femur are still not very uncommon in developing country like India. Due to poor socioeconomic status and lack of education in rural area, these injuries tend to neglected. Fracture neck femur tends to neglected more than intertrochanteric fracture because of several factors such as less severity of injury, lack of gross deformity, and impacted fracture in some cases. Most local bone setter tends to manage these fractures as soft tissue injuries. These fractures are more common in osteoporotic and osteomalacia females and these cases did not get early attention due to gender bias in rural areas.
Numerous methods were advised in literature for the management of neglected fracture neck of the femur. Various methods used for preservation of the neck in fracture femur in young adults such as multiple CCS, fibula graft with screw, , vascularized fibular graft, ,, vascularized iliac bone graft, , muscle pedicle graft,  various osteotomy around hip, ,, and combination of these procedures. ,
The major causes of nonunion and AVN after femoral neck fracture are combination of biomechanical and vascular conditions caused by the fracture, poor reduction, and inadequate internal fixation. Varus malreduction is the main risk factor for nonunion. CCSs were one of the most commonly used hardware for internal fixation of these fractures and also during revision surgery using fibular grafting. Osteotomy had been also used with better outcomes in neglected femoral neck fractures with good to excellent results. Osteotomy converts the vertical fracture line to the horizontal compressive force and thus creates better hip biomechanics for fracture healing. The primary issue in these situations is biology at the fracture site and stability of internal fixation. Fibular grafting and stable internal fixation also advocated method just to overcome the local compromised biology. It had been suggested that valgus osteotomy should be preferred for cases in which shortening is significant (>1.5 cm), as this helps improve limb length. In our cases, no significant limb length problems were seen. Higher Pauwels' type fractures have a greater chance of failure and varus collapse. The femoral head in a neglected femoral neck fracture is compromised by osteoporosis secondary to disuse. This greatly impairs the strength of fixation in the femoral head. Severe osteoporosis is one of the major areas of concern as most of failure cases belong to this group. Ambulation in these cases also delayed due to risk of loss of fixation or screw cut-out.
Nagi et al.  used a single cancellous screw along with the fibular graft for supplemental fixation and found this implant unstable and relied on postoperative hip spica. Various other authors used 2-3 cancellous screws for supplemental fixation. They all relied on the fibular graft for primary stable fixation and believed that the cancellous screws provided additional stability. This arrangement exerts great shear forces on the graft, which in our opinion would hamper the biological environment for graft uptake. Considerable forces acting on the grafts can be determined from the instances of fibular graft fractures or slippage while using screws. Fracture of the fibular graft was seen in four patients in the series by Nagi et al. Though Nagi et al. achieved 95% union rate in their study, similar results were not replicated in other studies, even when more than one screw was used for stability.
Elgafy et al.  achieved fusion rates of 69.2% by using screws and autogenous fibular graft. Mean fracture union duration was only 4.4 months, Although the vascularized fibula appears to be a more biological graft, it is technically more difficult and needs greater expertise, which may not be available in many centers. Union rates >90% can be seen with free vascularized fibular grafting. Moreover, there were donor site complications such as risk of nerve injury and foot drop or later ankle instability.
Jun et al. achieved union in 92.3% (24 of 26) cases in 5.3 months. The success rate in their series was 91%, which is almost equivalent to that reported using vascularized fibular graft. Again, vascularized fibular graft required help of vascular surgeon and technically more demanding surgery.
According to Sandhu et al.,  there are changes seen in the area of neglected femoral fracture like first, fracture surfaces get smoothened out, and there is progressive absorption of the neck of femur resulting in increase in the gap between the fragments; second, decrease in the size of the proximal fragment, and third, the head of the femur may start showing signs of AVN.
Various study shows good results of treatment of nonunion of neglected neck fracture with valgus osteotomy. Marti et al.  1989 done 50 cases of neck fracture with 86% union rate and developed technical difficulties in six cases. During the period 1973-1995, valgisation osteotomy according to Pauwels was performed in 66 patients, 18-72 years old (mean 49.5 years). Union of the femoral neck was achieved in 58 (88%) of the 66 patients, union of the osteotomy in 65 patients (99%). A good or excellent result was achieved in 62%: Uneventful healing in 23 cases and healing with AVN without need for further treatment in 13 cases of their patients. They also stated that under stable conditions, revascularization of the femoral head (fragment) is possible, but the final result is not predictable. In our series, radiological signs (sclerosis and crescent sign) of AVN are seen in seven cases and three of these cases show reversal of radiological sign of AVN during follow-up.
Anglen  had done DABP in 13 cases with 100% union rates and two AVN. Thirteen patients with failed internal fixation of the femoral neck were treated with valgus intertrochanteric osteotomy (VITO) performed by one surgeon from 1987 to 1995. The patients ranged in age from 18 to 59 years. The interval from injury to osteotomy ranged from 4 to 54 weeks. With an average follow-up of 25 months (range, 9-42 months), the femoral neck fracture healed in all patients. Twelve patients returned to being fully weight bearing without pain. The average limb shortening was improved by 1 cm. In our current series, 7 out of 36 cases had shown radiological signs of AVN, and out of these seven, three cases show union and good results and four AVN cases show poor result and later required replacement surgeries.
Kalra and Anand  in 2001 operated 20 cases of neglected neck femur fracture of more than 1-month-old with double angle blade plate and intertrochanteric osteotomy with 85% union rate and in two cases AVN seen. They reported good to excellent result in 75% of cases after a follow-up of 30 months. In our study, we included cases even after 2 weeks with history of massage and manipulation with neck resorption of radiograph under neglected cases and managed by trochanteric osteotomy and DABP with good to excellent results in 86% of cases Kalra and Anand  operated twenty cases of neglected (more than 1-month-old) displaced femoral neck fractures in young adults were treated with a VITO. A fracture union rate of 85% (17 cases) was achieved. Two of the healed cases developed AVN. After 30 months, 15 patients (75%) had achieved good to excellent results.
Pruthi et al. had done 28 cases of neglected fracture neck femur with DABP and showed 88% union rate and two cases of implant cut-out. In their study, 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 min in 25 cases.
In one patient, dynamic hip screw cut through the head of femur. Postoperatively, they achieved 25° Pauwels angle in 14 cases; in other 14 cases, it was 26-30°. In our series, we also able to achieve the Pauwels' angle in Grade I in 28 cases. They allowed partial weight bearing with the help of walker was allowed at an average period of 6 weeks after the operation, and full weightbearing was allowed at an average period of 10 weeks after operation. In 26 cases, union at fracture site occurred with an average of 5.2 months and two cases had nonunion of which one showed fair and the other case showed poor results. Six patients of Pauwels' Type II fracture showed good results, and 20 out of 22 patients of Pauwels' Type III fracture showed good results and one case showed fair and another one case had poor result. All 14 cases in which postoperatively we achieved Pauwels' angle of 25° showed good results and in other 14 cases in whom we achieved Pauwels angle between 26° and 30°, 12 cases showed good results while one case each showed fair and poor result. Two cases operated within 3 weeks after injury and 19 cases operated between 3 and 12 weeks after injury, the results of all their cases were graded as good results, 5 out of 7 cases operated after 12 weeks of injury showed good results and the result of one patient graded as fair and of another one graded as poor result.
Gupta et al. in 2014 operated 25 young adults (age 15-50 years) with femoral neck fractures were operated on an ordinary operating table, using a Watson-Jones approach. Open reduction of the fracture site through an anterior capsular incision was performed and fixation with three cancellous screws was done. Patients were regularly assessed for clinical and radiological evidence of nonunion and AVN. Average follow-up was 32 months. Nonunion was seen in one case (4%) and evidence of AVN was seen in three cases (12%).
Gupta et al. operated 60 cases of femoral neck fracture using valgus subtrochanteric osteotomy and repositioning and using 135 single angle blade plates and achieved union in 56 cases and 4 cases developed AVN. They reported excellent result in 30 cases, good result in 24 cases, and poor result in 6 cases. Four of their cases developed AVN.
Said et al. managed 36 patients presented with 19 recent vertical femoral neck fractures, and 17 nonunions with VITO and achieved union in 35 patients (97%), and one recent fracture failed to unite (3%).
Sen et al. (2009) operated 22 cases of failed neck fracture CCS fixation cases with revision surgery using angle blade plate and autologous free fibular graft and reported 91% union rate. They reported good to excellent result in 14 cases after 3.2 years of follow-up.
Kainth et al. operated 22 cases of neglected neck femur by valgus osteotomy and double angle 120 blade plate in 8 cases and with fibular grafting and CCS in 14 cases and achieved good to excellent outcome in 19 cases. They reported union in 21 cases and AVN in two cases.
Khan et al. operated 16 cases of neglected femoral neck fracture with valgus osteotomy and fixation with 120 DABPs and achieved union in 14 cases and cut-out seen in 2 cases.
Bansal et al. operated 30 cases of neglected fracture of femur of age from 20 years to 60 years using 120 DABP and hip screw. Union was achieved in 28 cases. Two cases went into nonunion and were treated by arthroplasty later on. They showed 85% good to excellent result according to Askin and Bryan criteria. They showed that failure was due to osteoporosis and screw cut-out in their series.
Pal et al. operated total 72 cases of neglected fracture of femur using fibular strut graft with cancellous screw and showed excellent result and noted nonunion in 4 cases.
In the current study, our result is comparable to already present study in these fractures. Out of 36 cases, 32 cases (86%) shows good to excellent result according to modified Askin and Bryan criteria after 4 years (48 months) of follow-up. Postosteotomy, there is definitive improvement in Pauwels' angle from Grade III to Grade I with favorable outcome. Seven cases show radiological sign of AVN during follow-up and out of these 7 cases, 3 cases fracture united and functional outcome was good. Rest four cases show poor result and revision replacement surgeries required in these cases.
| Conclusion|| |
Neglected femoral neck fracture in young adults should always be preserved. Replacement of femoral head should be secondary option in young adults after the failed osteosynthesis or AVN combined with head collapse. DABP combined with CCS had given a good to excellent result in neglected femoral neck fracture. Combination of Pauwels Grade III angle and fracture duration more than 3 weeks with history of massage and manipulation gave unfavorable results. These cases had shown higher rates of fixation failure, varus collapse, and cut through. Hence, neglected femoral neck fracture in adults could well be managed by DABP over trochanteric valgus osteotomy with CCS. Replacement surgery should be reserved for collapse heads and failed osteosynthesis cases in young adults.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Banks HH. Nonunion in fractures of the femoral neck. Orthop Clin North Am 1974;5:865-85.
Calandruccio RA, Anderson WE 3 rd
. Post-fracture avascular necrosis of the femoral head: Correlation of experimental and clinical studies. Clin Orthop Relat Res 1980; (152):49-84.
Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma 1986;26:932-7.
Sandhu HS, Sandhu PS, Kapoor A. Neglected fractured neck of the femur: A predictive classification and treatment by osteosynthesis. Clin Orthop Relat Res 2005;(431):14-20.
Cartlidge IJ. Primary total hip replacement for displaced subcapital femoral fractures. Injury 1981;13:249-53.
Coates RL, Armour P. Treatment of subcapital femoral fractures by primary total hip replacement. Injury 1979;11:132-5.
Gregory RJ, Wood DJ, Stevens J. Treatment of displaced subcapital femoral fractures with total hip replacement. Injury 1992;23:168-70.
Chang MC, Lo WH, Chen TH. Vascularized iliac bone graft for displaced femoral neck fractures in young adults. Orthopedics 1999;22:493-9.
Hou SM, Hang YS, Liu TK. Ununited femoral neck fractures by open reduction and vascularized iliac bone graft. Clin Orthop Relat Res 1993; (294):176-80.
Azam MQ, Iraqi A, Sherwani M, Sabir AB, Abbas M, Asif N. Free fibular strut graft in neglected femoral neck fractures in adult. Indian J Orthop 2009;43:62-6.
Elgafy H, Ebraheim NA, Bach HG. Revision internal fixation and nonvascular fibular graft for femoral neck nonunion. J Trauma 2011;70:169-73.
Jun X, Chang-Qing Z, Kai-Gang Z, Hong-Shuai L, Jia-Gen S. Modified free vascularized fibular grafting for the treatment of femoral neck nonunion. J Orthop Trauma 2010;24:230-5.
Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck. J Bone Joint Surg Br 1998;80:798-804.
LeCroy CM, Rizzo M, Gunneson EE, Urbaniak JR. Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years. J Orthop Trauma 2002;16:464-72.
Baksi DP. Internal fixation of ununited femoral neck fractures combined with muscle-pedicle bone grafting. J Bone Joint Surg Br 1986;68:239-45.
Meyers MH, Harvey JP Jr, Moore TM. Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle-pedicle-bone graft and internal fixation. A preliminary report on one hundred and fifty cases. J Bone Joint Surg Am 1973;55:257-74.
Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop Relat Res 1997; Aug; (341):175-82.
Ballmer FT, Ballmer PM, Baumgaertel F, Ganz R, Mast JW. Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-67.
Kalra M, Anand S. Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults. Int Orthop 2001;25:363-6.
Kainth GS, Yuvarajan P, Maini L, Kumar V. Neglected femoral neck fractures in adults. J Orthop Surg (Hong Kong) 2011;19:13-7.
Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop 2009;43:6-16.
Pauwels F. Schenkelhalsbruch. The hip fracture a mechanical problem: F. Enke; 1935.
Bartonícek J. Pauwels′ classification of femoral neck fractures: Correct interpretation of the original. J Orthop Trauma 2001;15:358-60.
Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop 1976;114:259-64.
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;86-A: 1711-6.
Beris AE, Payatakes AH, Kostopoulos VK, Korompilias AV, Mavrodontidis AN, Vekris MD, et al.
Non-union of femoral neck fractures with osteonecrosis of the femoral head: Treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy. Orthop Clin North Am 2004;35:335-43, ix.
Marti RK, Schüller HM, Raaymakers EL. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-7.
Pruthi KK, Chandra H, Goyal RK, Singh VP. Repositioning osteotomy with dynamic hip screw with 120° double angled barrel plate fixation in fracture neck femur. Indian J Orthop 2004;38:92-5.
Gupta S, Kukreja S, Singh V. Valgus osteotomy and repositioning and fixation with a dynamic hip screw and a 135° single-angled barrel plate for un-united and neglected femoral neck fractures. J Orthop Surg (Hong Kong) 2014;22:13-7.
Said GZ, Farouk O, Said HG. Valgus intertrochanteric osteotomy with single-angled 130° plate fixation for fractures and non-unions of the femoral neck. Int Orthop 2010;34:1291-5.
Khan AQ, Khan MS, Sherwani MK, Agarwal R. Role of valgus osteotomy and fixation with dynamic hip screw and 120 degrees double angle barrel plate in the management of neglected and ununited femoral neck fracture in young patients. J Orthop Traumatol 2009;10:71-8.
Bansal P, Singhal V, Lal H, Mittal D, Arya RK. A convenient way to do valgus osteotomy for neglected fracture neck of femur. Kathmandu Univ Med J (KUMJ) 2013;11:147-51.
Pal CP, Kumar B, Dinkar KS, Singh P, Kumar H, Goyal RK. Fixation with cancellous screws and fibular strut grafts for neglected femoral neck fractures. J Orthop Surg (Hong Kong) 2014;22:181-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]