NONUNIONOFFRACTURENECKOFFEMURFORINTERTROCHANTERIC

OSTEOTOMY
Singh G.P.*
ABSTRACT
BACKGROUND: Femoral neck Iracture is a diIIicult problem in adult patients and without proper treatment leads to high
Iunctional impairment andIrequent complications.
OB1ECTIVE: The aim oI this study was to see the Iunctional outcome in patients with non union oI Iracture neck oI Iemur
treated with intertrochanteric osteotomy.
MATERIALANDMETHODS: All 14 cases operated and non operated (neglected) Iracture neck oI Iemur were enrolled
Ior the study 2003 to 2009 in National Medical College, Birganj and Janaki Medical College, Janakpur. Patients were treated
conservatively and in some patients Iailure oI Iixation was used to evaluate the Iunctional outcome.
RESULTS: There were 14 patients with average age oI 30 years with age range 14-50 years. 8 patients were male and six
were Iemale. 10 patients were previously treated conservatively and 4 patients presented with Iailure oI Iixation. Average
duration oI Iracture was 7 months (2 months -3 years with pauwel angle oI 32.8.
CONCLUSION: Neglected neck oI Iemur Iracture should be treated by three cancellous screw Iixation with molded and
angled narrowDCPplate, valgus osteotomy and autogenous bone graIting round the Iracture to achieve a high rate oI patient
satisIaction and satisIactory Iunctional outcome.
KEYWORDS: Neglected Iracture neck oI Iemur, Intertrochantry osteotomy, Autogenous bone graIting.
* ProIessor, Department oI Orthopaedics, Universal College oI Medical Sciences & Teaching Hospital, Bhairahawa,
Nepal
ForCorrespondence
Dr. G.P. Singh, M.S., F.I.C.S. (U.S.A.),
F.A.C.S. (U.S.A.), M.I.F.S.C. (India),
ProIessor,
Department oI Orthopaedics,
Universal College oI Medical Sciences & Teaching Hospital,
Bhairahawa, Nepal
Email:gpsingh1hotmail.com
Journal oI Universal College oI Medical Sciences (2013) Vol.1 No.03
Ok|G|NAl Ak1|ClL
NON UNION OF FRACTURE NECK OF FEMUR FOR INTERTROCHANTERIC OSTEOTOMY
Singh G.P.
INTRODUCTION

Non-union Iractures neck oI Iemur in young adults is a vital
1-4
problem. Irom practical point oI view iI Iracture remains
untreated Ior 3 weeks or more it is designated as neglected
Iracture. As internal Iixation alone has a high Irequency oI
Iailure rate so in such cases to achieve union oI Iracture

internal Iixation has to be combined with some type oI bone
graIt or osteotomy.
Due to the liIe style and religious requirements oI the patients
oI western countries are treated by hip arthroplasty. The people
oI our country want to squat or sit in cross legged position. The
movements required are not possible with total hip
arthroplasty. It is thereIore required by all means that the god
giIted hip joint should be preserved particularly in young
adults. We have used the traditional pauwel intetrochantric
osteotomy, adding autogenous bone graIts taken come
osteotomy site to non union site. Molded angle narrowDCPwas
used as requirement Ior non union Iracture neck in adults in our
study. CertainmodiIications havebeenmadeinthis procedure.
MATERIALANDMETHODS
The study included Iourteen cases oI operated and non
operated (neglected) cases oI Iemoral neck Iractures. In
operated cases, improper Iixation was the apparent cause oI
non-union and non operated case were treated by quack (Bone
setter).
According to pauwal classiIication,the patients were divided
in three groups. 6 under C-Arm, operations were carried out on
Iracture table. Directed lateral approach was used to expose
the Iracture site. Vastus lataralis was liIted sub periosteally
7
aIter releasing it in L shape. In operated cases implant used
were removed and Iibrous tissue were excised at the Iracture
site. Narrow DCP oI 06-07 holes molded round to greater
trochanter and angled according to the required angle oI
intertrochanter osteotomy. Fracture neck reduced and Iixed
with initially single 6.5 concellous screws through the
7
contoured narrow DCP. At osteotomy level are made
7
proximol transeverse cut and distal angle cuts.
Pre-determined size oI wedge usually oI 30 degree was
removed. Two more 6.5 cancellous screws through plate in the
neck passed and compressed. The lower limb was abducted to
align the Iemur to plate and reduction clamps were applied.
Angled DCPwas Iixed to Iemur using 4.5 mm cortical screws.
The removed bone was used as a graIt around the Iracture site
7
anteriorly and posteriorly. Skin traction was applied to every
case postoperatively Ior 04 weeks to avoid any implant
Iailures as our patients were mostly illiterate and do not Iollow
the instruction strictly. The patients were advised isometric leg
exercise along with skin traction. AIter one month every
patient was examined clinically, under C-Arm and
radiologically to see sign oI union. AIter two months, patients
rd
were mobilized with non weight bearing with walker. In 3
months iI patient is pain Iree on passive hip movements,
radiologically satisIactory position and C-Arm shows sign oI
union. Patient is asked to walk with partial weight bearing and
once patient walked with conIidence and there is no pain
he/she was allowed Iull weight bearing. Patients were
reviewed at 06 month, 09 month and 1 year aIter surgery
individually.
RESULTS
The mean age oI patients was 30 years with age range 14-50
years. Eight patients were male and six were Iemale. Ten
patients were treated by Quack, one Iemale patient got bullet
injury to neck oI Iemur and three patients improper Iixation
was done at district private hospital. The duration between the
injury and Iinal surgery was 7 months on average (2 months to
3 years). None oI the patients had any signiIicant medical
problem. Initial radiographs oI the both hips were taken, to
assess the degree oI neck resorption, Pauwel angle and
inclination oI the Iracture.
All the Iracture showed diIIerent degree on neck resorption,
but maximum resorption were Iound in two cases, one with
bullet injury other three years old treated with DHS. No
evidence oI Iemoral head collapse was observed in any oI
Iemoral neck Iracture. No special investigations were
perIormed to detect per collapse or avascular necroses oI
Iemoral head. There were 8 Pauwel types II and 6 type III
Iractures in our series.
Clinically healing was presumed to be present when the
patient was pain Iree and was bearing Iull weight with out any
support. Radiologically healing was determined by presence
oI bridging trabeculae oI bone across the non union site on
plain radiographs and C-Arm examination. All hip movements
dynamically were visualized on C-arm examination.
One oI the patient got inIected aIter one month oI surgery and
girdle stone procedure was done in this case. In two cases, one
with bullet injury and other 3 years old operated non union, got
united aIter 28 weeks but Iollow up radiology showed
subluxation oI head oI Iemur perhaps due to resorption oI
Iemoral neck. Average Iollow up was 18 months in 13 cases.
Average time to healing oI non union was 18 weeks (16-28
Weeks). One patient who got subluxation oI Iemoral head,
complainedoI painat night mostlybut she walkedpainIree with
relative good range oI movements. There were no
thoromboembolic complications or implant Iailure in our series.
8.9
Functional out comewas basedonAskinBryanCriteria.
There were 7 cases with excellent results, 5 with good and 1
case was with Iair results. There was poor out come in one case
that got severe hospital inIection and ended up in gridlestone
Journal oI Universal College oI Medical Sciences (2013) Vol.1 No.03
Ok|G|NAl Ak1|ClL
NON UNION OF FRACTURE NECK OF FEMUR FOR INTERTROCHANTERIC OSTEOTOMY
Singh G.P.
pseudarthrosis. One operated patient showed signs oI non
union up till 24 weeks. There patients started walking with Iull
weight bearing with support oI walker.
DISCUSSION
Femoral neck Iracture in young adult is an emergency and the
patient needs to be treated by early closed reduction and stable
Iixation. In our country late and neglected presentation oI
Iemoral neck Iracture suggests that iI Iracture neck oI Iemur is
more than 2-3 weeks old then primary osteosynthesis with
10.11
cancellous screw alone does not give good results. Meyers
also classiIied acute Iracture oI neck oI Iemur on those treated
up to 30 days aIter injury and those beyond 30 days as delayed
or non union.
The aim oI treatment in young adult patients with non union or
neglected maltreated Iracture neck oI Iemur without apparent
avascular necrosis is salvage oI God giItedIemoral head.
Pauwel showed that aIter reduction and placing the non union
oI Iracture neck under compression by resecting the laterally
7
based wedge osteotomy resulted in union oI Iracture, In our
procedures, we used cancellous graIt taken Irom osteotomy
site and placed around the Iracture neck, and three 6.5
cancellous screws were passed through molded narrow DCP,
to avoid any Iracture non union oI Iracture neck oI Iemur and
to achieve revascularization oI head oI Iemur. Post
operatively, every case was given skin traction Ior Iour week to
secure Iixation. Except one patient who was given skin
traction Ior 16 weeks. We achieved union rate oI 92.8. The
13
largest series in literature is that oI Marti et al.
They presented results oI valgus osteotomy in 41 patients oI
non union oI Iemoral neck Iractures, with union rate oI 86
they experienced technical diIIiculties in 6 patients requiring a
second surgery Ior re-Iixation. 7 other patients required
replacement due to persistent non union. Late segmental
collapse or implant Iailure at the shaIt. Angelen reported 13
patients with Iailed internal Iixation oI Iemoral neck Iracture
treated with valgus osteotomyachieving a union rate oI 100.
Studies comparing blade plate with compression screw Ior
Iixation oI Iracture neck oI Iemur have high rate oI suboptimal
position oI implant, cut through and implant Iailure with blade
14
plate. While using blade plate, hammer impact can displace
15
the Iragments. In dynamic hip screw, no doubt the implant is
not hammered, but the chances oI rotation oI head oI Iemur are
there around DHS reamer as compared with application oI
three cancellous screw through molded narrow DCP give
equal compression at Iracture neck oI Iemur, reduce the
chance oI cut through, and rotation oI head oI Iemur as well.
The mechanism oI hip joint shows that in one leg stance phase
0
a load oI at last three time body weight will transIer 21
16
inIeriolaterally.
0
We as a routine planed a wedge 30 as it is diIIicult to precisely
calculate the size oI wedge. This can be explained on the basis
oI biological as well as mechanical reasons Ior eIIectiveness oI
13
osteotomy in promoting union. Avascular necrosis without
head collapse has not been considered to be contraindication
Ior valgus osteotomy. Colandruccio and Anderson considered
the vascular damage at the time oI Iracture which decides
17
whether oI not necrosis will develop. However Stromqust
and Harriso used tetracycline and Isotope studies to showthat
vascular damage may be increased during the Iixation oI
18
Iacture.
In Iresh Iemoral neck Iractures, over correction more than 20
to 30 degree valgus oI malrotation will aIIect the vessels and
increase the chance oI developing necrosis but whether this
18
holds true in old case with resorption oI neck is not clear. It is
also well documented that revascularization oI head is
possible both by artery oI ligamentum teres and by vessels
19
crossing the uniting Iracture.
Pre-collapse avascular necrosis is not a contraindication Ior
valgus osteotomy in non-united Iracture neck oI Iemur. We
believe Iurther studies by non invasive means are required to
evaluate eIIect oI osteotomy on vascularity oI Iemoral head.
CONCLUSION
Three cancellous screw Iixations with molded and angled
narrow DCP plate valgus osteotomy, autogenous bone
graIting round the Iracture gives good outcome in neglected
Iracture neckoI Iemur iI done properly.
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NON UNION OF FRACTURE NECK OF FEMUR FOR INTERTROCHANTERIC OSTEOTOMY
Singh G.P.
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14. Doppelt SH, The sliding compression screw. Todays best
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compression screw. comparison with and without
subtrochantricvalgus osteotomy. Infury. 1999, 46. 312-317.
16. Pring D. Biomechanics of hip. In. Barrett D. Essential
basic science for orthopaedics Oxford. Butterwothr-
Heinemann. 194, 62-93.
17. Calandruccio RA, Anderson WE. Post fracture AJN of
femoral head. Correlation of experience and clinical
studies. Clin Orthop. 1980, 152. 49-84.
18. Stromquist B, Harrison LJ. Femoral head vitality after
femoral neck fractures- Comparison between per and
perioperative tetracycline labeling. Arch Orthop Trauma
Surg. 1983, 101- 251.
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Journal oI Universal College oI Medical Sciences (2013) Vol.1 No.03
Ok|G|NAl Ak1|ClL
NON UNION OF FRACTURE NECK OF FEMUR FOR INTERTROCHANTERIC OSTEOTOMY
Singh G.P.
0a|vetso| Ce||ege eI Ne4|to| t|eates oa4 Ieotb|ag esp|to|
/s har/ng fa//aw/ng past gradaat/an pragrammes:-
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