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Abstract:
Background: Optimal method of fixation for intracapsular fracture neck femur still
eludes us as so many implants and configurations have been recommended for
it. This paper evaluates two methods of screw fixation with regard to the stability
of fixation, healing of the fracture, functional outcome & possible complications
associated with them.
Material and Methods: This retrospective & prospective study was conducted in the
Department of Orthopaedics & Traumatology, M.G.M. Medical College & associated
M. Y. Hospital, Indore from June 2005 to September 2007 in which 30 cases of neck
femur fractures were admitted and evaluated in the Orthopaedic wards and treated by
internal fixation with three cancellous screws in a triangular configuration with Apex
up or Apex down. Only medically fit skeletally mature patients between ages 17-50
years with fresh intracapsular fracture neck of femur with normal radiological bone
density and without posterior comminution with Gardens radiological classification
Grade I-Grade III were included in the study. Patients having associated secondary
degenerative osteoarthritis of hip were not included in the study.
Results: Out of 30 patients 14 patients were fixed in apex up and 16 patients were
operated for apex down configuration. In apex up 9 patients (64.3%) had excellent
or good functional outcome and in apex down 13 patients (81.25%) had excellent or
good functional outcome.
Conclusion: Achieving adequate reduction imparts inherent stability and using
triangular screw configuration with apex downwards results in lower implant failure
rate, speedy union and better functional results.
Introduction:
No
Department
of
Orthopedics-
07312528516
Email drmahendrasolanki@gmail.com
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47
Inclusion Criteria:
All skeletally mature patients between ages 17-50 years
with fresh intracapsular fracture neck of femur with
normal radiological bone density and without posterior
comminution and only patients with Gardens radiological
classification Grade I-Grade III were included.
Exclusion Criteria:
(1) Patients with Gardens Classification Grade IV, (2)
Skeletally immature patients, (3) Patients having associated
secondary degenerative osteoarthritis of hip were excluded.
There were 22 male and 8 female patients with youngest one
18 years old and the oldest one aged 50 years. Patients were
randomly categorized to the following two groups. Group I:
Apex proximal group: Three cannulated screws were fixed
in end positions of a triangle with its apex directed upwards.
Group II: Apex distal group: Three cannulated screws were
fixed in end positions of a triangle with its apex directed
downwards. Preoperative assessment of fracture geometry
was done using Gardens classification. Depending upon
the age and pattern of fracture as per x-ray, above knee skin
traction or skeletal traction was applied.
Gardens Classification: [14] It is based on the degree of
displacement seen on the anteroposterior radiograph of the
hip:
Type I: Incomplete valgus impacted fracture
Type II: Complete fracture without displacement
Type III: Complete fracture with partial displacement
Type IV: Completely displaced fracture with engagement
of the two fragment
Intra operatively pattern of reduction achieved by using
Garden alignment index as seen in anteroposterior and
lateral projections by image intensifier. All the cases were
operated under spinal anaesthesia on fracture table in supine
position under image intensifier control. Prophylactic
antibiotics were administered 30 minutes before surgery
(third generation cephalosporin).
Surgical technique:
Fracture fixed in a triangle or inverted triangle configuration
with the first screw running along calcar, controlling inferior
displacement of the head of the femur. The second screw
was placed posterosuperior, along the neck of the femur,
with the shaft of the screw being as close as possible to the
posterior cortex of the femoral neck. This screw was used
to prevent the femoral head from drifting posteriorly. A
final screw was placed anterosuperior as additional support
(Figure 1). In apex down position the first screw was placed
in centre of neck along calcar and in apex up position the
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47
Table No. 3
Functional Results in various age groups
Age group
17-25 yrs.
26-35 yrs.
36-45 yrs.
< 50yrs
Total
90-100
Good
60-89
Fair
30-59
Poor
<30
Excellent
5
10
1
16
Good
1
3
2
6
Fair
1
1
2
Poor
2
4
6
Total
6
9
11
4
30
Table No. 4
Screw Configuration correlated to Reduction Achieved
Reduction Achieved
Anatomic
Non-anatomic
Total
Screw Configuration
Apex Up Apex Down
11
12
3
4
14
16
Total No. of
Cases
23
7
30
Table No. 5
Functional results correlated with Screw
Configuration
Functional Results
Screw
Configuration
Excellent
Good
Fair
Poor
Apex UP
Apex Down
Total
7
9
16
2
4
6
2
2
3
3
6
Total
14
16
30
Results:
Functional Results
Poor
1
3
2
6
Functional Results
Excellent Good
Fair
5
1
6
2
5
2
1
1
1
16
6
2
Total
6
16
8
30
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47
Figure 1:
Screws in apex down triangle configuration.
Figure 2:
Screws in apex up triangle configuration
Discussion:
Since intracapsular fracture neck of femur heals by primary
healing, along with stability in coronal and sagittal planes,
absolute rotational stability is necessary across the fracture
site [16]. The commonly used screw fixation construct in
fracture neck femur may be imperfect with one or more of
technical flaws: Unacceptable reduction (less contact area),
lack of parallelism, convergence towards head center,
crowding of screws in small area, inadequate screw length,
repeated drilling into the head weakening screw purchase
and leaving fracture gap. Loading on imperfect mechanical
construct can result in uncontrolled collapse, tilting of head
into varus, loss of contact, nonunion and screw penetration
into the joint. The key therefore is to provide good stable
construct that can withstand the routine strains, still
maintain contact between the fracture ends, provide
stability and allow healing [17].
A total of 30 cases of intracapsular fracture neck of femur
were treated and fixed by three cannulated cancellous
screws fixed in two different triangular configurations i.e.
apex up and apex down were studied. The age of patients
varied from 17 yrs to 50 yrs. 75% patients were younger
than 45 yrs. Average age of the patient in this series was
33.5 yrs, which was significantly lower as compared to
various studies published [18-21]. The frequency of neck
femur fractures in relatively younger age group in this
series may be related to shorter life expectancy of the Indian
population and high velocity trauma causing the fracture in
several younger patients in the study.
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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47
Conclusion:
Anatomic reduction and Screw configuration are strong
predictors of Stability of fracture and final functional
results. When we correlated functional result with screw
configuration, we found that most patients in whom apex
down configuration was used, functional results were
excellent or good. On the other hand functional results are
almost comparable in grade I and II in apex up configuration
but in grade III screw configuration does affect the final
functional outcome.
Of course therefore, it is an oversimplification to consider
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