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 Table of Contents  
Year : 2022  |  Volume : 37  |  Issue : 1  |  Page : 3-5

Prospective study of osteosynthesis with fibular bone grafting and hip screw fixation for late femoral neck fracture in young adults

Department of Orthopaedics, F.H. Medical College, Agra, Uttar Pradesh, India

Date of Submission30-Jul-2021
Date of Acceptance29-Nov-2021
Date of Web Publication13-May-2022

Correspondence Address:
Javed Bhatti
Department of Orthopaedics, F.H. Medical College, Agra, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_14_21

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Background: Intracapsular fracture neck femur has always presented great challenges to orthopedic surgeons and still it continues to be a burning problem; thus, it is often called as an unsolved fracture. The femoral neck fracture is probably the fracture for which there exists the largest number of methods of osteosynthesis.
We came into the world under brim of pelvis
And go out through the Neck of Femur.
The above quotation reflects the defeatist attitude that has long been held by medical and lay personal toward femoral neck fractures. Materials and Methods: The study was conducted in F.H. Medical College and Hospital, Agra. The cases of this study were selected from the patients attending the outpatient Department of Orthopaedics and from those arriving at the Emergency Department of F.H. Medical College and Hospital, Agra from November 2017 to December 2020. A total of 64 young adults with femoral neck fracture treated by a fibular bone graft with hip screw fixation were included in the study. All the fractures were more than 3 weeks old. Each patient was subjected to detailed clinical and radiological examination along with routine pathological investigations. Result: Results were assessed in 60 patients, whereas 4 patients were excluded from the study due to loss of follow-up. In the subcapital type, 33.3% of cases were found to have good score, 44.4% of cases had fair score, and rest of the cases were found to have poor score. In the transcervical type, 57.4% of cases scored good, 36.1% cases scored fair, and rest of the cases scored poor. In the basal type, 100% of cases were found to have good score. Therefore, transcervical and basal types of fractures have a good prognosis as compared with the subcapital type. The average follow-up was 16.4 months. Out of 60 patients assessed clinico-radiologically. Conclusion: We conclude that treatment of late femoral neck fracture is a simple and cost-effective procedure in young adults with good results.

Keywords: Fibular graft, hip screw, late fracture neck femur, young adults

How to cite this article:
Pathak V, Bhatti J, Goyal RK, Sajid I. Prospective study of osteosynthesis with fibular bone grafting and hip screw fixation for late femoral neck fracture in young adults. J Bone Joint Dis 2022;37:3-5

How to cite this URL:
Pathak V, Bhatti J, Goyal RK, Sajid I. Prospective study of osteosynthesis with fibular bone grafting and hip screw fixation for late femoral neck fracture in young adults. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:3-5. Available from: http://www.jbjd.in/text.asp?2022/37/1/3/345160

  Introduction Top

Fractures of the proximal femur are the source of much confusion, conflicting statements, and pessimism. Even the terminology is not clear. An anatomical basis is the key to any nomenclature and for proximal femoral fractures the line of insertion of hip joint capsule on the femur is the best point of reference. Fractures proximal to this are termed as intracapsular femoral neck fracture. Intracapsular femoral neck fracture has always presented great challenges to orthopedic surgeons and still continues to be a burning problem; thus, it is often called as “the unsolved fracture.”[1] Femoral neck fracture in young adults differs in many respects from the same fracture in the older age group: first, it is a relatively uncommon injury; second, there is a considerable difference in the severity of trauma; and third, these fractures occur through relatively normal strong bone in young adults.[2] Only a few published reports have dealt with femoral neck fractures in young adults and even fewer with late cases.[3],[4]

In underdeveloped countries because of poverty, ignorance, and lack of facilities, these fractures are often seen only after a delay or improper treatment. These cases are associated with a high incidence of non-union and avascular necrosis (AVN).

Fibular bone graft with hip screw fixation is a recognized method of treatment for late femoral neck fractures even with early stages of AVN. The compression hip screw provides reasonably good fixation and placement of fibular graft has many advantages as it acts as a biological implant, prevents subchondral collapse, acts as a channel for revascularization, and because of its trifine shape it adds to the stability of fracture reduction.

The main aim of our study was to salvage the natural femoral head and to provide stable, mobile, and painless hip to the patient.

  Materials and Methods Top

A total of 64 patients with late femoral neck fractures (>3 weeks) were operated at our institution from November 2017 to December 2020. Four patients were excluded from the study due to loss of follow-up. There were 35 male and 25 female patients with a mean age of 37.4 (21–50) years at surgery [Table 1]. The interval from injury until surgery was 3–8 (average 4.7) weeks. All patients were contacted for clinical and radiological follow-up and had standard radiographs of pelvis with both hip anteroposterior (AP) view in internal rotation and lateral hip radiographs. Distribution of cases according to types of fracture [Table 2].
Table 1: Patientparticulars

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Table 2: Distribution of cases

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After necessary preoperative investigations, all patients were operated under spinal/epidural or combined anesthesia using the traction table. An acceptable reduction was achieved in all the patients by traction and closed manipulation under the image intensifier. Two surgical teams were formed. The first team harvested the ipsilateral fibular graft using a standard posterolateral approach and drill holes were made on the two surfaces leaving the interosseous border intact. The second team exposed the hip through a lateral approach. Three guide wires were introduced from the base of the trochanteric flare passing through the fracture site under image guidance. Over the middle guide wire the medullary canal was reamed using 8 mm part of the triple reamer, whereas compression hip screws were introduced over the remaining upper and lower wire after drilling and tapping. Fibular graft was gently hammered into the reamed area and after final impaction of the graft, the screw was tightened to provide compression at the fracture site. Closure was done in layers over a suction drain, and stitches were removed after 15 days.

After stitch removal, patients were followed at monthly intervals for the initial 3 months and thereafter at bimonthly intervals. Partial weight bearing with walker and then with a stick was started after 8–14 (average 12.7) weeks, whereas full weight bearing was started after 12–21 (average 15.6) weeks depending on the clinical and radiological evidence of union.

  Result Top

All patients showed union within 6 months with an average union time of 3.94 months. The average follow-up of our patients was 16.4 (range 9–24) months. Functional evaluation was done by Larson’s method, which showed good results in 33, fair in 22, and poor results in 5 patients. According to Larson’s method of functional evaluation out of 60 patients assessed, 33 patients were pain free and had flexion-extension range 90°–120°, adduction–abduction range 60°–80°, and external–internal rotation range 60°–80°. Postoperative shortening was seen in five patients ranging from 0.5 to 1.5 cm. During the postoperative period, two patients had a superficial infection that was managed conservatively. There were two cases of AVN [Table 3].
Table 3: Results based on Larson’s method

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  Discussion Top

In most of the published reports, the free fibular graft was used either to treat nonunion of the femoral neck fracture or to treat early stage of AVN. Henderson[6] at Mayo Clinic treated 77 cases of femoral neck fracture by open reduction and free fibular grafting followed by hip spica for 3 months. Dooley and Hooper[7] evaluated retrospectively 26 patients of nonunion treated with fibular bone graft with or without valgus subtrochanteric osteotomy; 24 of these cases were united. They concluded that an osteotomy did not improve the union rate but rather added a possible further site for complications. Inclan[8] and Patrick[9] used free fibular graft in conjunction with Smith–Petersen nail for treating femoral neck fracture. They reported nonunion and AVN at the rate of 10%–15%. Nagi et al.[1],[10],[11] reported a series of 26 cases (10 fresh and 16 old) treated by open reduction and one cancellous screw with free fibular graft followed by single hip spica to all his patients. Slater et al.[12] reported a single case study of femoral neck fracture treated by closed reduction and fibular grafting with two cannulated hip screw fixation. Singh et al.[13] reported AVN in 20% cases in their study of 25 cases treated by cancellous screw and single fibular strut graft. In a study by Gupta and Agarwal,[14] of 25 patients treated by 3 cannulated cancellous screws and single fibular graft, only 1 case showed AVN. In a previous study of single fibular grafting and double screw fixation, done in Sarojini Naidu Medical College (SNMC) Agra by Goyal et al.,[15] there was no case of AVN. In our series of 60 patients, we achieved closed acceptable reduction under image intensifier and put fibular graft with two compression hip screw providing reasonably secure fixation. We had not applied hip spica postoperatively; rather we achieved ambulatory status much earlier. In none of our cases, complications related to donor site morbidity[12] were reported. Recently described reconstructive procedures like total hip replacement and surface replacement arthroplasty have a high incidence of failure in the younger age group and also life expectancy of patients with late femoral neck fracture is much longer than that of the prosthetic implant. Furthermore, joint preserving surgery improves the quality of life in short and medium term while still leaving the possibility of total hip replacement at an older age. Results are good in basal type of fracture and poor in subcapital fracture [Table 4].
Table 4: Results

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We conclude that treatment of late femoral neck fracture in young adults is a valuable, simple, and cost-effective option of salvaging the natural femoral head while simultaneously providing stable, painless, and mobile hip leaving the option of reconstructive procedures open at an older age.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nagi ON, Dhillon MS, Gonl VG. Open reduction, internal fixation and fibular autografting for neglected fractures of femoral neck. J Bone Joint Surg (Br) 1998;80:798-804.  Back to cited text no. 1
Portzman RR, Burkhalter WE. Femoral neck fractures in young adults J Bone Joint Surg (Am) 1976;58:689-95.  Back to cited text no. 2
Baksi DP. Internal fixation of ununited femoral neck fracture combined with muscle-pedicle bone grafting. J Bone Joint Surg (Br) 1986;68:239245.  Back to cited text no. 3
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.  Back to cited text no. 4
Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res 1963;31:85-93.  Back to cited text no. 5
Henderson MS. Un-united fracture of the neck of the femur treated by the aid of the bone graft. J Bone Joint Surg (Am) 1940;22:91-106.  Back to cited text no. 6
Dooley BJ, Hooper J. Fibular bone grafting for non-union of fracture of the neck of the femur. Aust NZ J Surg 1982;52:134-40.  Back to cited text no. 7
Inclan A. Late complications in fracture of the neck of the femur treated by nailing, bone grafting or both. J Inl Col Surg 9:36-50.  Back to cited text no. 8
Patrick J. Intracapsular fractures of femur treated with a combined smith-Peterson nail and fibular graft. J Bone Joint Surg (Am) 1949;31:67-80.  Back to cited text no. 9
Nagi ON, Gautam VK, Matya 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
Nagi ON, Dhillon MS, Sharma S. Donor site morbidity and regeneration after harvesting of the fibula as free graft. Contemp Orthop1992;24:535-40.  Back to cited text no. 11
Slater RNS, Gore R, Slater GJR. Free fibular bone grafting for femoral neck fractures-technique. J R Co Surg Edinb 1993;38:376-77.  Back to cited text no. 12
Singh D, Sharma CS, Bansal M. Ununited fracture neck of Femur treated with closed reduction and internal fixation with cancellous screw and fibular strut graft. Ind J Orthop 2006;40:90-3.  Back to cited text no. 13
Gupta DK, Agarwal P. Fibular osteosynthesis in neglected Femoral fractures. Ind J Orthop 2006;40:97-9.  Back to cited text no. 14
Goyal RK, Chandra H, Pruthi KK, Nirvikalp . Fibular grafting with cannulated hip screw fixation in late femoral neck fracture in young adults. Ind J Orthop 2006;40:94-6.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]


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