TREATMENT
OF
FEMORAL
CANCELLOUS
SCREW
0.
From
Twenty-six
fixation
fresh
fractures.
Bony
union
The
was
and
avascular
necrosis.
plethora
up for
there
was
of
technical
Despite
a
in orthopaedics
of the “unsolved
surgery.
in all patients
either
partial
of avascular
except
one,
and
radiological
and
in the last
fracture”
signs
two
clinical
years.
or total,
remains
the
us.
the
treatment
ofchoice
for the fractured
neck offemur
in the
elderly
patient
(D’Arcy
and
Devas
1976; Devas
1977;
Coats
and Armour
1979; Cartlidge
198 1). The struggle
to
find the best treatment
in the relatively
younger
patient
continues
prognosis
as relentlessly
as it did
is all the more gloomy
half a century
ago.
if. as often
happens
The
in
India,
the patient
presents
several
months
after
the
injury.
often
with resorption
of the neck and sometimes
with radiological
signs ofavascular
necrosis.
In the middle
of 1981 we started
treating
these
patients
by open
Ilbular
grafting.
gross resorption
sis, The procedure
reduction,
cancellous
screw fixation
and
All the fractures
united,
even those with
ofthe
neck and signs ofavascular
necrowas then tried in all subsequent
cases
of femoral
neck fractures
of Garden
Types
III and IV
which presented
early; the results
were equally
gratifying.
This revived
our interest
in a procedure
that had been
tried
1946;
in the
Patrick
past
with
1949).
MATERIAL
Twenty-six
patients
and January
1983
the Postgraduate
less
encouraging
AND
results
for
reprints
shouldhe
I 986 British
Editorial
Society
0301
620X
863062
S2.()O
( .
\‘Ot..
68
B.
No.
3. MAY
1986
sentto
of Bone
Research,
by
open
50 years
necrosis
where
the
No
new
failure
before
all
Research,
Chandigarh.
ated
within
“fresh”
cases;
10 fresh
Case
with
narily
four
were
the treatment
because
was
was
patients
and
patients
error.
after
pre-operative
who
of injury
as “old”.
10
instituted.
detected
with
weeks
the others
screw
16 old
of a technical
necrosis
The
three
cancellous
There
of avascular
in
upon
reduction,
ofage.
occurred
case
Chandigarh
There
could
be oper-
were
labelled
were
I 6 old
as
and
cases.
selection.
Initially,
patients
below
50 years
of age
an old fracture
of the femoral
neck,
where
ordiMcMurray’s
osteotomy
would
have
been
per-
formed,
resorption
considered
were
selected
of the neck
for this new
with avascular
a contra-indication.
The
procedure.
necrosis
length
Partial
was not
of the
neck
was noted
on anteroposterior
films taken with the limb in
medial
rotation.
Good
results
encouraged
us to continue
with
further
patients,
and
then
to use this procedure
routinely
in all patients
below
50 years
of age with displaced
fractures
ofthe
femoral
neck.
Technique.
The
procedure
is carried
out
on
a standard
operating
table.
To expose
the hip we used Moore’s
postenor
approach
in the first three
cases
and
WatsonJones’
lateral
approach
in the rest. The capsular
incision
METHODS
0. N. Nagi.
MSOrth,
MSc, MAMS.
Associate
V. K. (lautam,
MSOrth,
Senior
Resident
Department
of Orthopaedics,
Postgraduate
Education
and Research,
Chandigarh
160012,
Requests
treated
GRAFT
MARYA
and
14 and
A
(Inclan
were operated
on between
May
in the Department
ofOrthopaedics
Institute
of Medical
Education
S. K. S. Marya.
MSOrth,
Senior
Resident
Department
of Orthopaedics.
All India
New Delhi
I 10028.
India.
S.
improvement
biomechanical
two decades,
is still with
were
between
at least
K.
Education
fractures
radiological
S.
were
WITH
FIBULAR
GAUTAM.
ofMedieal
patients
FRACTURES
AND
K.
neck
The
had
followed
advances
problem
Replacement
patients
V.
femoral
grafting.
achieved
were
treatment,
NAGI,
Institute
with
fibular
Four
patients
N.
tile Postgraduate
patients
and free
NECK
Professor
Institute
India.
Institute
Dr 0.
and
1981
at
and
of Medical
of
Medical
Sciences,
N. Nagi.
Joint
Surgery
Fig.
Diagram
short
showing
the incision
ofthe
intertrochanteric
I
in the anterior
capsule.
stopping
I cm
line, thus sparing
the arterial
ring.
387
388
0.
is made
in the
middle
of the
anterior
reduced
and
the acetahular
inserted
just below
the
fix the fracture
securely.
length
till the
six drill holes
(Fig.
2). The
A
base of the
Meanwhile
medullary
are made
fInal
line (Fig.
is scraped
temporarily
floor.
a 10cm
length
of fihula
from
interosseous
border
is nibbled
the
fixed
lag
Complications.
I).
out,
tered.
Superficial
wound
infection
patients
responded
to appropriate
union
occurred
in one case where
the
cellous
screw did not cross the fracture
The
and
greater
trochanter
to
an assistant
removes
same
limb;
away
along
of the fihular
its sharp
its whole
exposed.
and
in the cortex
graft
S. K. S. MARYA
stopping
with a K-wire
screw
is then
cavity
is partially
at various
places
length
V. K. GAUTAM,
capsule,
I cm short
of the intertrochanteric
fibrous
tissue between
the fragments
the f’racture
penetrating
N. NA(II,
required
for
impaction
No
at the
serious
fracture
complications
site and
the passage
of time. This patient
Three
fractures
united
with mild
were
encoun-
occurring
in two
antibiotics.
Nonthreads
of the cansite: there was no
the gap
increased
with
was lost to follow-up.
to moderate
coxa vara:
all had presented
very late after the injury
and had gross
resorption
of the neck.
Two of these were children
and
coxa vara probably
developed
as a result of injury
to the
growth
plate.
DISCUSSION
Fifty-five
years
as the panacea
ago the Smith-Petersen
for femoral
neck fractures
departure
from
(Smith-Petersen,
Fig.
I)ras
ing of the
fihular
graft.
2
prepared
as described
and l’emoral
a channel
for
hammered
into
removed.
The
neck just
the fihular
place.
leg is kept
and
below
graft.
the
was 70.9%
in displaced
fractures
(Frangakis
1966). The
rate of non-union
ranged
from
I I % to 22%
in various
large series (Boyd
and George
1947: Boyd and Salvatore
the screw head,
to
The graft
is then
acetabular
in a Thomas’
closed
method
of treatment
Vangorder
1931).
The pro-
cedure
was,
however,
not very
successful
in Garden
Types
III and
IV fractures.
and the total
failure
rate
including
non-union
and subsequent
avascular
necrosis
in the text.
fIxation
is measured
by placing
it directly
over the head,
neck and trochanteric
region.
A Henderson’s
drill is used
tO cut a dowel
of hone from the lateral
cortex
of the trochanter
make
Whitman’s
Cave
and
nail was received
and a welcome
splint
guide-wire
for
two
weeks.
after
which
the stitches
are removed
and a single
spica
cast applied.
This cast is removed
at the end ofsix
weeks
and the patient
allowed
to walk
with
crutches,
hearing
partial
weight
on the aflected
limb. Full weight-hearing
is
generally
allowed
at the end of three
months,
hut was
delayed
to six months
in four cases where
there was sigIllflcant
of
resorption
the
neck
with
signs
of avascular
necrosis.
.
RESULTS
The
results
niale
and
are
shown
12 female
years. eight were
41 to So years
aged
old.
in Tables
I and
patients:
three
II. There
were
aged
3 1 to 40 and the remaining
The right
hip was affected
were
14
14 to
17
Fig.3
Fig.4
Case 3. Figure
3-Two-week-old
comminuted
the neck of the femur.
Figure
4 -Six
months
solid
bony
union,
continuity
of the principal
and partial
incorporation
of the
intracapsular
after
operation
compressive
fibular
graft.
fracture
there
trabeculae
of
is
I 5 were
in 16
patients
and the left in 10. Of the 10 fresh femoral
neck
f’ractures.
six were Garden
Type
IV and four were Type
Ill. At operation.
posterior
cortical
comminution
and a
sharp
beak on the head fragment
were seen in seven
of
the
0 I’resh f’ractures.
Non-union.
All the fractures
I I ). The
failure
was
mentofthecancellousscrew(Figs
Avascular
necrosis.
There
was
lar necrosis
developing
after
patients
before
II11pR)Ved
united
a technical
it.
one
(Figs
3 to
place-
l2and
13).
not a single case of avascuthe operation.
In all four
with
radiological
signs
operation.
the condition
after
except
one--incorrect
of avascular
necrosis
of the femoral
head
Fig.
5
Fig.
-
6
Case
10. Figure
5 One-week-old
intracapsular
fracture.
One year after operation
there is complete
reconstitution
The patient
had a very good range
ofmovement
including
squat.
THE
JOURNAL
OF BONE
AND
JOINT
Figure
6---of the neck.
the ability
to
SURGERY
TREATMENT
Table
I. Results
OF FEMORAL
ofosteosynthesis
NECK
in 10 fresh
FRACTURES
WITH
A CANCELLOUS
SCREW
AND
FIBULAR
389
GRAFT
cases
Time
between
injury and
operation
(days)
Age
Follow-up
(rears)
Sex
I
45
M
R
3
+
2
40
F
L
7
+
Lateral
Bony
union
28
3
42
M
L
14
+
Lateral
Bony
union
24
4
48
F
R
20
-
Lateral
Bony
union
32
5
39
M
L
18
-
Lateral
Bony
union
40
6
23
M
R
2
+
+
Lateral
Non-union
7
47
F
R
6
+
+
Lateral
Bony
union
24
8
32
F
R
4
-
Lateral
Bony
union
32
9
43
F
L
2
+
Lateral
Bony
union
36
10
50
M
R
7
+
Lateral
Bony
union
29
Case
No
patient
Table
had
II. Results
Age
(rears)
Case
avascular
necrosis
ofosteosynthesis
before
or after
+
Surgical
approach
Result
Lateral
Bony
union
26
(months)
-
operation
in 16 old cases
Sex
Side
affected
Time between
injury and
operation
(seeks)
Postoperative
Pre-operative
Resorption
Surgical
AVN
approach
Bony
union
AVN
Follow-up
(months)
-
-
Lateral
+
-
24
24
+
+
Lateral
+
Improved
26
L
15
-
-
Posterior
+
-
26
F
R
10
-
-
Lateral
+
-
30
46
M
R
4
-
-
Lateral
+
-
32
16
36
F
L
6
-
-
Posterior
+
-
24
17
45
F
L
8
-
Lateral
+
-
28
18
17
M
L
16
+
Lateral
+
Improved
24
19
37
F
R
6
-
Lateral
+
-
32
20
15
M
R
62
-
Posterior
+
Improved
34
21
49
F
R
10
+
Lateral
+
-
31
22
46
M
R
II
-
Lateral
+
-
37
23
40
M
L
28
+
+
Lateral
+
24
43
M
L
22
+
-
Lateral
+
29
25
50
M
R
4
-
Lateral
+
28
26
50
F
R
6
-
Lateral
+
27
Avascular
necrosis
II
14
NI
R
6
12
42
F
R
13
43
M
14
32
15
AVN.
VOL.
Posterior
cortical
comminution
Side
affected
68
B.
No.
3.
MA\
986
+
+
Improved
33
390
0.
Fig.
N. NAG!,
V. K. GAUTAM,
7
Fig.
S. K. S. MARYA
8
Fig.
Case 20. Figure
7 Sixty-two-week-old
intracapsular
fracture
in a I 5-year-old
boy, treated
elsewhere
McMurrav’s
osteotomy.
There
was resorption
ofthe
neck and evidence
ofavascular
necrosis.
Figure
is almost
complete
incorporation
of the fihular
graft with reconstitution
at the fracture
site. Figure
operation
the femoral
head does not look avascular.
1964).
In
fractures.
least
a long-term
investigation
the Smith-Petersen
nail
effective
compared
form
to the
of fixation
sliding
nail,
of 1503
was found
suhcapital
to he the
in displaced
crossed-screw
fractures
fixation
as
and
9
by an incompletely
displaced
8- After osteosynthesis
there
9--Thirty-four
months
after
triangular
fixation
(Barnes
ci a!. I 976).
The techniques
of
internal
fixation
have been modified
repeatedly
because
none was perfect.
The newer appliances
have a lower rate
of non-union
than
Smith-Petersen
nailing:
4.7%
with
Deyerle
pins and 4% with Pugh’s
sliding
nail-plate
(Metz
et a!. 1970:
Fielding,
Wilson
and
Ratzan
sliding
nail has shown
promise;
fragments
to each
other
thus
1974).
Richard’s
it securely
impacts
the
helping
early
weight-
bearing,
but
non-union
is still
a problem.
Parkes
reported
an 18% incidence
ofnon-union
with Richard’s
screw (cited by Arnold,
Lyden
and Minkoff
1974).
In patients
below
the age of 50 we treated
all
Fig. 10
Fig. II
(ise
18. Figure
10
Four-month-old
fracture
with avascular
and resorption
of the neck.
Figure
1 I--After
IX months
there
plete
reconstitution
with no obvious
avascular
necrosis.
This
had full hip flexion
so that he was able to squat.
necrosis
is compatient
femoral
grafting.
previous
exerted
neck fractures
with open
reduction
and fibular
The mechanical
fixation
afforded
by the various
devices
depends
upon
the physical
pressure
between
the nail and the bone into which
it was
driven.
Normal
pressure
by absorption
vascular
bone
ofthe
reacts
bone
to
especially
if the implant
is ionisable
and
inert.
This produces
a halo of loosening
posedly
the cause
ing to non-union
1949).
By contrast,
four
fling
weeks,
to fuse
failure
union
was
ofavascular
starts
providing
with the parent
in the
not completely
which
is sup-
biological
fixation
by beginhone,
so that implant
loosen-
tenth
achieved
necrosis.
could
in these
was successful
series,
and the
have
nine
been
cases,
12
Fig.
13
(‘ase
16. Figure
12
Fractured
neck
of femur.
Figure
13
This was
treated
by a fihular
graft and screw.
but the threads
of the lag screw did
not cross the fracture
site, resulting
in non-union
and distraction
at the
fracture.
ducted
lished
grafting,
avascular
results
were
better
than
similar
in the past. Inclan
(1946)
and Patrick
their results
of Smith-Petersen
nailing
reporting
necrosis.
a 10%
to
We attribute
TI-IF
JOURNAL
OF
15%
of
our
BONE
in nine
techni-
avoided.
with
Our
Fig.
physical
interface,
of movement
at the fracture
site, leadin a sizeable
number
of cases (Patrick
a fibular
graft,
at the end of three
to
ing does not occur.
The procedure
ofthe
10 fresh cases in the present
cal
this
at the metal
Bony
no evidence
studies
con(1949)
puband fibular
non-union
better
results
AND
JOINT
SURGERY
and
to
atraumatic
approach
TREATMENT
OF FEMORAI.
tissue
technique
predominantly,
and
thus
NECK
the use
sparing
WITH
of the lateral
the posterior
retinacular
vessels.
The special
preparation
graft also helps in its early
incorporation.
screw
provides
reasonably
good
fixation
less space
than
a nail
in the femoral
encroachment
Smith-Petersen
the regenerating
FRACTURF.S
ofthe
fibular
A cancellous
and occupies
neck.
Greater
on this limited
space
by combining
a
nail with a fihttlar
graft seems
to depress
potential
of the head,
thus increasing
the chances
in our cases
of avascular
was made
necrosis.
anteriorly
The capsular
between
the
incision
two limbs
of the ligament
of Bigelow,
starting
from the acetabular
margin
and stopping
short
at least
I cm from
the intertrochanteric
line. This is thought
to be the least vascular
area and avoids
the major
arterial
circle around
the base
ofthe
neck.
Anatomical
reduction,
and
rigid
fixation
achieve
the best
are
results
femoral
neck.
All these
open
reduction,
fixation.
The
much
Closed
most
later
criteria
lag-screw
treatment
of
bigger
challenge
reduction
signs
of the
fragments
are
eminently
fixation
and
fulfilled
rigid
by
biological
and
old femoral
than
that
internal
fixation
fractures
after
begins
to resorb
of
avascular
neck
fractures
is a
of fresh
fractures.
three
and
is not
possible
in
weeks.
A few weeks
still later the radio-
necrosis
may
appear;
the
chances
of union
are then bleak.
Most
orthopaedic
surgeons
have
in the past
treated
such
fractures
with
a
McMurray’s
osteotomy.
which
often leaves
a short
limb
and a mechanically
unsound
hip. More
recently
various
muscle-pedicle
(Judet
1962:
1983).
They
bone
Meyer.
seem
grafting
Harvey
to hasten
procedures
have been tried
and
Moore
1973;
Baksi
union
even
in the presence
results
in treating
avascular
femoral
necrosis
or gluteus
non-union
of
the
achieved
union
in all 16 old fractures
improvement
in four cases ofavascular
VOL.
68 B. No.
3. MAY
femoral
of the
head
with
medius
muscle-pedicle
986
neck
plus
his quadratus
bone graft.
We
and radiological
necrosis.
FIBULAR
391
GRAFT
the collapse
was complete.
bone
of subchondral
until
revascularisation
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WD,
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Treatment
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avascular
necrosis
of the
femoral
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by multiple
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and muscle-pedicle
bone
grafting: a preliminary
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Joint
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[Br] 1983:65-B:
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R, Brown JT, Garden
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2 24.
Lyden JP, MinkoffJ.
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neck:
with
pinning.
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M, Voke
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4866.
HB,
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EM. Aseptic
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neck.
George
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RL,
primary
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Devas
Treatment
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fractures
special
reference
to percutaneous
Surg[AmI
1974:56
A:2S4
62.
Nicoll
EA. Subcapital
J Bone Joint
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J Bone
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M. Treatment
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1976:58
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subcapital
53.
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Injury
1979:
of
neck
nonA:
of the femoral
neck:
internal
Surg [Am] 1964:46
A: 1066 8.
hip replacement
1981 :13:249
Armour
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total hip replacement.
fractures
of the
lBrl 1976:58
B:
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Joint
Surg
[Am]
1968:50
of fractures
1 3 8.
Acute
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J Bone Joint
Cartlidge
lJ. Primary
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London:
femoral
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the
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fractures
femoral
Joint
Academic
by
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Surg [Br]
1977.
Fielding
JW, Wilson
SA, Ratzan
S. A continuing
end-result
study
of
displaced
intracapsular
fractures
of the neck of the femur
treated
with the Pugh nail. JBoneJoint
Surg[Arn]
1974:56-A:
l464-72.
Frangakis
EK. Intracapsular
fractures
ofthe
neck
influencing
non-union
and ischaemic
necrosis.
[Br] I966:48
B: I7 30.
Inclan
Judet
A. Late
complications
treated
by nailing.
bone
36 SO.
in fracture
of
grafting
or both.
R. Traitement
des fractures
.4eta Orthop
Scand
1962:32:421
ofthe
femur:
factors
J Bone Joint
Surg
the
J
du col du femur
7.
hit
neck
Co//
of the femur
Surg
1946:9:
par greffe
pdicuI#{233}e.
Metz CW Jr. Sellers
TD, Feagin
JA, et a!. The displaced
intracapsular
fracture
ofthe
neck ofthe
femur:
experience
with Deyerle
method
offixation
in sixty-three
cases.
J Bone Joint Surg [Am] 1970:52--A:
113 27.
of
an avascular
head.
Meyer
ci a!.
used quadratus
femoris
and sartorius
muscle-pedicle
grafts
or a free Ilbular
graft
in I 36 patients;
they had 1 1 % non-union
and 3% avascular
necrosis.
Baksi
(1983)
reported
excellent
to fair
AND
is a recognised
method
of
of the head
(Bonfiglio
and
ofa fibular
strut prevented
Boyd
to
the
SCREW
Cortical
bone
grafting
treating
avascular
necrosis
Voke
1968) and the presence
Coats
displaced
the neck
logical
impaction
the main
factors
necessary
in displaced
fractures
of
A CANCEI,LOUS
Meyer
MH,
Harvey
JP Jr. Moore
TM.
Treatment
of displaced
subcapital
and transcervical
fractures
of the femoral
neck by musclepedicle-hone
graft
and internal
fixation:
a preliminary
report
on
one hundred
and fifty cases.
J Bone Joint
Surg [Am]
1973:55-A:
257 74.
Patrick
J. Intracapsular
Smith-Petersen
nail
31 A:67 80.
fractures
ofthe
femur treated
and fibular
graft. J Bone Joint
Smith-Petersen
MN, Cave EF, Vangorder
ofthe
neck ()fthe
femur:
treatment
1931:23:715
59.
with a combined
Surg[AmJ
1949:
GW. Intracapsular
by internal
fixation.
fractures
Arch Surg