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| SYMPOSIUM: FRACTURE NECK OF FEMUR |
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| Year : 2018 | Volume
: 1
| Issue : 1 | Page : 21-22 |
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Neglected fracture neck of femur: Our experience
Alok C Agrawal
Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India
| Date of Web Publication | 28-Dec-2018 |
Correspondence Address:
Dr. Alok C Agrawal
Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh 492099
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jodp.JODP_9_18
Fracture neck of femur continues to be neglected in rural India. Several salvage options tried in the past are now out of local interest in favor of some sort of arthroplasty. Although the long-term viability of this policy is not known, only the future will guide to a definite path. Keywords: Neglected fracture, fracture neck of femur, treatment options
How to cite this article:
Agrawal AC. Neglected fracture neck of femur: Our experience. J Orthop Dis Traumatol 2018;1:21-2 |
| Introduction | |  |
A neglected fracture neck of femur is arbitrarily defined as a fracture that was not operated in the first 3 weeks from the time of the original injury. The patients with neglected fracture neck of femur are at a risk of developing nonunion, avascular necrosis, coxa vara, secondary osteoarthritis, muscular contractures, limb length deformities, gait problems, and a painful hip. Children in addition develop premature epiphyseal closure. These patients present with moderate-to-severe pain in the groin and front of thigh, walk with a trendelenburg gait, and following surgery, if the symptoms continue beyond 3 months, may develop nonunion.
The treatment of neglected fracture neck of femur usually depends on the age of the patient, his or her physical status, viability of the femoral head, amount of neck resorption, and the duration of nonunion.
Intracapsular fractures of the femur are treated as a medical emergency in young adults (Indian adults aged approximately 40 years) in an attempt to preserve the precarious blood supply of the femoral head. Some authors advise operative intervention within 6–8h.[1] But this is seldom possible in Indian circumstances where the patient first goes to a local osteopath and reaches a tertiary care hospital only after 3–4 weeks.
Multiple reports identify a subset of these patients who have delayed presentation for medical treatment.[2],[3],[4],[5] Although the incidence of this injury is not documented, the burden of disease is likely to be decreasing with improving health-care facilities in our country. Most orthopedic surgeons now like to treat this condition by some type of arthroplasty, but there are proponents of head salvage too. The specific problems before deciding the treatment options also include the severity of osteoporosis, as stable fixation is dependent on it; muscle contractures, as counteracting abnormal pull at the fracture site is a problem; and associated damage to the acetabular cartilage, as any osteosynthesis in these cases becomes purposeless.
Although there are no clear guidelines for the management of neglected femoral neck fractures, multiple methods have been used in the past to salvage these fractures including osteosynthesis, McMurray’s osteotomy, muscle pedicle bone grafting, Pauwels’ osteotomy, free fibular grafting, vascularized fibular grafting, excision arthroplasty, and arthroplasty.
| Osteosynthesis | | |
Internal fixation alone is seldom performed in the neglected femoral neck fracture. Lifeso and Younge[4] used this method in 3 of their 28 young patients with neglected femoral neck fractures, in those with undisplaced fractures. Out of these 3 patients one patient developed AVN and another nonunion. Although it is the simplest of procedures, it does not address either the altered mechanics of shortening or the biology of neglect and bone healing.
| Internal Fixation and Osteotomy ± Bone Grafting | | |
Osteotomy has been used to alter biomechanics at the fracture site to promote healing, both with or without internal fixation, and in some cases, with the addition of bone grafting to help stimulate bone healing [Figure 1] and [Figure 2].[4],
The two main types of osteotomies used have been the medial displacement osteotomy, such as that used by McMurray,[6] and the angulation osteotomy, such as that used by Kalra and Anand.[7] The valgus angulation osteotomy is usually of the subtrochanteric or intertrochanteric type, and is more efficient than the displacement osteotomy in converting the shearing forces at the fracture site into compression forces, thereby improving union chances. In addition, the angulation osteotomy can correct rotational and limb length discrepancies at the same time.
| Internal Fixation and Bone Grafting | | |
Various types of bone grafts have been used to address this problem. Vascularized grafts include muscle pedicle or vascular pedicle grafts whereas nonvascularized grafts include Phemister-type cortical tibial grafts and free fibular strut grafts.
McMurray[6] and Baksi[8] have used vascularized grafts using muscle pedicle grafts in separate studies involving patients with a delay of more than 3 months.
| Hip Arthroplasty | | |
Hip replacement arthroplasty has been reserved as a secondary salvage procedure. In the setting of neglected femoral neck fractures in the young adults, only one study has reported hip arthroplasty in 19 cases. This study classified outcome as good or poor soon after the initial operation based on nonstandardized criteria (i.e., not requiring further surgery, ambulatory in the community, discharged home, healed within 3 months, and minimal pain).
| Conclusion | | |
The neglected femoral neck fracture in young adults is among the most difficult to treat in the spectrum of femoral neck fractures. Dickson’s epithet of the “unsolved fracture” is especially applicable.
Attempts at head salvage in the young adults are important. Bone grafting or internal fixation in isolation has not provided predictable satisfactory outcomes. More and more orthopedic surgeons now in India perform arthroplasty (modular bipolar or uncemented total hip replacement) for these cases, but long-term assessment of the problem is still awaited.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984;1:837-46.  |
| 2. | Hou SM, Hang YS, Liu TK. Ununited femoral neck fractures by open reduction and vascularized iliac bone graft. Clin Orthop Relat Res 1993;176-80. |
| 3. | Huang CH. Treatment of neglected femoral neck fractures in young adults. Clin Orthop Relat Res 1986;117-26. |
| 4. | Lifeso R, Younge D. The neglected hip fracture. J Orthop Trauma 1990;1:287-92. |
| 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;1:798-804. |
| 6. | McMurray TP. Ununited fractures of the neck of the femur. J Bone Joint Surg 1936;1:319-27. |
| 7. | Kalra M, Anand S. Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults. Int Orthop 2001;1:363-6. |
| 8. | Baksi DP. Internal fixation of ununited femoral neck fractures combined with muscle-pedicle bone grafting. J Bone Joint Surg Br 1986;1:239-45. |
[Figure 1], [Figure 2]
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