- Email: [email protected]
Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults
Injury, Int. J. Care Injured (2005) 36, 110—122
Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults N.K. Magua,*, Roop Singha, Rahul Mittala, Ravinder Garga, Ashim Wokhlub, Ashwini K. Sharmaa a
Department of Orthopaedics, Physical Medicine and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India b Countess of Chester Hospital, Liverpool Road, Chester CH2 1UG, UK Accepted 7 February 2004
KEYWORDS Osteosynthesis; Valgus osteotomy; Osteoporosis
Summary Fifty-three adults sustaining intracapsular femoral neck fractures (subcapital 38 and transcervical 15) with osteoporosis were treated primarily by osteosynthesis with valgus intertrochanteric osteotomy. Final evaluation was done in 50 patients (1 patient died and 2 lost to follow up, were not considered). Union was achieved in 47 (94%) patients in an average period of 12.2 weeks (range 10—18 weeks) with 100% union at osteotomy site. An axial collapse between 2 and 14 mm was observed in 74% of patients at the fracture site. Average neck shaft angle achieved was 1418. Retroversion of the femoral head was seen in 28% of patients postoperatively, but none demonstrated a further posterior tilt of proximal femoral fragment, thus preventing implant cut through. One of the four patients with avascular necrosis of the femoral head exhibited late segmental collapse between 98 and 171 weeks. Final results were excellent to good in 76% of patients (average hip score 92), fair in 18% (average Harris hip score 73) and poor in 6% (average Harris hip score 30). Deep infection in 2%, superficial infection in 4%, implant penetration into the joint in 4%, limb length discrepancy in 6% and external rotation in 68% were other complications. Primary osteosynthesis with valgus intertrochanteric osteotomy is a dependable procedure to provide stable fixation in fresh fractures of the neck of femur with osteoporosis. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Once termed ‘‘the unsolved fracture’’ due to the difficulties in management, the treatment of dis*Corresponding author. Present address: 22/8 FM, Medical Enclave, Rohtak 124001, Haryana, India. Tel.: þ91-1262-213967. E-mail address: [email protected] (N.K. Magu).
placed intracapsular fracture of the neck of the femur still causes a dilemma.7 More than 100 internal fixation devices have been developed for fractures about thehip.27 However,noneofthecurrentlyuseddevices are able to indefinitely withstand the large cyclic forces without support from the adjacent bone.8 Osteoporosis is considered an important causative factor both in its etiopathogenesis and in the
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.02.017
Osteosynthesis and primary valgus intertrochanteric osteotomy
marked posterior comminution present in these fractures. It decreases the quality of internal fixation causing redisplacement of the fracture secondary to its poor hold.11 With a higher risk of non-union (20—35% in elderly), avascular necrosis (10—20%),
111
fracture around the implant (1—2%) and increased rate of re-operation (20—36%),17 the current temptation has been to perform hemiarthroplasty or total hip arthroplasty. However, the long term results of arthroplasty are not perfect. The risk of
Figure 1 Pre-operative drawing, technique and steps of surgery. (A) Tracing of preoperative X-ray in A—P view. Ab: femoral shaft axis, Ac: perpendicular to femoral axis, Ad: fracture line intersecting the perpendicular to femoral shaft axis. In this example, the Pauwel’s angle is 608. The repositioning angle to place the fracture line at right angle to the resultant R is therefore 60 25 ¼ 35 . (B) Draw a line ‘‘ef’’ at right angle to the femoral shaft a little above the superior margin of lesser trochanter. Draw an angle of 358 ‘‘efg’’ to define the intertrochanteric triangular wedge. The line ‘‘ef’’ and ‘‘eg’’ represent the proximal and distal limbs of the Y osteotomy. Point ‘‘h’’ is the anatomical landmark for inserting seating chisel. A 15 mm breadth of bone is preserved for the elbow of the double angle blade plate between ‘‘h’’ and ‘‘ef’’ to ensure stable osteosynthesis. The leser trochanter is felt per-operatively with the fingertip and a 2.5 mm Kirschner wire k1 is inserted at right angle to the femoral shaft for carrying out proximal limb of the Y osteotomy defined as ‘‘ef’’. Another Kirschner wire k2 is passed along the anterior surface of the neck of femur. A third Kirschner wire k3 is inserted from the trochanter into the head of the femur cranially parallel to k1 and k2. Stabilize the femoral neck fracture with a 6.5 mm cancellous screw prior to insertion of the seating chisel. The seating chisel is inserted into the femoral neck parallel to k3 with its flap ‘‘i’’ parallel to femoral shaft making an angle of 958 with the rest of the chisel (supplementary angle of the 1208 blade plate, i.e. 608 þ repositioning angle, i.e. 35 ¼ 95 ). The chisel is advanced into the inferior half of the femoral head for the length equal to blade length of the double angle 1208 osteotomy plate (in this example it is 85 mm). (C) Point ‘‘h’’ defined in the anterior half of the greater trochanter to place the chisel/blade in the center of the femoral neck. (D) Position the template of 1208 plate superimposing it over the chisel on the drawing ‘‘B’’ and ensure that the angle between the femoral shaft and the plate corresponds to 358 ‘‘the repositioning angle’’. Also check the angle between the seating chisel, and femoral shaft axis (608 þ repositioning angle ¼ 958). With the chisel in situ in the femoral head, the 358 intertrochanteric wedge of bone ‘‘k’’ based laterally is excised. The distal osteotomy precedes the proximal to avoid splintering of the calcar. Remove the seating chisel and insert the blade of the selected osteotomy plate by gently pushing it along the track made with the chisel. The correct placement and direction of the blade can be ascertained further by visualising it at the fracture site. However in case of any doubt, an X-ray may be taken to confirm the result. (E) Abduct the limb to close the osteotomy by inserting screws from distal to proximal direction one by one. After the first screw in the last hole is inserted the distal femoral fragment is supported with a narrow tip bone lever to prevent its posterior sagging. Note: For this particular patient, an intertrochanteric wedge of 308 was planned and excised. The illustration applies to the patient with Fig. 6—8.
112
superficial wound infection (5—15%), deep infection (3%), dislocation (2—5%), fracture around implant (1—3%), loosening of prosthesis (2—10%) and acetabular erosion (4—20%) indicate that a more conservative approach is worth considering.17 The results from a recent randomised trial suggest that both internal fixation and arthroplasty produce comparable final outcomes.22 Various types of osteotomies have been advocated for treatment of fractures of the neck of the femur.3,19,20,24,25 To optimise the late results after femoral neck fracture, Muller21 recommends that acute subcapital and intermediate femoral neck fractures be reduced under direct vision and then stabilised. When there is an inclination of the fracture plane of more than 408, an intertrochanteric re-directional osteotomy should follow the reduction of the fracture. While organising his discussion on intertrochanteric osteotomy, he groups fresh femoral neck fractures with severe osteoporosis a good indication for intertrochanteric osteotomy.20 The present study was undertaken to evaluate the results of combined osteosynthesis with valgus intertrochanteric osteotomy in primary treatment of fresh femoral neck fractures with osteoporosis in adults.
N.K. Magu et al.
Patients and methods From 1990 to 1998, a total of 53 adults (32 males and 21 females) with displaced intracapsular femoral neck fractures and osteoporosis (38 subcapital and 15 transcervical) were selected for osteosynthesis and primary valgus intertrochanteric osteotomy. The selection of the patients in the present study has been as per the following criteria: (a) Trivial injury. (b) Osteoporosis as evident by Singh’s index29 on plain radiography of the opposite sound hip. (c) Patient actively mobile; no serious medical disease, general debility or associated significant knee joint deformity. One hundred and thirty-two patients not fulfilling the above mentioned criteria in the same age group and the period of study were excluded from the present study. The study patients average age was 55.6 years (range 50—70 years) and the interval between injury and osteosynthesis ranged from 3 to 30 days. Forty-four (82.8%) patients were sedentary workers and sustained fracture after a trivial trauma where as 9 (17.2%) patients were non-committal about the degree of trauma. In 36 (68%)
Figure 2 Pre- and post-operative radiographs of a 65 year male in antero-posterior and frog leg views. AP view of normal hip shows Grade III osteoporosis.
Osteosynthesis and primary valgus intertrochanteric osteotomy
patients, the left side was involved, whereas in 17 (32%) patients the right hip was involved. One patient had previously been treated with McMurray’s osteotomy for an intra-capsular femoral neck fracture of the opposite hip 20 years previously. Similarly three other patients had sustained fracture of the wrist or leg bones due to trivial trauma in the past. On the basis of anatomical location 38 (72%) patients had subcapital and 15 (28%) trans-cervical fractures. According to Pauwel’s23 classification, 30 (57%) patients were of type II and 23 (43%) of type III fractures; and by Garden10 classification, 46 (87%) patients were of type IV and 7 (13%) of type III fractures. Quality radiographs of the opposite sound hip were taken to study the grade of osteoporosis as per Singh’s index.29 Pre-operative planning with drawings from the radiographs was done by the method of Muller20 to select an appropriate implant; and to define the intertrochanteric wedge and steps of surgery.
Operative procedure Surgery was performed on an ordinary operation table without the help of an image intensifier.
113
Osteosynthesis and primary valgus intertrochanteric osteotomy was carried out through a modified Watson Jones approach using a 1208 double angle blade plate. The capsule was divided in each patient to achieve reduction under direct vision and to facilitate the seating of the blade in the inferior quadrant of the head of the femur. Before performing the intertrochanteric osteotomy, the femoral head was stabilised with a partially threaded 6.5 mm cancellous screw to prevent its rotation while making passage for the blade with its seating chisel. A, Y-shaped inter-trochanteric osteotomy was made and stabilisation of the fracture and osteotomy was achieved as per AO techniques19 (Fig. 1). Additionally, a tension band wire was used around the abductors and the osteotomy in patients who had splintering of the anterior wall of the femoral neck/trochanter during osteosynthesis; in patients with excessive comminution or a technical failure. Lateralisation of the distal osteotomy fragment was done in patients with decreased hip joint offset to restore abductor lever arm mechanism. Postoperatively patients were given non-steroidal anti-inflammatory drugs for the relief of pain. Patients were allowed non-weight bearing walking in crutches or on a walker for 6 weeks followed by
Figure 3 Follow up of the same after 98 weeks shows good union. Proximal fragment shows buttressing by calcar of distal fragment (A).
114
N.K. Magu et al.
full weight bearing after 10—12 weeks when radiological signs of union of the fracture and osteotomy were observed. Radiologically osteotomy was considered healed by the following criteria: 1. Presence of bridging traveculae of bone crossing the osteotomy. 2. Consolidation and obliteration of the osteotomy site. 3. No displacement. The protocol had been approved by the Ethical Committee of the Institution. All patients gave their consent after receiving appropriate information.
Review Patients were followed at intervals of 6, 12, 24, 48, 75 and 100 weeks for the initial 2 years and once a year subsequently. One patient died after 6 months of surgery due to myocardial infarct and two patients were lost to subsequent follow up after 8 months. These patients were not considered for final evaluation of results. Therefore, 50 patients were followed clinically by Harris hip score,12 and radiologically for adequacy of fixation; union at fracture and osteotomy site; viability of femoral head and implant failure.
Figure 4
Results The patients were followed for an average period of 8.2 years (range 3—12 years). As per Singh’s index, 16 (32%) patients exhibited grade II osteoporosis, 24 (48%) had grade III osteoporotic changes and 10 (20%) had grade IV osteoporosis. Forty-seven (94%) patients showed union at the fracture site within an average of 12.2 weeks (range 10—18 weeks). Radiological union of the osteotomy site was observed in all the 50 (100%) patients within an average period of 7.2 weeks (range 6—8 weeks). Three (6%) patients developed non-union. In one patient, this was because of failure to valgise the head of femur adequately; in the second patient, the blade was partly out of the femoral head and the procedure was repeated to correctly place it in the inferior quadrant of the head of the femur. However, GirdleStone arthroplasty was subsequently undertaken in this patient because of deep infection. In the third patient, the blade penetrated the hip joint due to excessive collapse at the fracture site. The double angle blade plate was replaced with two cancellous screws after 132 weeks, which finally cut through to leave the femoral neck fracture un-united. The first and the last patients were subsequently treated with total hip arthroplasty.
Follow up at 171 weeks shows segmental collapse of the femoral head superiorly (arrow).
Osteosynthesis and primary valgus intertrochanteric osteotomy
The osteosynthesis and osteotomy was considered stable when: 1. There was no further comminution during osteosynthesis. 2. The tip of the blade was seated in the inferior quadrant of the femoral head. 3. The femoral head could be buttressed by the oblique distal limb of the osteotomy. 4. The shoulder of the blade plate contained a minimum of 1.5 cm block of bone. Stable fixation could be achieved in 36 (72%) patients with the 1208 double angle blade plate and a 6.5 mm cancellous lag screw alone. In 10 (20%) patients, an additional tension band wire was used due to splintering of the proximal femoral cortex during osteosynthesis. The remaining four patients were put in an abduction splint for 3—4
115
weeks postoperatively for not fulfilling the criteria of stability. The average neck-shaft angle was 1418 in the present study. The minimum neck-shaft angle was 1208 and the maximum was 1508. An intertrochanteric wedge of 20—308 was removed in 80% of the patients where as in 20% of the patients, a wedge of 10—208 was resected to valgise the femoral head. In 21 (42%) patients, the blade was seated in the posterior and inferior quadrant; in 20 (40%) patients in the central and inferior quadrant; and in the anterior and inferior quadrant in 9 (18%) patients. In 18 (36%) patients, lateralisation of the distal osteotomy fragment was done. Axial collapse between 2—5 mm was seen in 18 (36%) patients and of 5—10 mm in another 18 (36%) patients; whereas one patient exhibited a collapse of 14 mm at fracture site. In the remaining 13 (26%)
Figure 5 Follow up after 10 years. Patient can walk for 5 kilometers pain free inspite of avascular necrosis (arrow).
116
N.K. Magu et al.
Figure 6 Pre- and post-operative radiographs (AP and frog leg views) of 60 year old male with severe osteoporosis. Patient underwent Mcmurray osteotomy 20 year back for fracture neck femur of his right hip.
patients, no collapse was seen at the fracture site. Implant removal was required in two patients due to axial collapse. In one of these two patients, the tip of the blade penetrated the hip joint to cause painful 208 flexion deformity. Postoperatively, in 14 (28%) patients a retroverted position of the femoral head was observed. In none of these patients, a further appreciable posterior tilt of the femoral head, non-union or accelerated osteoarthrosis was observed till the last follow up. Four (8%) patients developed radiological signs of avascular necrosis. One patient exhibited radiological signs of avascular necrosis between 98 and 171 weeks resulting in antero-superior segmental collapse of the femoral head (Figs. 2—5) however; the patient could squat in cross-leg position and could walk pain free up to 5 km, 10 years after surgery. This particular patient also sustained a fracture of the opposite sound hip 9 years after surgery. Three patients showed increased density without any collapse. Other complications observed in the series are shown in Table 1. Range of movements at the hip joint observed in the series are shown in Table 2. All those patients
exhibiting 8—108 of retroversion of the head of femur had limitation of flexion of the hip in its extreme. Only three patients having neck shaft angles, more than 1458 had moderate degree of limp as per Harris hip score. Two patients gained length by 1.5 cm, whereas no limb length discrepancy was observed in remaining 48 patients. Thirty-eight (76%) patients had an average Harris hip score of 92 and were graded as good to excellent result (Figs. 6—11). Nine (18%) had an average Harris hip score of 73 and were graded as fair result. Three patients with non-unions had an average Harris hip score of 30 and were graded as poor results. Table 1
Other complications observed in the series
Complications
No. of patients (%)
Superficial infection Deep infection Crutch palsy Implant cut through Limb length discrepancy lengthening (1—1.5 cm) External rotation (5—158)
2 (4) 1 (2) 1 (2) Nil 2 (4) 34 (68)
Osteosynthesis and primary valgus intertrochanteric osteotomy
Table 2
Movements at hip joint
Type of movement
Range (8)
Average (8)
Flexion Extension Abduction Adduction Internal rotation External rotation
90—120 10—15 35—45 20—25 20—40 35—45
110 12 40 22 25 40
Discussion Femoral neck fractures can be divided into those occurring in younger patients from high energy trauma and those in older patients that typically occur from low energy mechanisms. In any of the patients with a femoral neck fracture, regardless of age, the most common reason for failure of internal fixation is an inadequate reduction closely followed by inadequate
117
fixation. The bone quality of an older patient plays an extremely important role in the success or failure of internal fixation outcomes.8 A recent meta-analysis of 106 reports of the treatment of femoral neck fractures suggested that non-union may occur in a third of patients treated with internal fixation alone, with higher rates in displaced or vertical fractures.17 The biomechanical reasons for such failure are due to the shear forces at the fracture site24 and the presence of osteoporosis which directly influences the degree of displacement of the fracture fragment as well as the posterior comminution of the femoral neck.6,11 The re-operation rate after femoral neck fractures is increased for osteoporotic patients and in patients with displaced fractures.4,16 It therefore, seems logical to overcome this biological and biomechanical failure by combining osteosynthesis with valgus intertrochanteric osteotomy to achieve eventless union of femoral neck fractures.24
Figure 7 A follow up at 35 and 91 weeks shows good union and a viable femoral head.
118
N.K. Magu et al.
Figure 8
Follow up after 540 weeks. Head is viable. Excellent functional results (Harris hip score 93).
Pauwel23 recognised that a pseudarthrosis of the femoral neck would unite if one changed its inclination at a right angle to the resultant of forces. Such a repositioning osteotomy results in stability. The valgus osteotomy plays a two-fold role: 1. It overcomes the shear forces and converts them to compression forces by placing the fracture site perpendicular to the resultant force. 2. It buttresses the head of femur from below and improves the stability provided by the internal fixation device.21 Our results validate this contention in that even in severe osteoporosis a union rate of 94% was observed. Osteosynthesis with an appropriate blade length of the implant in its optimum position in the femoral head, supplemented by the buttressing effect of the distal osteotomy fragment maintained co-aptation and immobilisation of the fragments during the time required for bony union and provided a high degree of stability. We therefore, had no implant failure or anteroposterior implant cut through in any of the patients presenting with grades II and III osteoporosis. Further, none of the 14 patients with an 8—108 postoperative retroversion of the femoral head exhibited a further sig-
nificant posterior tilt at the fracture site till the fracture united. The inter-trochanteric osteotomy seems to have the advantage of achieving and maintaining stability both in the coronal as well as sagittal plane. Garden11 advocates that stability may be restored in the ‘‘valgus’’ position, by various forms of osteotomy, by refashioning the fracture fragments or by a postero-inferiorly positioned bone graft. The changes in the trabecular pattern of the upper end of the femur has been universally used as an index for diagnosing and grading of osteoporosis.6,10 Although inter-observer differences for this grading system are high, Singh’s index 1, 2, 3 indicates significant loss of bone density, a potential risk for fixation failure.29 We therefore, used Singh’s classification of the trabecular bone structure in the proximal femur of the sound hip as a measure of osteoporosis and investigations like bone densitometry, or metacarpal cortical index were not done. The average age at the time of fracture in the present series is less when compared to western literature. In a study on osteoporosis in Indian patients, Sankaran28 has concluded that highest incidence of fracture of the neck of the femur, occurred in the 51—60-year age group in males.
Osteosynthesis and primary valgus intertrochanteric osteotomy
119
Figure 9 Pre and post-operative radiographs of a 65 year male with Grade II osteoporosis. A tension band wire was used around the abductors as shoulder of the blade plate contained less than 1.5 cm block of bone. Femoral head shows buttressing by calcar of distal fragment.
Further, males outnumbered females in the present series because they are the earning hand of the family, and are exposed to outdoor activities more than females in our society. A union rate of 94% in our series of 50 patients compares favourably with the only other study done by Rinaldi et al.26 who achieved 100% union in 25 patients of recent femoral fractures treated with primary osteosynthesis and valgus osteotomy. Their follow up was restricted to 3—5 years, and they have not mentioned the grade of osteoporosis in their patients. However, they justify extending the upper age limit above 65 years in selected cases. Avascular necrosis of the femoral head is a known complication of displaced femoral neck fractures. The present study comprised of fractures of recent
onset, therefore no bone scan study was undertaken preoperatively. Only 4 (8%) of our 50 patients had radiologically evident avascular necrosis postoperatively, however, all had good functional results. One of these four patients with late segmental collapse of the femoral head exhibited signs of osteoarthrosis, but it did not affect the final outcome (Figs. 2—5). The patient could squat in a crossleg position and could walk pain free up to 5 km, 10 years after surgery. Avascular necrosis without head collapse generally has not been considered a contraindication for this procedure.1 Marti et al.18 in a series of 50 patients had 22 patients with preoperative evidence of avascular necrosis but only three required hip replacement because of painful collapse. The outcomes of three cases in the series of
120
Figure 10
N.K. Magu et al.
Follow up radiographs after 6, 20 and 52 weeks. Femoral head viable. Stainless steel wire has broken.
Ballmer et al.2 were compromised by avascular necrosis and the authors recommended evaluating the viability of the head by non-invasive means. Provided there is no head collapse, osteotomy still was indicated because the neck fracture can heal and a necrotic head can be revascularised.1,2,18,21 Rinaldi et al.26 also have reported an incidence of 8% of late ischaemic necrosis, which they say is not higher than in any other material of osteosynthesis. We are of the opinion that the low incidence of avascular necrosis (8%) in our series may be due to following factors: 1. Osteosynthesis with valgus intertrochanteric osteotomy gives adequate, stable fixation. 2. The osteotomy may have a biological role in revascularisation of an ischaemic femoral head. Our contention is also validated by Catto5 who believed that a neck fracture can heal and a
necrotic head can be vascularised, although the process requires prolonged, adequate fixation. A retroversion of 8—108 of the femoral head observed postoperatively in 14 cases however did not affect the good functional results. The procedure of valgus osteotomy resulted in an increase of abduction of the operated hip (total range 35—458) as compared to opposite normal hip. The external rotation deformity between 5 and 128 in 68% of our patients helped them sitting cross-leg, ‘‘common position in Asian society/position of prayer’’. This avoidable deformity has also been reported by Hermichen et al.14 in all their patients. In the present series, 3 of 50 patients with neck shaft angle of 1508 had moderate limp. The 1208 double angle blade plate prevents medialisation of the distal osteotomy fragment. Further, lateralisation of the distal fragment restores hip joint offset
Osteosynthesis and primary valgus intertrochanteric osteotomy
121
Figure 11 Follow up radiographs in AP and frog leg views after 12 years. No sign of osteoarthrosis of hip (Harris hip score 92). The stainless steel wire has further broken in multiple pieces.
and the abductor lever arm mechanism. We have observed that excision of a wedge of 20—308 in 80% of the patients causes no significant limb length discrepancy. It explains why most of our patients retained a near normal neck length and exhibited a near normal gait. Zinghi et al.,30 mention that ‘‘valgising osteotomy associated with a degree of lateralisation must be the operation of choice because it compensates for the shortening and prevents the Trendelenburg gait’’. Rinaldi et al.26 in a study on fresh subcapital fractures however, do not mention limp in their series. Parker22 has emphasised that a total hip replacement is still of unproven value after fracture of the hip and should be reserved for fractures associated with osteoarthrosis of hip, pathological fractures with acetabular involvement and revision after complications following operation for fractures. Flanzen et al.9 also after reviewing 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures, opine that internal fixation should be the primary procedure; total hip replacement is safe secondary procedure when osteosynthesis fails.
The procedure of osteosynthesis with valgus intertrochanteric osteotomy in fresh femoral neck fractures is easy to perform. The availability of image intensification has made the procedure simple and biological. We performed the surgery through modified a Watson Jones approach because radiological assistance was not available to us. Preoperative planning is useful in selecting an appropriate implant, and overcoming the errors.15 The osteotomy with a 1208 double angle blade plate does not seriously disturb proximal femoral anatomy for carrying out arthroplasty in the future. A number of authors have carried out total hip arthroplasty after failed intertrochanteric osteotomy; and have not mentioned any difficulty in carrying out arthroplasty.1,18 However, it has also been reported that total hip arthroplasty after inter-trochanteric osteotomy may be more complex than primary surgery.13 In conclusion, valgus osteotomy with osteosynthesis gives good long term results in primary management of displaced intracapsular femoral neck fractures with osteoporosis in adults. It achieves mechanically stable fixation and combats the deforming forces at the fracture site. In spite of
122
segmental collapse of the femoral head and osteoarthrosis, patients may have a good functional outcome. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure.
References 1. Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop 1997;341: 175—82. 2. Ballmer FT, Ballmer PM, Baumgartel F, et al. Pawwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759—67. 3. Bansali RM. Symposium on McMurray’s osteotomy. J Bone Joint Surg (Br) 1966;48B:197. 4. Barnes R, Brown JT, Garden RS, Nicoll E. Subcapital fractures of the femur: a prospective review. J Bone Joint Surg (Br) 1976;58B:2—24. 5. Catto M. A histological study of avascular necrosis of the femoral head after transcervical fracture. J Bone Joint Surg (Br) 1965;47B:749—76. 6. Dalen N, Jacobsson B. Rarefied femoral neck trabecular patterns, fracture displacement and femoral head vitality in femoral neck fractures. Clin Orthop 1986;207:97—8. 7. Dickson JA. The ‘‘unsolved’’ fracture. J Bone Joint Surg (Am) 1953;35A:805—21. 8. Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure in femoral neck fractures. Clin Orthop Rel Res 2002;399:110—8. 9. Flanzen H, Nilsson LT, Stromqvist B, et al. Secondary total replacement after fractures of the femoral neck. J Bone Joint Surg (Br) 1990;72B:784—7. 10. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br) 1961;43B:647—63. 11. Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg (Br) 1964;46B:630—47. 12. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: Treatment by mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg (Am) 1969;51A:737—55. 13. Hernefalk L, Messner K. Rigid osteosynthesis decreases the late complication after femoral neck fracture: the influence of three different devices evaluated in 369 patients. Arch Orthop Trauma Surg 1996;115:71—4. 14. Hermichen HG, Thielemann FW, H’Ofler R, et al. Primary valgization osteotomy in femoral neck fracture. Acta Traumatol 1991;21(3):104—11.
N.K. Magu et al.
15. Kalra M, Anand S. Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults. Int Orthop 2001;25:363—6. 16. Kofoed H, Alberts A. Femoral neck fractures. Acta Orthop Scand 1980;51:127—9. 17. Lu-yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck: a metaanalysis of one hundred and six published reports. J Bone Joint Surg (Am) 1994;76A:15—25. 18. Marti RK, Schuller HM, Reaymakers ELFB. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg (Br) 1989;71B:782—7. 19. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by AO Group. 2nd ed. Berlin: Springer-Verlag; 1979. p. 360—5. 20. Muller ME. Intertrochanteric osteotomy: indications, preoperative planning, technique. In: Schatzker J, editor. The trochanteric osteotomy. Berlin: Springer-Verlag; 1984. p. 25—66. 21. Muller ME. The intertrochanteric osteotomy and pseudo arthrosis of the femoral head. Clin Orthop 1999;363:5—8. 22. Parker MJ. The management of intracapsular fractures of the proximal femur. J Bone Joint Surg (Br) 2000;82B:937— 41. 23. Pauwels F. Der Schenbelhalsbruch ein mechanisches problem: Grundlagen des Heilungsvorganges Prognose und kausale Therapie. Stuttgart: Ferdinana Enbe Verlag; 1935. 24. Pauwels F. In: Rondal JF, Paul M, editors. Biomechanics of the normal and diseased hip (Transl.). Berlin: SpringerVerlag; 1976. 25. Reich RS. Ununited fracture of the neck of femur treated by high oblique osteotomy. J Bone Joint Surg (Am) 1941; 23A:141—59. 26. Rinaldi E, Marenghi P, Negri V. Osteosynthesis with valgus osteotomy in the primary treatment of subcapital fractures of the neck of the femur. Ital J Orthop Traumatol 1984;10(3):313—20. 27. Ruedi TP, Murphy WM, et al. Femur: proximal. In: Colton CL, Dell’Oca AF, Holz U, Kellam JF, Oschner PE, editors. AO principles of fracture management. New York: Thieme; 2000. p. 447—8. 28. Sankaran B. Osteoporosis, clinical, radiological, histological, assessment and an experimental study. Mumbai: Novelty Printers; 2000. p. 9—18. 29. Singh M, Nagrath AR, Maini PS. Changes in the trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg 1970;52A:457—67. 30. Zinghi GF, Specchia L, Ruggieri N, Galli G. The role of osteotomy in the treatment of pseudarthrosis of the neck of the femur in younger patients. Ital J Orthop Traumatol 1985;11:341—8.
Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults N.K. Magua,*, Roop Singha, Rahul Mittala, Ravinder Garga, Ashim Wokhlub, Ashwini K. Sharmaa a
Department of Orthopaedics, Physical Medicine and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India b Countess of Chester Hospital, Liverpool Road, Chester CH2 1UG, UK Accepted 7 February 2004
KEYWORDS Osteosynthesis; Valgus osteotomy; Osteoporosis
Summary Fifty-three adults sustaining intracapsular femoral neck fractures (subcapital 38 and transcervical 15) with osteoporosis were treated primarily by osteosynthesis with valgus intertrochanteric osteotomy. Final evaluation was done in 50 patients (1 patient died and 2 lost to follow up, were not considered). Union was achieved in 47 (94%) patients in an average period of 12.2 weeks (range 10—18 weeks) with 100% union at osteotomy site. An axial collapse between 2 and 14 mm was observed in 74% of patients at the fracture site. Average neck shaft angle achieved was 1418. Retroversion of the femoral head was seen in 28% of patients postoperatively, but none demonstrated a further posterior tilt of proximal femoral fragment, thus preventing implant cut through. One of the four patients with avascular necrosis of the femoral head exhibited late segmental collapse between 98 and 171 weeks. Final results were excellent to good in 76% of patients (average hip score 92), fair in 18% (average Harris hip score 73) and poor in 6% (average Harris hip score 30). Deep infection in 2%, superficial infection in 4%, implant penetration into the joint in 4%, limb length discrepancy in 6% and external rotation in 68% were other complications. Primary osteosynthesis with valgus intertrochanteric osteotomy is a dependable procedure to provide stable fixation in fresh fractures of the neck of femur with osteoporosis. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Once termed ‘‘the unsolved fracture’’ due to the difficulties in management, the treatment of dis*Corresponding author. Present address: 22/8 FM, Medical Enclave, Rohtak 124001, Haryana, India. Tel.: þ91-1262-213967. E-mail address: [email protected] (N.K. Magu).
placed intracapsular fracture of the neck of the femur still causes a dilemma.7 More than 100 internal fixation devices have been developed for fractures about thehip.27 However,noneofthecurrentlyuseddevices are able to indefinitely withstand the large cyclic forces without support from the adjacent bone.8 Osteoporosis is considered an important causative factor both in its etiopathogenesis and in the
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.02.017
Osteosynthesis and primary valgus intertrochanteric osteotomy
marked posterior comminution present in these fractures. It decreases the quality of internal fixation causing redisplacement of the fracture secondary to its poor hold.11 With a higher risk of non-union (20—35% in elderly), avascular necrosis (10—20%),
111
fracture around the implant (1—2%) and increased rate of re-operation (20—36%),17 the current temptation has been to perform hemiarthroplasty or total hip arthroplasty. However, the long term results of arthroplasty are not perfect. The risk of
Figure 1 Pre-operative drawing, technique and steps of surgery. (A) Tracing of preoperative X-ray in A—P view. Ab: femoral shaft axis, Ac: perpendicular to femoral axis, Ad: fracture line intersecting the perpendicular to femoral shaft axis. In this example, the Pauwel’s angle is 608. The repositioning angle to place the fracture line at right angle to the resultant R is therefore 60 25 ¼ 35 . (B) Draw a line ‘‘ef’’ at right angle to the femoral shaft a little above the superior margin of lesser trochanter. Draw an angle of 358 ‘‘efg’’ to define the intertrochanteric triangular wedge. The line ‘‘ef’’ and ‘‘eg’’ represent the proximal and distal limbs of the Y osteotomy. Point ‘‘h’’ is the anatomical landmark for inserting seating chisel. A 15 mm breadth of bone is preserved for the elbow of the double angle blade plate between ‘‘h’’ and ‘‘ef’’ to ensure stable osteosynthesis. The leser trochanter is felt per-operatively with the fingertip and a 2.5 mm Kirschner wire k1 is inserted at right angle to the femoral shaft for carrying out proximal limb of the Y osteotomy defined as ‘‘ef’’. Another Kirschner wire k2 is passed along the anterior surface of the neck of femur. A third Kirschner wire k3 is inserted from the trochanter into the head of the femur cranially parallel to k1 and k2. Stabilize the femoral neck fracture with a 6.5 mm cancellous screw prior to insertion of the seating chisel. The seating chisel is inserted into the femoral neck parallel to k3 with its flap ‘‘i’’ parallel to femoral shaft making an angle of 958 with the rest of the chisel (supplementary angle of the 1208 blade plate, i.e. 608 þ repositioning angle, i.e. 35 ¼ 95 ). The chisel is advanced into the inferior half of the femoral head for the length equal to blade length of the double angle 1208 osteotomy plate (in this example it is 85 mm). (C) Point ‘‘h’’ defined in the anterior half of the greater trochanter to place the chisel/blade in the center of the femoral neck. (D) Position the template of 1208 plate superimposing it over the chisel on the drawing ‘‘B’’ and ensure that the angle between the femoral shaft and the plate corresponds to 358 ‘‘the repositioning angle’’. Also check the angle between the seating chisel, and femoral shaft axis (608 þ repositioning angle ¼ 958). With the chisel in situ in the femoral head, the 358 intertrochanteric wedge of bone ‘‘k’’ based laterally is excised. The distal osteotomy precedes the proximal to avoid splintering of the calcar. Remove the seating chisel and insert the blade of the selected osteotomy plate by gently pushing it along the track made with the chisel. The correct placement and direction of the blade can be ascertained further by visualising it at the fracture site. However in case of any doubt, an X-ray may be taken to confirm the result. (E) Abduct the limb to close the osteotomy by inserting screws from distal to proximal direction one by one. After the first screw in the last hole is inserted the distal femoral fragment is supported with a narrow tip bone lever to prevent its posterior sagging. Note: For this particular patient, an intertrochanteric wedge of 308 was planned and excised. The illustration applies to the patient with Fig. 6—8.
112
superficial wound infection (5—15%), deep infection (3%), dislocation (2—5%), fracture around implant (1—3%), loosening of prosthesis (2—10%) and acetabular erosion (4—20%) indicate that a more conservative approach is worth considering.17 The results from a recent randomised trial suggest that both internal fixation and arthroplasty produce comparable final outcomes.22 Various types of osteotomies have been advocated for treatment of fractures of the neck of the femur.3,19,20,24,25 To optimise the late results after femoral neck fracture, Muller21 recommends that acute subcapital and intermediate femoral neck fractures be reduced under direct vision and then stabilised. When there is an inclination of the fracture plane of more than 408, an intertrochanteric re-directional osteotomy should follow the reduction of the fracture. While organising his discussion on intertrochanteric osteotomy, he groups fresh femoral neck fractures with severe osteoporosis a good indication for intertrochanteric osteotomy.20 The present study was undertaken to evaluate the results of combined osteosynthesis with valgus intertrochanteric osteotomy in primary treatment of fresh femoral neck fractures with osteoporosis in adults.
N.K. Magu et al.
Patients and methods From 1990 to 1998, a total of 53 adults (32 males and 21 females) with displaced intracapsular femoral neck fractures and osteoporosis (38 subcapital and 15 transcervical) were selected for osteosynthesis and primary valgus intertrochanteric osteotomy. The selection of the patients in the present study has been as per the following criteria: (a) Trivial injury. (b) Osteoporosis as evident by Singh’s index29 on plain radiography of the opposite sound hip. (c) Patient actively mobile; no serious medical disease, general debility or associated significant knee joint deformity. One hundred and thirty-two patients not fulfilling the above mentioned criteria in the same age group and the period of study were excluded from the present study. The study patients average age was 55.6 years (range 50—70 years) and the interval between injury and osteosynthesis ranged from 3 to 30 days. Forty-four (82.8%) patients were sedentary workers and sustained fracture after a trivial trauma where as 9 (17.2%) patients were non-committal about the degree of trauma. In 36 (68%)
Figure 2 Pre- and post-operative radiographs of a 65 year male in antero-posterior and frog leg views. AP view of normal hip shows Grade III osteoporosis.
Osteosynthesis and primary valgus intertrochanteric osteotomy
patients, the left side was involved, whereas in 17 (32%) patients the right hip was involved. One patient had previously been treated with McMurray’s osteotomy for an intra-capsular femoral neck fracture of the opposite hip 20 years previously. Similarly three other patients had sustained fracture of the wrist or leg bones due to trivial trauma in the past. On the basis of anatomical location 38 (72%) patients had subcapital and 15 (28%) trans-cervical fractures. According to Pauwel’s23 classification, 30 (57%) patients were of type II and 23 (43%) of type III fractures; and by Garden10 classification, 46 (87%) patients were of type IV and 7 (13%) of type III fractures. Quality radiographs of the opposite sound hip were taken to study the grade of osteoporosis as per Singh’s index.29 Pre-operative planning with drawings from the radiographs was done by the method of Muller20 to select an appropriate implant; and to define the intertrochanteric wedge and steps of surgery.
Operative procedure Surgery was performed on an ordinary operation table without the help of an image intensifier.
113
Osteosynthesis and primary valgus intertrochanteric osteotomy was carried out through a modified Watson Jones approach using a 1208 double angle blade plate. The capsule was divided in each patient to achieve reduction under direct vision and to facilitate the seating of the blade in the inferior quadrant of the head of the femur. Before performing the intertrochanteric osteotomy, the femoral head was stabilised with a partially threaded 6.5 mm cancellous screw to prevent its rotation while making passage for the blade with its seating chisel. A, Y-shaped inter-trochanteric osteotomy was made and stabilisation of the fracture and osteotomy was achieved as per AO techniques19 (Fig. 1). Additionally, a tension band wire was used around the abductors and the osteotomy in patients who had splintering of the anterior wall of the femoral neck/trochanter during osteosynthesis; in patients with excessive comminution or a technical failure. Lateralisation of the distal osteotomy fragment was done in patients with decreased hip joint offset to restore abductor lever arm mechanism. Postoperatively patients were given non-steroidal anti-inflammatory drugs for the relief of pain. Patients were allowed non-weight bearing walking in crutches or on a walker for 6 weeks followed by
Figure 3 Follow up of the same after 98 weeks shows good union. Proximal fragment shows buttressing by calcar of distal fragment (A).
114
N.K. Magu et al.
full weight bearing after 10—12 weeks when radiological signs of union of the fracture and osteotomy were observed. Radiologically osteotomy was considered healed by the following criteria: 1. Presence of bridging traveculae of bone crossing the osteotomy. 2. Consolidation and obliteration of the osteotomy site. 3. No displacement. The protocol had been approved by the Ethical Committee of the Institution. All patients gave their consent after receiving appropriate information.
Review Patients were followed at intervals of 6, 12, 24, 48, 75 and 100 weeks for the initial 2 years and once a year subsequently. One patient died after 6 months of surgery due to myocardial infarct and two patients were lost to subsequent follow up after 8 months. These patients were not considered for final evaluation of results. Therefore, 50 patients were followed clinically by Harris hip score,12 and radiologically for adequacy of fixation; union at fracture and osteotomy site; viability of femoral head and implant failure.
Figure 4
Results The patients were followed for an average period of 8.2 years (range 3—12 years). As per Singh’s index, 16 (32%) patients exhibited grade II osteoporosis, 24 (48%) had grade III osteoporotic changes and 10 (20%) had grade IV osteoporosis. Forty-seven (94%) patients showed union at the fracture site within an average of 12.2 weeks (range 10—18 weeks). Radiological union of the osteotomy site was observed in all the 50 (100%) patients within an average period of 7.2 weeks (range 6—8 weeks). Three (6%) patients developed non-union. In one patient, this was because of failure to valgise the head of femur adequately; in the second patient, the blade was partly out of the femoral head and the procedure was repeated to correctly place it in the inferior quadrant of the head of the femur. However, GirdleStone arthroplasty was subsequently undertaken in this patient because of deep infection. In the third patient, the blade penetrated the hip joint due to excessive collapse at the fracture site. The double angle blade plate was replaced with two cancellous screws after 132 weeks, which finally cut through to leave the femoral neck fracture un-united. The first and the last patients were subsequently treated with total hip arthroplasty.
Follow up at 171 weeks shows segmental collapse of the femoral head superiorly (arrow).
Osteosynthesis and primary valgus intertrochanteric osteotomy
The osteosynthesis and osteotomy was considered stable when: 1. There was no further comminution during osteosynthesis. 2. The tip of the blade was seated in the inferior quadrant of the femoral head. 3. The femoral head could be buttressed by the oblique distal limb of the osteotomy. 4. The shoulder of the blade plate contained a minimum of 1.5 cm block of bone. Stable fixation could be achieved in 36 (72%) patients with the 1208 double angle blade plate and a 6.5 mm cancellous lag screw alone. In 10 (20%) patients, an additional tension band wire was used due to splintering of the proximal femoral cortex during osteosynthesis. The remaining four patients were put in an abduction splint for 3—4
115
weeks postoperatively for not fulfilling the criteria of stability. The average neck-shaft angle was 1418 in the present study. The minimum neck-shaft angle was 1208 and the maximum was 1508. An intertrochanteric wedge of 20—308 was removed in 80% of the patients where as in 20% of the patients, a wedge of 10—208 was resected to valgise the femoral head. In 21 (42%) patients, the blade was seated in the posterior and inferior quadrant; in 20 (40%) patients in the central and inferior quadrant; and in the anterior and inferior quadrant in 9 (18%) patients. In 18 (36%) patients, lateralisation of the distal osteotomy fragment was done. Axial collapse between 2—5 mm was seen in 18 (36%) patients and of 5—10 mm in another 18 (36%) patients; whereas one patient exhibited a collapse of 14 mm at fracture site. In the remaining 13 (26%)
Figure 5 Follow up after 10 years. Patient can walk for 5 kilometers pain free inspite of avascular necrosis (arrow).
116
N.K. Magu et al.
Figure 6 Pre- and post-operative radiographs (AP and frog leg views) of 60 year old male with severe osteoporosis. Patient underwent Mcmurray osteotomy 20 year back for fracture neck femur of his right hip.
patients, no collapse was seen at the fracture site. Implant removal was required in two patients due to axial collapse. In one of these two patients, the tip of the blade penetrated the hip joint to cause painful 208 flexion deformity. Postoperatively, in 14 (28%) patients a retroverted position of the femoral head was observed. In none of these patients, a further appreciable posterior tilt of the femoral head, non-union or accelerated osteoarthrosis was observed till the last follow up. Four (8%) patients developed radiological signs of avascular necrosis. One patient exhibited radiological signs of avascular necrosis between 98 and 171 weeks resulting in antero-superior segmental collapse of the femoral head (Figs. 2—5) however; the patient could squat in cross-leg position and could walk pain free up to 5 km, 10 years after surgery. This particular patient also sustained a fracture of the opposite sound hip 9 years after surgery. Three patients showed increased density without any collapse. Other complications observed in the series are shown in Table 1. Range of movements at the hip joint observed in the series are shown in Table 2. All those patients
exhibiting 8—108 of retroversion of the head of femur had limitation of flexion of the hip in its extreme. Only three patients having neck shaft angles, more than 1458 had moderate degree of limp as per Harris hip score. Two patients gained length by 1.5 cm, whereas no limb length discrepancy was observed in remaining 48 patients. Thirty-eight (76%) patients had an average Harris hip score of 92 and were graded as good to excellent result (Figs. 6—11). Nine (18%) had an average Harris hip score of 73 and were graded as fair result. Three patients with non-unions had an average Harris hip score of 30 and were graded as poor results. Table 1
Other complications observed in the series
Complications
No. of patients (%)
Superficial infection Deep infection Crutch palsy Implant cut through Limb length discrepancy lengthening (1—1.5 cm) External rotation (5—158)
2 (4) 1 (2) 1 (2) Nil 2 (4) 34 (68)
Osteosynthesis and primary valgus intertrochanteric osteotomy
Table 2
Movements at hip joint
Type of movement
Range (8)
Average (8)
Flexion Extension Abduction Adduction Internal rotation External rotation
90—120 10—15 35—45 20—25 20—40 35—45
110 12 40 22 25 40
Discussion Femoral neck fractures can be divided into those occurring in younger patients from high energy trauma and those in older patients that typically occur from low energy mechanisms. In any of the patients with a femoral neck fracture, regardless of age, the most common reason for failure of internal fixation is an inadequate reduction closely followed by inadequate
117
fixation. The bone quality of an older patient plays an extremely important role in the success or failure of internal fixation outcomes.8 A recent meta-analysis of 106 reports of the treatment of femoral neck fractures suggested that non-union may occur in a third of patients treated with internal fixation alone, with higher rates in displaced or vertical fractures.17 The biomechanical reasons for such failure are due to the shear forces at the fracture site24 and the presence of osteoporosis which directly influences the degree of displacement of the fracture fragment as well as the posterior comminution of the femoral neck.6,11 The re-operation rate after femoral neck fractures is increased for osteoporotic patients and in patients with displaced fractures.4,16 It therefore, seems logical to overcome this biological and biomechanical failure by combining osteosynthesis with valgus intertrochanteric osteotomy to achieve eventless union of femoral neck fractures.24
Figure 7 A follow up at 35 and 91 weeks shows good union and a viable femoral head.
118
N.K. Magu et al.
Figure 8
Follow up after 540 weeks. Head is viable. Excellent functional results (Harris hip score 93).
Pauwel23 recognised that a pseudarthrosis of the femoral neck would unite if one changed its inclination at a right angle to the resultant of forces. Such a repositioning osteotomy results in stability. The valgus osteotomy plays a two-fold role: 1. It overcomes the shear forces and converts them to compression forces by placing the fracture site perpendicular to the resultant force. 2. It buttresses the head of femur from below and improves the stability provided by the internal fixation device.21 Our results validate this contention in that even in severe osteoporosis a union rate of 94% was observed. Osteosynthesis with an appropriate blade length of the implant in its optimum position in the femoral head, supplemented by the buttressing effect of the distal osteotomy fragment maintained co-aptation and immobilisation of the fragments during the time required for bony union and provided a high degree of stability. We therefore, had no implant failure or anteroposterior implant cut through in any of the patients presenting with grades II and III osteoporosis. Further, none of the 14 patients with an 8—108 postoperative retroversion of the femoral head exhibited a further sig-
nificant posterior tilt at the fracture site till the fracture united. The inter-trochanteric osteotomy seems to have the advantage of achieving and maintaining stability both in the coronal as well as sagittal plane. Garden11 advocates that stability may be restored in the ‘‘valgus’’ position, by various forms of osteotomy, by refashioning the fracture fragments or by a postero-inferiorly positioned bone graft. The changes in the trabecular pattern of the upper end of the femur has been universally used as an index for diagnosing and grading of osteoporosis.6,10 Although inter-observer differences for this grading system are high, Singh’s index 1, 2, 3 indicates significant loss of bone density, a potential risk for fixation failure.29 We therefore, used Singh’s classification of the trabecular bone structure in the proximal femur of the sound hip as a measure of osteoporosis and investigations like bone densitometry, or metacarpal cortical index were not done. The average age at the time of fracture in the present series is less when compared to western literature. In a study on osteoporosis in Indian patients, Sankaran28 has concluded that highest incidence of fracture of the neck of the femur, occurred in the 51—60-year age group in males.
Osteosynthesis and primary valgus intertrochanteric osteotomy
119
Figure 9 Pre and post-operative radiographs of a 65 year male with Grade II osteoporosis. A tension band wire was used around the abductors as shoulder of the blade plate contained less than 1.5 cm block of bone. Femoral head shows buttressing by calcar of distal fragment.
Further, males outnumbered females in the present series because they are the earning hand of the family, and are exposed to outdoor activities more than females in our society. A union rate of 94% in our series of 50 patients compares favourably with the only other study done by Rinaldi et al.26 who achieved 100% union in 25 patients of recent femoral fractures treated with primary osteosynthesis and valgus osteotomy. Their follow up was restricted to 3—5 years, and they have not mentioned the grade of osteoporosis in their patients. However, they justify extending the upper age limit above 65 years in selected cases. Avascular necrosis of the femoral head is a known complication of displaced femoral neck fractures. The present study comprised of fractures of recent
onset, therefore no bone scan study was undertaken preoperatively. Only 4 (8%) of our 50 patients had radiologically evident avascular necrosis postoperatively, however, all had good functional results. One of these four patients with late segmental collapse of the femoral head exhibited signs of osteoarthrosis, but it did not affect the final outcome (Figs. 2—5). The patient could squat in a crossleg position and could walk pain free up to 5 km, 10 years after surgery. Avascular necrosis without head collapse generally has not been considered a contraindication for this procedure.1 Marti et al.18 in a series of 50 patients had 22 patients with preoperative evidence of avascular necrosis but only three required hip replacement because of painful collapse. The outcomes of three cases in the series of
120
Figure 10
N.K. Magu et al.
Follow up radiographs after 6, 20 and 52 weeks. Femoral head viable. Stainless steel wire has broken.
Ballmer et al.2 were compromised by avascular necrosis and the authors recommended evaluating the viability of the head by non-invasive means. Provided there is no head collapse, osteotomy still was indicated because the neck fracture can heal and a necrotic head can be revascularised.1,2,18,21 Rinaldi et al.26 also have reported an incidence of 8% of late ischaemic necrosis, which they say is not higher than in any other material of osteosynthesis. We are of the opinion that the low incidence of avascular necrosis (8%) in our series may be due to following factors: 1. Osteosynthesis with valgus intertrochanteric osteotomy gives adequate, stable fixation. 2. The osteotomy may have a biological role in revascularisation of an ischaemic femoral head. Our contention is also validated by Catto5 who believed that a neck fracture can heal and a
necrotic head can be vascularised, although the process requires prolonged, adequate fixation. A retroversion of 8—108 of the femoral head observed postoperatively in 14 cases however did not affect the good functional results. The procedure of valgus osteotomy resulted in an increase of abduction of the operated hip (total range 35—458) as compared to opposite normal hip. The external rotation deformity between 5 and 128 in 68% of our patients helped them sitting cross-leg, ‘‘common position in Asian society/position of prayer’’. This avoidable deformity has also been reported by Hermichen et al.14 in all their patients. In the present series, 3 of 50 patients with neck shaft angle of 1508 had moderate limp. The 1208 double angle blade plate prevents medialisation of the distal osteotomy fragment. Further, lateralisation of the distal fragment restores hip joint offset
Osteosynthesis and primary valgus intertrochanteric osteotomy
121
Figure 11 Follow up radiographs in AP and frog leg views after 12 years. No sign of osteoarthrosis of hip (Harris hip score 92). The stainless steel wire has further broken in multiple pieces.
and the abductor lever arm mechanism. We have observed that excision of a wedge of 20—308 in 80% of the patients causes no significant limb length discrepancy. It explains why most of our patients retained a near normal neck length and exhibited a near normal gait. Zinghi et al.,30 mention that ‘‘valgising osteotomy associated with a degree of lateralisation must be the operation of choice because it compensates for the shortening and prevents the Trendelenburg gait’’. Rinaldi et al.26 in a study on fresh subcapital fractures however, do not mention limp in their series. Parker22 has emphasised that a total hip replacement is still of unproven value after fracture of the hip and should be reserved for fractures associated with osteoarthrosis of hip, pathological fractures with acetabular involvement and revision after complications following operation for fractures. Flanzen et al.9 also after reviewing 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures, opine that internal fixation should be the primary procedure; total hip replacement is safe secondary procedure when osteosynthesis fails.
The procedure of osteosynthesis with valgus intertrochanteric osteotomy in fresh femoral neck fractures is easy to perform. The availability of image intensification has made the procedure simple and biological. We performed the surgery through modified a Watson Jones approach because radiological assistance was not available to us. Preoperative planning is useful in selecting an appropriate implant, and overcoming the errors.15 The osteotomy with a 1208 double angle blade plate does not seriously disturb proximal femoral anatomy for carrying out arthroplasty in the future. A number of authors have carried out total hip arthroplasty after failed intertrochanteric osteotomy; and have not mentioned any difficulty in carrying out arthroplasty.1,18 However, it has also been reported that total hip arthroplasty after inter-trochanteric osteotomy may be more complex than primary surgery.13 In conclusion, valgus osteotomy with osteosynthesis gives good long term results in primary management of displaced intracapsular femoral neck fractures with osteoporosis in adults. It achieves mechanically stable fixation and combats the deforming forces at the fracture site. In spite of
122
segmental collapse of the femoral head and osteoarthrosis, patients may have a good functional outcome. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure.
References 1. Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop 1997;341: 175—82. 2. Ballmer FT, Ballmer PM, Baumgartel F, et al. Pawwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759—67. 3. Bansali RM. Symposium on McMurray’s osteotomy. J Bone Joint Surg (Br) 1966;48B:197. 4. Barnes R, Brown JT, Garden RS, Nicoll E. Subcapital fractures of the femur: a prospective review. J Bone Joint Surg (Br) 1976;58B:2—24. 5. Catto M. A histological study of avascular necrosis of the femoral head after transcervical fracture. J Bone Joint Surg (Br) 1965;47B:749—76. 6. Dalen N, Jacobsson B. Rarefied femoral neck trabecular patterns, fracture displacement and femoral head vitality in femoral neck fractures. Clin Orthop 1986;207:97—8. 7. Dickson JA. The ‘‘unsolved’’ fracture. J Bone Joint Surg (Am) 1953;35A:805—21. 8. Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure in femoral neck fractures. Clin Orthop Rel Res 2002;399:110—8. 9. Flanzen H, Nilsson LT, Stromqvist B, et al. Secondary total replacement after fractures of the femoral neck. J Bone Joint Surg (Br) 1990;72B:784—7. 10. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br) 1961;43B:647—63. 11. Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg (Br) 1964;46B:630—47. 12. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: Treatment by mold arthroplasty. An end result study using a new method of result evaluation. J Bone Joint Surg (Am) 1969;51A:737—55. 13. Hernefalk L, Messner K. Rigid osteosynthesis decreases the late complication after femoral neck fracture: the influence of three different devices evaluated in 369 patients. Arch Orthop Trauma Surg 1996;115:71—4. 14. Hermichen HG, Thielemann FW, H’Ofler R, et al. Primary valgization osteotomy in femoral neck fracture. Acta Traumatol 1991;21(3):104—11.
N.K. Magu et al.
15. Kalra M, Anand S. Valgus intertrochanteric osteotomy for neglected femoral neck fractures in young adults. Int Orthop 2001;25:363—6. 16. Kofoed H, Alberts A. Femoral neck fractures. Acta Orthop Scand 1980;51:127—9. 17. Lu-yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck: a metaanalysis of one hundred and six published reports. J Bone Joint Surg (Am) 1994;76A:15—25. 18. Marti RK, Schuller HM, Reaymakers ELFB. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg (Br) 1989;71B:782—7. 19. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by AO Group. 2nd ed. Berlin: Springer-Verlag; 1979. p. 360—5. 20. Muller ME. Intertrochanteric osteotomy: indications, preoperative planning, technique. In: Schatzker J, editor. The trochanteric osteotomy. Berlin: Springer-Verlag; 1984. p. 25—66. 21. Muller ME. The intertrochanteric osteotomy and pseudo arthrosis of the femoral head. Clin Orthop 1999;363:5—8. 22. Parker MJ. The management of intracapsular fractures of the proximal femur. J Bone Joint Surg (Br) 2000;82B:937— 41. 23. Pauwels F. Der Schenbelhalsbruch ein mechanisches problem: Grundlagen des Heilungsvorganges Prognose und kausale Therapie. Stuttgart: Ferdinana Enbe Verlag; 1935. 24. Pauwels F. In: Rondal JF, Paul M, editors. Biomechanics of the normal and diseased hip (Transl.). Berlin: SpringerVerlag; 1976. 25. Reich RS. Ununited fracture of the neck of femur treated by high oblique osteotomy. J Bone Joint Surg (Am) 1941; 23A:141—59. 26. Rinaldi E, Marenghi P, Negri V. Osteosynthesis with valgus osteotomy in the primary treatment of subcapital fractures of the neck of the femur. Ital J Orthop Traumatol 1984;10(3):313—20. 27. Ruedi TP, Murphy WM, et al. Femur: proximal. In: Colton CL, Dell’Oca AF, Holz U, Kellam JF, Oschner PE, editors. AO principles of fracture management. New York: Thieme; 2000. p. 447—8. 28. Sankaran B. Osteoporosis, clinical, radiological, histological, assessment and an experimental study. Mumbai: Novelty Printers; 2000. p. 9—18. 29. Singh M, Nagrath AR, Maini PS. Changes in the trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg 1970;52A:457—67. 30. Zinghi GF, Specchia L, Ruggieri N, Galli G. The role of osteotomy in the treatment of pseudarthrosis of the neck of the femur in younger patients. Ital J Orthop Traumatol 1985;11:341—8.