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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 17-20

Ipsilateral fracture neck and shaft of femur: A prospective analysis of two methods


Department of Orthopaedics, SCB Medical College, Cuttack, Odisha, India

Date of Web Publication29-May-2017

Correspondence Address:
Nirmal Chandra Mohapatra
Plot No: B-1360, Sector-6, CDA, PO Markata Nagar, Cuttack - 753 014, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_16_16

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  Abstract 


Background: Optimum management of ipsilateral fracture neck and shaft of femur is controversial and lacks general consensus. Both fractures should be treated with implants that optimize fracture healing while minimizing complications. Major issues are diagnosing occult fracture neck of femur combined with ipsilateral shaft fracture which may be part of polytrauma, surgical decision making, and work up to prioritize fixation and the selection of optimal implant. In this study, we report 18 cases of ipsilateral fracture neck and shaft treated with two methods, i.e., single implant which is a nail versus double implants for two fractures which can be cannulated hip screw, dynamic hip screw (DHS), and plate or distal femoral nail. Materials and Methods: A total of 18 patients were treated and divided into two groups. Group 1 included eight patients (six males, two females) who were operated with cancellous hip screws or DHS for fracture neck and compression plate fixation for fracture shaft of femur. Group II included ten patients (eight males and two females) who were operated with cephalomedullary nailing. Results: The mean age was 32 and 36 years in Group I and Group II, respectively. The mean delay in surgery was 5 and 6 days, respectively. Average union time for femoral neck fracture in Group I and Group II were 14.1 and 16.2 weeks, respectively, and for shaft fractures, these time were 20 and 22 weeks, respectively. There were 6 (75%) good, 2 (25%) fair functional results in Group I. There were 7 (70%) good, 2 (20%) fair, and 1 (10%) poor functional results in Group II. Conclusion: Both the treatment methods used in the study gives satisfactory functional results. In displaced fracture neck of femur, it is better to use double implants for both the fractures. Unlike isolated fracture neck of femur, union in fracture neck, and shaft is usually better. In most of the cases, fracture neck of femur was undisplaced and gave satisfactory results with cephalomedullary nails.

Keywords: Cephalomedullary nail, dynamic hip screw, ipsilateral femoral neck and shaft fracture


How to cite this article:
Mohapatra NC, Sethy GC, Rana R. Ipsilateral fracture neck and shaft of femur: A prospective analysis of two methods. J Orthop Traumatol Rehabil 2017;9:17-20

How to cite this URL:
Mohapatra NC, Sethy GC, Rana R. Ipsilateral fracture neck and shaft of femur: A prospective analysis of two methods. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2017 Dec 11];9:17-20. Available from: http://www.jotr.in/text.asp?2017/9/1/17/207165




  Introduction Top


Ipsilateral neck and shaft fractures occur in 3%–10% patients of fracture shaft of femur. Many times associated femoral neck fractures are nondisplaced and missed injuries to be diagnosed. Ipsilateral neck and shaft fractures are encountered in high-energy cases where victims are usually young with multiple associated injuries.[1] Diagnosis of neck fractures is delayed in 30% cases. Treatment of combined neck and shaft fractures has been a source of controversy because there is no generalized consensus regarding its treatment. These two fractures should be treated with implants that optimize fracture healing while simultaneously prioritizing fracture neck of femur.[2] The major issues related to these fractures are optimal timing of surgery, fracture to be stabilized, and optimal implant to use. This prospective study highlights the managing experience of 18 patients of ipsilateral femoral neck and shaft fractures using two different treatment methods, i.e. single implant [2] versus double implant.


  Materials and Methods Top


Between January 2011 and December 2015, we treated 18 patients with ipsilateral femoral neck and shaft fractures. All patients were injured after high-energy trauma in road accidents. Seven patients had injuries other parts of the body such as abdomen, chest, head, and other limb. None of the patients had pathological or open fracture. We divided patients into two groups: Group 1 included eight patients (six males, two females) who were operated with cancellous lag screws or dynamic hip screw for fractured neck and distal femoral nail or biological plate fixation for fracture shaft of femur. Mean age was 32 years (range 22–43 years). Six patients had basicervical, and two had transcervical femoral neck fracture. Six patients had had garden Type 2 and two patients had garden Type 3 neck of femur fracture. According to Winquist–Hansen classification, two of the diaphyseal fractures were Type 1, three were Type 2, one was Type 3, and two were Type 4. Group 2 included ten patients (eight males, two females) who were treated with cephalomedullary nail, i.e., recon nail or long proximal femoral nail.[3] Mean age was 31.2 years (20–51 years). Eight patients had basicervical, one had transcervical, one had subcapital neck fracture. Eight had garden Type 2 and two had garden Type 3 neck of femur fracture. According to Winquist–Hensen classification, five of the diaphysis fracture were Type 1, three were Type 2, one was Type 3, and one was segmental. All patients were initially managed in emergency accident department. Vital signs were stabilized. Temporary skeletal traction through Steinmann pin was used in patients who could not be operated immediately.[4] We stabilized femoral neck fracture first in patients treated with double implants. A temporary stabilization with guide wires was done in patients with displaced neck fractures to prevent further displacement, and this was followed by stabilization of shaft and definitive fixation of the neck fracture.[3],[4] In cephalomedullary nailing, we temporarily stabilized the neck fracture with two guide wires; this was followed by insertion of nail, proximal locking, and distal locking.[4]

All patients received perioperative antibiotic prophylaxis in the form of injection cefuroxime 1.5 g from 1 h before surgery until 3 days postoperative. On the second postoperative day, range of movement exercises was started. Toe touch weight bearing was allowed using a frame or crutches after stitch removal. Patients were followed up at monthly interval up to 6 months, then 3 monthly intervals up to 1 year, and then 6 monthly intervals up to the last follow-up. The follow-up study included both clinical and radiological evaluations. Progressive weight bearing was allowed after the appearance of callus on radiographs. Union was defined as painless full weight-bearing on the affected limb with the presence of radiologic consolidation in both anteroposterior and lateral view. Delayed union was defined as a fracture that was not united after 24 weeks. The functional results of the patients were assessed with system used by Friedman and Wyman. A good result required no limitation of in activates of daily living (ADL), no pain, and a 20% loss of hip or knee motion. A fair result indicated mild limitation of ADL, mild to moderate pain, and a 20%–50% loss of motion. A poor result was associated with moderate limitation of ADL, severe pain, and >50% loss of motion.


  Results Top


Group 1

Operations were performed with in a mean of 5.9 days (range 2–11 days) following trauma on an ordinary operation table under image intensifier control. All patients were operated using a closed technique for fracture neck and shaft. Average operation time was 75 min. Patients were followed up for a mean of 23.4 months (range 18–35 months). All femoral neck fractures united at an average union time of 15 weeks (range 14–18 weeks). Neither osteonecrosis of femoral head nor proximal fracture nonunion was observed. Two patients had delayed union of femoral shaft fractures.[5] Average union time for fracture shaft of femurs was 20 weeks (range 17–28 weeks). There were 6 (75%) good, 2 (25%) fair results in Group 1 [Figure 1].
Figure 1: (a) Preoperative X-ray femur anteroposterior view, (b) preoperative X-ray femur lateral view, (c) postoperative X-ray pelvis anteroposterior view, (d) postoperative X-ray femur anteroposterior view, (e) postoperative X-ray femur lateral view, (f) X-ray femur with hip anteroposterior and lateral view with good union

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Group 2

Operations were performed within a mean of 5.2 days (range 2–11 days) following trauma under image intensifier control. Both femoral neck and shaft fractures were operated using close technique in all patients. The average time of operation was 90 min (range 80–130 min). Patients were followed up for mean of 28 months (range 20–32 months). Anatomical reduction of femoral neck fracture could not be achieved in one case. One case got nonunion with coxa vara of 98° and was reoperated later with valgus osteotomy. Fractured neck and shaft of femur united 28 and 18 weeks (range 14–32 weeks).[6],[7] Two patients had delayed union for fracture shaft femur and dynamization was needed.[7] Average union time for fracture shaft of femur was 23.4 weeks (range 18–34 weeks). Avascular necrosis of head of femur developed in one patient at 1 year. There were 7 (70%) good, 1 (10%) fair, 2 (20%) poor functional results in Group 2. One patient got poor functional outcome because of avascular necrosis and one patient got 1 cm shortening.[8],[9]

Statistical analysis

Data were analyzed using the Chi-square test and Student's t-test. For all tests, a probability of <0.05 was considered significant. Chi-square testing showed no significant differences between Group 1 and 2 with respect to gender, type of femoral neck fracture, type of femoral shaft fracture, functional outcome, and complications. An unpaired t-test revealed no preoperative significant differences between Group 1 and 2.


  Discussion Top


Ipsilateral femoral neck and shaft fracture are rare and challenging.[8],[9] Most of the cases are young adults and with high-energy trauma.[9],[10] Femoral neck fractures are often missed in initial diagnosis up to 30% cases.[8] Hence, a through roentgenographic evaluation of pelvis with both hips should be done in all fracture shaft of femur cases.[10] If required computed tomography scan should be done. Most often these patients also have multiple associated trauma such as head injury, abdominal injury, and chest injury.[11],[12] The patient should be stabilized first then both the fractures are treated. Operations were done within 2–11 days. Rates of femoral neck nonunion and aseptic necrosis are lower in patients with combined femoral neck and shaft fractures than in young patients with high-energy femoral neck fracture in isolation. This is due to commonly observed extracapsular location of neck fracture, the tendency of these fractures to be minimally or undisplaced,[12] or a combination of two. These two fractures should be treated with an implant that optimizes fracture healing while simultaneously prioritizing the fracture of neck of femur.

There is still no generalized consensus on the optimal treatment method for these complex fractures.[13] In a meta-analysis of the reports published in literature, the locked intramedullary nails or reconstruction nails yielded results that were superior to double implants.[14] However, the difference between the two methods with respect to union, complications, and functional outcome was not significant in the present series. The average time for femoral neck and shaft union in the present series was consistent with that reported in other series. Cephalomedullary nailing is technically more demanding. In our study, we found that it is technically more challenging [10] to do cephallomedulary nail [14] in completely displaced neck and garden Type 3 cases. However, in most of the cases, neck fracture is minimally displaced and where it is easier to do and we are getting same results.

The goal of any treatment plan should be anatomic reduction of neck fracture and stable fixation of both fractures, so the patient can be mobilized early.[14],[15] Both the treatment methods used in the present study achieved satisfactory functional outcomes in these complex fractures. A cephalomedullary nail [15] is advantageous in terms of possible closed antegrade nailing with minimal incision, reduced blood loss, and biological fixation of both the fractures with single implant. Fixation of both fractures with two implants is relatively easy in technique point of view. In our view, both the treatment modalities give satisfactory results. In displaced fracture neck of femur, it is better to use double implant for both fractures. In most of the cases, fracture neck of femur union is better unlike isolated # neck of femur. Most of the cases of # neck of femur were displaced and gave satisfactory result with cephalomedullary nails.[12] In all cases, # neck of femur should be stabilized first.


  Conclusion Top


Combined fractures of shaft and neck femur are complex injuries and need judicious evaluation and surgical work up to achieve a good outcome. Fracture fixation with both single and double implants can achieve good union. While each has its own merits and demerits, there is a little consensus which is better. Although in the present study, a good outcome was observed in using both the methods, its difficult to draw a definite conclusion as the no of cases are comparatively small. A study consisting of more no of cases can give a definite conclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kesemenli CC, Tosun B, Kim NS. A comparison of intramedullary nailing and plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft. Musculoskelet Surg 2012;96:117-24.  Back to cited text no. 1
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2.
Wang J, Yang T, Ning J, Fang Y, Wang G, Lan Y. Comparison of proximal femoral nail antirotation and reconstruction nail for ipsilateral fractures of hip and femoral shaft. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2012;26:905-9.  Back to cited text no. 2
    
3.
Gary JL, Taksali S, Reinert CM, Starr AJ. Ipsilateral femoral shaft and neck fractures: Are cephalomedullary nails appropriate? J Surg Orthop Adv 2011;20:122-5.  Back to cited text no. 3
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4.
Wang WY, Liu L, Wang GL, Fang Y, Yang TF. Ipsilateral basicervical femoral neck and shaft fractures treated with long proximal femoral nail antirotation or various plate combinations: Comparative study. J Orthop Sci 2010;15:323-30.  Back to cited text no. 4
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5.
Tsai MC, Wu CC, Hsiao CW, Huang JW, Kao HK, Hsu YT. Reconstruction intramedullary nailing for ipsilateral femoral neck and shaft fractures: Main factors determining prognosis. Chang Gung Med J 2009;32:563-73.  Back to cited text no. 5
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6.
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures – An analysis of various internal fixation strategies. J Orthop Trauma 2009;23:249-53.  Back to cited text no. 6
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7.
Singh R, Rohilla R, Magu NK, Siwach R, Kadian V, Sangwan SS. Ipsilateral femoral neck and shaft fractures: A retrospective analysis of two treatment methods. J Orthop Traumatol 2008;9:141-7.  Back to cited text no. 7
    
8.
Shetty MS, Kumar MA, Ireshanavar SS, Sudhakar D. Ipsilateral hip and femoral shaft fractures treated with intramedullary nails. Int Orthop 2007;31:77-81.  Back to cited text no. 8
    
9.
Alfonso D, Vasquez O, Egol K. Concomitant ipsilateral femoral neck and femoral shaft fracture nonunions: A report of three cases and a review of the literature. Iowa Orthop J 2006;26:112-8.  Back to cited text no. 9
    
10.
Jain P, Maini L, Mishra P, Upadhyay A, Agarwal A. Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures. Injury 2004;35:1031-8.  Back to cited text no. 10
    
11.
Wu LD, Wu QH, Yan SG, Pan ZJ. Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail. Chin J Traumatol 2004;7:7-12.  Back to cited text no. 11
    
12.
Wu CC. Ununited ipsilateral femoral neck and shaft fractures: Treatment of 16 patients. Arch Orthop Trauma Surg 2004;124:173-8.  Back to cited text no. 12
    
13.
Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg 1998;6:106-13.  Back to cited text no. 13
    
14.
Antti A, Arne E, Bjarne G, Robert DJ. A locked hip screw­intramedullary nail cephalomedullary nail for the treatment of fractures of the proximal part of the femur combined with fractures of the femoral shaft. J Trauma Inj Infect Crit Care 1996;40:10­6.  Back to cited text no. 14
    
15.
Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral neck and shaft. J Orthop Trauma 1992;6:159-66.  Back to cited text no. 15
    


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