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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 82-85

Free fibular graft augmentation in delayed fixation of fracture neck of femur in young adults


1 Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India

Date of Submission17-Jan-2018
Date of Acceptance26-Jun-2018
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. S G Thejaswi
Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_4_18

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  Abstract 


Introduction: This clinical study was conducted to assess the long-term follow-up results of using free fibular graft to augment fracture fixation with cannulated cancellous screw (CCS) or dynamic hip screw (DHS) as a treatment option for femoral neck fractures in young adults who presented after 24 h of injury but within 3 weeks. Methodology: A prospective study was conducted on the patients of femoral neck fractures managed with multiple cancellous screws or DHS with fibular graft. Patients aged between 15 and 50 years and having Garden Type III or IV fracture with duration of injury >3 weeks were included in the study. They were assessed for radiological outcome and functional outcome using modified Harris hip score. Results: Twenty-two cases were operated between day 2 and day 21 after sustaining injury. The mean time of union was 3.4 months. Nineteen fractures united uneventfully. Two fractures went in for nonunion and one developed avascular necrosis (AVN) of the femoral head. According to Harris hip score, 14 patients scored “excellent,” three patients scored “good,” three scored “fair,” and “poor” score was recorded in two patients. Conclusions: Delay in surgery as a contributing factor for the development of complications in fracture neck of femur cannot be ruled out with the present literature available. Using a free fibular graft as an adjunct to implant construct helps in reducing the rates of nonunion and AVN. However, this cannot be a substitute for proper surgical precision that is required in the treatment of fracture neck of femur. Further prospective studies involving large sample size are required.

Keywords: Free fibular graft, fresh fracture neck of femur, multiple cancellous screws


How to cite this article:
Thejaswi S G, Sagar B G, Kumar PC. Free fibular graft augmentation in delayed fixation of fracture neck of femur in young adults. J Orthop Traumatol Rehabil 2021;13:82-5

How to cite this URL:
Thejaswi S G, Sagar B G, Kumar PC. Free fibular graft augmentation in delayed fixation of fracture neck of femur in young adults. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 22];13:82-5. Available from: https://www.jotr.in/text.asp?2021/13/2/82/333561




  Introduction Top


Fracture neck of femur is considered as one of the three most common fractures seen in elderly, other two being vertebral fractures and distal radius fracture.[1] Incidence of fractures around hip has increased among young adults due to a rising incidence of high-energy trauma. Femoral neck fractures in young adults are considered as a separate group because of its relative rarity and associated complications of aseptic necrosis and nonunion in this age group reported in the literature.[2] Following three criteria were recommended for successful treatment of femoral neck fractures in young adults: (a) fixation must be achieved within 12 h of injury or as soon as possible; (b) anatomic reduction must be obtained through closed manipulation or open reduction, if necessary; and (c) the fracture should be stabilized with some forms of multiple screw fixations.[3] Among many other factors, timing of surgery plays a key role in union of fracture neck of femur. After the landmark report by Swiontkowski et al.[4] in 1984, this fracture came to be known as “orthopedic emergency.” However, the controversy of delay in surgery affecting the fracture neck of femur union still persists and there are not enough conclusive reports to disprove its role in causing nonunion or avascular necrosis (AVN) of the femoral head.

In a country like India, these fractures rarely present to hospital immediately, and in many setups, fixation within 12 h of injury might not be possible. In view of late presentation and precarious blood supply, it is difficult to ensure fracture union without complications through cannulated cancellous screw (CCS) or dynamic hip screw (DHS) fixation alone. In such situations, free fibular graft could be a useful supplement to the construct of implants. Free fibular graft not only offers structural support but also promotes bone healing. Free fibular graft has been used as a treatment option for nonunion or neglected fracture neck of femur. Earlier studies using fibular grafts have shown good results in treatment of nonunion.[5]

This clinical study presents long-term follow-up results of using free fibular graft to augment fracture fixation with CCS or DHS as a treatment option for femoral neck fractures in young adults who presented after 24 h of injury but within 3 weeks. The outcome was analyzed by modified Harris hip scoring system and by radiographs taken during follow-up.


  Methodology Top


After obtaining “Institutional Ethics Committee” approval, 22 cases of intracapsular fracture neck of femur in adult patients between the age group of 15 and 50 years presenting after 24 h but within 3 weeks were treated by closed reduction and internal fixation (CRIF) with CCS or DHS and free fibular grafts. Cases were selected among patients operated at our hospital between January 2011 and October 2013.

Surgical techniques

All patients were operated under spinal anesthesia and over traction table. Closed reduction of fracture was attempted, and reduction was confirmed using a fluoroscopic image intensifier. CCSs were inserted into the neck over the guide wires passed through aiming device. In an ideal condition, two screws were used. In cases where neck width was less, one screw was used. In fractures which seemed to be unstable or basicervical, DHS was preferred for better stability. Free fibular graft of precalculated length was harvested either from ipsilateral leg or contralateral leg. Through one of the guide wires that was put through the aiming device, a drill hole was made using a small triple reamer and peg of fibula was inserted into it under image intensifier guidance.

Follow-up

Patients were followed up at 3 weeks, monthly till 6 months, and yearly for 3 years. Nonweight-bearing crutch walk was allowed immediately after surgery and partial weight-bearing was allowed after 4 weeks. Standard X-rays were taken at monthly intervals till radiological union was obtained. At the end of 3 years, patients were evaluated according to Harris hip scoring system (HHS) and graded as poor for score <70, fair for score between 71 and 80, good for score between 81 and 90, and excellent for score between 91 and 100.


  Results Top


The study group comprised 18 males and four females. The average age of study group was 33.7 years. Out of 22 cases, 12 fractures were of Garden Type III, nine were Type II, and one case of Type IV. Sixteen out of 22 cases were operated between day 2 and day 7 after injury, and six patients were operated between day 8 and day 21. All cases were reduced by closed maneuver, 20 fractures were fixed with CCS and free fibular graft, and two were fixed with DHS and free fibular graft.

Radiological outcome

Fracture union was seen in 19 patients with trabecular continuity being established completely between proximal and distal fragments without any complications. Mean time for union was found to be 3.4 months. Two (9%) fractures went into nonunion which required further surgical intervention [Figure 1], [Figure 2], [Figure 3]. Main reason for nonunion in these cases was short fibular graft in one case which failed to give enough stability and severe posterior comminution in another case. On long-term follow-up, one patient developed AVN of hip.
Figure 1: Immediate postoperative (case 1)

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Figure 2: United fracture after 4 months (case 1)

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Figure 3: Union after 4 months (case 2)

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There was no statistically significant difference in mean time for union or complication rate among fractures that were operated within 1 week and after 1 week.

Functional outcome

The average HSS in this study was 87.8, with scores ranging from 53.9 to 99.9. In this study, 14 patients scored “excellent,” three patients scored “good,” three scored “fair,” and “poor” score was recorded in two patients.

There was no statistically significant relationship between age of fracture and final HSS; however, it was noted that only 6.25% cases who presented within 1 week had poor results as compared to 33.3% in case of fractures presenting after 1 week of trauma [Table 1].
Table 1: Summary

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  Discussion Top


Femoral neck fractures in young adults are considered as a challenge to orthopedic surgeons in view of the treatment options and high rates of complications such as nonunion and AVN. The controversy regarding when to fix this fracture and the influence of delay in surgery and rates of complication persists even today. Among the various treatment options that have evolved over the years, internal fixation with CCSs is used widely as the mode of treatment for fracture neck of femur in young adults. Literature also supports the use of DHS in fixing intracapsular fracture neck of the femur.[6] In view of the late presentation of patients in a developing country like ours, the union and functional outcome after fixation of this fracture bring in a special interest. This study was conducted in that aspect to treat the fracture with internal fixation and using fibular graft as an adjunct to encourage better result.

Although fracture neck of the femur is considered to be an emergency,[7] delay in seeking treatment and delay inside hospital are expected in a developing country like ours. Studies done in similar setup have also shown considerable delay between trauma and surgery. The study by Upadhyay et al. recorded a mean time of 47–52 h before open reduction and internal fixation and CRIF.[8] In our study, mean duration between trauma and surgery was 4.02 days.

In 1984, Swiontkowski et al.[4] reported that by following their institutional protocol of immediate reduction and internal fixation, they could get low rates of AVN (20%) and no symptomatic nonunion in 27 patients aged 15–50 years. Following this paper, fracture neck of the femur was labeled as “orthopedic emergency.” Ever since then, several reports have been published supporting the correlation between time interval to surgery and the outcomes of nonunion and AVN. There have been several studies which suggest that there is positive correlation between delay in surgery and development of AVN and nonunion.[9] Similarly, there are studies which state that there is no correlation with delay in surgery and development of complications.[8],[10] However, the reported rates of AVN are 16%–23% and for nonunion are 10%–25%.[8],[10] Forsh and Ferguson in their review article[11] concluded that the current best evidence suggests a lack of an association but is limited to retrospective observational cohorts that are far underpowered to reach meaningful conclusions. Hence, the controversy regarding the delay in surgery as a contributing factor for the development of complications still persists.

With this background, many studies have been taken up recently to address the probable consequences of delay in surgery. One among them is using free fibular graft as an adjunct to the fracture fixation with cannulated cancellous graft. Zahid et al.[12] in their study used CCSs and free fibular graft in fractures which had posterior comminution. They reported that 27 of the 33 patients (87%) achieved bone union after a mean of 4.7 (range, 4.2–7) months. Six of their patients developed nonunion and none had AVN of head of the femur. In a similar study on long-term follow-up of young patients with fracture neck of femur operated with CCS and free fibular graft, Singh et al.[13] reported 100% union in their 37 patients by the end of 1 year and two patients (5%) developed AVN. Contrary to these studies, a study done by Kumar et al.[14] compared the fracture fixation with multiple screws with and without free fibular graft. In their study of fractures presenting after 24 h, they recorded a total nonunion rate of 13% (11 out of 87) among which six (out of 45) were in the group of fractures fixed with screws alone and five (out of 42) were in the group fixed with screw and fibular graft. They mentioned that the reason for nonunion was early weight-bearing, noncompliance of patient, and improper screw placement in two patients, which are modifiable risk factors.

Our present study also shows similar lower rates of nonunion (9%) and lesser rate of AVN (4.5%) when fibular graft was used as an adjunct. It can be noted that these studies, including our present study, have demonstrated a considerably lower rate of AVN as compared to the previous reports of 16%–23% and nonunion rates of up to 25% [Table 2].[8],[9],[10],[11]
Table 2: Complication rates in previous studies on elayed fixation of fractures

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Mean HHS in our study was 87.8 which is similar to 87.1 obtained by Roshan and Ram in their study using CCSs and fibular graft.[16] In this study, we could obtain a final functional outcome of collection of “excellent” and “good” in 77.2% of cases (63% and 13.3%, respectively). This result is better than what was reported by Zahid et al.[12] where they obtained collective “good” to “excellent” in 54% patients and Kumar et al.[14] where they had excellent results in 28.5% in the group where free fibular graft was used and 66.6% where fibular graft was not used. Previous studies done by Goyal et al. could obtain a result of “good” in 68% of patients[17] and Nagi et al. had a result of “good” in 75% of patients[5] where HHS was not used as a functional scale.

In our study, no donor site complications were noted, as compared to Kumar et al, who reported donor site complications of incision site pain, temporary extensor hallucis weakness and increased blood loss when fracture fixation was augmented with fibular graft as compared to multiple screw fixation alone.


  Conclusions Top


Treatment of fracture neck of the femur in young adults is controversial, and various methods are evolving. Delay in surgery as a contributing factor for the development of complications in fracture neck of the femur cannot be ruled out with the present literature available. Thus, using a free fibular graft as an adjunct to implant construct helps in reducing the rates of nonunion and AVN. However, this cannot be a substitute for the proper surgical precision that is required in the treatment of fracture neck of the femur. Further prospective studies in this regard involving large sample size are required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parker MJ, Pryor GA. 1993. Hip Fracture Management. Oxford: Blackwell Scientific Publications. p.2.  Back to cited text no. 1
    
2.
Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am 1976;58:689-95.  Back to cited text no. 2
    
3.
Bray TJ. Femoral neck fracture fixation. Clinical decision making. Clin Orthop Relat Res 1997;339:20-31.  Back to cited text no. 3
    
4.
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;66:837-46.  Back to cited text no. 4
    
5.
Nagi ON, Gautam VK, Marya SK. Treatment of femoral neck fractures with a cancellous screw and fibular graft. J Bone Joint Surg Br 1986;68:387-91.  Back to cited text no. 5
    
6.
Schwartsmann CR, Jacobus LS, Spinelli Lde F, Boschin LC, Gonçalves RZ, Yépez AK, et al. Dynamic hip screw for the treatment of femoral neck fractures: A prospective study with 96 patients. ISRN Orthop 2014;2014:257871.  Back to cited text no. 6
    
7.
Ragnarsson JI, Boquist L, Ekelund L, Kärrholm J. Instability and femoral head vitality in fractures of the femoral neck. Clin Orthop Relat Res 1993;287:30-40.  Back to cited text no. 7
    
8.
Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK, et al. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br 2004;86:1035-40.  Back to cited text no. 8
    
9.
Gerber C, Strehle J, Ganz R. The treatment of fractures of the femoral neck. Clin Orthop Relat Res 1993;292:77-86.   Back to cited text no. 9
    
10.
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;86-A: 1711-6.  Back to cited text no. 10
    
11.
Forsh DA, Ferguson TA. Contemporary management of femoral neck fractures: The young and the old. Curr Rev Musculoskelet Med 2012;5:214-21.  Back to cited text no. 11
    
12.
Zahid M, Bin Sabir A, Asif N, Julfiqar M, Khan AQ, Ahmad S, et al. Fixation using cannulated screws and fibular strut grafts for fresh femoral neck fractures with posterior comminution. J Orthop Surg (Hong Kong) 2012;20:191-5.  Back to cited text no. 12
    
13.
Singh S, Kumar D, Kumar S. Long term results of fresh femoral neck fractures treated by cancellous screw and fibular autograft. MOJ Orthop Rheumatol 2014;1:00020.  Back to cited text no. 13
    
14.
Kumar S, Bharti A, Rawat A, Kumar V, Avasthi S. Comparative study of fresh femoral neck fractures managed by multiple cancellous screws with and without fibular graft in young adults. J Clin Orthop Trauma 2015;6:6-11.  Back to cited text no. 14
    
15.
Butt MF, Dhar SA, Gani NU, Farooq M, Mir MR, Halwai MA, et al. Delayed fixation of displaced femoral neck fractures in younger adults. Injury 2008;39:238-43.  Back to cited text no. 15
    
16.
Roshan A, Ram S. Early return to function in young adults with neglected femoral neck fractures. Clin Orthop Relat Res 2006;447:152-7.  Back to cited text no. 16
    
17.
Goyal RK, Chandra H, Pruthi KK, Nirvikalp. Fibular grafting with cannulated hip screw fixation in late femoral neck fractures in young adults. Indian J Orthop 2006;40:94-6.  Back to cited text no. 17
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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