Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck

Abstract

N eglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed.We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.

Osteosynthesis of femoral-neck nonunion with angle blade plate and autogenous fibular graft

“…There was no instance of fibular graft fracture or slippage or implant cutthrough. After a mean of 3.2 years, using the criteria of Nagi et al [4], excellent results were seen in four, good in ten, fair in six and poor in two patients. Patients with poor results included one with nonunion and other with AVN with collapse (Table 2).…”

“…Osteotomy converts the vertical fracture line to the horizontal compressive force and thus creates better hip biomechanics for fracture healing. However, in view of the described morbidities, it may not be justified in cases where nonunion is not associated with significant varus deformity at the fracture site [4,5]. The primary issue in these situations is biology at the fracture site and stability of internal fixation.…”

“…Radiographically, they were assessed for evidence of union on anteroposterior and lateral views and development of avascular changes. Functional evaluation was done using the criteria used by Nagi et al (Table 1) [4].…”

“…The technique involved nonvascular fibular graft with a cannulated cancellous screw [4]. Other studies report using two to three screws as supplemental fixation with a fibular graft [5][6][7][8][9].…”

“…Other studies report using two to three screws as supplemental fixation with a fibular graft [5][6][7][8][9]. Union rates with this technique in two different studies were 69% and 95% [4,5]. We have evolved the method used for fixation with fibular bone grafting.…”