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A study of internal fixation of intracapsular fracture neck of femur in adults by multiple cannulated cancellous lag screews.

INTRODUCTION: Civilization has ushered in high injury rates increased fracture pattern by virtue of high speed transportation accidents, industrial accidents, sports and recreational injuries. Fracture of the neck of the femur have always presented great challenges to orthopaedic surgeons and remain in many ways today the unsalved fracture as far as treatment and results are concerned. With life expectancy increasing each decade, our society is becoming more and more geriatric with significant increase in number of hospitalized and nursing home patients suffering from femoral neck fractures and their sequalae. (1) The femoral neck fractures in young patient usually are caused by high energy trauma and often are associated with multiple injuries and high rates of avacular necrosis and nonunion. Even when undisplaced fracture neck of femur, there is no assurance that a fracture will attain an excellent result. From 10% to 15% of these patients will develop complications over which the surgeon has little or no control.

The quotation "we came in to the world under the brim of pelvis and go out through the neck of femur" reflects the defeatist attitude that has long been held by medical and lay personal towards femoral neck fractures. (2) Though most of these fractures are due to trivial trauma the elder age group in which they commonly occur, leads to catastrophic consequences unless early mobilization out of the bed is made possible. Moreover successful union with conservative management is uncommon. So operative intervention has become the routine for all types of femoral neck fractures early anatomical reduction, compression of the fracture and result internal fixation are used to promote union. (3,4)

1st CASE:

2nd CASE:

TREATMENT (5,6,7) : Pre-Operative: Patient was admitted and below knee skin fraction applied with 3kg weight. Analgesics were given for pain relief. Prepared for surgery.

SURGERY: Under spinal anesthesia patient was shifted on to the fracture table. The fracture reduced with Lead better technique and reduction was conformed to Image intensifier both AP and lateral.

Through lateral approach fracture fixation was done with two cannulated Cancellous screws under Image intensifier. (8,9,10)

Post-operative: ISO metric quadriceps exercises were advised. Suture removed was done on 10th post OP day. Discharge with an advice not to weight bear for two months.

FOLLOWUP: Follow-up was done upto 4 months.

COMMENT: A 32 years old male was admitted with Intra Capsular fracture neck of femur with garden Type-IV. Surgery was done and the post-operative period was uneventful. Patient regained full range of movements and is able to bear the weight at 4 months and the result was excellent.

MATERIAL AND METHODS: The present work on "A Study of Internal fixation of Intracapsular fracture neck of femur in adults by Multiple Cannulated Cancellous Lag Screws" is carried out during the years 2011 to 2014.

All the patients were pre-operatively assessed to grade the type of fracture by "GARDEN'S CLASSIFICATION" and prepared for surgery. All fractures were reduced by LEADBETTER (In flexion) method.

A total of 22 cases of Intracapsular fracture neck of femur in adults were treated after accurate reduction and rigid internal fixation under X ray control with 2 or 3 cannulated cancellous screws.

Post operatively all patients were mobilized in the bed with Quadriceps exercises. Sutures were removed on the 10th day. A pair of crutches was advised and no weigh bearing till the fracture got united.

ANALYSIS:

Age Incidence

Age Incidence   No. of Cases

20-30 Years          8
31-40 Years          6
41-50 Years          5
51-60 Years          3

Sex Incidence

 Sex     No. of Cases

Male          17
Female        5

Relation Of Union with Garden's Grading of Fracture

Grade   No. of Cases   Union   Non-Union

I            --         --        --
II           2           2        Nil
III          13         13        --
IV           7           5         2
TOTAL        22         20         2

Result of Cases Treated

Result      No. of Cases   Percentage

Excellent        5           22.63%
Good             13          59.09%
Fair             2           9.09%
Poor             2           9.09%


GRADING OF RESULTS:

EXCELLENT: There is sound bony union of the fracture, No avascular necrosis of head. Full range of movements and strength. Full weight bearing. No pain or tenderness.

GOOD: There is a sound bony union of the fracture. No avascular necrosis of the head. No pain or tenderness. Minimal restriction of movement's particularly last degree of flexion and abduction.

FAIR: Sound bony union, Gross restriction of hip movements and pain on walking with discomfort to squat.

POOR: Severe restriction of function with corroborative radiographs requiring salvage procedures.

COMPLICATIONS NOTED IN THIS SERIES (11):

1. Non-union and loosening of screws in one case.

2. Non-union and Extrusion of screws in one case.

3. Cut through of screws into articular surface leading to painful joint in one case.

DISCUSSION: The total number of cases of Intracapsular fracture neck femur followed is 22. The cases were treated by Multiple cannulated cancellous screws and follow up from 6 months to 2 years. Male patients are more than female patients. The commonest age group of the followed cases in between 30-50 years.

This serious contains patients who are hardworking labourers and sedentary females. The mechanisms of injury in most cases are in the form of fall from height. There is also slightly violent injury leading to intracapsular fracture. The commonest radiological type of fracture is Garden's grade-III followed by type-II.

All the patients were explained the precaution to the followed after surgery. The reduction of fracture was done by lead better method without fail. The reduction was confirmed by an Image intensifier both Anteroposterior and lateral views.

Though lateral approach, the fracture was fixed by multiple cannulated cancellous screws. In most of the cased the fixation of fracture was done by 2 or more than two to prevent notion of the proximal fragment. The threaded portion of the screws was seen to cross the fracture line to get a better lag effect.

One case have developed absorption of the neck and loosening of the screws and for that Girdle Stone excision arthoplasty done. One case developed collapse at the fracture site and extrusion of screws due to early weight bearing and the case not turned up for further follow up

SUMMARY: In this series, we have operated 22 cases who were in the age group of 18-60 years. We have used cannulated cancellous screws with a pitch of 16 TPL. We have got excellent results.

We have encountered 2 cases of poor results with a complication of nonunion and loosening of the screws. One case landed up in Girdlestone Excision arthroplasty and one case not turned up for further follow up.

The prerequisites for sound healing of intracapsular fracture neck of femur are (12,13,14):

1. Anatomical Reduction.

2. Rigid Fixation.

3. Impaction.

4. Strict post-operative physiotherapy.

5. No premature weight bearing.

CONCLUSION: The injuries around the hip were mostly extra capsular neck of femur followed by intracapsular neck of femur and posterior dislocations of hip:

1. The most of the cases of intracapsular neck of femur were in the age group of 30-50 years.

2. There was male preponderance as shown in this study of intracapsular neck of femur.

3. The nature of violence in this study shows, mainly, fall from a height. This injury usually not associated with any other injuries.

In our institute accurate reduction and rigid internal fixation of intracapsular fracture neck of femur was done with the help of Image Intensifier and the results were encouraging even up to the age of 60 years. In early mobilization of the patients the complications of prolonged immobilization like thromboembolism, hypostatic pneumonia etc., were avoided.

By the usage of multiple cancellous lag screws has compression effect at the fracture site avoid re displacement and rotations.

The implant occupies less volume in the small sized femoral necks of South Indian Patients allowing better osteosynthesis of intrascapsular fracture neck of femur.

The results have been encouraging and better than the implants which do not causes compression at fracture site or occupies large volume in the femoral neck or allows rotations.

DOI: 10.14260/jemds/2015/1338

REFERENCES:

(1.) Zetterberg CH, Elmerson S, Andersson GB. Epidemiology of hip fractures in Goteborg, Sweden, 1940-1983. Clin Orthop Relat Res 1984; 191: 43-52.

(2.) Raaymakers E. Fractures of the femoral neck: a review and personal statement, Acta Chir Orthop Traumatol Cech 2006; 73(1): 45-59.

(3.) MM Anwar, The fracture of the neck of the femur: A review of the relevant aspects as a guide in clinical practice, The ORIN vol. 2 January 1999.

(4.) Gwilym GD, The treatment of intracapsular fractures of the hip. Philadelphia Academy of Surgery, Ann Surg 1912; 56(4): 622-30.

(5.) Olerud C, Rehnberg L, Hellquist E. Internal fixation of femoral neck fractures. Two methods compared. J Bone Joint Surg Br 1991; 73: 16-9.

(6.) Gautam VK, Anand S, Dhaon BK. Management of displaced femoral neck fractures in young adults (a group at risk). Injury 1998; 29: 215-8.

(7.) Lin SQ Peng LP, Yao ZC. Case-control study on cannulated screw fixation and percutaneous autogenous bone marrow grafting for the treatment of femoral neck fractures]. Zhongguo Gu Shang 2010; 23(9): 675-8.

(8.) Soontrapa S, Soontrapa S, Srinakarin J, Chowchuen P. Singh Index Screening for Femoral Neck Osteoporosis. J Med Assoc Thai 2005; 88: S13-6.

(9.) Cho MR, Lee SW, Shin DK, Kim SK, Kim SY, Ko SB, Kwun KW. Predictive method for subsequent avascular necrosis of the femoral head (AVNFH) by observation of bleeding from the cannulated screw used for fixation of intracapsular femoral neck fractures. J Orthop Trauma 2007; 21(3):158-64.

(10.) Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma 1986; 26:932-7.

(11.) Skala-Rosenbaum J, Dzupa V, Bartonicek J, Dousa P, Pazdirek P. Osteosynthesis of intracapsular femoral neck fractures. Rozhl Chir. 2005; 84(6):291-8.

(12.) Naseem UG, Khursheed AK, Mohammed FB, Gulam ND, Mudassir MW. More than two years delay in the union of fracture neck of femur after primary intervention. Cases Journal 2008, 61.

(13.) Skala-Rosenbaum J, Dzupa V, Bartomcek J, Dousa P, Pazdirek P. Osteosynthesis of intracapsular femoral neck fractures. Rozhl Chir 2005; 84(6): 291-8.

C. Sanjeevaiah [1], K. Praneeth Reddy [2]

AUTHORS:

[1.] C. Sanjeevaiah

[2.] K. Praneeth Reddy

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Orthopaedics & Traumatology, RIMS, Medical College, Kadapa, Andhra Pradesh.

[2.] Senior Resident, Department of Orthopaedics & Traumatology, RIMS, Medical College, Kadapa, Andhra Pradesh.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. C. Sanjeevaiah, H. No-501, Sai Residency, Arvind Nagar, Kadapa, Andhra Pradesh.

E-mail: drsanjeevaiahchalla@gmail.com

Date of Submission: 04/06/2015. Date of Peer Review: 05/06/2015. Date of Acceptance: 24/06/2015. Date of Publishing: 01/07/2015.

Master Sheet

Sl.                          Age in            Garden's
No.           Name           Years     Sex     Grading

1.          Rajendra           45      Male      III
2.         A. Sathemma         45     Female     III
3.           D. Raju           33      Male       IV
4.        Ch. Srinivas         34      Male      III
5.         P. Nagaiah          51      Male       IV
6.         P. Venkanna         18      Male      III
7.          K. Radha           22     Female      II
8.          T. Ramana          54      Male      III
9.          Sabasirin          19     Female      II
10.        Ravi Kumar          26      Male      III
11.         D. Satish          18      Male      III
12.          J. Ravi           22      Male      III
13.         B. Laxmi           40     Female     III
14.     A. Surya-narayana      45      Male       IV
15.        B. Valsingh         32      Male       IV
16.       S. Krishnaiah        52      Male      III
17.       E. Ram Murthy        40      Male      III
18.          G. Balu           28      Male       IV
19.        B. Rajanna          35      Male       IV
20.         N. Laxmi           40     Female      IV
21.    Shiva Koteshwar Rao     30      Male       IV
22.       Narsimha Rao         24      Male      III

Sl.      Union      Follow
No.    occurred       up        Results

1.     4 Months     2 years      Good
2.     3 Months     1% year      Good
3.        --          --         Poor
4.     4 Months     1% year      Good
5.     3 Months     1% year      Good
6.     3 Months     1 year     Excellent
7.     3 Months     1 year       Good
8.     3 Months     1 year     Excellent
9.     3 Months     1 year     Excellent
10.    3 Months     1 year       Good
11.    3 Months     1 year     Excellent
12.    3 Months     1 year       Good
13.    4 Months    9 Months      Good
14.    Non Union   9 Months      Poor
15.    3 Months    9 Months    Excellent
16.    3 Months    6 Months      Good
17.    3 Months    6 Months      Good
18.    3 Months    6 Months      Good
19.    3 Months    6 Months      Good
20.    3 Months    6 Months      Fair
21.    3 Months    6 Months      Good
22.    4 Months    10 Months     Fair
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Sanjeevaiah, C.; Reddy, K. Praneeth
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jul 2, 2015
Words:2051
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