|Ahead of print
|Role of valgus osteotomy in old fracture neck of femur: A retrospective cohort study
Tanmoy Mohanty1, Suvam Choudhury2, Braja Sundar Sahoo3, Ramesh Chandra Maharaj2, Debi Prasad Nanda4
1 Department of Orthopedics, KIMS, Bhubaneswar, Odisha, India
2 Department of Orthopedics, PRMMCH, Baripada, Odisha, India
3 Department of Orthopedics, VSSIMSAR, Burla, Odisha, India
4 Department of Orthopedics, SCBMCH, Cuttack, Odisha, India
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|Date of Submission||22-Jul-2022|
|Date of Decision||14-Sep-2022|
|Date of Acceptance||25-Sep-2022|
Background: Nonunion fracture of the neck of the femur remains an unsolved issue owing to peculiar vascular anatomy and the relationship of weight transmission to fracture pattern stability. Salvaging the viable biological head is more preferable than replacement to avoid revision surgeries, especially in young adults.
Objective: This study was designed to evaluate the outcome of old fractured necks of femur patients who underwent osteosynthesis through valgus osteotomy.
Materials and Methods: We did a retrospective cohort study and collected the data for old fracture neck of the femur from 2010 to 19 from hospital records who underwent valgus osteotomy (McMurray's and Pauwel's osteotomy) and followed them for complications. The Student's t-test was used to compare the results of the two methods, i.e., McMurray's and Pauwel's.
Results: About 83.3% of cases were of Pauwel's Type II and III groups. In cases that underwent McMurray's osteotomy, the mean shortening was 0.9 cm. Forty percentage had a full range of movements (ROM), 60% had occasional pain, 20% had complications such as screw back out, trochanteric bursitis, and 10% had avascular necrosis of the head femur. In cases that underwent Pauwel's osteotomy had a mean shortening of 1.5 cm, 20.83% had full ROM, 62.5% had limping, 45.5% had pain, 25% had screw back out, and infection in 25. Two cases underwent trans-fracture abduction osteotomy, so results are not discussed.
Conclusions: We found that valgus osteotomy showed promising results and was comparable with the results of acceptable literature. Hence, it is suggested that osteosynthesis rather than arthroplasty should be the preferred method of treatment for old fractures of the neck of the femur.
Keywords: Arthroplasty, femoral neck fractures, fractures, osteotomy, ununited
|How to cite this URL:|
Mohanty T, Choudhury S, Sahoo BS, Maharaj RC, Nanda DP. Role of valgus osteotomy in old fracture neck of femur: A retrospective cohort study. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=359955
| Introduction|| |
Orthopedic science has evolved tremendously in the last decade, which has completely revolutionized the approach to fracture management, with fracture-specific anatomically designed implants for specific indications. However still, there are some grey areas that are yet to be answered in the management of certain fractures such as the neck of the femur, scaphoid, talus, lunate, and so on. There is difficulty in choosing the right kind of management for them. This may be due to various specific factors such as anatomic peculiarity, vascularity, fracture patterns, and their relationship with the weight-bearing mechanism. Hence, the proper understanding of the anatomy of each bone and the peculiarities associated with them is a must for their proper management.
For the above-mentioned reasons, the fracture neck of the femur is aptly called an “unsolved fracture.” This is because there is no one method that can give successful results for this fracture. It is a common fracture encountered in the elderly, and its incidence is also increasing day by day in young adults due to a rise in industrial and vehicular accidents.
Fracture neck of the femur is considered a surgical emergency in orthopedics because of the peculiar blood supply of the head of the femur. If it is not fixed surgically within 6 h, it leads to nonunion which is seen in almost one-third of cases. In the long term it may lead to avascular necrosis (AVN). Another crucial deciding factor is the angle of inclination of the fracture line with respect to the horizontal in the coronal plane. According to Pauwel's principle, with an increase in the angle of inclination, chances of fracture union diminish as the weight-bearing force will act as a shearing force across the fracture line rather than compression, thus leading to nonunion. Hence, fractures with an angle of inclination <30° unites well and those with more than it may result in nonunion. Nonunion cases are further encountered following the fracture treatment by traditional bone setters who do not have the proper understanding of the vascular anatomy and principle of weight transmission and its effect on fracture healing in femoral neck fractures.
All these conditions actually lead to a high rate of nonunion seen in the fracture neck of the femur, despite how well it may be fixed. In elderly people, surgeons have the choice to go straight away with partial or total hip arthroplasty. However, this option becomes questionable where the age of the patients is <50 years and the head is still viable with a nonunion. Due to the ease of doing it, many surgeons prefer arthroplasty to osteosynthesis for neglected fracture neck of femur in young adults too. However still, there is a temptation among a few surgeons to salvage the viable head as it is natural, autogenous and preferable than a prosthetic head with its own pros and cons. If osteosynthesis works, then arthroplasty may not be needed at all, or if it so, it will be delayed for a long period.
The principle for osteosynthesis is the “Pauwel's principle,” which states that the angle of inclination should be reduced to <30° so that shearing force will be converted to compressive force that eventually helps in the union of the fracture with time. The method is intertrochanteric valgus osteotomy, and the options are McMurray's medial displacement osteotomy, modified Pauwel's osteotomy, and trans-fracture abduction osteotomy. This study is thus designed to analyze long-term results of valgus osteotomy done in the last 10 years for old or neglected fracture neck of femur in a Tertiary Care Institute in the East Zone of India.
| Materials and Methods|| |
This retrospective cohort study was conducted from 2018 to 2020 in a Tertiary Care Institute in India's East Zone, where data were collected retrospectively from October 2010 to December 2019 for a period of 10 years from past records and all data were analyzed prospectively with Institutional Ethical Committee approval (IEC-No 366, dated October 14, 2020). It included all patients with an intracapsular fracture neck of the femur of more than 3-week-old who were operated on at this institute. Those patients who were lost to follow-up were excluded from the study. For patients who were treated in the past, details were collected from the hospital records from old bed head tickets, operation theatre (OT) registers, and patients were contacted over phone, mail, or by personal appearance for follow-up and fresh cases were admitted, operated on, and followed up from time to time. The minimum period of follow-up was kept to 1 year and a maximum of 9 years was available with the study. The details of the patients selected for the study were recorded in a predesigned preform, which included demographic data, Pauwel's classification, time since fracture, type of surgery, pre- and post-operative limb length and limping, along with other notable parameters. Signed informed consent from each participant was obtained [Figure 1].
Preoperative planning was done beforehand. The principle in all this was to reduce the angle of inclination of the fracture to or below 30°. All of the patients were operated on while under spinal anesthesia, using a traction table and an image intensifier. Before 2013, it was McMurray's intertrochanteric medial displacement osteotomy fixed with a Wainwright plate or Trochanteric hook plate. Modified Pauwel's lateral close wedge intertrochanteric osteotomy fixed with double-angled dynamic hip screw (DHS) or angled blade plate was used starting in 2013. Pingle's lateral close wedge transfracture abduction osteotomy, which is fixed with a proximal femoral plate, was recently preferred. In all, the aim was to convert the shearing force to compressive force by reducing the angle of inclination through osteotomy and not touching the fracture directly.
Technique-wise, McMurray's osteotomy was a simple medial displacement intertrochanteric osteotomy without any open or close wedge of bone resection, and the osteotomy site was stabilized with a Wainwright plate or trochanteric hook plate. Here, patients walk with adduction of the limb postoperatively, thereby correcting the angle of inclination by itself. For modified Pauwel's osteotomy, a preoperative X-ray, anteroposterior view of the pelvis showing both the hips in 15° internal rotation was obtained, and from that, the angle of correction needed to reduce the angle of inclination to 30° was measured. Based on that, a laterally based close wedge of bone at the level of the lesser trochanter was removed and fixed with double-angled DHS or angled blade plate with which the osteotomy site, as well as fracture neck of femur, was also stabilized. For transfracture abduction osteotomy same principle was applied like that of Pauwel's osteotomy, except here the osteotomy site is more proximal, extending from the intertrochanteric region to the nonunion site of the fracture neck and was fixed with a proximal femoral plate or trochanteric plate which fixes both the osteotomy site and the fracture neck. None of the methods required postoperative immobilization with boot and bar cast [Figure 2].
|Figure 2: (a-c) McMurray's osteotomy, (d and e) Modified Pauwel's osteotomy, (f and g) Transfracture abduction osteotomy|
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All new postoperative cases during the study period were called for follow-up at a 2-month interval for the first 6 months and then every 6 months, and all old operated cases were called for follow-up clinical and radiological assessment. As in old records, no proper follow-up protocol was mentioned; all the cases were followed up clinically and radiologically for evidence of AVN of the head, secondary osteoarthritis of the hip, ability to walk with or without support, limb length discrepancy or shortening, subsidence of pain, infection, implant back out or failures.
All data are recorded in an excel sheet of Microsoft word 2017. Continuous data were shown as proportions, while categorical data were shown as mean and standard deviation. Attrition bias was avoided by the intention to treat analysis and account for all dropouts. Reporting bias was avoided by complete reporting of all outcomes.
| Results|| |
This is a retrospective cohort with data compiled over the past 10 years with a minimum follow-up period of 1 year to a maximum of 9 years and the average was 4.14 years. Out of 882 cases of fractured neck of femur, 11 cases in the pediatric age groups were treated with Moore's pin, 212 cases with multiple cannulated cancellous screws, 62 cases with DHS, 486 patients in the upper age group were considered for hemiarthroplasty and 40 cases with total hip arthroplasty. A total of 42 cases of valgus osteotomy for old or neglected fracture neck of femur were considered in the study group, of which six were lost to follow-up [Table 1]. The mean duration of delay in obtaining treatment for fracture neck was 17.06 weeks and ranged from 6 to 32 weeks, with a maximum delay of two and a half years in one case who underwent osteosynthesis. The average age of the patients was 38.83 years, with a range of 15–72 years, with the male being three times more commonly affected than females. The left side hip was more commonly fractured in 58.3% of cases. Pauwel's classification was used to classify old fracture neck of femur, of which Type II was the most frequent in 47.2% of cases [Table 2]. Of 42 cases, 14 (33.3%) underwent Mc Murray's osteotomy with 4 lost to follow-up, 26 were managed with modified Pauwel's osteotomy with 2 lost to follow-up and 2 underwent transfracture abduction osteotomy [Table 3].
|Table 1: Distribution of total numbers of cases of fracture neck of femur|
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It was seen that McMurray's osteotomy, which was fixed with Wainwright plate, required a boot and bar plaster to immobilize postoperatively, but with trochanteric hook plate, no immobilization was necessary. One case with 5-week-old fracture neck operated in 2011 with McMurray's osteotomy was found walking around and doing his profession of cultivation 7 months postoperatively but died of chronic renal failure in 2018. Another case of McMurray's osteotomy done in 2011 was admitted for secondary osteoarthritic changes and was treated with implant removal in January 2018 and underwent total hip arthroplasty in December 2018. The patients with McMurray's osteotomy could mostly ambulate and go back to their work within 6–7 months from the date of surgery. The common complication was backing out of cannulated screws or irritation at the tip of the trochanter. Out of 14 cases, 4 were lost to follow-up. Of the rest 10, it was found that 4 (40%) patients had nearly full range of motion of the hip joints with very minimal limping and the Trendelenburg test was negative. Of the rest 7 who have been followed up for more than 9 years, 6 patients were found to be limping and had occasional pain and may require total hip replacement (THR) in future, and 1 patient died in 2018 of chronic renal failure [Figure 3] and [Figure 4].
|Figure 3: (a) 52-year-old male with 4-month-old fracture neck of left femur with high Pauwel's angle, (b) McMurray's osteotomy done and fixed with trochanteric hook plate through which 2 CC screws were passed into the neck, (c) and (d) Patient had nearly full range of motion and Trendelenburg negative but required removal of the plate for trochanteric bursitis. The patient was followed up in 2018. CC: Cancellous cannulated|
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|Figure 4: (a) McMurray's osteotomy done for 6-month-old fracture neck of the left femur in 43-year-old lower middle-class male and fixed with Wainwright's Plate in 2011, (b) Avascular necrosis of the head of the femur (plate removal done in January 2018), (c) Total hip replacement done for AVN femoral head in December 2018 and (d) Clinical follow-up in July 2019. AVN: Avascular necrosis|
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After 2013, McMurray's osteotomy was virtually abandoned, and Pauwel's intertrochanteric valgus osteotomy was the preferred method where implants used were double-angled DHSs or angled blade plates. This fixation was augmented with a washer. The fibula was used to augment in two cases of McMurray's and three cases of Pauwel's osteotomy. None of them required postoperative immobilization with boot and bar plaster. Out of 26 cases of Modified Pauwel's osteotomy, two were lost to follow-up. Of the remaining 24, double-angled DHS was used in 21 and angled blade plate in 3. Near full range of movements (ROM) was possible in 5 (20.83%), limping in 15, occasional pain in 11, and infection in 2 and screws back out was seen in 6. There were no cases of trochanteric bursitis, secondary osteoarthritis hip, or a vascular necrosis of the femoral head [Figure 5].
|Figure 5: (a) 35-year-old male with 2-month-old fracture neck of the left femur with high Pauwel's angle, (b) Modified Pauwel's osteotomy done and fixed with single angled blade plate and one CC Screw and (c) Clinical follow-up with no shortening but the restriction of terminal 20° of flexion and extremes of rotation. CC: Cancellous cannulated|
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Of three cases of trans-fracture abduction osteotomy since February 2018, two did not require immobilization postoperatively. Out of three cases, two cases were included as they had completed more than 1 year of follow-up and both of them had gained a good ROM at the hips with minimal limping, and no other complications were seen [Figure 6] and [Table 4].
|Figure 6: (a) 20-year-old male with 2-month-old fracture neck of the left femur with high Pauwel's angle, (b) Transfracture abduction osteotomy done and fixed with the modified trochanteric plate in October 2019, (c) Clinical follow-up in November 2020 shows no limb shortening and the full range of motion of the left hip|
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| Discussion|| |
The fractured neck of the femur is rightly called the “unsolved fracture.” There have been numerous methods described for this single entity to date, but none of them can be considered the best. This is because of the peculiar vascular anatomy of the proximal femur, the site of the fracture, the fracture pattern, and the age of the patient. The different modalities commonly preferred are cannulated cancellous screws, DHSs, proximal femoral nails, and partial or total hip arthroplasty. However still, these options are not the answer for neglected or old ununited fracture neck of the femur with a viable head in a middle-aged patient. Then comes the role of valgus intertrochanteric osteotomy such as McMurray's osteotomy, modified Pauwel's osteotomy, and transfracture abduction osteotomy.
In this study, the most common age group affected was (15–72) with an average of 38.83 years. The average delay in the time of presentation was 13.91 weeks with a range of 5–24 weeks, with one case of two and a half years, which was the outlier. Males (75%) were more commonly affected than females and the left side was more commonly affected than the right in 58.33% of cases with a mean period of follow-up of 4.14 years with a range of 1–9 years. Pauwel's Type II fractures of the neck were more commonly encountered in 47.2% of cases. The average age of this study was lower with a mean delay in the presentation was higher than that of Magu et al. where the average age was 48 years with a mean delay of 7 weeks and in Nair with the average age was 52 years with a mean delay in presentation of 6 weeks.,
Limping was reported in 58.33% of cases, with occasional pain in 47.22%, infection in 5.55%, cancellous screws coming out in 22.22% of cases, trochanteric bursitis in 5.55%, secondary osteoarthritis hip in 5.55%, and AVN in 5.55%. The pre- and post-operative limb length discrepancy (shortening) as well as the type of ambulation (assisted or unassisted) were recorded and compared with a few study articles.
The results of this study were compared with Nair for McMurray's osteotomy; he did not use any internal fixation following the osteotomy but used hip Spica immobilization instead. Nair, with a sample size of 12 cases, found a mean shortening of 1.875 cm (1–4 cm) with a standard deviation of 0.75. This study, with a sample size of 10, found a mean shortening of 0.9 cm (0–2 cm) with a standard deviation of 0.5. This could be due to internal fixation (Wainwright plate or trochanteric hook plate) used in this study compared to hip Spica immobilization used by Nair.
The results of valgus osteotomy using modified Pauwel's osteotomy for old fracture neck of the femur of this study were compared with Magu et al. Magu et al. found a mean shortening of 1.9 cm (1.5–2.5 cm) with a standard deviation of 0.4 in a sample size of 8. This study found an average shortening of 1.5 cm (0–2.5 cm) with a standard deviation of 0.625 in 24 cases. Thus, in this study, we found similar results as of Magu et al. with respect to postoperative shortening and that too in the higher sample size of 24 as compared to 8 in Magu et al.
We compared the different complications of McMurray's and Pauwell's osteotomy and found no statistical significance between them (P > 0.01).
Postoperative shortening in transfracture abduction osteotomy could not be compared with any other article as the sample size is very low, and the comparison would not be statistically significant.
The limitations of this study were: small sample size, with 6 (14%) cases lost to follow-up, and the number of cases of transfracture abduction osteotomy followed up was very small (two cases). The follow-up parameters taken into account are only the pre- and post-operative limb length discrepancies and type of ambulation. The magnitude of attrition bias was moderate, and it was avoided by accounting for all dropouts. Reporting bias was avoided by complete reporting of all outcomes.
The strength of the study is that the results of it are at par with the internationally accepted articles with similar numbers of sample size, thus strongly recommending valgus intertrochanteric osteotomy as the mainstay of the treatment for old fracture neck of femur mostly in young adults. Thus it supports modified Pauwel's osteotomy and transfracture abduction osteotomy as an option holding good in old or neglected fracture neck of the femur over arthroplasty. We had higher population validity in our study because we included people of all ages and fractures of varying duration; in total, we studied 882 cases of fractured neck femur over a 10-year period. Hence, the external validity of the study is quite acceptable. We believe there are very limited number of threats to the external validity of our study. We reduced the risk of selection bias by doing probability sampling of participants. Ignorance about the need for surgical intervention in fracture neck of femur and faith in native treatment, and unwillingness or lack of desire to receive institutional treatment are the key factors that lead to a rise in numbers of cases of neglected fracture neck of the femur which eventually need a valgus osteotomy.
| Conclusions|| |
The results of the study suggest that valgus intertrochanteric osteotomy should be the mainstay of treatment for neglected fracture neck of femur. It gives a stable, mobile hip with no functional restrictions and preserves the native hip joint. In cases of complications, conversion to arthroplasty is always possible though technically demanding.
We are thankful to all our patients for their cooperation during the study period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Ramesh Chandra Maharaj,
PRMMCH, Baripada, Odisha
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]
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