Current Orthopaedics (2003) 17, 394-- 402

c 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0268 - 0890(03)00046 -X

TRAUMA RECONSTRUCTION

Management of neglected/ununited fractures of the femoral neck in young adults

O. N. Nagi and M. S. Dhillon
Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

INTRODUCTION
Proximal femoral fractures may be extra or intra-capsular injuries, and they occur with about the same frequency in the elderly population. They are more common in women, with the inter-trochanteric extracapsular injuries occurring in a relatively older segment of the population.1 Intra-capsular femoral neck fractures, known since the advent of medicine, are still a management enigma, in spite of increased understanding of the technology, diagnostic methods and treatment. In the last century, treatment protocols have evolved considerably from Whitmans protocols of spica application, and have now become better def|ned.2 This injury is most frequently encountered in the elderly population, where a minor slip may be the cause, and is relatively uncommon in young adults. The modern literature reflects a disturbing trend of more injuries occurring in the younger age groups, and these are usually the result of high-energy trauma. At whatever age they present, complications are frequent, with union rates being relatively low; a combination of factors is responsible for this.

different forms of stabilisation, and having much better union rates.

EPIDEMIOLOGY
Koval and Zuckerman,1 reported that in1994, 250 000 femoral neck fractures occurred in the USA (projected1.3 million fractures worldwide). This rate is expected to double by 2025. Martin et al. found increasing incidence of fractures of the proximal femur, which could not be explained by changing demographics alone.3 Approximately half of the fractures reported in all studies are intra-capsular, and the average age of these cases is approximately 80 years, with 75% being females. Conversely, when the injury occurs in young adults, most of these cases are healthy adults, with no super-added pathology, and good bone stock. The velocity of trauma is also higher, with a larger number of associated injuries.

ARTERIAL BLOOD SUPPL Y

A lot of detail has now been gleaned about the blood supply to the proximal end of the femur, which has some unique features. The arterial supply becomes tenuous after injury, endangering the femoral head, risking subsequent avascular necrosis and collapse. The arterial arcades which supply the blood to the head and neck maybe divided into three major groups; these were clearly described by Crock.4 (1) An extra capsular arterial ring, located at the base of the femoral neck, and encircling it. (2) Ascending cervical branches arise from this arterial ring on the surface of the femoral neck. (3) The arteries of the ligamentum teres, which also supply a signif|cant part of the blood supply. The extra-capsular arterial ring is formed posteriorly by a large branch of the medial femoral circumflex artery

TERMINOLOGY
Basically, all femoral neck fractures, where the fracture line is primarily within the joint capsule, are called Intracapsular fractures of the hip. Fractures that involve the articular surface should be considered a more complex variety and some authors even consider them separately. A host of names has been given to intra-capsular patterns, varying from transcervical to Subcapital injuries, and the prognosis in these cases is much worse. On the other hand, those at the base of the neck, are primarily extra-capsular and are separate entities, requiring
Correspondence to: ONN. 1027 , Sector 24, Chandigarh 160024, India. Tel.: +91172 728851; Fax: +91172 744401

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and anteriorly by a branch from the lateral femoral circumflex artery. The ascending cervical branches or retinacular vessels ascend on the surface of the femoral neck in anterior, posterior, medial, and lateral groups; the lateral vessels are the most important. Their proximity to the surface of the femoral neck makes them vulnerable to injury in femoral neck fractures. As the articular margin of the femoral head is approached by the ascending cervical vessels, a second, less distinct ring of vessels is formed, referred to by Chung5 as the subsynovial intra-articular arterial ring. It is from this ring of vessels that vessels penetrate the head and are referred to as the epiphyseal arteries, the most important being the lateral epiphyseal arterial group supplying the lateral weight-bearing portion of the femoral head. These epiphyseal vessels are joined by inferior metaphyseal vessels and vessels from the ligamentum teres.

MECHANISM OF INJURY
In contrast to the elderly population, femoral neck fractures in young adults can only occur with signif|cant force. Kocher suggested two mechanisms of injury in all age groups. In the elderly, the injury is more commonly due to a direct blow over the greater trochanter during a fall. In young adults, the more common injury is a lateral rotation force applied to the extremity, with or without a proximally directed force. With deforming force, the head is held f|xed by the anterior capsule and iliofemoral ligaments while the hip rotates externally. By this rotation, the posterior cortex of the neck impinges on the lip of the acetabulum, and the neck buckles. This leads to a complete break in the anterior cortex, and also causes buckling of the posterior cortex (Fig. 1a and b). This also explains the marked posterior comminution of the neck often seen with this injury.

RADIOLOGY
The radiological examination6 should include the routine views (AP, and lateral), and in the cases of fractures with neglect, some special views maybe benef|cial. The AP view should be taken in maximum internal rotation of the limb to evaluate the extent of neck resorption; it may also be a good idea, in cases with proximal migration of the neck, to take X-rays using the push pull method, to see how much the trochanter can be brought down with manual traction. In special cases, it may be advantageous to use CT scans to determine the extent of comminution of the posterior cortex; MRI could be done for assessment of the vascular status of the femoral head, as bone marrow changes may give indirect evidence of presence or lack of vascularity.

Figure 1 (a) Line diagram showing mechanism of femoral neck fracture with external rotation force.The anterior aspect of the fractureis opened out (A), whilethereisbuckling ofthe posterior cortex (B). The anterior blood vessels are invariably torn (C) while the posterior vessels may potentially be intact (D). (b) X-ray photograph (lateral view) showing break in anterior cortex (A) and buckling of posterior cortex (B).

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CAUSES OF DELA YED HEALING/ NON-UNION

In all intra-capsular fractures, the synovial fluid bathing the fracture may interfere with the healing process. Angiogenic-inhibiting factors in synovial fluid can also inhibit fracture repair. Additionally, as the femoral neck has essentially no periosteal layer, all healing must be endosteal. These factors, along with the precarious blood supply to the femoral head, make healing unpredictable and non-unions fairly frequent. In the developing countries, we still see patients with delays in treatment due to poor medical facilities, missed diagnosis (especially in polytraumatised young adults), or improper surgical techniques.The factors known to contribute to non-union of the femoral neck include vascular insuff|ciency, inaccurate reduction, and loss of f|xation. The f|rst one is usually not in our control, but the latter two, along with delayed diagnosis, make up a signif|cant number of cases still encountered in the developing world. In the recent past, improved treatment, earlier diagnosis, and an understanding of the treatment regimens of femoral neck fractures has drastically reduced the incidence of non-union after these injuries. Inspite of this, non-unions are still estimated to occur in 10 --20% of patients in the developed world in all age groups. With anatomical reduction and stable f|xation, the incidence of non-union should be acceptably low. However, in a meta-analysis of 106 reports of displaced femoral neck fractures (seen at all ages) by Lu-Yao et al., non-union occurred in a cumulative 23--37% of fractures.7 The appropriate treatment depends on several factors, including the age and physical status of the patient, the viability of the femoral head, the amount of resorption of the femoral neck, and the duration of the nonunion.8 Most patients with femoral non-unions are over 60 years of age; these cases are poor surgical candidates for repeated surgical interventions, and extreme osteoporosis decreases the eff|ciency of any internal f|xation. The answer in this age group is simple, and a replacement arthroplasty as a primary procedure gives reliable results. In the younger age group, however, where it is important to save the femoral head, and in children, where some potential for growth is still present, the operation should be devised so as to make all attempts to save the head of the femur.This is not always possible, as delays in treatment invariably lead to problems.

fracture reduction and incidence of avascular necrosis (AVN): fractures reduced within 12 h of injury had a 25% incidence of AVN, whereas for fracture reduced more than 7 days after injury, the rate was 100%. Manninger et al.10 reported a signif|cantly lower incidence of segmental collapse in patients treated within 6 h of injury, when they compared two subsets who were treated early and late. At 1-year follow-up, 1.9% of fractures in the early treatment group and 19.3% of cases in the delayed treatment group had segmental collapse; follow-up at 6 --10 years revealed segmental collapse rates of 36.8% in the early treatment group and 63.9% in the delayed treatment group. Additionally, more patients in the delayed treatment group developed non-union. It is also interesting to note that in the early treatment group, segmental collapse often involved only a portion of the femoral head, whereas total head involvement was much more common in the delayed treatment group.This shows how the treatment becomes more diff|cult in cases who have a signif|cant period of delay prior to surgery.

EVOLUTIONOF TREATMENT METHODS

Historically, most of these cases were managed by different kinds of osteotomies, in which the femur was divided near the lesser trochanter and was either angulated to provide a line of weight bearing more directly beneath the femoral head, or was displaced medially.11 These were not universally successful, as they were operations done away from the fracture site, and did not ensure fracture union, or re-vascularisation of the head.Two types of osteotomy or modif|cations of them have been used to treat non-unions of the femoral neck: the displacement osteotomy (McMurray), made just proximal to or at the lesser trochanter, and the angulation osteotomy (Schanz), made through or just distal to the lesser trochanter.The displacement osteotomy of McMurray12 held centre-stage for a long time, and in our country was only discontinued in the late 1970s as the primary treatment modality, when more reliable methods of osteosynthesis became available. The mechanical advantages of an osteotomy are that the line of weight bearing is shifted medially and that the shearing force at the non-union is decreased because the fracture surface tends to become more horizontal.These advantages are greater after the angulation osteotomy than after the displacement osteotomy. A serious disadvantage is produced if the femoral neck and head are placed in an extreme valgus position, and this position must be avoided if possible because it shortens the lever arm between the trochanter, on which the abductor muscles pull, and the head, which is the fulcrum. In 1936, Pauwels13 called attention to this mechanical problem.

PROBLEMS WITH DELA Y

The effect of surgical delay on the incidence of avascular necrosis and non-union after displaced femoral neck fracture has been reviewed by several investigators. Massie9 demonstrated a direct relationship between delay of

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397 graft. The literature reports many techniques,20 --22 ranging from of the use of Phemister grafts,23 vascularised24 or muscle pedicle grafts,25,26 and f|bular grafts with or without osteotomy,27--29 but none of these studies has been prospective or large enough to allow any conclusion about the best form of treatment. Lifeso and Young,30 concluding that non-union in young adults was diff|cult to treat, felt that valgus osteotomy gave acceptable results. However, displacement osteotomy is no longer popular, as it interferes with subsequent arthroplasty procedures if there are any complications with the primary operation.31 The best results come from some form of bone graft with stable f|xation. Baksi25 has popularised the use of the muscle pedicle graft procedure described by Meyers,26 and it has been used for neglected cases as well as for cases with established AVN. This procedure basically uses the posterior approach, which in the authors opinion damages whatever residual blood vessels remain in this area after the injury. There are now some reports in the literature which caution against the use of the posterior approach.17 In cases in which a Meyers muscle pedicle graft had been delayed for more than 3 months after injury, Johnson and Brock reported up to a 75% rate of non-union.32 On the other hand, excellent results have been obtained with open reduction and vascularised iliac-crest grafting, using an anterior approach.24 However, the procedure involves the use of specialised instrumentation and is technically demanding, and since only a few cases have been reported the long-term acceptability has yet to be proven.

In treating non-unions with a viable head, the angulation osteotomy was not intended to provide a partial pelvic support but rather to shift the line of weight bearing medially and to change the inclination of the fracture surfaces. Blount14 devised a blade plate that held the fragments securely without external support. The angulation osteotomy is currently f|xed with variable angled hip screws and side plates, and several more recent reports have indicated its usefulness. Marti et al.15 reported union in 86% of 50 non-unions treated with inter-trochanteric osteotomy alone; three non-unions healed after revision procedures. Another operation, arthrodesis, involves different procedures where the hip is fused, and is mentioned only for the sake of completion. Some authors advocate it as an option in children and adults less than 21 years of age who have frank non-unions in which the femoral head is not viable. The advantages of an arthrodesis for nonunion of the femoral neck are freedom from pain and stability during weight bearing; this may lead to a useful extremity that allows ambulation and weight bearing, albeit with a limp.This can occasionally be recommended in adults under the age of about 50 years whose work is heavy manual labour, or after the failure of previous surgery with an infection in the hip. A major disadvantage is the delayed onset of severe degenerative changes in the spine and contralateral hip, as well as signif|cant diff|culty in subsequent conversion to an arthroplasty. In the present day scenario, the best option perhaps is to obtain union in these fractures by the best possible method, and to avoid the development of AVN and the ensuing collapse of the head. In 1984, the senior author published the results of cases with delayed or neglected fractures which were treated by a combination of internal f|xation, accurate reduction and f|bular osteosynthesis.16 The good results seen in those cases lead us to make this the primary treatment method in all cases of femoral neck fracture seen in young adults, after signif|cant periods of delay in treatment (6 weeks or more). Consistently reproducible union rates and a lowered incidence of AVN allowed us to expand our indications to include those cases in which previous surgical procedures had failed, 17and even in children.18

Operative technique
This involves open reduction of the fracture, which should be accurate and stable, special modif|cations in the anterior capsular incision to try and save anterior vessels, and the use of a f|bular graft to supplement the f|xation achieved by an AO cancellous screw.

LITERATURE REVIEW
The few reports that have been published concerning neglected fractures of the femoral neck in young adults emphasise that the outcome is usually poor.19 Early accurate reduction and f|xation under compression has given good results, but in developing countries early operation is not always possible. This can lead to problems of management. It is desirable to try to salvage the femoral head in young adults, and this often calls for some form of bone

Anterolateral approach (modif|ed fromWatson--Jones) Since the inception of the methodology of f|bular osteosynthesis, the approach used at our institute has been one modif|ed from the standard Watson--Jones approach. This positions the patient in a semi-supine position, with a sandbag under the buttock, and allows good radiological imaging as well as making manipulation of the leg easier. This approach allows an easy exposure of the anterior aspect of the hip through the inter-muscular interval between the sartorius and the gluteus medius muscles, by splitting the iliotibial band and the tensor fascia lata muscle.The skin incision is about 15 cm long; instead of the straight, longitudinal incision centred over the greater trochanter, we employ a curved incision, starting from an inch posterior to the anterior superior iliac spine, to the greater trochanter, and then distally for about 6 cm parallel to the lateral shaft of the

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Figure 2 Line diagram showing the incision in the skin and ilio tibial band.

Figure 3 Line diagram showing the exposed fracture after adequate retraction of muscles.

femur (Fig. 2).The deep fascia of the thigh is incised in line with the skin incision, just posterior to the border of the tensor fasciae latae muscle; this clearly shows the vastus lateralis muscle distally and the gluteus medius muscle proximally. The interval between the tensor, sartorius and the gluteus medius muscle is then developed using blunt dissection, and there may be a few troublesome vessels encountered (branches of the superior of gluteal artery). We do not routinely detach the vastus lateralis muscle from its origin at the lateral ridge on the femur. The anterior aspect of the hip capsule is carefully exposed; this is facilitated by laterally rotating the leg. The reflected head of the rectus femoris is separated from its attachments on the hip joint capsule and a clear exposure of the anterior capsule is achieved and maintained by three bone levers, placed above and below the neck of femur, and one over the anterior brim of the acetabulum (Fig. 3). A T-shaped incision in the capsule is now made by using a cutting cautery, with the longitudinal limb of the T stopping short of the sheath of vessels at the base of the femoral neck (Fig. 4).The capsular incision is then extended superiorly and inferiorly, and the fracture site is exposed. By externally rotating the limb, the fracture can be cleaned of all soft tissues, and freshened; reduction is now achieved by longitudinal traction, internal rotation and maximal abduction. A K-wire is inserted into the centre of the femoral head, by which the femoral head can be manipulated to assist fracture reduction. The position of this wire also gives a rough estimate of the length of the cancellous screw required. Once the fracture is reduced and verif|ed radiographically, fracture stabilisation is performed by drilling two K-wires across

Figure 4 Line diagram showing theT-shaped cut in the anteriorcapsule.The verticallimb ofthis cut (A) stopswell shortofthe arterial arcade atthe base of the femoral neck (B).

it.The lag screw is then inserted after drilling a hole with a 4.5 mm AO cancellous drill. Using an 8 mm DHS drill bit, a hole is made for the prepared f|bular graft distal to the screw. The graft is then inserted by gentle tapping with a mallet, and once the f|bula is flush with the lateral surface, the screw is re-tightened, and the f|nal hammering of the graft is done. The fracture reduction and positioning of the screw and graft are checked radiographically and the wound is closed in layers over a suction drain.

Method of harvesting f|bular graft A separate team can harvest the f|bula from the contralateral side, or the same team may do so from the ipsilateral side prior to the hip exposure. Using a 12 cm long incision over the postero-lateral aspect of the f|bula,

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the lateral border of the bone is palpated and the mobile muscles are pushed anteriorly, developing the interval between the muscle groups on either side of this border. The periosteum over the border is now cut, and a 10 cm long segment of bone is exposed. We do not routinely strip the periosteum from the medial aspect to avoid troublesome bleeding. We also remove only the lateral two-third of the bone, ensuring that we stay subperiosteally, and leave behind a tube of soft tissue and periosteum that can be stitched back. The bone is cut with an oscillating saw, leaving the inter-osseous border intact. Careful resuturing of the periosteal tube and leaving behind the intact inter-osseous border, allows a better regrowth of the bone, does not affect ankle stability (especially in children) and minimises bleeding from vessels in the area of the inter-osseous membrane. Bone (10 cm in length) is taken out, and drill holes are made at regular intervals on its surfaces. We believe that these aid in the incorporation of the bone in the neck.The leading edge of the graft may be bevelled for about1cm to aid in the insertion.This graft is now kept aside pending use.

AUTHORS EXPERIENCE
Over a 20 -year period, more than150 cases with varying degrees of neglect have been treated by the above regimen (Figs. 5 and 6). The two main problems encountered were resorption and compromise of the vascularity of the femoral head. It is not possible to achieve accurate reduction of neglected fractures by closed methods, and repeated attempts at manipulation further harm the blood supply to the head of the femur. Careful open reduction causes only minimal additional insult to the blood supply. A Tshaped incision in the anterior capsule will ensure that the arcade of vessels at the base of the neck is not damaged (Fig. 4). This approach gives suff|cient exposure for removal of the interposed f|brous tissue and allows accurate reduction. It is important to note that most of these fractures are external rotation injuries, with the anterior cortex ruptured. The vessels along this are invariably torn, and there maybe a chance that the posterior vessels are intact (Fig. 1). By approaching the neck posteriorly, these are almost always damaged. Additionally, in cases with posterior comminution, the anterior cortex acts as a hinge for reduction of the fragments. Our choice of a cortical graft has certain advantages. The f|bula is easy to harvest and, provided that suff|cient care is taken, leads to minimal morbidity at the donor site. The trif|n shape of the f|bula stabilises the fracture by preventing rotation, and the drilled holes in its surface may promote bony in-growth. The graft acts as a biological Smith--Petersen nail. The subchondral placement of the bone in avascular or osteopenic femoral heads may minimise structural collapse until re-vascularisation

Figure 5 (a) AP radiograph of the femoral neck showing a 4week-old femoralneck fracture. (b) Same case (AP) view,8 years after open reduction and osteosynthesis using a f|bular graft and cancellous screw.Note some residual varus, but good union. (c) Lateral view of same case, showing graft incorporation.

takes place (Fig. 7). Where there is radiological evidence of AVN we deferred weight bearing until union had taken place, which in some patients meant for up to 6 months. The use of the cortical graft may stabilise the neck if it is comminuted and allow reconstruction in cases of resorption (Fig. 8), which can be supplemented by additional use of cortico-cancellous bone from the iliac crest. We believe that this is a biological f|xation and that the bond between the implant and the femur strengthens with time. In all our patients, after a suff|ciently long follow-up period (in some instances more than 19 years), serial radiographs showed incorporation of the f|bular graft into the femoral neck and head.This was noted particularly in the distal part of the neck.This incorporation is variable, and is not dependant upon any specif|c factors, as we have observed fully incorporated and fully visible f|bulae at long-term follow-up. This resorption or incorporation can occur only if the host bone in contact with the graft is vascularised.

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Figure 6 (a) AP view of a case with multiple previous failed surgeries. (b) AP view 5 years after f|bular osteosynthesis, showing good union and no avascular necrosis. (c) Lateral view of the same case.

In our experience, we encountered f|bular graft fractures in four cases. One of them went on to uneventful union, while three developed signif|cant complications needing secondary intervention. The central part of the f|bula in the case that united ultimately became part of the primary compressive trabeculae of the femoral neck. The incidence of AVN reported in the literature is between 8% and 35% after fracture of the femoral neck, and is probably higher in neglected displaced cases. The radiological features of developing AVN are well known, but without performing a bone scan it is diff|cult to say with certainty whether re-vascularisation of the femoral head is occurring.We took the following signs to be indirect evidence of re-vascularisation of the femoral head: reconstitution of the trabecular pattern, incorporation of the f|bula into the femoral head proximal to the fracture line, and little or no progression of structural collapse after a suff|ciently long period of follow-up. These features correlated well with the clinical f|ndings, although over time minor radiological changes may be

Figure 7 (a) AP view of a 9-month-old femoral neck fracture with mottling of the head indicative of avascular changes. (b) AP view of the same case, 6 years after f|bular osteosynthesis.There is good union, and head has revascularised. (c) Lateral view ofthe same case showing how subchondral placement of the graft has prevented excessive collapse of the femoral articular surface. Note graft incorporation (arrows).

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serves as a good bone graft which is almost completely incorporated into the host. The complications include leg-length discrepancy and coxa vara, which are a small price to pay for a united femoral neck and a vascular femoral head; these may also be treated by adduction osteotomy once the fracture has united.

FURTHER READING
Figure 8 CT scan showing excellent reconstruction of the neck by the use of f|bular graft and cortico cancellous iliac crest graft.
1. Koval K J, Zuckerman J D. Hip fractures: overview, evaluation and treatment of femoral neck fractures. J Am Acad Orthop Surg 1994; 2: 141--150. 2. Whitman R. The treatment of central luxation of the femur. Ann Surg 1920; 71: 62--65 3. Martin A D, Silverthorn K G, Houston C S, Bernhardson S, Wajda A, Roos L L. The incidence of fracture of the proximal femur in two million Canadians from 1972 to 1984. Projections for Canada in the year 2006. Clin Orthop 1991; 266: 111--118. 4. Crock H V. An atlas of the arterial supply of the head and neck of the femur in man. Clin Orthop 1980; 152: 17--27. 5. Chung S M K. The arterial supply of the developing proximal end of the human femur. J Bone Joint Surg 1976; 58A: 961--970. 6. Rogers L F (ed). Radiology of Skeletal Trauma, 2nd edn. N. York: Churchill Livingstone, 1992; 1139--1140. 7. Lu-Yao G L, Keller R B, Littenberg B et al. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg 1994; 76-A: 15. 8. Stewart M J, Wells R E. Treatment of ununited fractures of the neck of the femur. J. Bone Joint Surg (Am) 1956; 38: 33--49. 9. Massie W K. Fractures of the hip. J Bone Joint Surg 1964; 46A: 658--690. 10. Manninger J, Kazar G, Fekete G, Nagy E et al. Avoidance of avascular necrosis of the femoral head, following fracture of the femoral neck, by early reduction and internal xation. Injury 1985, 16, 437--438. 11. King T A. Critical consideration of primary subtrochanteric osteotomy and internal xation for fractures of the neck of femur. Aust NZ J Surg 1950; 19: 177--198. 12. McMurray T P. Ununited fractures of the neck of the femur. J Bone Joint Surg (Am) 1936; 18: 319--328. . tfolgen der Schenkelhalsfraktur (late results of 13. Pauwels F. Spa fractures of the neck of the femur). Hefte Unfallheilkd 1953; 45: 22. 14. Blount W P. Proximal osteotomies of the femur, Am Acad Orthop Surg Instr Course Lect 1952; 9: 1. . ller H M, Raaymakers E L F B. Intertrochanteric 15. Marti R K, Schu osteotomy for non-union of the femoral neck. J Bone Joint Surg 1989; 71-B: 782. 16. Nagi O N, Gautam V K, Marya S K S. Treatment of femoral neck fractures with a cancellous screw and a bular graft. J. Bone Joint Surg. 1986; 68-B: 387--391. 17. Nagi O N, Dhillon M S, Goni V. Open reduction, internal xation and bular autografting for neglected femoral neck fractures in young adult. J Bone Joint Surg 1998; 80-B: 798--804. 18. Nagi O N, Dhillon M S, Gill S S. Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children. J. Orthop. Trauma. 1992; 6: 306--313. 19. Nordkild P, Sonne-Holm S. Necrosis of the femoral head following fracture of the femoral neck. Injury 1986; 17: 345--348. 20. Henderson M S. Ununited fracture of the neck of the femur treated by the aid of the bone graft. J Bone Joint Surg, 1940; 22: 91--106. 21. Wardle E N. Subcapital fractures of femoral neckFxation by pin and graft. Lancet 1945; 31: 399--402.

seen. Our f|ndings suggest that the f|bular graft, by providing structural support and promoting union, indirectly contributes to re-vascularisation of the femoral head. Another aspect to note is the fate of the f|bular graft inside the femoral neck. Long-term evaluation of these grafts in extra-osseous situations for reconstruction of cortical defects after excision of tumours, etc., has shown the hypertrophy of these grafts. However, no long-term assessment of the intra-osseous fate of the f|bular graft in cancellous bone exists. The authors have analysed a few cases after periods ranging from 8 to 19 years, and have found that the rate of incorporation is variable. Some f|bulae get incorporated completely, while the others may be seen as almost complete scars of the original bone (data on f|le, submitted for publication).The reasons for this variability are not known, and maybe dependent on local vascularity and other host factors.

SUMMARY
Our experience shows that preservation of the femoral head in young patients with neglected fractures of the femoral neck is achievable.The f|bular graft acts as a biological implant, and its incorporation into host bone is evident after suff|cient follow-up. Avascular heads may re-vascularise after union. Review of specimens removed in cases undergoing THA showed excellent incorporation of the f|bular autograft in the cancellous bone of the femoral neck This underlines the fact that the bond of the bone graft with the host bone strengthens with time, making the f|bula a reliable combination of f|xation device and bone graft. Open reduction ensures good alignment of the fracture: the anterior approach minimises vascular insult. A postoperative spica, which can easily be tolerated in these young individuals, maybe needed in cases with excessive resorption of the neck, or perceived instability of the reconstruction. Despite being cortical, the f|bula

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22. Patric J, Bonifglio, M, Voke, E M. Aseptic necrosis of the femoral head and non-union of the femoral neck. Effect of treatment by drilling and bone grafting. J Bone Joint Surg 1968; 50-A: 48--66. 23. Bonglio M, Badensterin M B. Treatment by bone-grafting of aseptic necrosis of the femoral head and non-union of the femoral neck (phemister technique). J Bone Joint Surg 1958; 40-A: 1329--1346. 24. Leung P C, Shen W Y. Fracture of the femoral neck in younger adults: a new method of treatment for delayed and nonunions. Clin Orthop 1993; 295: 156. 25. Baksi D P. Treatment of post-traumatic avascular necrosis of the femoral head by multiple drilling and muscle-pedicle bone graft. Preliminary report. J Bone Joint Surg 1983; 65-B: 268--273. 26. Meyers M H, Harvey J P, Moore T M. Treatment of displaced sub capital and transcervical fractures of the femoral neck by musclepedicle-bone-graft and internal xation. J Bone Joint Surg 1973; 55-A: 257--274.

27. Dooley B J, Hooper J. Fibular bone grafting for non-union of fracture of the neck of the femur. Aust N Z J Surg 1982; 52: 134--140. 28. Slater R N S, Gore R, Slater G J R. Free bular bone grafting for femoral neck fractures: precise graft placement using a cannulated screw technique. J R Coll. Surg. Edinburgh 1993; 38: 376--377. 29. Snyder S J, Sherman O H, Hattendorf K. Nine year functional, nonunion of a femoral neck stress fracture: treatment with internal xation and bular graft, a case report. Orthopaedics 1986; 9: 1553--1557. 30. Lifeoso R, Young D. The neglected hip fracture. J Orthop Trauma 1990; 4: 287--292. 31. Nagi O N, Dhillon M S. Total hip arthroplasty after McMurrays osteotomy: problems and pitfalls. J Arthroplasty 1991; 6: S17--S22. 32. Johnson K D, Brock G. A review of reduction and internal xation of adult femoral neck fractures in a country hospital. J Orthop Trauma 1989; 3: 83.