TABLE OF CONTENTS

CONTENT PAGES

Acknowledgement 1

Introduction 2-4

Aims & Objectives 5

Review of literature 6-72

Materials & Methods 73-80

Data analysis and results 81-96

Discussion 97-98

Summary and Conclusion 99

Limitation 100

101-106
Bibliography
Appendix I 107-111

Appendix II 112-114
Grand Chart 115-116

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ACKNOWLEDGEMENT
I am extremely grateful to our professor and Head of the Department, Orthopaedics,Dr. Prof Sanjay Kumar of
R.G Kar Medical College and Hospital for his encouragement given in fulfilling my work.

I am extremely grateful to Prof. Dr. Sandip Kumar Ray, Department of Orthopaedics of Burdwan Medical
College and Hospital for his valuable guidance, encouragement and support throughout my study.

I am grateful to Dr. Sunit Hazra, Associate Professor, Orthopaedics, RGKMC&H for his invaluable knowledge
and meticulous involvement throughout the study.

I am also grateful to Dr Tapobrata Guha Ray, Department of Preventive and Social Medicine , for his valuable
inputs and time.

I thank all the patients for their coopertion.

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 INTRODUCTION

The main causes of femoral neck fractures in young adults are high energy injuries sustained in traffic
accidents, falls and so on. Since Smith-Petersen introduced the use of three wing screws for internal
fixation, over 100 other internal fixation devices have been developed. The most recent therapeutic
methods include closed internal fixation and open reduction with internal fixation. Orthopedists tend
to select cannulated screw for closed internal fixation and standard DHS for open reduction with
internal fixation materials; however, these devices have many adverse consequences, such as screw
cut out1, delayed bone healing, bony nonunion (about 15%) and avascular necrosis (20%-30%). So far,
because there have been no significant breakthroughs in therapeutic approaches, these fractures have
been considered one of the unresolved issues in orthopedics.

Fracture of neck of femur is most common injury in adults. In old age it occurs as a low energy trauma
while in young individuals it is due to high energy. Management of this fracture has been changing
from time to time. With the better understanding of importance of proper reduction, vascularity of the
neck of femur and improvement in fixation devices(implants) the results become better and better 6.
Anatomical features which need consideration are; Fracture is inside the joint capsule and bathed by
synovial fluids that interferes with healing, Retinacular arteries supplying the neck and head run close
to bone and prone to injury, as the bone is anatomically and functionally important for the sharing
force so proper reduction and fixation is almost always necessary for the union. Management of
displaced fracture are challenging and no single procedure available or practiced is universally
applicable and operator choose what is best for the patient at that time. Treatment varies according to
the age, level, displacement and duration of the fracture but internal fixation for younger than 50 years
and hemiarthroplasty and total hip replacement can be used for patient older than 60 years 8. The age
between 50 and 60 years are called grey zone in which most orthopedic surgeon choose Dynamic hip
screws (DHS) for internal fixation or arthroplasty. Various studies show that DHS is more stable in the
9,10
treatment of unstable neck of femur fracture (NOF) . Some surgeons had used autogenous bone
grafting with considerable success. As there are no firm guidelines do deal with fracture NOF in adults
and many hip preserving procedures are then adopted like proximal femoral osteotomy or bone
grafting or both to prevent the complications like avascular necrosis and non-union2. One study shows
that there is 73.6% union rate with bone graft and DHS. The purpose of this study is to evaluate the
healing process of fractured NOF treated with DHS and autogenous Bone grafts. There is no local data
2
available for the above aforementioned procedure while the incidence of fracture and complications
seems far more as stability and healing chances of the fractures depends especially on age and general
conditions.

Intra-capsular femoral neck fractures are seen commonly in elderly people following a low energy
trauma. 2-3% of all femoral neck fractures occurs in adults younger than 50 years and is often the
result of high-energy trauma. Femoral neck fracture continues to be considered as an unsolved fracture
in view of poor prognosis and variable outcome reported after different procedures. 3 In developing
countries the fracture often remains untreated as the patients do not seek treatment due to
nonavailability of treatment facility or may be treated primarily by osteopaths or operated under
suboptimal theatre conditions with poor quality implants. The problem gets compounded and the
outcome deteriorates further in such situations.

Femoral neck fracture has a devastating effect on the blood supply of the femoral head, which is
directly proportional to the severity of trauma and displacement of the fracture. The intra-capsular
hematoma is also implicated with development of avascular necrosis (AVN) of femoral head.2
Femoral neck fractures in young adults are associated with higher incidences of osteonecrosis, with
the rate reported in the literature from 12% to 86%. Early anatomical reduction and stable internal
fixation restores the vascularity and reduces the incidence of AVN. Nonunion and AVN of the femoral
head are the main complications following femoral neck fractures. The reasons for such complications
include precarious vascularity, shearing forces at the fracture site, inadequate reduction and inadequate
fixation.4 The nonunion (NU) is complicated by resorption at fracture ends leading to significant
shortening of the femoral neck.

Various authors have described a wide array of options for treatment of neglected/NU femoral neck
fracture. 5,6,7 There is lack of consensus in general, regarding the best options.

Treatment options include :

(a) treated by muscle-pedicle bone grafting (MPBG),

(b) closed/open reduction internal fixation and fibular grafting

(c) open reduction and internal fixation with valgus osteotomy,

(d) miscellaneous procedures.

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We used a novel technique by using hollow iliac crest bone graft and using it as a structural graft with
Dynamic Hip Screw to augment the process of union. The ICBG was planted in a tunnel made with a
triple rimmer above and parallel to the lag screw of DHS. This is proposed to result in a more
biological union.

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 AIMS AND OBJECTIVES

• To ascertain the radiological and clinical outcome in old traumatic neck of femur fracture with
DHS and bone graft

• To ascertain the fact that the head of femur can be salvaged in most of the cases of old neck of
femur fracture in young adults (<60 years) when treated with DHS and bone graft

• To decrease the need for Total Hip Arthroplasty and future revision surgeries that follow in the
patient group under trial.

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 REVIEW OF LITERATURE

ANATOMY OF THE HIP JOINT

The hip joint is an enarthrodial or ball-and-socket joint, formed by the reception of the head of the
femur into the cup-shaped cavity of the acetabulum. The ball-and-socket type of architecture provides
it a high degree of the stability as well as a good range of movement. The articular cartilage on the
head of the femur, thicker at the center than at the circumference, covers the entire surface with the
exception of the fovea, to which the ligamentum teres is attached. The articular cartilage on the
acetabulum forms an incomplete marginal ring, the lunate surface. Weight bearing occurs in the upper
part of the acetabulum where the cartilaginous strip is widest. Within the lunate surface there is a
circular depression devoid of cartilage, occupied in the fresh state by a mass of fat and covered by
synovial membrane. The articular capsule is strong and dense. Above, it is attached to the margin of
the acetabulum 5 to 6 mm beyond the glenoidal labrum posteriorly and anteriorly it is attached to the
outer margin of the labrum. It surrounds the neck of the femur, and is attached, in front, to the
intertrochanteric line and the base of the neck anteriorly and posteriorly to the neck, about 1.25 cm
above the intertrochanteric crest. From its femoral attachment some of the fibers are reflected upward
along the neck as longitudinal bands, termed retinacula.

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The capsule is much thicker at the superior and anterior part of the joint where the greatest
amount of resistance is required. However, the capsule is thin and loose inferiorly and
posteriorly. The thickened outer longitudinal fibers of the capsule form three strong ligaments
around the hip joint.

HIP JOINT – ANTERIOR VIEW

The ilio-femoral ligament/ Y-shaped ligament of Bigelow is the strongest ligament in the body
and lies in front of the joint. It is intimately connected with the capsule, and serves to strengthen
it in this situation. It is attached, above, to the lower part of the anterior inferior iliac spine;
below, it divides into two bands, one of which passes downward and is fixed to the lower part of
the intertrochanteric line; the other is directed downward and lateralward and is attached to the
upper part of the same line. In some cases there is no division, and the ligament spreads out into
a flat triangular band which is attached to the whole length of the intertrochanteric line. The
pubo-femoral ligament is attached, above, to the obturator crest and the superior ramus of the
pubis. Below, it blends with the capsule and with the deep surface of the vertical band of the ilio-
femoral ligament. The Ischio-femoral ligament/ligament of Bertin consists of a triangular band
of strong fibers which spring from the ischium below and behind the acetabulum and blend with
the circular fibers of the capsule.

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HIP JOINT – POSTERIOR VIEW

The Ligamentum Teres Femoris is a triangular, somewhat flattened band implanted by its apex
into the antero-superior part of the fovea on the head of femur. Its base is attached by two bands,
one into either side of the acetabular notch, and between these bony attachments it blends with
the transverse ligament. It is ensheathed by the synovial membrane varies greatly in strength in
different individuals. The ligament is made tense when the hip is semi flexed, adducted and
externally rotated. It is relaxed when the limb is abducted. The Glenoidal Labrum is a
fibrocartilaginous rim attached to the margin of the acetabulum, the cavity of which it deepens. It
also protects the edge of the bone, and fills up the inequalities of its surface. It bridges over the
notch as the transverse ligament, and thus forms a complete circle, which closely surrounds the
head of the femur and assists in holding it in its place. It is triangular on section, its base being
attached to the margin of the acetabulum, while its opposite edge is free and sharp. Its two
surfaces are invested by synovial membrane, the external one being in contact with the capsule,
the internal one being inclined inward so as to narrow the acetabulum, and embrace the
cartilaginous surface of the head of the femur. The Transverse Acetabular Ligament is in reality

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a portion of the glenoidal labrum, though differing from it in having no cartilage cells among its
fibers. It consists of strong, flattened fibers, which cross the acetabular notch, and convert it into
a foramen through which the nutrient vessels enter the joint.

MUSCLES AROUND THE HIP

A. MUSCLES IN FRONT OF THE THIGH

1. Psoas major

2. Iliacus

3. Tensor fascia latae

4. Sartorius

5. Quadriceps femoris

B. Muscles of the gluteal region

1. Gluteus maximus

2. Gluteus medius

3. Gluteus minimus

4. Obturator internus

5. Superior and inferior gemelli

6. Quadratus femoris

C. Muscles posterior to the hip :

1. Semi tendinosus

2. Semimembranosus

3. Biceps femoris

D. Medial muscles of hip :

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 1. Pectineus

2. Adductor longus

3. Adductor brevis

4. Adductor magnus

MOVEMENTS OF THE HIP

The hip joint, being a ball and socket type of joint allows movements in a multidirectional
pattern. Grossly the movements are as follows:

Flexion – Anteriorly, Extension – Posteriorly, Abduction & adduction – Laterally Rotations and
combination of the above - Circumduction. When the thigh is flexed upon the trunk, the head of
femur rotates about the transverse axis that passes through both acetabula, the muscles that bring
about this motion are iliopsoas - supported by Rectus femoris, sartorius and pectineus. Flexion
gets arrested when the thigh is on the trunk and by the hamstrings when knee is in extension.
Normal flexion is about 120° - 130°.

EXTENSION

This is the opposite of flexion, carried out by the Gluteus maximus.

The motion is limited by tension of ileo-femoral ligament.

Normal range is 5° - 20°.

ADDUCTION

Adduction of the thigh produces similar movements in the femoral shaft and neck. The femoral
head rotates in the acetabulum over an anteroposterior axis. Movements are brought about by-
Pectineus, adductors, gracilis. It is limited when the thigh rests upon the opposite one or if the
latter is kept abducted, the tension in the gluteus Medius and minimus limits the adduction.

Normal range 25 –35.

ABDUCTION

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This is the opposite of abduction and is brought about by gluteus Medius and minimus assists by
piriformis. It is limited by tension on the adductors and pubo- femoral ligament. Normal range
40° - 45°.

EXTERNAL ROTATION

This is carried out by flexing the hip and knee to 90 and rotating the foot towards the opposite
side. Gluteus maximus is the major lateral rotator. The gluteus Medius, minimus, piriformis,
obturator internus, gemelli and quadratus femoris serve as stabilizers of the hip. Normal range is
about 40- 45° as measured in both extension and flexion of the hip.

INTERNAL ROTATION

With the hip and knee flexed to 90, the leg being rotated away from the midline of the body
produces medial rotation at the hip and is brought by anterior fibers of gluteus Medius and
minimus. Normal range is 40°-45 in flexion and 30 -35 in extension.

BLOOD SUPPLY OF HEAD AND NECK OF THE FEMUR

Avascular necrosis of femoral head is one of the most serious complications following femoral
neck fractures, which have all the problems associated with healing of intracapsular fractures
elsewhere in the body. Hip joint capsule is strong fibrous structure which encloses femoral head
and most of its neck. That portion of neck which is intracapsular has no cambium layer to
participate in peripheral callus formation. Thus, femoral neck area is dependent on endosteal
union alone. Arterial supply of proximal end of femur has been studied extensively. Crock
described arteries of proximal end of femur into 3 groups and provided a definitive anatomical
nomenclature to these vessels thus avoiding ambiguity.

1. The extra-capsular arterial ring located at the base of femoral neck.

2. The ascending cervical branches of extra-capsular arterial ring on the surface of the
femoral neck.

3. The arteries of the round ligament.

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The extra-capsular arterial ring is formed posteriorly by a large branch of medial circumflex
femoral artery and anteriorly by branches of lateral circumflex femoral artery with the superior
and inferior gluteal arteries having minor contributions to this ring. The ascending cervical
branches arise from the extra-capsular arterial ring. Anteriorly they penetrate the hip joint
capsule at the intertrochanteric line and posteriorly they pass beneath orbicular fibers of the
capsule. The ascending cervical branches pass upward under the synovial reflections and fibrous
prolongations of capsule towards the articular cartilage that demarcates femoral head from its
neck. These arteries are called retinacular arteries described initially by Weibrecht. This close
proximity of retinacular arteries puts them at risk of injury in any fracture neck of femur. As the
ascending cervical arteries traverse superficial surface of the neck of the femur, they send small
branches into the metaphysis of femoral neck. As the ascending cervical arteries traverse the
superficial surface of the femoral neck, they send many small branches into the metaphysis of
the femoral neck. Additional blood supply to the metaphysis arises from the extracapsular
arterial ring and may include anastomoses with intramedullary branches of the superior nutrient
artery system, branches of the ascending cervical arteries, and the sub synovial intra- articular
ring. In the adult, there is communication through the epiphyseal scar between the
metaphyseal and epiphyseal vessels when the femoral neck is intact. This excellent vascular
supply to the metaphysis explains the absence of avascular changes in the femoral neck as
opposed to the head. The ascending cervical arteries can be divided into four groups based on
their relation to the neck of femur - anterior, posterior, medial and lateral. Of these the lateral
providing most of the supply to femoral head and neck. At the margin of articular cartilage on
the surface of the neck of femur, these vessels form a second ring – the sub synovial intra-
articular ring described by Chung, which can be complete or incomplete, the complete rings
being more common in male specimens. At the sub synovial intra - articular ring - epiphyseal
arterial branches arise that enter head of the femur. Disruption of this arterial ring in high intra-
articular fractures, leads to aseptic necrosis. Once the arteries from sub synovial arterial ring
penetrate femoral head they are termed as epiphyseal arteries. Claffey demonstrated that in all
femoral neck fractures that communicated with the point of entry of the lateral epiphyseal
vessels, aseptic necrosis occurred. The artery of ligament teres is a branch of obturator or the
medial circumflex femoral artery. This arterial supply is often inadequate to provide nourishment
to the femoral head. Howe, et al found that although the vessels of the ligamentum teres did

12
supply vascularity to the femoral head, they were often inadequate to assume the major
nourishment of the femoral head after a displaced femoral neck fracture. Claffey also
reported that simple patency of the vessels of the ligamentum teres did not make them capable of
keeping the femoral head alive.

BLOOD SUPPLY TO THE HEAD AND NECK OF FEMUR

CLINICAL SIGNIFICANCE OF VASCULAR ANATOMY

Femoral head circulation arises, therefore, from three sources:

(a) intra- osseous cervical vessels that cross the marrow spaces from below;

(b) the artery of the ligamentum teres (medial epiphyseal vessels); and

(c) the retinacular vessels, branches of the extracapsular arterial ring, which run along the
femoral neck beneath the synovium.

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When a femoral neck fracture occurs, the intraosseous cervical vessels are disrupted; femoral
head nutrition is then dependent on remaining retinacular vessels and those functioning vessels
in the ligamentum teres. The amount of the femoral head supplied by the medial epiphyseal
vessels varies from a small area just beneath the fovea to the entire head. Sevitt and Thompson
reported that the anastomoses between the sub foveal vessels and other vessels in the femoral
head may be insufficient to support viability. Therefore, every attempt should be made to protect
the remaining vascular supply to the femoral head after fracture.

BIOMECHANICS OF HIP JOINT:

The hip joint is a ball and socket joint, it provides the multiaxial movement in the joint. The
structures responsible for stability are

1. Bony structures

2. Ligaments around hip

3. Muscles attaching around hip joint,

But ligaments and muscles less relying, bone is the major stabilizer. The bony structures
responsible for the stability in walking, change of postures from sitting to standing, from
standing to sitting. This function will be disturbed, when there is a fracture in the neck of femur
& disturbances of supporting structures. The treatment is aimed at providing support, restoring
the function, anatomical realignment.

Basic structures:

Bony structures play a vital role in supporting the frame work. Cortical and Cancellous bones
have their respective distinct mechanical properties. Cortical bone is solid and rigid structure, its
anisotropic feature makes the analysis difficult. In, 1807, von weyer (anatomist), culman (an
engineer) made comparison and developed the stress trajectorial bone theory by comparing the
trabecular patterns of Cancellous bone in the neck of femur with the Fairbairn cane. The
proportion of cortical and Cancellous bone in the neck of femur and trochanter is different, in
neck 95 percent is cortical, whereas reverse in trochanter. Paul calculated the direction and
magnitude of force across femur head in walking and gait. Under normal circumstances,

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maximum compression on the medial aspect of the neck than lateral aspect of neck. There is no
tension force in the neck at rest. On loading and in unphysiological conditions tension produced
in the lateral and superior aspect of femur neck. So, compression is the major loading
configuration of proximal femur with tension only in abnormal conditions. The multi axial
movement in the low friction joint makes the tension in neck less negligible.

Articular Cartilage:

Articular cartilage is very important in

1. Load transmission

2. Absorption of energy

3. Joint lubrication

The contact and weight bearing area is demonstrated by Greenwald. Bullough et al., described
the importance between articular surfaces. The friction coefficient between articular surfaces in
the range of 0.005 - 0.01. To achieve this advantageous level, which reduces the wear to very
minimum, many theories shave been put forward.

Muscles and ligaments:

The arrangements of muscles and ligaments around hip provide the support, movements, prevent
abnormal movements, proprioception, absorption of energy after fall.

Factors Acting on Hip Joint:

The factors acting on hip joint are 1. Body weight

2. muscle forces around hip

The force exerted by the movements across joint is described by Rydell, in terms of
magnification factor to body weight.

Standing on one leg = 2.5 * body weight

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Standing with 2 legs: force = ½ body weight to each joint Running: force = 5 times * body
weight

Mechanism of injury:

Fracture neck of femur is common in elderly women due to osteoporosis. It is uncommon in

young patients and few races like black people. Most of the fractures is due to trivial fall and
minor trauma. Ethil Theodor Kocher suggested 2 mechanisms of injury in neck of femur
fractures.

1. Direct blow over greater trochanter which was confirmed by linten in 1955.

2. External rotation of the extremity which was confirmed by protzman in 1978. In this
mechanism while there is external rotation, the head is fixed firmly by anterior capsule &
ileofemoral ligament. The posterior cortex of the neck impinges on the acetabulum and buckling
happens. The third mechanism is a cyclical loading which produces micro and macro fractures.
In osteoporotic bone forces within physiological limits will produce fractures.

Mechanism of bone failure:

In the hip joint, overloading occurs due to number of independent but often inter related factors.
The important factors are

1. Influence of fall

2. Impairment of energy absorbing mechanism

3. 0steoporosis

Influence of fall:

In standing position, body possess considerable amount of potential energy while falling
potential energy converted to kinetic energy which should be absorbed by body structures, if not
fractures occurs. In a human, average amount of energy absorbed by the body on fall would be
approximately 4000 kg/cm, but in the proximal femur its only about 500 kg/cm.

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Impairment of energy absorbing mechanism:

The dissipation of energy is done by active contraction of muscle. The dissipation requires
reacting time. In high velocity injury, no sufficient period for the muscles to contract to absorb
energy to avoid overloading. In the elderly patient, there will be slower neuromuscular
coordination, thus there will be impairment of energy absorbing mechanism

Bone weakness:

In osteoporosis, the bone strength reduces to approximately 3/4th of the normal healthy bone
with low energy absorbing capacity leading to failure. Aitkin et al in 1984, demonstrated the
presence of osteoporosis (mild to severe) in 84 percent of patients with neck of femur fractures.
Drone and lander described a group of patients who sustained neck of femur fracture
spontaneous without apparent trauma. They used the term insufficiency fractures to describe the
neck of femur fractures in elderly with osteoporosis. Griffin et al showed fatigue fracture can
occur in elderly if neck of femur on cyclical loading within physiological limits. Freeman et al
demonstrated sub capital fractures in osteoporosis due to fatigue, preceded by isolated trabecular
fatigue fractures.

Patterns of Fracture:

It is influenced by the resultant force which is applied at the moment prior to the fracture. In a
normal physiological conditions, the resultant line force can be seen, one perpendicular to
femoral neck axis, other in the line of axis of femur neck axis. If the resultant line of force alters
at the moment before fracture. Then relative size of two components will be altered.

In 1950, Frankel has shown experimentally a transverse fracture occurs if the ratio of bending
component to compression component increases 1:6, if the ratio is 1:7, a sub capital fracture with
spike occurs.

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Classification of fracture neck of femur:

1. Anatomical

2. Gardens

3. Pauwels

4. AO classification

Anatomical classification:

It was first designed by sir Astley cooper in 1823

It is based on the fracture line involves which part of neck

1. Sub capital fracture

2. Transcervical fracture

3. Basi cervical fracture

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Garden Classification:

Garden proposed this classification based on the displacement of fracture in the Antero posterior
view. Classified into 4 types

Type 1: incomplete fracture or impacted fracture. In this type of fracture, inferior neck
trabeculae are intact. This group includes abduction impacted fracture.

Type II: It’s a complete fracture without displacement. The trabeculae in the neck is disrupted

Type III: is complete fracture with partial displacement, the trabecular pattern doesn’t not line
with trabeculae pattern of acetabulum. There will be breakage of trabeculae of the neck.

Type IV: is a complete and fully displaced fracture. The trabecular pattern of head is in
alignment with the acetabular trabecular pattern. Eliasson – esker and Ostgaard and recently
Kreider demonstrated that there is no big difference in outcome and management, when
classified based on fracture and displacement.

Pauwels Classification: based on fracture angle Pauwels divided femoral neck fractures based
on the direction of fracture line across the femoral neck into three types.

• Type - I is a fracture 30° from the horizontal

• Type - II is a fracture 50° from the horizontal

• Type III is a fracture 70° from the horizontal.

Type I fractures are much more horizontal than type III fractures, which are almost vertical.
Pauwels attributed nonunion in type III to the increased shearing force of this vertical fracture.

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AO classification:

It is universal classification. For femur the alphanumeric is 31B, in which 3 stands for femur, 1
for proximal femur, B for neck fractures, further classified on the anatomical site and fracture
patterns.

 31-B1- sub capital fracture

 31 -B1.1 – impacted in valgus > 15 degrees

 31-B1.2- impacted in valgus < 15 degrees

 31- B1.3- non impacted fracture.

 31- B2- transcervical fracture

 31-B2.1 – Basi cervical fracture

 31-B2.2- mi cervical adduction

 31- B2.3- mi cervical shear

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  31- B3 – displaced, non-impacted sub capital fractures.

 31-B3.1- moderate displacement in varus and external rotation

 31-B3.2- moderate displacement with vertical translation and external rotation

 31-B3.3- marked displacement in varus with translation

Clinical features of fracture neck of femur: 8, 9

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The classical picture will be pain in the groin often referred to inner thigh and knee.
Movements of the hip and whole will be painful and severely restricted with spasms. Greater
trochanter will be migrated upwards with crepitus on movements. The injured limb will present
with shortening and external rotation. In impacted fracture sometimes patient can move his
limb or even walk with pain and limp. Quite often there will be external rotation deformity

Roentgenography of the hip region:

The routine x ray evaluation which includes anteroposterior view of pelvis, true anteroposterior
view with traction and maximum internal rotation and cross table lateral view. The hip joint is
usually radiographed with heel slightly separated and toe symmetrically directed forwards and
medially. In this position femur is rotated medially, the femoral neck is parallel to the film. The
shadow of the upper end of femur and acetabular region is clearly seen. A curved white line of
cortical bone delineates the superior and medial edge of acetabulum and the cortex of head also
appears as white line. The joint space is measured by the gap between the white line of head of
femur and acetabulum. Normal space is in adults about 4-7mm. the appearance of neck, greater
trochanter, lesser trochanter are altered by the rotation of thigh. When foot directed slightly
medially, neck lies in transverse plan, when foot is directed anteriorly, greater trochanter lies in
posterior to head of femur, if foot directed outwards, greater trochanter still moves posterior,
neck shortened. The angle between neck and shaft is best seen when x ray taken on limb with
internal rotation of about 15 -20 degrees. The angle is usually 120- 140 degrees.

Calcar femorale:

According to Harty 94 and Griffin, the calcar femoral is a dense vertical plate of bone
extending from the poster-medial portion of the femoral shaft under the lesser trochanter and
radiating lateral to the greater trochanter, reinforcing the femoral neck posteroinferiorly. The
calcar femoral is thicker medially and gradually thins as it passes laterally the presence and
adequacy of Calcar femorale can be best appreciated by an AP view of the hip taken in 150
internal rotations.

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Biomechanical basis of the BDSF-method

This method’s innovation is laying of the three screws in two planes, which allows for the entry
points of two of the implants to be placed much more distally, in the solid cortex of the proximal
diaphysis, and also to lean onto the femoral neck distal cortex. Thus, we establish two points of
support. The solid distal cortex of the femoral neck acts as a medial supporting point for the
screws, which works under pressure - supporting point A. The entry points of two of the screws
(the distal and the middle one) in the thick cortex of the diaphysis, ensure a second solid
supporting point for the screws – a lateral one, which works under tension (or pressure in
proximal direction) - supporting point B. The position of the distal screw as well as of the middle
screw, which are achieved by the method, in terms of the statics, turns them into a simple beam
with an overhanging end, loaded by a vertical force. This beam with an overhanging end
successfully supports the head fragment, bearing the body weight and transferring it to the
diaphysis. Furthermore, due to the biplane placement, enough space for a third screw is provided,
unlike the classic authors’ models, where just one or maximum two implants are placed at an

23
obtuse angle. Another advantage of the method is that due to the increase in the distance between
the two supporting points, the weight borne by the bone is significantly reduced. An advantage

of the BDSF-method is that the entry points of the screws are positioned wide apart from each
other, which ensures that upon weight bearing, the tensile forces spread over a greater surface of
the lateral cortex and thus the risk of its fracturing decreases significantly. Another advantage
with the BDSF is that the screw, placed at a highly increased angle, works in a direction close to
the direction of the loading force, which guarantees better results for the screw in its role as a
beam because the influence of its sagging decreases.

With the conventional methods of femoral neck fixation - by three cancellous screws, placed
parallel to each other and parallel to the femoral neck axis, the entry points of the three screws
are placed at the thin, fragile cortex of the greater trochanter or close to it. The screws are often
located near the axis of the femoral neck in the soft cancellous bone, without any cortical
support. With conventional methods, due to the lack of two solid supporting points, the implant
acts statically like a beam on an elastic foundation. The elastic foundation is implemented by the
soft cancellous bone.

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Static model of the conventional methods of fixation – the implant acts statically like a
beam on an elastic foundation. F = load

In contrast to the conventional methods, when the Biplane double- supported screw fixation -
method is applied, the implant is additionally supported at points A and B of the cortex. The
interaction between the implant and the cancellous bone is neglected, because of the
comparatively small stiffness of the cancellous bone. In this way, with enough practical
accuracy, with the BDSF-method, the static model is considered to be a simple beam with an
overhanging end. This beam is supported at points A and B only.

Static model of the new BDSF-method of fixation – the implant acts like a simple beam
with an overhanging end. F = load; L = length of beam; a = distance between points A and
B

The load acting at point A is pressure in a distal direction and it equals to A=FL/a; The load
acting at point B is pressure in a proximal direction and it equals to B = A – F. At the BDSF-
method, due to the increase in the distance between the two supporting points, the weight borne
by the bone is reduced. If we look at two cases of equal vertical weight but different distances
between the supporting points, we will see that the greater the distance, the smaller the weight at
each of the two supporting points. The average anatomical distance from the tip of the screw to
the distal femoral

25
neck cortex curve (point A) is 3.5 cm. With conventional methods (case 1.) the average
distance from point A to the entry point of the screws in the lateral cortex (point B) is 5.5 cm (a =
5.5 cm). In order to make a comparison with the BDSF, when body weight of 100 kg is given,
with conventional methods the load acting on the curve of the femoral neck distal cortex (if the
screws lean on this support at all) is estimated as

An equal to 163.63 kg. The load on the fragile lateral cortex (point B) is estimated as B equal to
63.63 kg, directed in the opposite direction (proximally).

With the BDSF method, with increasing the angle of the implant towards the diaphysis, the
distance between points A and B increases by 4 cm to reach up to 9.5 cm (a = 9.5 cm). That is
why, the load on the cortex decreases significantly. Given the same body weight of 100 kg, the
load acting on the medial supporting point is estimated as an equal to 136.84 kg or with 16.38%
less than conventional methods, and on the lateral supporting point the load is estimated as B
equal to 36.84 kg or with 42.11% less than conventional methods. The distal screw normally
applied with the BDSF method has a length of 13 cm. It is subjected to compressive stress in a

26
proximal direction, and to horizontal tensile stress as well. In the lower part of the cortex the
stress is mainly tensile.

Fixation of the femoral neck: a. Conventional method; b. The BDSF- method.

As it was mentioned, these forces of tension are decreased by 42% with the BDSF-method,
compared to the conventional methods of fixation. Besides, with the BDSF-method the entry
points of the screws are located wide apart from each other (from 2 to 4 cm), which leads to
dispersion of the tension stress on the lateral cortex over a wide surface and decrease of the
fracture risk, contrary to the conventional methods, with which the entry points of the screws are
at a distance less than 1 cm from each other and the forces of tension are concentrated over a
small surface.

FEMORAL NECK

The femoral neck is flat from before behind, middle contracted and broader laterally than medial
side. The vertical dimension of the lateral side is increased by the oblique dimension of the lower
part which declines to join body at the lesser trochanter level, so that it averages one-third more
than the Anteroposterior diameter. The medial half of the femoral neck is small and circular
in shape. The anterior neck surface is perforated by multiple vascular openings. Upper junction
of the anterior surface with the head is a very shallow depression, seen in old aged individuals;
groove has the hip joint capsule that contains orbicular fibers.

27
The posterior region is smooth in surface, and is wider and more concave than t anterior region.
The posterior part of hip joint capsule is attached to it about 1 cm above the intertrochanteric
crest. The superior part is shorter and thicker, and fused the greater trochanter laterally; its
surface is perforated by large openings. The inferior region is long and curved behind to end
lesser trochanter level.

TRABECULAR PATTERN

28
 Inclination angle

In infants, the angle is wider, and during growth it lessened. At puberty period it forms a gentle
curve from the axis of the bone. In the adult period, the femoral neck makes an angle of about
125°, but varies and inversely proportional to the development of the individual pelvis shape and
the stature. The angle declines during growth period, but after growth period attained, it does not
get change. It varies in different persons of the same age. female populations due to increased
pelvis width, the femoral neck forms right angle with the body than the male. It is smaller and
narrower than long bones, and when the pelvis is wider. In projecting upward and medial ward
from the femur, the neck projects forward; the amount of forward projection may change, but an
average range from 12° to 14°.

Femoral Neck Angle:

29
Neck of femur extends inferolateral from the head and meets the shaft of femur at an angle of
around 125 degrees. This Angle varies with stature, age & width of the pelvis. When the angle is
more than 135 degrees, the condition is called as coxa valga and if less than 120 degrees,
condition is called as coxa Vara Femur neck is not parallel to the plane of femur and the head is
located anterior to the midline of the shaft of the femur and so anteverted. This causes internal
rotation of shaft of femur, and with increasing anteversion the patient may walk with intoning
gait in adult period. The Neck - shaft anteversion angle is approximately between 5-15 degrees,
when it is more than 15 degrees increased femoral anteversion is present and when less than
5degrees, condition is termed as femoral retroversion.

BLOOD SUPPLY:

The femoral head is supplied by following arteries:

Extracapsular arterial ring Seen at the base of the femoral neck. Ring is formed posteriorly by the
large branch from Medial Femoral Circumflex Artery (MFCA), anteriorly by the smaller
branches from Lateral Femoral Circumflex Artery (LFCA), and the branches from superior &
inferior gluteal artery have a minor role in forming the ring.

Ascending cervical branches

The Ascending cervical branches give rise to the retinacular arteries which further gives rise to
the sub synovial intra articular vascular ring .

Artery of the Ligamentum teres femoris

It may be a branch of obturator artery or MFCA. As such the artery is inadequate to supply
femoral head. Only small part of the femoral head is nourished by artery of ligamentum teres.

Epiphyseal blood supply: Arise from lateral epiphyseal vessels that reach head posterosuperior
and medial epiphyseal artery entering through ligamentum teres, epiphyseal arterial branches
arise as arteries of sub synovial intraarticular ring. There are two groups of epiphyseal arteries:
lateral group & inferior group.

30
Metaphyseal blood supply:

The metaphysis gets its blood supply from extracapsular arterial ring, branches of ascending
cervical arteries, & sub synovial intra articular ring.

Changes with Age:

There is minimal anastomosis between epiphyseal and metaphyseal blood vessels in the adult
even after closure of epiphyseal plate, The major blood supply to head of femur is from vessels
on posterior superior surface of femoral neck.

Retinacular Vessels

Ascending cervical vessels arise from the extracapsular ring of anastomosis seen at the base of
the neck formed by the medial and lateral circumflex femoral artery. Ascending Cervical
Branches ascend under the hip capsule and continue proximally along neck deep to synovial
membrane towards the femoral head. These branches ascending under the hip capsule are called
as the retinacular arteries. These ascending branches are classified into 3 groups.

• Posterior inferior group from medial circumflex

• posterior superior group femoral artery

31
• Anterior groupfrom lateral femoral circumflex artery

At the margin of the articular cartilage along the surface of the neck of femur, these vessels form
a second ring called the sub synovial intra articular ring and from this ring the epiphyseal arteries
arise.

Vascular Anatomy of Head and Neck of Femur

Intraosseous Blood Supply of Neck of Femur

The intramedullary branches of nutrient artery [arise from upper perforating arteries of the
profunda femoris], metaphyseal artery [Arise from medial circumflex artery, the extracapsular
arterial ring, sub synovial ring] and the epiphyseal vessels [from sub synovial ring] supply both
marrow and cortical bone. In cases of fracture of neck of femur, if the fracture is complete, this
supply gets disrupted.

32
CLASSIFICATION OF FRACTURE NECK OF FEMUR

There are various systems for the classification of femoral neck fractures.

Garden classification

This classification is a system of categorizing the intracapsular hip fractures of the femoral neck.
This type of fracture often disrupts the blood supply to the head of femur. Proposed by the
British orthopedic surgeon Robert Symon This is based on the degree of valgus displacement.
This classification consists of four grades

 Type I: Incomplete/valgus impacted

 Type II: Complete and nondisplaced on AP and lateral views

 Type III: Complete with partial displacement; trabecular pattern of the femoral
head does not line up with that of the acetabulum

 Type IV: Completely displaced; trabecular pattern of the head assumes a parallel
orientation with that of the acetabulum

Clinical relevance

The blood supply of the femoral head is more likely to be disrupted in Garden types 3 or
4 fractures. These types of fracture are treated mostly by replacing the fractured bone
with a prosthesis arthroplasty. Alternatively, the fracture may be reduced to get the
fragments back into a good position and fix them in place with metal screws.

33
Commonly Garden 1 and 2 fractures are fixed with screws, and Garden 3 and 4 fractures are
treated with arthroplasty, except in young patients where screw fixation is attempted first,
followed by arthroplasty if screw fixation fails. The screw fixation is done first to preserve the
natural joint since prosthetic joints ultimately wear out and have to be replaced. A serious but
common complication of a fracture neck of femur is avascular necrosis. The blood supply to the
femur head is easily disrupted during fracture of neck of femur or from the swelling that
increases inside the joint capsule. This cuts off the blood supply and results in the avascular
necrosis.

PAUWEL’S CLASSIFICATION

Pauwels classified fracture neck of femur according to the degrees of the inclination of the
fracture line to the horizontal plane known as the Pauwels' angle. The classification consists of 3
grades. The distinction between grade II and III is often misinterpreted. Moreover, as originally
pointed by Pauwels, the difference between grade I and grade II should also be based on the

34
presence of a shearing force, which can be neutralized by impaction. Therefore, some fractures
with more vertical fracture line (>30 degrees) may still be considered grade I. Similarly, the
distinction between grade II and grade III fractures is based on the presence of free torque, that
distracts the upper part of the fracture line. If present, the fracture should be classified as grade
III.

Pauwels’ Grade Pauwels' angle

Pauwels I Less than 30 degrees

Pauwels II Between 30 - 50 degrees

Pauwels III More than 50 degrees

Anatomical classification

The fracture Neck of Femur are anatomically a type of proximal hip fractures i.e., fractures
proximal to the inter-trochanteric line. This means that all the proximal hip fractures are
intracapsular fractures. These can be further subdivided as

1. Sub capital – occurring at junction of femoral head and neck

2. Transcervical – midportion of femoral neck

3. Basi cervical – base of femoral Neck

35
 Orthopedic Trauma Association (OTA) Classification

 B1 group fracture is nondisplaced to minimally displaced sub capital fracture

 B2 group includes transcervical fractures through the middle or base of the neck

 B3 group includes all displaced nonimpacted sub capital fractures

PATHO- ANATOMY

The Fractures of neck of femur are mostly displaced with the distal fracture fragment in external
rotation, abduction and proximal migration. But These displacements are less than the
displacements seen in intertrochanteric fracture. This is because the hip joint’s capsule is
attached to distal fragment and this prevents the extreme rotation and the displacement of the
distal fracture fragment. Thus the affected leg is

Shortened due to the displacement of the distal bone fragment proximally caused
by the pull of Rectus Femoris (RF), Adductors (AM) and Hamstring muscles (HS)

External rotation of the leg so that the foot points laterally due the action of
Gluteus Maximus (GM); Piriformis (PI); Obturator Internus (OI); Gemelli (GE); Quadratus
Femoris (QF);

36
MECHANISM OF INJURY:

Fall injury is responsible for more than 90% of the cases seen in patients aged more than 50
years.

1. High impact activities in younger individuals leading to stress fracture

Pathologic fracture may occur at any age, including secondary deposit of malignancy,
hyperparathyroidism, osteogenesis imperfecta, steroids, Paget’s disease, and infection

COMMONLY ASSOCIATED INJURIES:

Hip dislocation

Ipsilateral shaft of femur fracture and patella

Chest injuries

Abdominal injuries

Head injuries

Pelvic and acetabular fractures

Associated distal radius fracture

37
CLINICAL FEATURES:

Signs and Symptoms of a Femoral Neck Fracture

• Severe pain in hip or groin

• Difficulty in movement immediately after a fall

• Inability to bear weight on the leg on the side of injury

• Stiffness, bruising and swelling in and around your hip area

• Limb shorter on the side of injury

• Rest the fractured leg in an outward direction

Stress fracture, especially in younger individuals may not have a history of fall or trauma. The
following points need to be noted in the history.

• Participation in repetitive cyclic activity

• Recent change in activity or equipment

• Atraumatic history

• Pain with weight bearing

• Relief of pain with rest

• Menstrual irregularity

• Predisposing osteopenia

• Insidious onset of pain in hip

Demographics of the young femoral neck fracture patient

The literature suggests that femoral neck fractures in young adults are most often a result of
high-energy trauma such as motor vehicle collisions10. Patients often present with poly-traumatic

38
injuries such as other fractures or head, chest and abdominal trauma. While this is true for
patients with dense bone, more recent work demonstrates femoral neck fractures in
chronologically young patients occur from low energy trauma with a higher than expected
frequency11. A study conducted by examined ninety-five patients with both intra and extra-
capsular hip fractures under the age of 50 over a five-year period. They identified two
demographics within this population; a male predominant group between the ages of 20 and 40
years who sustained high-energy injuries, and a larger group between the ages of 40 and 50 years
who sustained fractures after falls. The majority of patients within the latter group had long
standing medical conditions and a high prevalence of alcoholism. This demonstrates that there
are two main reasons for femoral neck fractures in chronologically young adults, significant
trauma in healthy patients or comparatively low energy trauma in patients with predisposing
diseases, alcoholism or early age related bone fragility. A low threshold for referral to specialist
services for analysis of bone marrow density and/or treatment of osteoporosis should be
observed in young patients with femoral neck fractures.

Anatomy

Femoral head vascularity is at risk after femoral neck fractures because the vascular supply is
intra-capsular. The most common hypotheses of causes for femoral head ischemia after femoral
neck fracture are direct disruption or distortion of the intra-capsular arteries during the initial
femoral neck fracture, compression secondary to elevated intra-capsular pressure due to fracture
hematoma, pre-operative traction and quality of the surgical reduction and its ability to restore
blood flow12.

Blood supply to the femoral head comes from three main sources, the medial femoral circumflex
artery (MFCA), the lateral femoral circumflex artery (LFCA) and the obturator artery. The
majority of the blood supply to the femoral head, more specifically to the vital superior-lateral
weight-bearing portion, comes from the lateral epiphyseal artery, a branch of the MFCA. This
artery courses up the posterior-superior aspect of the femoral neck where it is prone to damage
during femoral neck fracture fragment displacement. The second largest contributor to femoral
head blood supply is the LFCA whose ascending branch gives rise to the inferior metaphyseal

39
artery supplying the anterior-inferior aspect of the femoral head. Finally, the smallest and most
variable contributor to blood supply in the adult femoral head is via the obturator artery which
enters the head via the ligamentum teres13.

INITIAL EVALUATION

The mechanism of injury is important. As previously discussed, a large majority of young

patients with femoral neck fractures present after high-energy trauma. If a young patient with
femoral neck fracture presents after a low-energy trauma or no clear history of trauma, a more in
depth history should be carried out. Low-energy fracture can be due to underlying osteoporosis,
stress fracture or pathologic bone. One should inquire specifically about risk factors for
osteoporosis, previous pain about the hip both at rest or with activity and constitutional
symptoms including fever, weight loss and night sweats. In a poly-trauma presentation, Advance
Trauma Life Support (ATLS) protocol is promptly initiated; fixation of the femoral neck fracture
is dealt with following the appropriate treatment algorithm based on priority of the injuries.
Nevertheless, in isolated or in poly-trauma situations, the patient needs to be medically
optimized prior to surgery and evaluated by an anesthesiologist. Physical examination findings in
patients of all ages with femoral neck fractures are similar. Classically, the affected limb is
painful, especially with movement, shortened, flexed and externally rotated. However, the
diagnosis of femoral neck fracture in young patients can be more elusive. With a significant
proportion of patients presenting after high-energy injuries and often in poly-traumatized
patients, these fractures can easily be overlooked. In the presence of a femoral shaft fracture, an
ipsilateral femoral neck fracture will occur up to 9% of the time. In this clinical setting, the
diagnosis is missed approximately 30% of the time. Most of these fractures (between 25% and
60%) are non-displaced at initial presentation. Because of the morbidity associated with
osteonecrosis, a high index of suspicion should be entertained when evaluating the poly-
traumatized patient. Prompt recognition of femoral neck injuries cannot be underemphasized as
timing to surgical intervention may affect outcomes14.

IMAGING AND CLASSIFICATION

Regardless of the mechanism of injury, antero-posterior (AP) pelvis, AP and lateral plain
radiographs of the affected hip and entire femur should be obtained. In addition, traction-internal

40
rotation radiographs may allow for a better interpretation of fracture pattern. Up to 2%-10% of
femoral neck fractures may not be clearly visible on standard radiographs and computed
tomography (CT) can aid in the diagnosis. In cases of significant trauma where an abdomin-
pelvic CT scan is required, it is recommended to extend imaging to the level of the lesser
trochanter in order to fully evaluate the femoral neck. This enables identification of occult
injuries, especially in the obtunded patient where a reliable physical examination is difficult.
Recent studies have found CT scan to be as effective as MRI in detecting these fractures and
reducing the chance of a missed injury15.

Several characteristics identified on imaging have been shown to influence the biomechanical
stability of the fracture. First, the verticality of the fracture line in the coronal plane should be
assessed. Pauwels first recognized the significance of high angle fractures in the 1930s. He
established a descriptive classification scheme that helps determine fracture stability based on the
“Pauwels angle”. A femoral neck fracture line < 30 degrees from the horizontal plane is Pauwels
Type I, fractures with an angle between 30 and 50 degrees is Pauwels Type II, and an angle of >
50 degrees categorizes a Pauwels Type III fracture. Increased verticality of the fracture decreases
the load shared through the fracture fragments resulting in a biomechanically unstable pattern,
susceptible to the development of mal-unions, non-unions and osteonecrosis16.

Another well-known and widely used classification system is that of Garden, originally
published in 1961 (Figure (Figure1).1). Low inter and intra-rater reliability has led to it being
mostly used for femoral neck fractures in the elderly population where the classification can be
simplified to non-displaced (Garden I or II) vs displaced (Garden III or IV) in order to dictate
appropriate management. Secondly, special consideration should also be given to fractures with
posterior neck comminution. Several studies have indicated this to be a poor prognostic factor
after internal fixation and correlate the comminution with fracture severity and instability17.

41
Garden classification. A: Incomplete fracture of the femoral neck with valgus impactor. Note the
radiopaque overlap of the femoral neck and head; B: Displaced complete fracture of the femoral
neck; C: Less than 50% displacement of a complete fracture of the femoral neck; D: Complete
fracture of the femoral neck with complete displacement.

PRINCIPLES OF MANAGEMENT

Non-operative treatment of femoral neck fractures in younger patients has a very limited role and
is only reserved for the sickest of patients whose surgical risks negate any benefit of fixation.
Moreover, operative management is recommended for non-displaced impacted fractures. In a
prospective study of three hundred and twelve patients with impacted femoral neck fractures
(Garden I-II), Rainmakers et al18 found that 5% of healthy patient below age 70 had secondary
displacement and only 87% of patients in this age group achieved union. Considering the pre-
injury activity level of most young patients, surgical management is recommended, as union
rates are higher with operative treatment. Goals of the surgical management of femoral neck
fractures in young adult patients are three-fold: (1) Return to pre-injury level of function; (2)
Achieve an anatomic reduction of the fracture to preserve the blood supply and effectively
prevent ONFH; and (3) Provide a stable fixation while preserving bone stock to achieve union.

42
PRE-OPERATIVE CONSIDERATIONS

Surgical timing of displaced and non-displaced fracture

The consensus for time to surgery following femoral neck fracture in the young patient is still a
matter of debate. Minimally or non-displaced fractures are classically treated on an urgent basis
and displaced fractures are managed on an emergent basis with the aim to regain and preserve
blood flow to the femoral head. The difficulty with basing this decision on an X-ray finding is
that the single time radiographs may not represent ongoing instability or displacement. Studies
have shown that early fixation decreases osteonecrosis and increases functional outcome. In a
retrospective study, Jain et al19 looked at thirty-six young patients with femoral neck fractures.
Patients treated within twelve hours of injury had a decreased rate of osteonecrosis as compared
to the delayed fixation group. However, there was no difference in functional outcome between
the early and delayed fixation group. In contrast, other studies have found no difference in
osteonecrosis rates between early and delayed time to fixation. Razak et al20 retrospectively
analyzed ninety-two patients with femoral neck fractures and found no difference in rates of
osteonecrosis when comparing treatment within 6 h post-injury, and delayed treatment 48 h post-
injury. They found that the rate of osteonecrosis was related to the type of fixation, which may
be indicative of surgeon treatment bias. The conflicting results in the literature are indicative of
the wide amount of variance in the studies, which did not uniformly control for cofounding
variables such as the quality or the type of reduction and fixation. Given the controversial
evidence and considering the impetus to prevent osteonecrosis and improve functional outcome,
our recommend treating displaced femoral neck fractures on an urgent basis.

Anesthesia consideration

There is little debate regarding the benefits of intra operative regional anesthesia compared to
general anesthesia in young healthy adults; however special circumstances including extreme
hypovolemia or coagulopathy associated with poly-trauma, or patient specific factors including
respiratory or cardiovascular comorbidities might warrant a particular anesthetic approach. A
meta-analysis of randomized controlled trials of hip fractures in all aged group showed a
decrease in incidence of deep vein thrombosis and reduction in fatal pulmonary embolism with
regional anesthesia. General anesthesia was associated with a reduction in the length of the

43
operation. A lumbar plexus block may be the post-operative modality of choice for analgesia of
the hip as it reliably blocks the lateral femoral cutaneous, femoral and obturator nerves 21.

SURGICAL MANAGEMENT

Open vs closed reduction

The decision between attempting an open or closed approach for fracture reduction is the first
step when attempting primary fixation. Most authors agree on performing a closed reduction and
internal fixation for management of non-displaced femoral neck fractures (Garden I-II) given
low rates of ONFH and non-union22. However there is considerable debate between the two
strategies for reduction of displaced fractures (Garden III-IV). Obtaining an anatomic reduction
is paramount in the young patient as a poorly reduced fracture is a major risk factor for non-
union and ONFH. Some authors argue that closed reduction can achieve anatomic reduction with
intra-operative fluoroscopy; they suggest that this approach decreases cost, is less invasive and
saves operating time. Care should be taken while performing the close reduction, as multiples
attempts are associated with an increased risk of ONFH. Others support the need for an open
reduction to facilitate direct visualization for anatomic reduction, and with the same token,
provide relief of a possible intra-capsular tamponade. Traditionally, there are two different
surgical approaches for the internal fixation of femoral neck fractures; the Watson-Jones (antero-
lateral) and the Modified Smith-Peterson (anterior). There is no gold standard as to proceed with
closed or open reduction for displaced femoral neck fractures in young adults as long as
anatomic reduction is achieved. Closed reduction can be attempted by adequate sedation and
relaxation of muscle tone. Leadbetter first described in 1939 the maneuver to reduce of femoral
neck fractures23. The affected leg is flexed to 45° with slight abduction and then extended with
internal rotation while longitudinal traction is applied. The reduction is verified with fluoroscopy
in the AP and lateral view of the hip to verify the anatomic reduction. The quality of reduction
can be ascertained using Garden’s alignment index, which evaluates the angle of the compressive
trabeculae as compared to the femoral shaft on both AP and lateral hip radiographs. Anatomic
reduction is achieved with an angle of 160° on the AP, and 180° on the lateral view. Varus
angulation of less than 160° on the AP view and posterior angulation of more than 5° on the
lateral view indicate an unsatisfactory reduction24.

44
Hematoma decompression

Another topic of controversy in treating femoral neck fractures in young patients is the role of
capsulotomy for hematoma decompression. The theoretical goal of capsulotomy is to relieve the
tamponading effect of the developed intra-capsular hematoma and subsequently increase blood
flow to the femoral head. There is good evidence in the literature correlating hemarthrosis
following femoral neck fracture and increased intra-articular joint pressure25.

In an interventional study, Beck et al26 injected saline into intact intra-capsular space of eleven
patients before having surgical dislocations and subsequently measured blood flow to the
femoral head with laser Doppler flowmetry. The measurable blood flow to the femoral head
disappeared with increased pressure (average 58 mmHg) and the blood flow returned once the
saline was re-aspirated. In contrast, in a prospective study involving thirty-four patients with
femoral neck fractures, Maruenda et al27 found no correlation between increased intra-capsular
pressure and femoral head perfusion. Interestingly they also showed no difference in intra-
capsular pressure between non-displaced and displaced fractures. Others have suggested higher
pressures are found in non-displaced fractures. Disruption of the hip capsule during facture
fragment displacement is thought to be responsible for the decreasing intra-capsular pressures.
Numerous clinical studies have shown a reduction in intra-capsular pressure with capsulotomy
and a resulting improvement in femoral head blood flow. However there are no clinical data
documenting improved outcomes with capsulotomy. In their retrospective study of ninety two
young patients with femoral fractures, Upadhyay et al28 found no difference in the rate of
osteonecrosis with patients treated with open (capsulotomy) or closed reduction (no
capsulotomy) and internal fixation. In the above-mentioned study by five out of the six patients
that developed osteonecrosis had pre-operative intra-capsular pressures below diastolic pressure.
They concluded what many presently think: high-energy trauma and the initial fracture
displacement probably play a more significant role than intra-capsular tamponade in the
development of osteonecrosis.

Some surgeons perform capsulotomy while proceeding with their open procedures while others
opt for fluoroscopic guided hip capsulotomy; this latter technique has been previously found to
be safe and effective at decreasing intra-articular pressure29. Nevertheless, given the current
evidence, our do not recommend the routine use of capsulotomy for femoral neck fractures.

45
Choice of construct

There are several biomechanical constructs available for the fixation of femoral neck fractures
and knowing when and how to position the implant is paramount to attain a stable fixation.
Compression screws (CS) and fixed-angle dynamic implants, or a combination of both, promote
union during weight bearing by allowing the fracture fragments to slide along the implant while
being axially loaded. Fixed-angle and length stable implants, such as blade plates, maintain
intraoperative reduction by providing a rigid construct. Currently, hemiarthroplasty or total hip
arthroplasty are not used as the primary surgery in young patients. Total hip arthroplasty and
valgus osteotomy are used as salvage operations in case of failure of fixation. There is still a
debate on the optimal method of fixation for promoting union and preventing ONFH in young
patients. This is mainly because most opinions on fixation in this population are extrapolated
from studies in elderly osteoporotic patients. Multiples compressive screws: The use of the
multiple compressive screws has been advocated for Garden type I-II in attaining union. In a
prospective randomized controlled trial of patients allocated to CS or dynamic hip screw (DHS)
with non-displaced or minimally displaced femoral neck fracture, Watson et al30 found no
difference in union rate, ONFH or functional outcome between the groups. Numerous studies
have looked at biomechanical variations of this construct including the number and placement of
the screws or variability in the proprieties of the screws themselves such as the length of the
threads. For instance, parallel screws have been shown to be superior construct than convergent
screws in maintaining stability reduction. Some authors advocate the use of a fourth screw in
cases of fractures with posterior comminution. However, optimal stiffness can be achieved with
a three-screw configuration. Three parallel screws placed perpendicular to the fracture line in an
inverted triangle with the most inferior screw placed on the medial aspect of the distal femoral
neck provides the ideal stability and compression at the fracture site31

46
Cannulated screw fixation. A: Anterior posterior view; B: Anterior posterior view with
cannulated screw.

Fixed angle implants: The dynamic compressive screw has been advocated as a more stable
construct than compressive screws for high shear angle neck fractures (Pauwels type III)(Figure
(Figure3).3). Addition of a derotational screw placed in the cranial part of the femoral neck
superior to the dynamic hip screw can improve the rotational stability of the construct (Figure
(Figure4).4). In a biomechanical study comparing four commonly used constructs for Pauwels
type III fractures, Bonnaire et al32 found the DHS with derotational screw to be more load stable
than compressive screws, a fixed-angle plate or a simple DHS construct. However, for more
stable fracture patterns this screw may be of little benefit. Recently Makki et al33 showed no
benefit in union rate or development of ONFH in patients with Garden I-II femoral neck
fractures treated with a DHS alone or with a DHS with a derotational screw. Furthermore, in
their retrospective study of ninety-two young patients with femoral neck fractures, Razik et al34
found that DHS alone or DHS supplemented with a derotational screw had significantly less
osteonecrosis for Garden III-IV fractures.

47
Dynamic hip screw fixation. A: Anterior posterior view with 2 holes 135° dynamic hip screw; B:
Lateral view of 2 holes 135° dynamic hip screw.

Dynamic hip screw with derotation screw. A: Anterior posterior view pre-operative of 4 holes
145° dynamic hip screw; B: Lateral view pre-operative of 4 holes 145° dynamic hip screw.

48
In a cadaveric study, Aminian et al35 compared the stability of DHS, CS, dynamic condylar
screw and a proximal femoral locking plate (PFLP) for Pauwels type III femoral neck fractures.
PFLP was the most stable for this fracture pattern, followed by the dynamic condylar screw, the
DHS and CS. Currently, no clinical studies directly compare proximal femoral locking plate with
DHS and/or DHS with derotational screw. They recommend the treatment of Garden I-II fracture
with CS and Garden III-IV with a DHS and the addition of a derotational screw for Pauwels type
III fractures. Replacement arthroplasty: Replacement arthroplasty is not considered a first line
treatment in young patients as bone stock should be preserved and the potential complications of
replacement arthroplasty avoided. The major early complications are dislocations for total hip
arthroplasty and acetabular erosion for hemiarthroplasty. In the elderly patients, short-term
follow up has shown better functional outcome for total hip arthroplasty over hemiarthroplasty.
Studies have shown that internal fixation has higher re-operation rates and that both
hemiarthroplasty and internal fixation have comparable functional outcomes36. To this date, there
are no level-I studies comparing arthroplasty to internal fixation in the young adult.

SUBACUTE PRESENTATION AND MANAGEMENT

The term “neglected” femoral neck fracture has been described as a subacute presentation of at
least 30 d delay after initial injury. This pathology is more prevalent in developing countries
where urgent orthopedic care is not readily available. There is no consensus on the treatment of
this pathology and different surgical managements have been described in treating non-union of
femoral neck fractures in young adults. Operations such as internal fixation with valgus
intertrochanteric osteotomy and internal fixation with vascularized muscle pedicle bone grafting
or non-vascularized bone grafting are frequently used to achieve union. Valgus osteotomy and
free fibular bone graft has had better reported outcomes with osteonecrosis rates ranging from 0-
17% and non-union from 0%-15%37.

POST-OPERATIVE CONSIDERATIONS

The postoperative recommendations are geared to lower the incidence of wound infection, deep
vein thrombosis (DVT), and pulmonary embolism as well as to encourage mobilization. An
antibiotic regimen with a first generation cephalosporin is indicated for 24 h. The patients should
be placed on DVT prophylaxis for thirty days with a pharmacologic agent such as low molecular

49
weight heparin. Physiotherapy should not be delayed and patients should be encouraged to
mobilize with no restriction on range of motion of the hip. The patients are usually subject to toe-
touch weight bearing with a walker or crutches for 12 weeks until the fracture is healed. They are
then progressed to full weight bearing as tolerated. The patient should follow-up in 10-14 d post-
operatively to assess the wound for infection and to assess the stability of the fixation construct.
Follow up visits are indicated at six weeks and three months to assess for clinical and radiologic
signs of non-union, osteonecrosis and hardware failure.

COMPLICATIONS

Femoral neck fractures in the young are not known to be associated with a high mortality rate as
they are in the elderly population. However, young patients suffer great morbidity from the
injury due to high rates of osteonecrosis and tolerable yet significant delays in union. In this
section we present a brief overview of these two complications with an emphasis on their
management.

Osteonecrosis of the femoral head

Osteonecrosis of the femoral head, previously referred to as avascular necrosis, remains one of
the greatest concerns in the young patient with a femoral neck fracture. Despite their increasing
understanding of the pathophysiology surrounding post-traumatic osteonecrosis, the incidence
has been documented to be as high as 86% in young adults post femoral neck fracture. The
development of osteonecrosis has been correlated with multiple factors including age at time of
injury (older patients develop less osteonecrosis), the degree of displacement, presence of
posterior comminution, verticality of the fracture line, quality of reduction, and implant
removal38. Osteonecrosis of the femoral head can present anywhere between 6 months and many
years after the initial injury; however, most cases will present within 2 years. For this reason,
patients should be followed at least for two years post-operatively looking for signs of
osteonecrosis, both clinically and radiologically. Patients will characteristically present
complaining of pain localized in the groin, sometimes radiating to the anterior-medial thigh
and/or ipsilateral knee. The pain is usually described as deep, throbbing and is exacerbated by
weight-bearing activities or at night. There exist many different imaging modalities for
diagnosing ONFH however plain radiographs and MRI remain the most useful. To date, there is

50
no universally accepted classification. Ficat and Arlet, one of sixteen different systems existing
in the literature, is the most commonly quoted39.

Surgical management of osteonecrosis of the femoral head: Treatment of post-traumatic

osteonecrosis depends on multiple factors including patient age, stage of disease, level of activity
and symptoms. In the majority of cases, once osteonecrosis develops and particularly if it is
symptomatic, it will eventually progress to subchondral collapse and secondary osteoarthritis.
Once this occurs, the only definitive option remaining is total hip arthroplasty. However,
questions remain surrounding the young patient with pre-collapse and early post-collapse ONFH.
Multiple joint salvaging techniques have been proposed for patients in whom revision
arthroplasty within the patient’s lifetime is a foreseeable concern. Core decompression has been
almost exclusively studied in the treatment of idiopathic ONFH. It is the most common method
of treatment for pre-collapsed stages of ONFH. It is theorized to work by reducing elevated intra-
osseous pressure, improving venous outflow and thereby restoring vascular inflow. Despite early
studies showing improvement for all stages of disease, a recent review of four prospective
studies with validated outcome scores and a minimum two year follow up showed only
minimally improved outcomes. In all four studies, better results were found in pre-collapse and
smaller femoral head lesions. Overall, core decompression is a cost-effective choice over
observation and its use is recommended as a first line treatment for pre-collapse disease40.

Various methods of non-vascularized bone grafting have also been used in the treatment of
ONFH. Bone grafting has been recommended when there is less than 2 mm of subchondral bone
depression, when less than 30% of the femoral head is involved and when core decompression
fails. It has also been used in conjunction with other methods, such as core decompression. Post-
traumatic osteonecrosis tends to create large lesions and decompression alone is thought to be
insufficient to completely prevent collapse. Without good reproducible evidence, evaluation of
these techniques in long-term prospective studies is necessary before they can be recommended
for routine use. Vascularized bone grafting using either a local muscle pedicle iliac crest graft or
a free vascularized fibular graft have been described for young patients with femoral neck non-
union or ONFH. Commonly cited indications from studies of non-traumatic ONFH include no
evidence of bony collapse or articular collapse of less than 3-mm in lesions involving less than
50% of the femoral head. The main pitfalls of vascular grafting are donor site morbidity and

51
advanced microvascular surgical techniques. Although less predictable for larger lesions typical
of post-traumatic ONFH, when following indications, vascularized bone grafting can be effective
if used early and should be considered for improving hip function and delaying disease
progression41.

For patients with more advanced ONFH, usually with post-collapse disease, proximal femoral
osteotomies have been proposed with the premise of moving the lesion away from the weight
bearing zone. There is currently no general consensus on indications for proximal femoral
osteotomies with some authors obtaining good results while others observed high failure rates.
Other concerns surrounding these procedures are poorer outcomes with more challenging
subsequent total hip arthroplasty, with increased rates of blood loss, operative time, femoral shaft
fracture and component loosening42. We believe that in the right hands osteotomies can lead to
reproducible results however without generalizable results one should proceed cautiously when
considering proximal femoral osteotomies for treatment of ONFH.

Non-union

The incidence of non-union after femoral neck fixation has been reported to be between 10% to
33%. Initial fracture displacement, quality of reduction and increasing patient age correlate with
a higher risk of non-union. A recent study evaluating the survivorship of the hip in patients
younger than 50 years after femoral neck fractures, reported that 8% of patients were diagnosed
with non-union and 23% with evidence of osteonecrosis. Moreover, in this series, patients with
anatomic reductions had only a 4% rate of aseptic nonunion. In comparison to osteonecrosis of
the femoral head, patients with non-unions present with symptoms earlier, often several months
after internal fixation. Most commonly patients describe a history of persistent pain, typically
localized to the groin and over the anterolateral aspect of the injured leg, aggravated by weight-
bearing. Three to six months should have elapsed before a nonunion may be diagnosed but
evidence of failure of fixation can allow the diagnosis to be made sooner. Plain radiographs may
demonstrate a lucent fracture zone, osteopenia or bone loss, or signs of instability of the implant
such as changes in screw position or backing out of the screws. When plain radiography is
equivocal, computed tomography can help determine whether bony union has occurred. Once
non-union has been diagnosed, several factors will decide whether salvage of the femoral head is
a viable revision option, including the patient’s physiological age, femoral head viability, the

52
amount of femoral neck resorption, and the duration of the nonunion. Four options are available
for treatment: fixation with new hardware, angulation osteotomy, prosthetic replacement and
arthrodesis. In the physiologically young patient, salvage of the femoral head and preservation of
the hip joint is preferable. This can be achieved by either improving the mechanical environment
to favor healing with valgus-producing osteotomies or by improving the biologic milieu at the
non-union site with bone graft. In young patients’ femoral neck non-union is thought to be more
often a result of mechanical factors over biological ones. Varus displacement of the femoral head
leads impaired blood supply to the fracture and femoral head resulting in non-union and
avascular necrosis. Two features commonly seen in young patients have been identified as
predicting higher incidences of fixation failure and non-union; posterior wall comminution and
high shear angled fractures (Pauwels Type III). With a vertical fracture line, the calcar does not
offer enough support to prevent the femoral head from shearing and displacing into varus. It is
unclear whether posterior comminution indicates a more extensive soft tissue and vascular injury
or whether this pattern compromises stability after fixation.Valgus osteotomy reorients the
fracture so that its plane is nearly perpendicular to the force across the hip joint. This converts
the shearing forces parallel to the nonunion to compressive forces to stabilize the nonunion and
promote healing. This procedure also restores femoral length improving the abductor mechanics
by restoring the abductor moment arm43. As much as 2 cm of length can be gained in some
instances. Rotational and angular deformities can also be corrected at the same time. The
disadvantage of this osteotomy as a salvage procedure is that the valgus orientation of the
proximal femur increases contacts pressures on the femoral head potentially leading to
degenerative disease or progression of osteonecrosis. Although there are no concrete contra-
indications for this procedure, Varghese et al44 have demonstrated that a decreased preoperative
femoral neck bone stock was a risk factor for non-union after valgus osteotomy. Several
published series reporting on the outcomes of valgus-producing proximal femoral osteotomies
for the treatment of femoral non-union have demonstrated positive results. Marti et al45 reported
a union rate of 86% after osteotomy in 50 patients with femoral neck non-unions with an average
time to union of 4 mo. Mean postoperative Harris Hip Score was 91 points in reviewed patients.
Although 22 patients had radiographic evidence of osteonecrosis at the time of osteotomy only
three of these patients showed progressive collapse of the femoral head that eventually required
hip replacement surgery. Four other patients required replacement surgery for persistent non-

53
union or hardware failure. Ballmer et al46 reported on a series of 17 patients treated with valgus
osteotomies with a total union rate of 88%. Three patients required revision fixation but
eventually healed. Three patients had progressive osteonecrosis and required hip arthroplasty.
Excellent functional results were reported in 11 of the 17 patients. Some authors have recently
advocated sliding hip screws for the same purpose based on favorable outcomes and technical
ease associated with this implant. We recommend the use of valgus intertrochanteric osteotomy
for the treatment of aseptic non-union after femoral neck fracture fixation.

Autogenous bone grafting is used in an attempt to improve the biologic milieu at the nonunion
site. This can be done using non-vascularized, free vascularized or muscle pedicle-type grafts.
Rarely are bone grafting procedures undertaken for isolated femoral non-unions, but are
indicated more so when concomitant ONFH is present. There are no clear indications for the use
of grafting techniques for femoral neck non-union, however these procedures should be
considered when there is considerable loss of bone stock or non-unions are present in well-
aligned fractures with low shear angles.

DIAGNOSIS

The Fracture neck of femur is diagnosed by

1. Clinical diagnosis

Pain: it is evident most common symptom, with pain on movements and axial
compression at the hip joint and tenderness at the groin.

Tenderness over Triangle of Scarpa.

Active Straight Leg Raising Test is not possible

2. Radiological diagnosis

An anteroposterior view of the pelvis with both hips in 15 ° internal rotation and a cross-
table lateral view is indicated.

Magnetic Resonance Imaging or Bone Scan may be of use in identifying nondisplaced fractures
or occult fractures that are not evident on plain radiographs.

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MRI:

• Can be taken if there is high clinical suspicion of fracture with negative or equivocal
radiological evidence.

• For occult fractures, MRI is more sensitive than a CAT scan.

• For the evaluation of bone marrow or joint space, any osteochondral injuries, for early
diagnosis of Avascular Necrosis and its staging.

• But it is limited in cases of emergency settings.

• The useful sequences in MRI regarding fracture identification are coronal STIR to
identify edema and coronal T1 for fracture line

Bone Scan

• Indicated in cases where fracture or AVN is suspected but not seen on plain film, and
when MRI is not available

• Bone scan has a High sensitivity and a poor specificity

• It takes at least 4 hours to perform, and may sometimes take up to 24- 48 hours. Not
useful in patients with osteoporosis.

TREATMENT

Goals of treatment are

to minimize patient discomfort,

restore hip function,

allow rapid mobilization by obtaining early anatomic reduction and stable internal
fixation or prosthetic replacement.

Factors influencing the treatment

55
1. Patient’s Age:

1-16 years. 16-50 years 50-60 years> 60 years

2. Fracture site Sub-capital Transcervical Basal type

3. Fracture displacement: Based on Garden’s classification.

4. Fracture duration:<21 days – fresh >21 days - chronic.

FRESH FRACTURE

Age 1-16 years Implant used for stabilization should not pierce the growth plate.

Sub capital fracture:

In undisplaced fracture fixation with two or three Kirschner wire (K- wire). In displaced
fractures - closed reduction and fixation with K- wires.

Trans cervical fracture:

In undisplaced fractures fixation with K-wires. In displaced fractures closed reduction and
fixation with K-wires. Basi cervical fractures:

In undisplaced fractures fixation with 2.5 mm K-wire / cannulated cancellous screws. When
screws are used for fixation; these must not cross the physeal plate. In displaced fracture - then
closed reduction and fixation with K wire.

If closed reduction not satisfactory, open reduction and internal fixation with K-wire /
screws. Other options:

1. MacMurray’s osteotomy with POP one and a half hip spica

2. abduction osteotomy and fixation with 135 angled pediatric blade plate /DHS.

Post operative protocol: skin traction for 4-6 weeks or POP hip spica.

Age 16-50 years:

1. Sub-capital fracture:

56
 In Undisplaced fractures - fixation with 2-3 cannulated cancellous screws

In Displaced fracture - Closed reduction & fixation with cancellous screws. Abduction
osteotomy with DHS - converts shearing force into compression force. Closed reduction fixation
with 2 screws.

2. Transcervical fracture:

In Undisplaced fractures -Fixation with screws / DHS.

In Displaced fracture- Closed reduction and fixation with 3 screws

Closed reduction is unsatisfactory,

1. Open reduction with screws.

2. Reduction & fixation with screws and a) free fibular graft b) muscle pedicle bone graft
based on quadratus femoris or sartorius or tensor fascia femoris are useful.

3. Basi cervical fracture:

In Undisplaced fractures - fixation with DHS.

In Displaced fractures- Reduction and fixation with DHS / cancellous screws.

Age 50-60 years:

Sub capital fracture:

In Undisplaced fractures: Fixation with screws.

In Displaced fractures: Open Reduction and fixation with screws. If unsatisfactory, fibular graft
is done.

3. Abduction osteotomy and fixation with DHS.

4. Replacement arthroplasty: Bipolar or hemiarthroplasty /THR

57
Transcervical fracture:

In Undisplaced fractures: Fixation with cancellous screws.

In Displaced fractures: 1.Reduction and fixation with screws 2. free fibular graft.

If closed reduction is unsatisfactory

1. Open reduction & fixation with screws and free fibular graft or bone muscle pedicle
graft.

2. Replacement arthroplasty - hemiarthroplasty or total hip arthroplasty.

Basi cervical fracture:

In Undisplaced fractures: Fixation with screws / DHS.

In displaced fractures: Reduction and fixation with screws / DHS.

Above 60 years of age:

Sub-capital fracture:

In Undisplaced fracture

1. Fixation with screws.

2. Replacement arthroplasty: hemiarthroplasty or total hip arthroplasty.

In Displaced fractures

Replacement arthroplasty is the treatment of choice:

Closed reduction and fixation with screws and free fibular graft may be tried.

Transcervical

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In Undisplaced fractures:

1. Fixation with screws.

2. Replacement arthroplasty.

In Displaced fractures

1. Reduction and Fixation with screws.

2. Replacement arthroplasty - - hemiarthroplasty or total hip arthroplasty.

If closed reduction fails - Replacement arthroplasty.

Basi cervical fracture

In Undisplaced fracture

Reduction and fixation with screws or D.H.S

Reduction is unsatisfactory then Replacement arthroplasty.

In our study, we have compared two treatment options for fracture neck of femur.

1. cancellous screw fixation

2. dynamic HIP screw

REDUCTION TECHNIQUE

• Attempt closed reduction before open reduction.

• Lateral x-ray after reduction to evaluate posterior comminution.

 posterior comminution leads to the loss of a buttressing effect posteriorly, with

subsequent loss of reduction and non-union.
 majority of patients with non-union, have posterior comminution inferior comminution is
also important.
 According to Wein robe, et al (1998), “a non anatomic reduction will often lead to
postoperative displacement”.

59
 Chua, et al (1998), “noted varus angulation is an important predictor of early fixation
failure”. Leadbetter Technique: (preferred technique)

60
61
 47
Davidovich RI et al (2010) observed that femoral neck fractures in young patients are a
relatively rare event and are often the consequence of a high-energy injury. Concomitant injuries
are present more than 50% of the time. Previous reports have found the rate of nonunion and
avascular necrosis in this population to be as high as 35% and 45%, respectively. The salvage
options, which tend to yield more acceptable results in elderly patients with femoral neck
fractures, yield disproportionately poor results in young, active patients who are often productive
members of the labor force. Many reports exist in the literature evaluating the various treatment
options of these injuries. This review will address the epidemiology and diagnosis of the injury.
In addition, the various treatment options in the acute presentation, as well as options available
for treating the sequelae of femoral neck fractures in the young, was discussed. Although longer
life expectancy and the sustained activity level of many people previously considered elderly has
blurred the definition of “young,” this review will use the available literature dealing with
skeletally mature patients up to the age of 60 years.

Shen JZ et al 48(2012) showed that delayed bone union, nonunion or osteonecrosis often occur
after femoral neck fractures in young adults. Secondary bone healing requires strong internal
fixation, intramedullary pressure reduction and early functional exercise. To compare bone
healing of femoral neck fractures treated with hollow-bone-graft dynamic hip screws (Hb-DHS)
and standard dynamic hip screws (DHS) in an animal model. Testing of specifically designed
fixation devices in a pig animal model. They designed Hb-DHS and DHS devices appropriate to

62
the femoral neck and head of experimental animals and used them in eight pigs (4-month-old,
male or female, 30-40 kg/each). Under anesthesia, they induced medium neck type, Garden III
type femoral neck fractures in each pig with fracture gaps of 0.5 mm and then fixed each left
femur with Hb-DHS and each right femur with DHS. They assessed the animals radiographically
and by postmortem visual appraisal of evidence of bone healing 8 and 16 weeks postoperatively.
There were significant differences in radiographic and general findings between the Hb-DHS and
DHS groups at weeks 8 and 16 postoperatively. They found statistically significant differences
between the Hb-DHS and DHS groups in bone healing scores, trabecular bone volume
percentage and bone mineral density as assessed on plain radiographs and computed tomography
images (P < 0.05). There were also significant differences between the Hb-DHS and DHS groups
in postmortem visually assessed indicators of bone healing at both 8 and 16 weeks
postoperatively. The Hb-DHS device promotes femoral neck bone union, stimulates trabecular
bone formation, increases BMD and has advantages over DHS for internal fixation of femoral
neck fractures. This animal experiment will contribute to developing optimal treatment for
femoral neck fractures in young adults.

49
Ibrahim MS et al (2013) found that the increasing numbers of patients undergoing total hip
arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing
repertoire of surgical techniques and interventions available have put considerable pressure on
surgeons and other healthcare professionals to produce excellent results with early functional
recovery and short hospital stays. The current economic climate and the restricted healthcare
budgets further necessitate brief hospitalization while minimizing costs. Clinical pathways and
protocols introduced to achieve these goals include a variety of peri-operative interventions to
fulfill patient expectations and achieve the desired outcomes. In this review, they present an
evidence-based summary of common interventions available to achieve enhanced recovery,
reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-
operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical
stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound
dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty
units.

63
 50
Paulo T et al (2014) observed that femoral neck fractures account for nearly half of all hip
fractures with the vast majority occurring in elderly patients after simple falls. Currently there
may be sufficient evidence to support the routine use of hip replacement surgery for low demand
elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However,
for the physiologically young patients, preservation of the natural hip anatomy and mechanics is
a priority in management because of their high functional demands. The biomechanical
challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead
to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of
displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials
in achieving the goals of treatment in this young patient population. Furthermore, other
management variables such as surgical timing, the role of capsulotomy and the choice of implant
for fixation remain controversial. This review will focus both on the demographics and injury
profile of young patients with femoral neck fractures and the current evidence behind the
surgical management of these injuries as well as their major secondary complications.

51
Singh S et al (2014) examined that femoral neck fractures in adults have a poor prognosis
because of high incidence of non-union and aseptic necrosis. Prosthetic replacement of the
femoral head is reserved for the physiologically older patients while osteosynthesis with
preservation of femoral head is the treatment of choice for fracture neck femur in younger adults.
Various types of bone graft supplementation have been advocated to reduce the incidence of
nonunion and avascular necrosis. They tried cancellous screw fixation supplemented by fibular
autologous grafting to overcome nonunion and avascular necrosis. Thirty-five (M-18: F-17)
skeletally mature patients (mean age 49.38 years) of fresh femoral neck fracture were treated.
Weight bearing was allowed only after 3 months, or later if the radiological signs of union was
not seen. All fractures showed union at one year follow up. Complications included, avascular
necrosis (2 cases), broken fibular graft (3 cases), screw back out with collapse (2 cases),
penetration of the femoral head articular surface by screw and graft (1 case each). Patients are
able to sit cross-legged and squatting position. Cancellous screw fixation and fibular autologous
grafting is a safe, cost effective and reliable surgical technique for treating femoral neck fractures
in properly selected patients.

64
 52
Lin D et al (2015) observed that the neglected femoral neck fracture is one where there has
been a delay of more than 30 days to seek medical help from the time of the original injury.
Salvage procedures, such as osteotomy and other treatment options such as vascularized and
neovascularized bone grafts have high failure rates and arthroplasty procedures are not ideal,
given the patient’s young age and higher levels of activity. They designed a hollow bone graft
dynamic hip screw (Hb-DHS) (modified DHS, Hb-DHS) for use in neglected femoral neck
fractures. This study evaluates the efficacy and safety of the modified dynamic hip screw (DHS)
with autogenous bone and bone morphogenetic protein 2 (BMP-2) composite materials grafting
for the treatment of the neglected femoral neck fractures. A prospective study was carried out in
twenty patients of neglected femoral neck fractures treated with the modified DHS with
autogenous bone and BMP-2 composite materials grafting between July 2007 and February
2010. There were 14 men and 6 women with a mean age of 29.6 years (range 19–42 years). The
mean time from injury to surgery was 9.7 weeks (range 6–16 weeks). The operation time,
intraoperative blood loss, fracture healing time, Harris scoring for hip function and complications
were recorded to evaluate treatment effects. The mean operation time was 75.8 min (range 55–
100 min) with mean intraoperative blood loss volume of 105 mL (range 70–220 mL). The mean
time to union was 17 weeks (range 12–24 weeks). One patient did not achieve union, and two
patients had avascular necrosis of the femoral head. This patient with nonunion underwent
intertrochanteric osteotomy. In patients with avascular necrosis one required total hip
arthroplasty, the other did not require intervention at the last follow-up. A total of 14 patients
(70%) had excellent results, 2 (10%) had good, 1 (5%) had moderate and 3 (15%) had poor
results. The modified DHS with autogenous bone and BMP-2 composite materials grafting for
the treatment of neglected femoral neck fractures was effective and had less complications.

Jain AK et al 53(2015) showed that intra-capsular femoral neck fractures are seen commonly in
elderly people following a low energy trauma. Femoral neck fracture has a devastating effect on
the blood supply of the femoral head, which is directly proportional to the severity of trauma and
displacement of the fracture. Various authors have described a wide array of options for
treatment of neglected/nonunion (NU) femoral neck fracture. There is lack of consensus in
general, regarding the best option. This Instructional course article is an analysis of available
treatment options used for neglected femoral neck fracture in the literature and attempt to suggest
treatment guides for neglected femoral neck fracture. They conducted the “PubMed” search with

65
the keywords “NU femoral neck fracture and/or neglected femoral neck fracture, muscle-pedicle
bone graft in femoral neck fracture, fibular graft in femoral neck fracture and valgus osteotomy
in femoral neck fracture.” A total of 203 print articles were obtained as the search result. Thirty
three articles were included in the analysis and were categorized into four subgroups based on
treatment options. (a) Treated by muscle-pedicle bone grafting (MPBG), (b) closed/open
reduction internal fixation and fibular grafting (c) open reduction and internal fixation with
valgus osteotomy, (d) miscellaneous procedures. The data was pooled from all groups for mean
neglect, the type of study (prospective or retrospective), classification used, procedure
performed, mean follow-up available, outcome, complications, and reoperation if any. The
outcome of neglected femoral neck fracture depends on the duration of neglect, as the changes
occurring in the fracture area and fracture fragments decides the need and type of biological
stimulus required for fracture union. In stage I and stage II (Sandhu's staging) neglected femoral
neck fracture osteosynthesis with open reduction and bone grafting with MPBG or Valgus
Osteotomy achieves fracture union in almost 90% cases. However, in stage III with or without
AVN, the results of osteosynthesis are poor and the choice of treatment is replacement
arthroplasty (hemi or total).

Jain H et al 54(2017) old fracture neck femur fixations in young adult are still a great challenge
to orthopedics’ with no definite guidelines to follow with various methods of fracture fixation
according to fracture biomechanics. Aim of the study was to find out the impact of valgus
osteotomy and fibular grafting on chances of bone union in old fracture neck of femur and to
establish a pattern of treatment in an attempt to preserve femoral head 32 patients of old and
neglected intracapsular femoral neck fracture were treated with valgus osteotomy with double
angle DHS with strut fibular grafting. Patient was followed for an average of 2.2 years.
Radiological sign of union were found in 95% of patients in an average period of 3.46 months.
The result was excellent in 12 patients, good in 8 patients and poor in 12 patients (according to
modified Harris hip score) and in 2 patients non-union, 2 patients with fulminant infection finally
managed with girdle stone arthroplasty. The double angle DHS with valgus osteotomy with
fibular grafting increase the chances of union and attained satisfactory clinical and radiologic
results on follow-up.

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Luo D et al 55(2017) found that management of Pauwels type-3 vertical femoral neck fractures
has been a challenging clinical problem as they experience high shear forces and thus a greater
risk of treatment failure. There is no apparent consensus on the optimal implant type for these
injuries. They developed a modified dynamic hip screw (DHS), which was designed to a cage in
the lag screw, loaded with autologous bone graft for the treatment of Pauwels type-3 vertical
femoral neck fractures. Between February 2010 and January 2012, 17 consecutive patients with
Pauwels type-3 vertical femoral neck fractures were treated with the modified DHS loaded with
autologous bone graft. All patients were followed up for a minimum of 24 months (range, 24–36
months). Surgical details, operative and postoperative complications, the rates of nonunion and
osteonecrosis and the Harris hip score were evaluated. There were thirteen men and four women
with a mean age of 37.2 years (range, 27–52 years). There were no intraoperative complications
related to this technology. All fractures healed within 14.1 weeks (range, 12 to 20 weeks). One
patient required total hip replacement because of avascular necrosis of the femoral head at 27
months after surgery. According to the Harris hip score, eleven patients (64.7%) had excellent
results, four (23.5%) had good results, one (5.9%) had moderate and one (5.9%) had poor result.
The modified DHS loaded with autologous bone graft appears to be a reliable implant for the
treatment of Pauwels type-3 vertical femoral neck fractures with fewer complications.

Elgeidi A et al 56(2017) examined that posterior comminution of the femoral neck fracture is a
major cause of delayed and non-union owing to the loss of the buttressing effect against the
posterior rotation. When a femoral neck fracture with posterior comminution is anatomically
reduced, only the anterior portions of the femoral neck fracture surfaces are brought into contact
leaving a posterior defect. The purpose of this study was to evaluate the use of fibular strut
grafting and dynamic hip screw (DHS) for fresh femoral neck fractures with posterior
comminution in young patient less than 50 years. Between October 2012 and March 2016, 35
patients aged 20–50 years, 30 men and 5 women underwent fixation using DHS and fibular strut
grafts for Garden grades III (25 patients) and IV (10 patients) femoral neck fractures with
posterior comminution. All fractures were reduced by closed methods, and no hip was aspirated.
Clinical and radiological outcomes were evaluated. All patients were in the age group of 20–50
years (mean 37 years). The mean delay in presentation after injury was 1 day. The mean final
follow-up for these 35 patients was 27.2 months. Healing of the femoral neck was attained in 34
cases, with an average time to union of 4.8 months (range 4–8 months). One patient underwent

67
arthroplasty due to failure of fixation. According to the Harris hip score, outcome was good to
excellent in 30 patients, fair in 4, and poor in 1. In their study, only one patient developed non-
union and no patients had avascular necrosis of the femoral head. Closed reduction, fibular strut
grafts, and DHS fixation is a reliable procedure for femoral neck fractures with posterior
comminution in young adults.

Stravinskas M et al 57(2018) observed that the primary objective was to investigate the clinical
and radiological outcome in patients undergoing major hip surgery using a novel antibiotic
containing bone substitute for local augmentation in trochanteric fracture fixation or revision of
total hip arthroplasty (THA). They implanted a novel biphasic bone substitute CERAMENT™|G
consisting of hydroxyapatite, calcium sulphate and gentamicin for bone regeneration and local
antibiotic delivery in 20 patients treated surgically for trochanteric femoral fracture or
uncemented hip revision. Preoperative, postoperative, 3 months and 1 year clinical and
radiological assessment were performed including registration of any complications. In one
trochanteric fracture patient, histological analyses were performed of bone biopsies taken at
removal of hardware. None of the trochanteric fractures or revision of THA showed any large
migration. No local wound disturbances were seen and no infection was observed at one year
follow-up. All trochanteric fractures healed at 3 months with a minimal sliding screw
displacement on average 3 mm. Radiological analysis showed signs of bone remodeling and new
bone formation in the substitute, illustrated also by histology in the biopsies taken from one
trochanteric fracture at one year post-op. Local CERAMENT™|G was shown to be safe in a
limited prospective major hip surgery study. Remodeling of the bone graft substitute was
observed in all patients.

Xu Q et al 58(2019) this study was performed to compare the long-term clinical and radiological
outcomes of conversion total hip arthroplasty (CTHA) following prior failed InterTan nail (IT)
fixation or dynamic hip screw (DHS) fixation in Asian patients with osteoporotic
intertrochanteric hip fractures (IHFs) and to clarify which implant tends to be more favorable for
CTHA. Records of consecutive Asian patients with osteoporosis who underwent conversion of
failed primary unilateral IT or DHS fixation to THA from 2010 to 2013 were extracted from the
comprehensive database of the China Pacific Insurance Company Ltd. All consecutive
procedures were managed by high-volume surgeons. The primary endpoint was the clinical

68
outcome. The secondary endpoint was the radiological outcome. In total, 447 Asian patients with
osteoporotic IHFs (DHS, n = 223; IT, n = 224) were assessed during a median follow-up of 46
months (range, 39–53 months). The two groups showed a significant difference in the Harris hip
score at final follow-up and in the orthopedic complication rate (DHS, 20.2%; IT, 9.8%).
Conversion to THA following prior failed DHS fixation tends to be associated with poorer
clinical and radiological outcomes in Asian patients with osteoporotic IHFs than that following
prior failed IT fixation.

59
Nayak C et al (2019) observed that reduction and fixation in femoral neck fracture in young
patients have a problem of nonunion, requiring additional procedures like valgus osteotomy; but
fixation devices are technically difficult for inexperienced surgeons. They aims to assess the
results of valgus osteotomy in femoral neck fracture in their setup. They reported a series of 20
patients of higher Pauwels’s angled fracture of femoral neck fracture presenting late wherein
valgus osteotomy was added to reduction fixation which was secured with a commonly available
135° dynamic hip screw and plate. Femoral neck fractures united in 16 patients (80%). Excellent
to good results (Harris hip score >80) were seen in 70% patients. Angle of correction of
preoperative Pauwels has been changed from 68.3 to 34.3. The 135° dynamic hip screw and plate
provides rigid internal fixation after valgus osteotomy and being a more familiar fixation device
simplifies the procedure with good results.

Li Z et al 60 (2020) the aim of their study was to compare the clinical effect of short dynamic hip
screw (DHS) combined with fibula bone graft and short DHS combined with cannulated screws
(CS) on the treatment of femoral neck fracture in young adults. Thirty-five Pauwels type III
femoral neck fracture patients between January 2014 and May 2019 were divided into two
groups: group A (patients treated with DHS combined with fibula bone graft) and group B
(patient treated with DHS combined with CS). The operative time, intraoperative blood loss,
fracture healing time and complication of two groups were recorded. There were no significant
differences in operative time, intraoperative blood loss in two groups. Fracture healing time in
group A (5.28±1.07) was significantly shorter than group B (7.31±1.65). The rate of fracture
nonunion (0), femoral head necrosis (0) and withdrawal rate (0) in group A were significantly
lower than that in group B (4, 23.5) (4, 23.5) (6, 35.3) (P<0.01). Postoperative Harris function
score in group A (95.44±2.57) was higher than group B (87.82±7.79) (P<0.01). DHS combined

69
with fibula bone graft can shorten the healing time of fracture, reduce the rate of bone nonunion
and femoral head necrosis, and provide a new treatment method for Pauwels type III femoral
neck fracture in young adults.

61
Xia T et al (2020) found that hip preserving procedures are still a challenge in late-stage
osteonecrosis of femoral head (ONFH) patients. They aimed to compare the clinical outcomes of
surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy
for treatment of ONFH in Association Research Circulation Osseous (ARCO) stage III patients.
They retrospectively reviewed 30 ARCO stage III patients (33 hips) who had surgical dislocation
and impaction bone graft or surgical dislocation and rotational osteotomy in their center from
June 2012 to December 2017. Baseline characteristics, clinical evaluation using Harris score and
radiologic evaluation up to 12 months after surgery were recorded and compared. Fifteen
patients (17 hips) were in the surgical dislocation and impaction bone graft group and 15 patients
(16 hips) were in the surgical dislocation and rotational osteotomy group. No significant
differences in age, gender, etiology, ARCO stage, duration of illness, operation time, and length
of hospitalization were observed between the 2 groups. Compared to preoperational Harris score,
the Harris score of 6 months post operation and 12 months post operation significantly improved.
At 12 months post operation, the excellent and good rate was 76.5% in the impaction bone graft
group and 87.5% in the rotational osteotomy group. No significant difference in Harris scores
was detected in the 2 groups. Surgical dislocation and impaction bone graft and surgical
dislocation and rotational osteotomy had satisfactory 1-year efficacy for ARCO III ONFH
patients. Surgical dislocation and rotational osteotomy had better short-term efficacy than
surgical dislocation and impaction bone graft.

62
Kumar R et al (2020) showed that fractures of proximal femur are amongst the most
often encountered fractures by orthopedic surgeon. Intertrochanteric fractures were one of
the most common fractures of the hip especially in the osteoporotic bones and high velocity
trauma. Many treatment techniques are described in literature but internal fixation with Dynamic
Hip Screw is the versatile treatment of choice. To analyze the clinico-radiological and functional
outcome of intertrochanteric fractures by dynamic hip screw. A retrospective study with 64
adult patients with intertrochanteric fractures according to Boyd & Griffin classification were
treated with dynamic hip screw (DHS) in School of Medical Sciences & Research from

70
January 2014 and December 2018. All the cases were followed at regular intervals as per their
study protocol. The functional outcome was assessed with Modified Harris Hip Score. In the
present study, 64 intertrochanteric fractures underwent surgical fixation with dynamic hip screw
(DHS). The functional results assessed by Modified Harris Hip score showed excellent in 37
cases (57.81%), good in 13 cases (20.31%), fair in 9 cases (14.06%) and poor in 5 cases (7.81%).
they conclude that the dynamic hip screw (DHS) is an ideal and versatile implant of choice for
intertrochanteric fractures, leading to high rate of bone union restoring the postero-medial
wall, reducing the chances of implant failure and decreasing the post-operative morbidity by
improving the functional quality of life.

Li Z et al 63(2020) the aim of their study was to compare the clinical effect of short dynamic hip
screw (DHS) combined with fibula bone graft and short DHS combined with cannulated screws
(CS) on the treatment of femoral neck fracture in young adults. Thirty-five Pauwels type III
femoral neck fracture patients between January 2014 and May 2019 were divided into two
groups: group A (patients treated with DHS combined with fibula bone graft) and group B
(patient treated with DHS combined with CS). The operative time, intraoperative blood loss,
fracture healing time and complication of two groups were recorded. There were no significant
differences in operative time, intraoperative blood loss in two groups. Fracture healing time in
group A (5.28±1.07) was significantly shorter than group B (7.31±1.65). The rate of fracture
nonunion (0), femoral head necrosis (0) and withdrawal rate (0) in group A were significantly
lower than that in group B (4, 23.5) (4, 23.5) (6, 35.3) (P<0.01). Postoperative Harris function
score in group A (95.44±2.57) was higher than group B (87.82±7.79) (P<0.01). DHS combined
with fibula bone graft can shorten the healing time of fracture, reduce the rate of bone nonunion
and femoral head necrosis, and provide a new treatment method for Pauwels type III femoral
neck fracture in young adults.

Sun Y et al 64(2020) this study aimed to explore the effect of the treatment through autologous
fibula graft and hollow needle fixation to treat femoral head cutting after dynamic hip screw
(DHS) fixation. A total of 41 patients were admitted to the department of orthopedic trauma and
received DHS fixation. Preoperative and postoperative Harris score of hip function, limb
shortening length and collodiaphysial angle between operation group (n = 11) and non-operation
group (n = 13) were compared. There was no difference between the two groups before surgery

71
(P > 0.05). There was a difference between the preoperative and postoperative in the operation
group (P < 0.05). The excellent and good rate of the hip function score in patients 6 months after
the operation was 55.6%. In the operation group, the hip function score increased after surgery
(P < 0.001). Except for two groups of patients before operation, there was a difference in the
limb shortening length and collodiaphysial angle between the operation group and non-operation
group in other time points after surgery (P < 0.001). The application of the autogenous fibula
graft and hollow nail fixation was effective in treating femoral head cutting after DHS fixation,
and patients’ subjective evaluation and objective indicators’ outcomes of follow up were
satisfactory, which was worthy of clinical application.

Wei YP et al 65 (2021) this study was to evaluate the risk factors related to osteosynthesis failure
in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age;
smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction;
unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct. Patients over
the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level
one medical center between 2003 and 2019 were included. Treatment modalities included single
construct with/without an antirotational screw for the neck and dual constructs. Radiographic
outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher
exact test was used to analyze categorical variables. The presence of avascular necrosis of the
femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture and
loss of reduction were identified as factors related to treatment failure. A total of 22 patients
were included in this study. The average age was 58.5 years, and the majority was male (68.2%).
The minimum radiographic follow-up duration was 12 months, and the median follow-up time
was 12 (interquartile range 12–24) months. Femoral neck osteosynthesis failed in 3 patients,
whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the
failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct
cohort in 16 infra-isthmus femoral fracture cases (P = .034). In ipsilateral femoral neck and
infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate
implants (dual constructs). In a dual-construct cohort, separate plate fixation of the femoral shaft
achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union
rate: 4/8 vs 0/2)

72
 MATERIAL AND METHODS

Study design: Institution based prospective cohort study.

Study setting and timeline: Study was conducted for 12 months. In the 12 months, there was
patient recruitment. The patients recruited till April 2022. Next two months would be for
statistical analysis and another of one month for thesis writing and submission.

Place of study: Patients attending Outpatient/Inpatient department and Trauma care of

Orthopaedics, RG Kar, Kolkata.

Period of study: August 2020 to April 2021

Study population: Patients with age less than 60 years, presenting with traumatic Neck of femur
fracture more than 6 weeks since date of injury , and without avascular necrosis of the femoral
head on MRI.

Statistical Software

Sample size has been calculated with help of Epi Info (TM) 3.5.3. EPI INFO which is a
trademark of the Centers for Disease Control and Prevention (CDC). For statistical analysis data
were entered into a Microsoft excel spreadsheet and then analyzed by SPSS 27.0. and Graph Pad
Prism version 5. Data had been summarized as mean and standard deviation for numerical
variables and count and percentages for categorical variables. p-value ≤ 0.05 was considered for
statistically significant.

Sample Size Justification

One study found that incidence of femoral neck fractures was 45.5%. So for this study p=0.455.

Thus the number of patients required for this study was 24.9~ 25 with power 87%.

The formula used for sample size calculation was as follows:-

n = 4pq / (L2)

Where, n= required sample size,

73
p= 0.455 (as per the study Koval KJ et al),23

q = 1 – p,

L = Loss % (Loss of information)

Calculation:

Here p= 0.455,

q=1-p = 1-0.455 =0.545,

4pq = 4 x 0.455 x 0.545 = 0.9919

L2 = 0.0397

L= 0.1992

Loss of information percentage = 19.92%

n= 4pq / (L2) = 0.9919/0.0397= 24.9= 25

Study group: 25 patients will take in their study

Inclusion criteria

1. Age < 60 years

2. Time since injury > 6 weeks

Exclusion criteria

1. Avascular Necrosis of Femoral Head

2. Pathological Neck of Femur Fracture

74
TECHNIQUE USED IN THE STUDY – CLOSED REDUCTION OF FRACTURE DONE WITH
DYNAMIC HIP SCREW. ILIAC CREST BONE GRAFT WAS THEN HARVESTED AND A
HOLE MADE WITH 3.2 MM DRILL.A TUNNEL WAS MADE WITH A TRIPLE REAMER
ABOVE THE FRACTURE SITE PARALLEL TO THE LAG SCREW.THE GRAFT WAS THEN
IMPACTED INTO THIS SPACE.NO SEPARATE SCREW FIXATION WAS REQUIRED FOR
THE GRAFT.

75
PARAMETER

1. Harris Hip Score: 90-100=Excellent, 80-89=Good,70-79=Fair and <70=poor

76
2. Union status on Digital Xray

3. Quality of reduction- Assessed by trabecular pattern at the fracture site post-reduction.

An angle of 160⁰-180⁰ in both antero-posterior and lateral skiagrams is considered as good
quality of reduction.

4. Post-operative collapse

Lab investigations: Routine blood investigations and other tests required for anaesthetic fitness.

Radiological investigations: Skiagram of the affected limb to rule out associated bony deformity.
MRI of affected hip.

77
Procedure: Clinical examination of patients in the post-operative period and calculation of Harris
Hip Score was done.

Assessment of Union, Post-operative collapse and Quality of reduction will do based on post-
operative skiagram and serial skiagrams( at 1, 3 and 6 months post-op)

Statistical analysis plan: Data for patients was tabulated in a Microsoft Excel 2019 worksheet
and statistical analyses was done by IBM SPSS ver 26. A continuous variable was summarized
with mean and standard deviation. For the two tests, sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV) was calculated and compared by Mc Nemar
test. Sensitivity=true positives/(true positives+false negatives) Specificity=true negatives/(true
negatives+false positives) Positive predictive value=true positives/(true positives+false positives)
Negative predictive value=true negatives/(true negatives+false negatives). The accuracy, defined
as the proportion of true positive plus true negative findings for all results, was also calculated
for each of the 2 examination maneuvers. P < .05 was considered statistically significant.

Ethical clearance: The current study will conform to the ethical guidelines laid down by the
Declaration of Helsinki for biomedical research involving human subjects. The Study Protocol,
Patient Information Sheet and the Informed Consent Form (ICF)(Bengali, English and Hindi
versions) was submitted to the Institutional Ethics Committee (IEC) of RG Kar Medical College,
Kolkata, for approval. Subject recruitment will commence once written approval is obtained
from IEC. During screening of the subjects, all potential subjects who fulfilled the study
selection criteria was informed by the investigator, verbally, in vernacular, about the study in
details (including the rationale, aims and objective of the study, study related procedures,
potential discomfort and benefits of participation). Following this copy of Informed Consent
Form and Patient Information Sheet was provided to the subjects and they were requested to go
through them. The investigator will also answer any study related queries raised by the subject.
After the above-mentioned procedure only those subjects who are willing to participate was
asked to sign and date the written informed consent form expressing their voluntary participation
in the study. All study related activity will start only after such consent is obtained. Subjects
were duly explained that they will not receive any monetary remuneration for participation in the

78
study. The investigator will ensure the confidentiality of the study participants. The case record
forms, study documents and biological samples collected were untitled and anonymous. All
study related documents was kept under the strict supervision of the principal investigator at a
designated place in RG Kar Medical College, Kolkata. Sterility and universal precaution was
maintained during the process.

Work plan: Study was started after clearance from ethical committee. Patients were examined
after taking consent. Study was conducted for 12 months. In the first 12 months, there was
patient recruitment. Next one month was for statistical analysis and another of one month for
thesis writing and submission.

79
Statistical Analysis:
For statistical analysis data were entered into a Microsoft excel spreadsheet and then analyzed by
SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and Graph Pad Prism version 5. Data had
been summarized as mean and standard deviation for numerical variables and count and
percentages for categorical variables. Two-sample t-tests for a difference in mean involved
independent samples or unpaired samples.

Z-test (Standard Normal Deviate) was used to test the significant difference of proportions.

Once a t value is determined, a p-value can be found using a table of values from Student's t-
distribution. If the calculated p-value is below the threshold chosen for statistical significance
(usually the 0.10, the 0.05, or 0.01 level), then the null hypothesis is rejected in favor of the
alternative hypothesis.

P-value ≤ 0.05 was considered for statistically significant.

80
 RESULT & ANALYSIS

Table: Distribution of Sex

Sex Frequency Percent

Female 10 50.0%
Male 10 50.0%
Total 20 100.0%

In our study, 10 (50.05) patients were female and 10 (50.0%) patients were male.
The value of z is 0. The value of p is 1. The result is not significant at p < .05.

50%
50%
Female
Male

81
 Table: Distribution of Chief Complaint

Chief Complaint Frequency Percent

Pain And In ability To Walk 15 75.0%
Pain And Walking With Support 5 25.0%
Total 20 100.0%

In our study, 15 (75.0%) patients had Pain and in ability to Walk and 5 (25.0%) patients had Pain
and Walking with Support.
The value of z is 3.1623. The value of p is .00158. The result is significant at p < .05.

25%
Pain And In ability To
Walk
75% Pain And Walking With
Support

82
 Table: Distribution of Immediate Post-Operative Quality of Reduction

Immediate Post-Operative (Quality Of Reduction) Frequency Percent

Acceptable 2 10.0%
Good 18 90.0%
Total 20 100.0%

In our study, 2 (10.0%) patients had Acceptable and 18 (90.0%) patients had good quality of
reduction in Immediate Post-Operative skiagram.
The value of z is 5.0596. The value of p is < .00001. The result is significant at p < .05.

10%

Acceptable
Good
90%

83
 Table: Distribution of Post-Operative 1 Month Quality of Reduction

Post-Operative 1 Month (Quality Of Reduction) Frequency Percent

Acceptable 2 10.0%
Good 17 85.0%
Implant Failure 1 5.0%
Total 20 100.0%

In our study, 2 (10.0%) patients had Acceptable, 17 (85.0%) patients had Good and 1 (5.0%)
patient had Implant Failure in Post-Operative 1 Month (Quality of Reduction).The patient with
implant failure was non-compliant and came to follow-up 2 weeks later in weight bearing
position.
The value of z is 4.7494. The value of p is < .00001. The result is significant at p < .05.

5% 10%

Acceptable
Good
Implant Failure
85%

84
 Table: Distribution of Post-Operative 3 Months -Quality of Reduction

Post-Operative 3 Months (Quality Of Reduction) Frequency Percent

Acceptable 2 10.5%
Good 17 89.5%
Total 19 100.0%

In our study, 2 (10.0%) patients had Acceptable and 17 (89.5%) patients had Good maintenance
of Post-Operative reduction 3 Months .

The value of z is 4.7494. The value of p is < .00001. The result is significant at p < .05.

11%

Acceptable
Good
89%

85
 Table: Distribution of Post-Operative 6months (Quality of Reduction)

Post-Operative 6months (Quality Of Reduction) Frequency Percent

Acceptable 2 10.5%
Good 17 89.5%
Total 19 100.0%

In our study, 2 (10.0%) patients had Acceptable and 17 (89.5%) patients had Good in Post-
Operative 6 Months (Quality of Reduction).
The value of z is 4.7494. The value of p is < .00001. The result is significant at p < .05.

11%

Acceptable
Good
89%

86
 Table: Distribution of Post-Operative 1 Month (Union Status)

Post-Operative 1 Month (Union Status) Frequency Percent

Implant Failure 1 5.0%
Uniting 19 95.0%
Total 20 100.0%

In our study, 1 (5.0%) patients had Implant Failure and 19 (95.0%) patients had Uniting in Post-
Operative 1 Month (Union Status).
The value of z is 5.6921. The value of p is < .00001. The result is significant at p < .05.

5%

Implant Failure
Uniting
95%

87
 Table: Distribution of Post-Operative 3 Months (Union Status)

Post-Operative 3 Months (Union Status) Frequency Percent

Uniting 19 100.0%
Total 19 100.0%

In our study, 19 (100.0%) patients had Uniting in Post-Operative 3 Month (Union Status).
The value of z is NaN. The value of p is < .00001. The result is significant at p < .05.

Frequency

100%

88
 Table: Distribution of Post-Operative 6 Months (Union Status)

Post-Operative 6 Months (Union Status) Frequency Percent

Uniting 19 100.0%
Total 19 100.0%

In our study, 19 (100.0%) patients had Uniting in Post-Operative 6 Month (Union Status).
The value of z is NaN. The value of p is < .00001. The result is significant at p < .05.

Frequency

100%

89
 Table: Distribution of Post-Operative Collapse

Post-Operative Collapse (Union Status) Frequency Percent

No 18 94.7%
Yes 1 5.3%
Total 19 100.0%

In our study, 1 (5.3%) patients had Post-Operative Collapse (Union Status).

The value of z is 5.5155. The value of p is < .00001. The result is significant at p < .05.

5%

No
Yes

95%

90
 Table: Distribution of Age

Number Mean SD Minimum Maximum Median

Age 20 33.4500 11.2272 21.0000 55.0000 32.0000

In above table showed that the mean Age (mean±s.d.) of patients was 33.4500±11.2272.

50
45
40
35
30
Mean ± SD

25
Age
20
15
10
5
0
Mean

91
 Table: Distribution of Time Since Injury at Presentation (Weeks)

Number Mean SD Minimum Maximum Median

Time Since Injury At
20 11.5000 2.3283 8.0000 17.0000 11.0000
Presentation (Weeks)

In above table showed that the mean Time Since Injury at Presentation (Weeks) (mean±s.d.) of
patients was 11.5000±2.3283.

16

14

12

10
Mean ± SD

8 Time Since Injury At

Presentation (Wks)
6

0
Mean

92
 Table: Distribution of Interval between Injury and Intervention (Weeks)

Number Mean SD Minimum Maximum Median

Interval between
Injury And 20 13.5000 2.4602 10.0000 20.0000 13.0000
Intervention (Weeks)

In above table showed that the mean Interval between Injury and Intervention (Weeks)
(mean±s.d.) of patients was 13.5000±2.4602.

18
16
14
12
Mean ± SD

10
Interval between Injury
8 And Intervention (Wks)
6
4
2
0
Mean

93
 Table: Distribution of Interval to Weight Bearing (Weeks)

Number Mean SD Minimum Maximum Median

Interval To Weight
20 6.6000 2.2337 1.0000 12.0000 6.0000
Bearing (Weeks)

In above table showed that the mean Interval to Weight Bearing (weeks) (mean±s.d.) of patients
was 6.6000±6.6000.

10
9
8
7
6
Mean ± SD

5 Interval To Weight
4 Bearing (Wks)

3
2
1
0
Mean

94
 Table: Distribution of 3 Months Harris Hip Score

Number Mean SD Minimum Maximum Median

3 Months Harris Hip
19 84.3158 4.0968 74.0000 92.0000 84.0000
Score

In above table showed that the mean 3 Months Harris Hip Score (mean±s.d.) of patients was
84.3158±4.0968.

90

88

86
Mean ± SD

84
3 Months Harris Hip Score
82

80

78

76
Mean

95
 Table: Distribution of 6 Months Harris Hip Score

Number Mean SD Minimum Maximum Median

6 Months Harris Hip
19 88.6842 3.5442 77.0000 93.0000 88.0000
Score

In above table showed that the mean 6 Months Harris Hip Score (mean±s.d.) of patients was
88.6842±3.5442.

94

92

90
Mean ± SD

88
6 Months Harris Hip Score
86

84

82

80
Mean

96
 DISCUSSION

The present study was an Institution based prospective cohort study. This Study was conducted
from August 2020 to April 2021 at Outpatient/Inpatient department and Trauma care of
Orthopaedics, RG Kar, Kolkata. Total 20 patients were included in this study.

Shen JZ et al 48 (2012) showed that delayed bone union, nonunion or osteonecrosis often occur
after femoral neck fractures in young adults. They designed Hb-DHS and DHS devices
appropriate to the femoral neck and head of experimental animals and used them in eight pigs (4-
month-old, male or female, 30-40 kg/each).

Wei YP et al 65 (2021) this study was to evaluate the risk factors related to osteosynthesis failure
in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; The
average age was 58.5 years, and the majority was male (68.2%).

In our study, 10 (50.0%) patients were male and female. (p=1.0000), (z=0.0000)

We found that, the greatest number of patients had Pain and in inability to Walk [15 (75.0%)]. It
was statistically significant (p=.00158), (z=3.1623)

We examined that, majority of the patients had Good Immediate Post-Operative (Quality of
Reduction) [18 (90.0%)] and it was statistically significant (p<.00001), (z=5.0596)

We found that, significantly higher of patients had Good in Post-Operative 1 Month (Quality of
Reduction) [17 (85.0%)]. (p<.00001), (z=4.7494)

We examined that, most of the patients were Good in Post-Operative 3 Months (Quality of
Reduction) [17 (89.5%)]. Which was statistically significant (p<.00001), (z=4.7494)

We found that, a greater number of patients had Good maintenance in Post-Operative 6 Months
(Quality of Reduction) [17 (89.5%)]. Which was statistically significant (p<.00001), (z=4.7494)

We examined that, majority of the patients had Uniting in Post-Operative 1 Month (Union
Status) [19 (95.0%)] and it was statistically significant (p<.00001), (z=5.6921)

We examined that, significantly 19 (100.0%) patients had Uniting in Post-Operative 3 Month

(Union Status) (p< .00001), (z=0.0000)

97
We revealed that, significantly 19 (100.0%) patients had Uniting in Post-Operative 6 Month
(Union Status). (p< .00001), (z=0.0000)

In our study, 1 (5.3%) patient had Post-Operative Collapse (Union Status) which was statistically
significant (p<.00001), (z=5.5155).

In our study, the mean Age (mean±s.d.) of patients was 33.4500±11.2272, the mean Time Since
Injury at Presentation (weeks) (mean±s.d.) of patients was 11.5000±2.3283, the mean Interval
between Injury and Intervention (Weeks) (mean±s.d.) of patients was 13.5000±2.4602, that the
mean Interval to Weight Bearing (Weeks) (mean±s.d.) of patients was 6.6000±6.6000, the mean
3 Months Harris Hip Score (mean±s.d.) of patients was 84.3158±4.0968 and that the mean 6
Months Harris Hip Score (mean±s.d.) of patients was 88.6842±3.5442.

Out of 2 patients who had acceptable quality of reduction, 1 had post-operative collapse.

The patient with post operative collapse had the poorest Harris hip score which was 74 at 3
months( z score: -2.5,p value : 0.0621)) and 77 at 6 months ( z score:-3.3,p-value:0.000483).
This is statistically significant.

3 out of 17 patients ,who had good quality of reduction, has Harris Hip Score of >= 90 at 3
months. The t-score is -4.54 with p-value of 0.000030. This is statistically significant.

7 out of 17 patients with good quality of reduction at 6 months has Harris Hip Score of >=90.
The t-score is -3.359 with p-value 0.000928 which is statistically significant.

Hence, we can conclude that good quality of reduction has a statistically significant correlation
with Harris Hip Score of 90 and above.

98
 SUMMARY AND CONCLUSION

 In our study, number of the patients were equal in male and female.
 We found that, most number of patients had Pain and in ability to Walk. It was
statistically significant.
 We examined that, majority of the patients had Good in Immediate Post-Operative
(Quality of Reduction) and it was statistically significant.
 We found that, significantly higher of patients had Good in Post-Operative 1 Month
(Quality of Reduction).
 We examined that, most of the patients were Good in Post-Operative 3 Months (Quality
of Reduction). Which was statistically significant.
 We found that, a greater number of patients had Good in Post-Operative 6 Months
(Quality of Reduction). This was statistically significant.
 We examined that, majority of the patients had Uniting in Post-Operative 1 Month
(Union Status) and it was statistically significant.
 We examined that, significantly patients had Uniting in Post-Operative 3 Month (Union
Status).
 We revealed that, significantly patients had Uniting in Post-Operative 6 Month (Union
Status).
 In our study, patient had Post-Operative Collapse (Union Status) which was statistically
significant
 In our study, the mean Age (mean±s.d.) of patients was 33.4500±11.2272, the mean Time
Since Injury at Presentation (Weeks) (mean±s.d.) of patients was 11.5000±2.3283, the
mean Interval between Injury and Intervention (Weeks) (mean±s.d.) of patients was
13.5000±2.4602, that the mean Interval to Weight Bearing (Weeks) (mean±s.d.) of
patients was 6.6000±6.6000, the mean 3 Months Harris Hip Score (mean±s.d.) of patients
was 84.3158±4.0968 and that the mean 6 Months Harris Hip Score (mean±s.d.) of
patients was 88.6842±3.5442.
 We demonstrated that radiological and clinical outcome in a case of old traumatic neck of
femur fracture fixed with dynamic hip screw with bone graft.

99
LIMITATIONS OF THE STUDY

In spite of every sincere effort my study has lacunae.

The notable short comings of this study are:

1. The sample size was small. Only 20 cases are not sufficient for this kind of study.

2. The study has been done in a single center. The study was carried out in a tertiary care

hospital, so hospital bias cannot be ruled out.

3. BMD test was not available. Hence, effect of quality of bone on union could not be

assessed.

4. Poor quality ,make of implants due to Covid-19.

100
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APPENDIX I

107
108
109
110
111
 APPENDIX II

INFORMED CONSENT FORM

APPENDIX 1

Patient’s name: Bed

No:

I , Mr/Mrs. have been informed about all aspects of the study, the drug, the procedure and
possible adverse effects by the investigator verbally in language known to me. After
understanding ail the above aspects carefully, give my full, informed voluntary consent to
participate in this study.

Signature of the investigator Signature of the patient

Date.

112
113
114
NAME AGE SEX REG NO TIME SINCE INJURY AT PRESENTATION CHIEF COMPLAINT INTERVAL BETWEEN INJURY AND INTERVENTION
BIDISHA BISWAS 21 F 2100029445 08 WEEKS PAIN AND INABILTY TO WALK 10 WEEKS
SRIKANTA BAGDI 30 M 2100066068 17 WEEKS PAIN AND WALKING WITH SUPPORT 20 WEEKS
AFRIN BANO 22 F 2100082039 11 WEEKS PAIN AND INABILTY TO WALK 13 WEEKS
BELA DAS* 50 F 2100090166 12 WEEKS PAIN AND INABILTY TO WALK 14 WEEKS
MAYA JOARDAR 55 F 2100079542 08 WEEKS PAIN AND INABILTY TO WALK 11 WEEKS
AMBU DOLUI 32 M 2100072060 11 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS
SARMILA ADHIKARY 38 F 2100050614 09 WEEKS PAIN AND INABILTY TO WALK 11 WEEKS
NETAI GHOSH 47 M 2100038568 12 WEEKS PAIN AND WALKING WITH SUPPORT 14 WEEKS
AUROBINDO KAR 36 M 2100052679 10 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS

115
NEHA MONDAL 22 F 2200066444 11 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS
SUDIP MONDAL 32 M 2200082835 10 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS
PRIYA HALDER 33 F 2200062274 11 WEEKS PAIN AND INABILTY TO WALK 13 WEEKS
BHAKTI JANA 22 M 2200083129 14 WEEKS PAIN AND WALKING WITH SUPPORT 16 WEEKS
ASMA BIBI 25 F 2200077971 11 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS
SK HASEM 22 M 2200034060 10 WEEKS PAIN AND INABILTY TO WALK 12 WEEKS
ANITA ADHIKARY# 48 F 2200064761 12 WEEKS PAIN AND INABILTY TO WALK 14 WEEKS
PARBATI DAS 21 F 2200044172 16 WEEKS PAIN AND WALKING WITH SUPPORT 18 WEEKS
SK JISHAN 47 M 2200059944 14 WEEKS PAIN AND WALKING WITH SUPPORT 16 WEEKS
SUBHA MURMU 25 M 2200050247 11 WEEKS PAIN AND INABILTY TO WALK 14 WEEKS
RAKTIM DAS 41 M 2200026337 12 WEEKS PAIN AND INABILTY TO WALK 14 WEEKS
*IMPLANT FAILURE
#POST-OPERATIVE
COLLAPSE
 POST- POST- POST- POST- POST- POST- POST-
IMMEDIATE POST OPERATIVE OPERATIVE OPERATIVE OPERATIVE 1 OPERATIVE 3 OPERATIVE 6 OPERATIVE 3 6
OPERATIVE 1 MONTH 3 MONTHS 6MONTHS MONTH MONTHS MONTHS COLLAPSE MONTHS MONTHS
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 91 92
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 84 91
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 83 86
IMPLANT IMPLANT
GOOD FAILURE FAILURE
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 84 88
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 85 91
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 92 93

116
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 86 91
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 85 90
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 82 87
ACCEPTABLE ACCEPTABLE ACCEPTABLE ACCEPTABLE UNITING UNITING UNITING NO 83 87
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 85 91
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 82 88
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 92 93
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 83 87
ACCEPTABLE ACCEPTABLE ACCEPTABLE ACCEPTABLE UNITING UNITING UNITING YES 74 77
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 84 88
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 82 88
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 83 89
GOOD GOOD GOOD GOOD UNITING UNITING UNITING NO 82 88