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Management of Neglected Fracture Neck of Femur by Pauwels Osteotomy: A Prospective and Retrospective study
INTRODUCTION: Fracture neck of femur is aptly called as “the unsolved
fracture”. This is because even with so much of advances in
orthopedic field, there is no simple method of treatment which can
give consistently successful results for this fracture. Management
of this fracture especially in younger patients is a really demanding
and challenging task for any orthopaedic surgeon.
Fracture neck of femur is common in old people as many of
them are osteoporotic. With improvement in quality of life leading
to increased life expectancy, the incidence is even more common
nowadays. Due to the congested vehicular traffic, it is also
commonly seen in young patients after road traffic accidents and
many a times they are polytraumatized.
The best end result after fracture neck of femur treatment is the
patients own healed femoral head and neck and every attempt
must be made to achieve that goal.
AIM: The aim of this study is to analyse the role of valgus osteotomy in neglected fracture neck of femur.
MATERIALS AND METHODS: Study conducted at the department orthopedics , Kilpauk
medical college hospital, Chennai.
Period of study –1998 – 2006
Both retrospective & prospective study.
We operated 19 cases neglected fracture neck of femur and one
case after implant failure. Totally 20 patients included for study.
Inclusion Criteria -
1. Age group less than 60 years,
2. Duration of fracture more than 3 weeks old,
3. Pauwels type II & III,
4. Garden TYPE III & IV,
5. Active individuals.
Exclusion Criteria -
1. Age group more than 60 years,
2. Duration of fracture less than 3 weeks old,
3. Pauwels type I,
4. Garden TYPE I & II,
5. Osteoporosis,
6. AVN with severe collapse.
RESULTS: All the 20 cases were followed up our follow up period ranges from 4 months to 8 years.
All patients were assessed by clinical, functional & radiological evaluation using Harris hip scoring system.
1. PAIN -
3 out of 20 patients had persistent pain in the hip because of avascular necrosis of femoral head.
2. UNION -
All but one patient had good consolidation of both osteotomy site and fracture at the end of 6 months. One patient had implant cut out partly due to inadequate fracture reduction and partly due to premature weight bearing. Planning for redo of surgery. One patient had union with retroversion.
3. GAIT - 14 of 20 patients had normal gait. 3 had minimal limp and one had moderate limp.
4. SUPPORT -
All of 20 patients walked without any support.
5. HIP FUNCTION -
16 patient more than 75 % of range movements & 4 had 50 -75 % of ROM.
17 of our 20 patients were able do normal day to day activities like walking, cycling, squatting & sitting cross legged. 3 patients has difficulty in squatting & sitting cross legged.
6. LIMB LENGTH DISCREPANCY -
15 patients had no limb length discrepancy. One patient had lengthening 1cm. 4 patients had shortening 1-2 cm.
7. INFECTION -
One of our patient superficial wound infection which was controlled with antibiotics and dressings.
CONCLUSION: Our Indian patients require squatting and sitting cross legged
for normal day to day activities. Therefore in a patient with
neglected fracture neck of femur, we can not achieve this by
prosthetic replacement as it has its own limitations. One must aim
to preserve the natural head of femur.
Though many methods for treating neglected fracture neck
of femur, valgus osteotomy is a very effective procedure. The other
procedures like Meyer’s muscle pedicle grafting and free or
vascularised fibular grafting are more extensive, expensive and
high morbidity to the patient.
Meticulous pre operative planning regarding placement of
blade and level of osteotomy along with early stable fixation is
essential for fracture union.
We conclude that for the patients under 55 years of age with
neglected fracture of the femoral neck, the Pauwels osteotomy
produces many good results, even in the presence of avascular
necrosis of femoral head providing the head has not collapsed