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Trauma: A. Gupta The management of ununited fractures of the femoral neck using internal fixation and muscle pedicle periosteal grafting J Bone Joint Surg Br 2007; 89-B: 1482-1487 [Abstract] [Full text] [PDF]

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Ajay Gupta   (11 January 2008)

The management of ununited fractures of the femoral neck

Ravi V Badge, DK Jain (Clinical Fellow), MV Hemmady (Consultant)   (20 December 2007)

Author's reply 11 January 2008
Ajay Gupta, Professor, Dept. of Orthopaedics Maulana Azad Medical College & associated LN Hospital, New Delhi-110002.INDIA Send letter to journal: Re: Author's reply drajaygupta{at}hotmail.com Ajay Gupta	Sir, I thank Mr Badge et al for their interest in my paper and for raising some vital issues. Visual loss following surgery in the prone position has been related to prolonged hypotension, anaemia, long operative time and direct pressure on the globe, and is seen mostly after long spinal operations. We did not have any complications related to the prone position since the procedure undertaken in the present study does not involve long operating time or significant blood loss to cause prolonged hypotension. It is never a problem obtaining intra-operative lateral views of the hip with the patient in the prone position on a fracture table although the lateral position on a fracture table may not provide good visualisation of the femoral head, particularly the lateral view. The lateral position is definitely a more desirable option than the prone position. I have also performed a few quadratus femoris myoperiosteal graftings with the patient in the lateral position but in patients with idiopathic osteonecrosis of the femoral head with an intact neck. I have acknowledged the possibility of damage to femoral head vasculature through a posterior approach. However, I have also expressed doubts about the usefulness of the remaining intact retinacular vessels after a displaced fracture of the femoral neck. I fail to visualise any lateral approach which will allow the surgeon to transpose the insertion of the quadratus femoris to the femoral neck. If one is very keen to avoid the prone position and the posterior approach, a myoperiosteal graft on tensor fascia lata is a good alternative and has been successfully used by one of my colleagues to treat nonunion of the femoral neck. Anatomical reduction, impaction of the fragments and rigid fixation are the main factors necessary to achieve the best results in displaced fractures of the femoral neck. It is difficult, however, to increase leg length and retain the vascularity to the femoral neck and head. The present study involves a neck sparing procedure rather than the prevalent neck sacrificing ones where various measures to achieve fracture union involve compromising the available neck length, neck shaft angle or femoral offset. The prime emphasis of the present work has been to highlight the osteogenic potential of the periosteum which allowed us to achieve fracture union in all cases despite such adversities as the vertical alignment of the fracture and the absence of the appositional and compression stability at the fracture surfaces. The technique of vascularised periosteal graft can surely be applied to any fracture nonunion management. We have successfully used it for scaphoid nonunion with osteonecrosis of the proximal pole using myoperiosteal graft on a pronator quadratus muscle pedicle and also for segmental nonunion of the ulnar shaft using a myoperiosteal graft on a supinator muscle pedicle. The time taken for fracture union and the post-operative rehabilitation in a 12-year-old child is different from that of a 40-year-old patient. The described post-operative rehabilitation in the manuscript refers only to the adult patients. A. Gupta, MS(Orth), Professor, Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India.
The management of ununited fractures of the femoral neck 20 December 2007
Ravi V Badge, Clinical Research Fellow Wrightinton Hospital, Wrightington, Wigan and Leigh NHS Trust, DK Jain (Clinical Fellow), MV Hemmady (Consultant) Send letter to journal: Re: The management of ununited fractures of the femoral neck raviorth{at}rediffmail.com Ravi V Badge, et al.	Sir, We read this article with interest and we congratulate the author for obtaining such excellent results in his series with this novel technique for treating a challenging orthopaedic problem. There are certain points we would like to comment on. Did any of the patients in the study have complications related to the prone position?1-3 Is there any advantage over lateral position? Were intra-operative lateral views taken and if so, how was it done with patient in prone position on a fracture table? The author acknowledges the possibility of damage to femoral head vasculature through a posterior approach. Would a lateral approach as suggested in literature for the same condition not be a better alternative?4,5 Anatomical reduction, impaction of the fragments and rigid fixation are the main factors necessary to achieve best results in displaced fractures of the femoral neck.5,6 How did the author manage these when it is mentioned in the paper that no attempt to improve contact between the fracture surfaces is made if it involved compromising the length of the femoral neck or the neck shaft angle? Could this technique of vascularised periosteal graft be applied for any fracture non union management? Three patients in the series are shown to have achieved fracture union by two months, which is contradictory to post-operative rehabilitation as patients are not made to walk for three months post operation (six weeks in plaster and six to eight weeks non weight bearing), and union as described by the author was confirmed by ability of patients to bear weight on the affected side. R.V. Badge, Clinical Research Fellow, D.K. Jain, Clinical Fellow, M.V. Hemmady, Consultant, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Trust, Wigan, UK. 1. Rupp-Montpetit K, Moody ML. Visual loss as a complication of non-ophthalmic surgery: a review of the literature. Insight 2005;30:10-7. 2. Stambough JL, Dolan D, Werner R, Godfrey E. Ophthalmologic complications associated with prone positioning in spine surgery. J Am Acad Orthop Surg 2007;15:156-65. 3. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol 2005;63:5-18. 4. Roshan A, Ram S. Early return to function in young adults with neglected femoral neck fractures. Clin Orthop Relat Res 2006;447:152-7. 5. Nagi ON, Gautam VK, Marya SK. Treatment of femoral neck fractures with a cancellous screw and fibular graft. J Bone Joint Surg [Br] 1986;68-B:387-91. 6. Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck. J Bone Joint Surg [Br] 1998;80-B:798-804.