Evaluation Of Treatment Of Fracture Intracapsular Neck Femur With Special Reference To 55-65 Years Age Group

INTRODUCTION Majority of femoral neck fractures occurs in elderly patients with osteopenic bone by trivial strains, but no age is immune to it. The incidence of hip fractures rises with increasing age, doubling for each decade beyond 50 yrs of age.The treatment of these fractures is so fraught with failures that surgeons have labeled it the “unsolved fracture”. Inspite of so many methods and procedures which have been tried to overcome this mishap, it still lives up to its disrepute as far as treatment and results are concerned.

The complex biomechanics acting at the upper end of femur, the inrolling of synovium into the fracture site, the continuous lysis of the fracture hematoma by synovial fluid and peculiar vascular pattern of the femoral neck all contribute to the high incidence of complications like non union and avascular necrosis following fracture of the neck of femur, renders and makes the definite treatment of this entity difficult and frustrating. Replacement surgery, total or partial, is now the treatment of choice in fracture of the femoral neck in elderly patients, but the quest for optimal surgical treatment for fracture neck femur in physiologically active elderly patient is still on, efforts are focused on preserving the femoral head in physiologically active and elderly patients.

The treatment alternative include prosthetic replacement (arthroplasty) and internal fixation. Arthroplasty option include hemiarthroplasty, bipolar arthroplasty, and total hip arthroplasty. Proponents of prosthetic replacement argue that replacement of femoral head eliminates the necessity for revision surgery due to avascular necrosis and nonunion, both of which are serious problems following internal fixation. Surgeons who favor internal fixation report decreased operative time, blood loss, and risk of mortality because the procedure is quicker and often simpler than arthroplasty.

In selecting a treatment for these fractures it is of utmost importance and priority to select the method that incurs the lowest mortality and morbidity and yet allows and permits early mobilization and rehabilitation to previous activities and independence.

This study aimed to evaluate different modalities of treatment of fracture intracapsular neck femur with particular reference to 55 to 65 year age group where controversies are maximum.

AIMS AND OBJECTIVES-

1. To evaluate the incidence of fracture neck femur in various age group.2. To evaluate the treatment of fracture intracapsular neck femur amongst these

patients with special reference to 55-65 age group patients.3. To review literature in the management of fracture intracapsular neck femur.

Review of Literature

HISTORY:-

The fracture neck of femur is known to man since antiquity, and various methods of treatment have been tried ever since to overcome this problem, by different workers at different periods of time. But the inability to find a definite treatment to this fracture has earned a new eponym for this fracture ie. the unsolved fracture.

The various modalities of treatment tried have ranged from conservative to joint replacement.they include-

Conservative treatment. Oesteotomies. Internal fixation. Hip reconstruction procedure. Hemiarthroplasty. Total joint replacement.

In 1824 sir Astley Cooper point out that chances of Union in intracapsular neck femur variety is poor and was the first person to suggest that the people sustainng this fractures tolerated immobilization poorly,further deteriorating their conditions.In 1904, Whiteman advocated closed method of reduction and holding reduced fractures in a POP spica cast. His results were never published but a series from st. Lukes hospital noted a 30% union rate in this fractures treated by the above said modality.

In 1911, artificial impaction of fracture fragments by blows from a heavy mallet applied to the padded trochanter were recommended by Cotton. Later a cast was applied.

In 1927, Leadbetter described a technique of closed reduction and immobilization with abduction with application of hip spica. This is considered a milestone in treatment of fracture neck femur before nailing was accepted.

INTERNAL FIXATION: In 1878, internal fixation of any fracture by a rigid pin was reported by Van Langenbeck. In his report it was stated that in 1860 he has used a silver pin passed through a trachanter and into the head to fix an oblique fracture of neck of femur. The procedure had failed due to sepsis. Konig (1875) had used a nail in similar operation performed under aseptic conditions. These fixations of the neck of femur were not accepted widely because of the lack of knowledge concerning various metals.

Davis (1900) and Decosta (1907) from Philadelphia used an ordinary wood screw.

Albee (1911) used bone pegs to immobilize the fragments in an attempt to avoid the complication of non- union.

In 1925,Smith Peterson developed the triflange nail for the fixation of the fracture fragments after reducing them, and the principle of pin fixation became generally accepted. The rate of non- unions was reduced by nearly 50% by this procedure. Smith Peterson and associates first published a report of their triflange nail in the year 1931. smith Peterson considered a real milestone that changed the accepted treatment from the reduction and abduction plaster spica as advocated by the Whiteman & Leadbetter to pin fixation of fractures.

In 1932, a cannulated triflange nail was introduced by johanson. This advancement is design allowed the operating surgeon to reduce the fracture without opening the fracture site and then fix the fracture blindly using the cannulated nail over a guide wire, thus confirming the ensuring a more accurate nailing.

Henry in 1934 introduced a flanged screw to obtain a still better fixation in the head with a nut which was placed laterally that was designed and used to compress the fracture fragments.

The use of three or four parallel threaded pins inserted through the fractured neck and into the head after reduction was introduced by moore in 1934. he opined that this method resulted in a better fixation of fractured fragments causing less damage to the vascularity and circulation than that caused by a triflange nail. He continued to emphasize the need and importance of implication of fragments and also devised a punch to accomplish this.

Gaension, 1935 and compere in 1940 also advocated the use of multiple pins.

Knowles, in 1936 advocated threaded pins placed as far apart as possible in the head in an effort to obtain absolute fixation.

Charnley in 1957 introduced a spring leaded compression with the lateral plate fixation but the final results were disappointing.

Judet in 1962 reported the use of a muscle pedicle graft of the quadratus femoris muscle in displaced femoral neck fractures. Later on Mayer et al (1973) modified the above technique and reported better results.

Smith (1964) popularized the use of an indigenous combination of two screws that were joined by plate to form a triangular fixation which, he claimed, followed the normal trabecular pattern that support the femoral neck.Gaden in 1964 also described similar pattern arrangement using two crossed screws, but the technique involved in introduction of closed screw was more tedious and difficult and their position more critical than the sample insertion of the smith Peterson triflange nail.

Deyerie (1965) published a series of 75 fractures of neck femur treated by peripherally placed multiple pins with side plate and reported no case of non-union and 8% incidence of avascular necrosis in his results.

Baksi (1983) reported satisfactory results following multiple drilling of femoral head and internal fixation combined with free and muscle pedicle bone grafting.

Kyle, Dahl and Mattson (1984)reported higher rate of complications with large compression screws without ancillary fixation compared with multiple screws.

Later Kyle (1986)determined consistently good results by some form of multiple screw fixations. He has used multiple cannulated screws.

Cannulated screws were also developed by the AO group. There were changed in its dimensions.

UPPER FEMORAL OSTEOTOMIES :-

The low subtrochanteric abduction osteotomy was introduced by Schanz in 1922. it was proposed to secure better stability for old hip fractures and also for unreduced congenital dislocation. The operation became very popular.

T. P. McMurray (1936) advocated an oblique osteotomy of upper femur for treatment of non union of femoral neck. In 1938 he published the results of his method in fresh fractures. He showed good results. In this procedure the shearing forces are converted to compressive or impaction force, which helps in healing of fracture. The main disadvantage of this operation was the prolonged post operative immobilization,

shortening and inability to squat, which was considered a major factor, specially in the elderly patient. It is therefore an operation for the young and intermediate age group.

Blounts (1943) and Moore (1944) each described an excellent blade plate fixation of the high subtrochantric osteotomy. This was considered a significant contribution because it allowed for early ambulation.

Leadbetter (1944) described a cervical axial displacement osteotomy in which a osteotomy was done in same axial line of the neck at the junction of the middle and inner third and the base of greater trochanter. The lower neck and the femoral shaft were displaced medially in ways similar to Mc Murrays osteotomy.another high femoral osteotomy was described by Dickson in 1947 for both ununited fracture neck femur and osteoarthritis.

HIP RECONSTRUCTION PROCEDURES :-

Albee (1915) described the use of grafts taken from tibia which were introduced through the greater trochantere into head to secure union in ununited fracture neck of femur.

Bracket (1917) advocated a reconstructive operation for the neck femur non- union which considered hollowing of femoral head and placing of upper femur in this hollow after transplanting the greater trochanter distally.

Colonna(1935) modified the whiteman operation in which the abductor muscle were transplanted distally and the whole upper end of femur was placed in acetabulum.

Many other reconstructive procedures were reported but there ultimate success depended largely on the after care.

ARTHROPLASTY :-

Arthroplasty is a method of fracture neck femur treatment and is practiced since a long time. This treatment method is generally well accepted world over and is considered a good salvage procedure.

Delber(1919) was the first person to have used a rubber femoral prosthesis(france).

Hey groves (1922) implanted an ivory femoral head prosthesis for a fracture of neck femur. Reportedly, the patient did well post operatively.

Smith Peterson (1923)popularized the concept of hip arthroplasty, performing the first mould arthroplasty using glas as the interpositional membrane. Component breakage led to the fabrication of cups of various materials including Viscaloid (1925),pyrex(1933), Bakelite(1937), and Vitallium (1938).

Harold and Moore (1939) resected the proximal femur of a patient with giant cell tumour and replaced it with a vitallium hemiarthroplasty.

Robert & Jean Judet (1946) fabricated a short stem femoral head replacement from methyl methacrylate.

Earl Mebride (1947) introduced the doorknob prosthesis wherein, its threaded stem was screwed into proximal femoral canal.

Jude brothers (1950) reported a series in which a short stem acrylic hip prosthesis was used. Originally the Judet prosthesis was made of methyl methacrylate but later nylon and other materials like vitallium and steel were also used.

Robert lippman (1951) introduced the transfixation hip prosthesis in which freely rotating head was transfixed to a long inter modullary femoral rod a short axial rod.

Moore (1952) developed the self locking prosthesis. Self locking refers to the three point fixation concept which results from the impaction of a straight intramedullary device into a bowed femoral canal. Fenestration proximally in the stem were provided to allow for the bone ingrowth thus improving the vascularity of proximal femur.

Freidrick R. Thompsonin (1954) reasoned that prosthesis should confirm to the anatomic shape of the neck based on his observations of inevitable neck resorption following neck fractures. Therefore the Thompson prosthesis was designed with inbuilt anteversion necessitating left and right component.

Otto Aufrane (1957) reported 82% satisfactory result in 1000 moulds arthroplasties. The results were considered encouraging and secured an impetus for further development and evolution of prosthesis.

Bateman (1974) introduced the bipolar concept. In this the outer metallic cup was articulating with the preserved acetabular cartilage and housed an internal low friction universal bearing. A number of investigators working with the bipolar concept have refined the type of internal articulation, internal head size, external component geometry and tailored the component materials and type of fixation according to the clinical situation and requirements.

Gilberty (1974) developed his prosthesis as an alternative to the prosthesis of Austin Moore and Thompson. It was aimed to reduce the friction and impact of forces at the prosthesis head Acetabular cartilage interface by interposing a movable cup of zymology lined with UHMWPE (Ultra High Molecular Weight Poly Ethlene).

The gilberty prosthesis was considered as the prototype and consisted of a metallic cup, a separate UHMWPE liner and a metallic femoral stem head. The UHMWPL liner is compressed fit into a highly polished cobalt chromium molybdenum cup. This one piece unseparable in vivo and no motion is possible also between these two surfaces of the liner and the cup, converting into one unit with a 32mm aperture, which allows a snap fit of 32mm stem head, when implanted. This assembled unit provides two centres of articulation, which has been designated as a low friction bipolar endoprosthesis.

Langen (1978) revised 90 cases of gilberty prosthesis. There was no case of dislocation of prosthesis. In each case the prosthetic head was in relatively vertical orientation with respect to the transverse axis of pelvis. These detailed observations suggests that the persistently mobile, vertically positioned unbounded cup remains stable despite the stress of trauma, which was sustained by 3 of the cases of Langens series. It is

probable that the potential for cup movement, even where on X ray it appears to have stopped, acts as a safety valve in absorption of forces that might otherwise dislocate or fracture the hip.

Iorio R. et el (2001) in study of displaced femur neck fracture in the elderly : outcomes and cost effectiveness, concluded that elderly patient with displaced femoral neck fractures achieve the best functional result with a healed femoral neck without oestonecrosis after reduction in internal fixation. Rogmark C, et el (2002) in an overview and evaluation of the femoral neck fractures concluded that – young(≤ 65 years old) and active patients should undergo internal fixation after reduction (open or closed), if required, while older, less active patients should undergo Hemiarthroplasty.

Sharif K M, Parker F J (2002) in technical aspect and their effects on outcome in patients with fractures neck femur recommended that when inserting an austin moore hemiarthroplasty, particular attention must be paid to the seating of the collar of the prosthesis on calcar and correct choice of head size.

F.A. Bonnaire, et el(2002), concluded that the tested osteosysnthetic procedures for femoral neck fracture, the DHS with an additional Lag screw seemed the best suited osteosysnthesis to fulfill the demands on the quality of an implant for femoral neck fractures.

Nikolopoulos K E, et el (2003) in long term outcome of patients with avascular necrosis, after internal fixation of the femoral neck fractures, concluded that internal fixation remains simple and safe method of treatment for undisplaced and displaced femoral neck fractures in middle-age patients. Despite the relatively high rate of avascular necrosis after internal fixation, only a few of these patients (20%) required further surgical treatment. KBL Lee et el (2004) in view of the higher complication rates in the displaced group, concluded that the primary hip arthroplasty(hemi or total) in patients more than 65 year old and cancellous screw fixation in younger patients.

Selvan V T et el(2004) in optimum configuration of cannulated hip screws for the fixation of intracapsular hip fracture, a biochemical study result clearly shows that a triangular configuration had a higher peak load, higher ultimate load, less displacement and more energy absorption before failure than other configurations.

Bhandari M. et el (2005) in their international survey of operative management of displaced femoral neck fractures in elderly patients, found that most surgeon believed that internal fixation was the procedure of choice in less than 60 years old patients with displaced fractures (garden type III or IV) and for patients over 80 years old with garden type III or IV choice was arthroplasty. Most surgeon disagree about the optimal approach to the management of patient between 60 and 80 year old with displaced fracture and active patients with garden type III fracture.

Raaymakers E L (2006) in fracture of femoral neck : a review and personal statement, concluded that fracture with steep fracture line(Pauwel III) should be anatomically reduced ant stabilized with sliding hip screw. And the less steep fracture(Pauwel I II) can be slightly over reduced in valgus and anteversion, which provides a bony support against shearing forces and fixed with parallel screw according to the 3 point fixation principles.

Leighton R K et el (2007) in advances in the treatment of intracapsular hip fracture in elderly, recommended that more than 60 year old patients with undisplaced stable fractures should be treated with an ORIF. 60 year old patints with displaced fractures use of Moore or Thompson prosthesis should be relegated to the medically infirm and minimally ambulateraly patients. And an uncemented modular Hemiarthroplasty should be considered in the patients with significant cardio vascular risk factor.

Ateschrang A et el(2007) in their study osteosynthetically treated intracapsular femoral neck fracture, concluded that patients treated with DHS had head necrosis of 17.6 % and those by Dynamic Martin Screw(DMS) was 19 % but DMS had lower operating time as compared to DHS.

ANATOMY

The femoral head , neck, greater trochanter and lesser trochanter together comprise the proximal end of femur. The femur neck projects superiorly, medially and anteriorly from the upper end of shaft. The greater trochanter is a quadrilateral shaped eminence lateral to femoral neck, which gives attachment to the gluteus medius and gluteus minimus and short rotators.the lesser trochanter is a posteromedial projection of bone at the site where the neck arises from the diaphysis, on which the psoas muscle is inserted. Posteriorly a ridge of bone,the intertrochantric crest, bridges the trochanters. The femoral neck is flattened in the antero- posterior plane and broader at the base than its medial end where the femoral head originates.

The femoral head forms two third of a sphere arising from the femoral neck and having an axis parallel to that of the neck. By virtue of the location of the epiphyseal plate below the ossification centre for the femoral head and possibility for differential epiphyseal growth, the axis of the head may not always be parallel to that of neck. The surface of the femoral head is covered with articular cartilage about 4 mm in thickness in the superior portion and about 3 mm in the equator. A small area devoid of articular cartilage serves as the point of attachment of the ligamentum teres and is called the fovea centralis. Synovial membrane covers the entire femoral neck anteriorly but only the upper portion of the femoral neck posteriorly. It arises at the border of the margin of the articular cartilage of femoral head and is reflected onto the under surface of the capsule of the hip joint.

The capsule is attached at the inter trochantric line anteriorly and about 1.5 cms proximal to the inter trochantric crest posteriorly. Distal attachment of the capsule explains why basal fractures are considered intra capsular. Synovial membrane also covers the acetabular labrum, ligamentum teres and transverse ligament of the acetabulum.

PERIOSTEUM AND BONE STRUCTURE

Beneath the synovial membrane, the periostreum covers the entire proximal femur. Banks in 1964 has shown however, that the periosteum does not have a cambium layer on the femoral neck which accounts for the lack of callus formation after a fracture in this region.

Internal architecture of upper end of femur has been a subject of considerable investigation, discussion and controversy. If the upper end of femur is sectioned in the frontal plane, the orientation of the bony trabeculae can be visualized. There are two principle trabecular systems which confirms to the stress lines in this portion of the femur. The medial system arises from the medial cortex of the shaft and runs upwards along medial half of neck and ends at the subchondral bone on the superior aspect of the

hip. The lateral system arises at the base of the greater trochanter from the lateral cortex and passes up along the superior lateral aspect of the neck, crossing the medial system to the end at the subchondral bone near the inner and lower quadrant.

The superior lateral arch is called merkel’s arch. The cancellous bone is weak in the centre of the neck just below the area where the two arches cross each other, called ward’s triangle. In addition there are secondary systems at the inter trochantric region which croses these lines at right angles. The dense portion of the neck formed where thhe two trabecular arch cross each other, is called the calcar femorale. This calcar represents the upward elongation of the dyaphyseal cortex into the interior of the neck. The inferior medial trabecular arch is always subjected to compression force and is well developed. This is due to the fact that compression force is three times as much as the tension force. The superior lateral trabecular arch is subjected to tension force and is less well developed.

Inman (1954) and others demonstrated that femoral head is not loaded in the vertical direction. The resultant force in the frontal plane during static loading forms an angle of 165 degree to 170 degree. The direction of this reacting force is independent of the position of pelvis. Its direction corresponds to the orientation of the medial trabeculae. The direction of the lateral trabecular system corresponds fairly to the orientation of the abductor musculature and tensor fascia lata.

FEMORAL NECK

The development of the normal architecture of the hip joint depends on the normal distribution of forces of gravity and muscular action. As a result of embryonic development and modification after the birth, the femoral head and neck becomes angulated onto the shaft in two planes. The frontal and transverse.

As projected on the frontal plane, the angle formed by long axis of femoral neck and shaft is called angle of inclination or neck shaft angle. This angle in newborn is 150 degrees and gradually decreases to about 125 to 135 degrees in adults. This angle facilitates the freedom of motion by placing the femoral shaft away from pelvis.

The angle between the femoral neck and shaft in transverse plane is called the angle of declination,antetorsion or anteversion. It is defined as the projection of angle between the long axis of the femoral neck and axis through the femoral condyles in transverse plane; usually about 10 to 15 degrees in adults.the angle starts developing from the fourth intrauterine month as limbs start rotating internally, adducting, and flexing. At birth the angle of anteversion is about 31 to 40 degrees, decreasing to 15 degree until skeletol maturity is reached. excessive anteversion is present in congenital dislocation of hip, coax plana and cerebral palsy. In isolated cases the neck projects posteriorly and is said to be retroverted.

THE SHAPE OF FEMORAL HEAD

Anatomists of the 19 th century reported that the femoral head, including bone and articular cartilage was not round. Recent studies by clark and amstutz (1975) have clearly shown the definite but subtly variations in the raddi of the femoral head as measured in anatomic specimens.

The equatorial plane of the femoral head was shown to be virtually circular in specimens, both males and females. They found however, that the raddi of the meridians which were perpendicular to the equator were longer, differing in length according to there location. For example, the radius of superior meridian (the curve of femoral head in

plane parallel with the neck shaft and lateral to the femoral head axis) was longer than the posterior and anterior meridians.

This lack of sphericity was greater in males than in females and resulted in a barrel shaped femoral head with a flattened area over its superior lateral surface. In the average femoral head of 48 mm diameter, the distance between equator and tip is 2 to 3 mm longer than the radius of the equator. Clark and Amstutz showed that acetabular shape coincided with that of the femoral head in the anatomic position.

BLOOD SUPPLY OF THE FEMORAL HEAD AND NECK

Trueta and Harrison in 1953 cleared the confusion regarding the blood supply of the femoral head and neck. They found that the vascular pattern established during phase of growth persisted throughout life.

The medial and lateral circumflex femoral arteries arising from either the femoral or profunda arteries femoris artery; supply most of the head and neck of the femur femur with supplymentary vessels in the ligament of the femoral head arising from the obturator artery. The base of the femoral neck is surrounded by a ring of arteries formed by branches of the medial and lateral circumflex femoral arteries, at the level of the attachment of the capsule of the hip joint. Ascending branches from the extra capsular arterial ring penetrate the capsule and form the inferior, posterior and superior retinacular vessels. The superior retinacular vessels enter the superiolateral aspect of the neck to become the main intra osseous vessel of the femoral head, the lateral epiphyseal vessel.

Hunter in 1743 described a subsynovial arterial ring which he called circulus articuli vasculosus. Chung in 1956 called attention to the intracapsular subsynovial arterial ring at the junction of the neck and the articular cartilage. Disruption of this ring may have particular significance in hip diseases such as slipped capital femoral epiphysis in children and high intracapsular fracture of the neck of femur.

THE ARTERIAL SUPPY AT BIRTH

At birth the ossification of the shaft of the femur extends to a clear cut expanded upper end with a curved margin which is capped by the cartilaginous epiphyses of the femoral head and greater trochanter. The base of the femoral head is surrounded by an extra capsular arterial ring from which ascending cervical branches pass around the neck around its circumference. They penetrate the cartilage of the head, each branch terminating in sinusoidal expansions. All these branches of the extracapsular arterial ring to epiphyseal and meta physeal branches.

Within the epiphysis no anastomoses between sinusoidal terminations of epiphyseal arteries are found before the secondary centres of ossification appears. From birth until closure of the epiphsis, vessels within the bone do not cross between the epiphysis and metaphysis. Some metaphyseal arteries arising from the extra capsular arterial ring pass vertically downward towards the centre of the frmoral shaft where branches anastomose with the ascending branches of the superior nutrient artery system. Other metaphyseal branches arise from the subsynovial intraarticular arterial ring as described by chung.

THE ARTERIAL SUPPLY IN THE ADULT

During growth there is an effective anastomosis between epiphyseal and metaphyseal vessles on the surfaces of the femoral neck. Within the bone the supplying the epiphysis and metaphysic until maturity when the two vascular systems blend.

The arterial supply of the upper end of the femur is derived principally from the branches of the extra capsular and intra articular arterial rings. Arteries running in the ligament of the head of the femur supplement the blood supply head, usually to a variable extent. Branches from the nutrient artery system of the femoral shaft form a loose anastomosis with descending metaphyseal arteries but they cannot be traced upwards into the femoral neck as discrete trunks.

BIO MECHANICS OF THE HUMAN HIP

The hip is the pivot upon which the human body is balanced in gait. True bipedalism is limited to birds and man, and in both the stability of the joint depends upon its bony configuration. In birds the centre of gravity of the body mass is below that of the hip joints so that little force is required to balance the body in stance and the body of birds acts as a pendulum. The centre of gravity in human beings is above the hip joints, thus some mechanism must exist to balance the body mass on the hip. The only forces which can act in this fashion are muscular.

FUNCTIONAL ANATOMY

The acetabulum and femoral head are composed mainly of spongy trabecular bone, which provides some elasticity (ie an ability to be deformed without sustaining structural damage), the socket is not a fully formed cup but is shaped like a horseshoe and surrounds the femoral head.

The presence of large quantities of relatively deformable bone in this configuration suggest spreading under load and; indeed, spreading occurs and is essential; if the stress (force per unit area) on the articular cartilage is to be kept within tolerable limits. Thus it is of great functional advantage to have the hip joint slightly incongruous under low loads; so that, with the flattening of cotact under high load, diminishing the force per area and maintaining it withing tolerable limits.

Excessive deformation of trabecular bone can lead to microfracture. A certain level of trabecular fracture is clearly physiological but high levels sustained repetitively, can lead to bone remodeling and actual stiffening of the underlying trabecular network. It has been suggested that stiffening and loss of congruence can lead to deterioration of the articular surface and to osteoarthritis.

FEMORAL NECK VARUS AND ANTEVERSION

The anatomic varus position of the femoral neck vis-a- vis the femoral shaft allows the abductor muscle considerable functional advantage, as they counter balance they body weight in the frontal plane during one legged stance. Ideally the abductors should be as far lateral from the hip joint as possible in order to achieve muscle stability in bipedal stance, however, a compromise must be made, because too extreme a lateral placement will limit abduction.

Compared with the lever arm of body weight, the abductor lever arm is relatively small. The lever arm length obviously multiples the torque produced by the contraction of the muscles. Increase in the varus position, accidently or from growth disturbances, fracture or malunion, or intentionally due to osteotomy, will increase the lever arm through which the abductor and provide these muscles with an increased mechanical advantage. Since the total laod across the hip joint is to a large extent generated by the

muscles, diminishing the muscles force, required by increasing the muscles leverage, will considerably decrease the load on the hip joints.

In the lateral or sagittal plane increased leverage results from the anteverted attitude of the femoral neck. This anteversion provides the gluteal maximus with a lever arm and thus multiplies the muscle effectiveness. The longer this lever arm, the less force the gluteus maximus has to exert to maintain the upright posture over the hip joints. It shoud be however remembered that excessive anteversion can have a deleterious effect on the range of external rotation of the joint.

Human iliac wings are flared laterally in contrast to those of quadrupeds, who have no need for strong abductors, a lateral flare moves the abductors further away from the centre of rotation of the hip joint, increasing the lever arm through which they act. The tuberous excrescence on which these muscles are inserted the greater trochanter, further acts to increase the abductor lever arm.

MOTION OF THE HIP

Because it is a ball and socket joint, the hip allows a wide range of motion,greater than would appear to be required for the activieties of daily living. . However since man sits for a considerable period of time, hyperflexion is a most useful movement for sitting on chairs which are lower than the knees, or sitting cross legged on the ground, as well as to assure that the lumbosacral junction is in hyperflexion while sitting. The necessity for rotation in bipedal gait involves the required pivoting on the stance phase in order to allow for efficient bipedal forward gait. Quadrupeds do not require significant external rotation of the hip in gait. A quadruped pivots the pelvis by rotating the spine relative to the pelvis.

FORCES ON THE HIP

The forces on the hip joint are multiples of the body weight created by the muscles which act across the joint. Lowering the stress on the hip can be accomplished by increasing the joint contact area by appropriate osteotomy or by diminishing the overall force by lateral displacement of the trochanter. Selective tenotomy about the hip, although it will create a limp, because of diminuition of the stabilising forces, is another method by which to lower the overall forces.

Since the acetabulum cannot significantly change in volume during hip rotation, the socket always covers an identical quantity of the femoral head. What is implied by the term “hip coverage” is the attitude of femoral head with the acetabulum in the neutral position. Lack of coverage is better stated as lack of containment,clearly in situations where the load bearing on cartilage is concentrated and one can with certainty predict the late degenerative changes. Operations which successfully improve “coverage”, actually increase the contact area of the joint and minimize the stress acting on the articulating tissues. They may also increase joint stability.

The varus position of the femoral neck causes it to bend. The muscles which pull up the greater trochanter accentuate this bending of the femoral neck,creating compression medially and tension laterally. failure to appreciate the significant bending to which the femoral neck is subjected, has lead to significant problems in internal fixation of fractures of this region.

Muscles not only act to stabilize joint and provide the forces required to move the bone across the joints, but they also can act to diminish the bending stress on the bones.

Consider the femoral neck, stressed in bending, transmitting the bending stress down to the femoral shaft which is angled inward towards the mid line. A guy wire would be useful on the lateral side of the femur in order to pull it straighter and diminish the potentially harmful tensile strains in the bone.

This is accomplished by the fascia lata, which has a muscle at its proximal end that maintains it at the appropriate level of tightness. The fasica lata and its associated muscle should be considered as a lateral tensile band. Care should be taken at operation to maintain the integrity of this important muscle, without which the strains within the femoral shaft will be increased.

CLASSIFICATION OF INTRA CAPSULAR FRACTURE NECK FEMUR

Displacement is very important from the prognostic point of view. It varies from slightly valgus in abduction fractures. Displacement results from various types of lateral rotation strains. Per linton in 1944 showed that the position of fragments in relation to one another depended more on violence of injury and degree of resistance offered by the skeleton than on direction of the forces. He demonstrated that various types of fracture are different stages of same displacement movement. The distal fragment is laterally rotated around the longitudinal axis of the femur and the neck becomes directed forward so that the head lies towards the posterior aspect of the neck. Displacement of the femoral head is downward and backward on the posterior aspect of the neck. Extensive comminution or splintering of the posterior cortex of the neck gives rise to gross displacement.

Pauwel’s Classification (1935)

Pauwel’s classification is based on the angle of inclination of the fracture line across the neck with type I being most horizontal and type II being most vertical. The incidence of nonunion is higher in pauwel’s type III fractures, probably due to shearing force at the fracture site because of its relatively vertical plane.

Type I : Angle of inclination is below 30 degrees.Type II : Angle of inclination is between 30 and 50 degrees.Type III : Angle of inclination is between 50 and 70 degrees.

Linton’s Classification (1944)

Linton used the long axis of the shaft of femur as one line and another line drawn from fracture surface of the inferior fragment. The angle where the two lines meet is the linton’s angle which is usually 5 to 7 degree larger than the correspondence Pauwel’s angle due to inclination of femur produces an appearance of shortening of neck and presents an irregular fracture surface. Therefore, before measuring linton’s angle, displaced fractures have to be reduced in internal rotation.

Garden’s Classification (1961)

Garden’s classification is of prognostic significant as well as a helpful aid in treatment decisions. This classifications is based on the displacement of the fracture which is related to

1. blood supply to femoral head.2. continuity of the ligament of weitbretch.

On the posterior aspect of femoral neck the casule of the hip joint is folded back and is continued as a retinaculum which is normally flush with the surface of the femoral neck. This retinaculum is thought to carry the main vessels to the femoral head, which may be damaged in case it is disrupted.

Grade I : incomplete fracture The trabeculae of the inferior aspect of the neck are still intact. Head is tilted in posteriolateral direction.

Grade II : complete fracture with displacement The weight bearing trabeculae are interrupted by the fracture line at the medial part of the neck.

Grade III : complete fracture with partial displacement The two fragments remain in contact with each other. The retinaculum of wiethbretch is still attached to both fragments.Grade IV : complete fractures with full displacement. The continuity of proximal and distal fragments is lost. The head returns to its normal position in the acetabulum and the trabecular pattern again lines up with the trabecular pattern of the acetabulum. The retinaculum of weitbretch is disrupted.

SINGH’S INDEX

(Singh M., Nagrath A. R., and Maini P.S., 1970)

Before the surgeon decides to attempt to salvage the femoral head, he must consider another factor, which is the quality of bone. Many patients with hip fractures have markedly porotic bone. The quality of fixation and the stresses which can be tolerated postoperatively are related to the severity of the porosis.

The singh’s index is an easily learned and applied method of assessing the quality of bone. It is based on the trabecular pattern of the proximal femur.

Grade 6 : Normal trabecular pattern with primary compression and tensile trabeculae and secondary compression and secondary tensile trabeculae.Grade 5 : Decrease in secondary trabecular pattern and wards triangle become prominent.Grade 4 : Secondary trabecular pattern is absent. Primary trabecular pattern is decreased.Grade 3 : a break occurs in the tensile trabeculae.Grade 2 : Loss of primary tension trabeculae is complete and marked reduction in compression trabeculae seen.Grade 1 : only few compression trabeculae seen.

The fixation is proportional to the grade with higher grade allowing fixation, grade 3 and below indicate significant osteoporosis.

Garden’s Alignment Index

Garden, R. S. (1961) proposed an index for acceptable reduction using the trabecular pattern, alignment as viewed in both the anterior posterior and lateral roentgenographic planes. This has been referred to as garden alignment index. In the anterio posterior view, the central axis of the medial cortex of the femoral shaft should form an angle no less than 160 degrees and no greater than 180 degrees with the trabecular pattern. An angle smaller than 160 degree denotes unacceptable varus position while more than 180 degree indicates excessive valgus, both of which jeopardize the blood supply of the head. In the lateral view the acceptable range is within 20 degrees of the normal 180 degrees.

FACTORS AFFECTING UNION

1. Type of fracture : good prognosis can be expected in pauwel’s type I while in garden’s type I & II, the prognosis will be better than garden’s type III & IV.

2. Original displacement : The greater the degree of displacement following trauma, the greater is the chance of disruption of the blood supply to proximal fragment. Hence, the chances of avascular necrosis and non union will be more.

3. Quality of reduction and maintenance of reduction : anatomic reduction of the fracture is essential to obtain good union. Internal rotation and abduction of the limb is a must to put the proximal fragment in valgus position as stated by Dickson (1953). Adduction or varus of the head is not desirable.

For garden’s grade I & II fractures, reduction can be maintained successfully. For garden’s grade III fractures, leadbetter’s manoeuvre is good if done with care. Reduction of grade IV fractures always pose a problem. Cleveland and fielding(1959) evaluated 335 fractures of femoral neck and stated that perfect apposition of fragment is never obtained in grade IV, any attempt to restore equilibrium of unstable fractures must compensate for the defect in the posterior inferior cortex of the neck. Reduction in extreme valgus position closes this defect but may compromise the blood supply of femoral head. Wedge graft taken from the anterior superior iliac spine and used to fill the defect is ideal but practically difficult. Chips of cancellous bone may be packed in with good effect (Meyers et

al) The stability can also be achieved by various forms of osteotomy as suggested by pauwel (1935) Mc Murray(1936) and Voss (1937) etc.

4. Associated diseases : wound infection and avascular necrosis of head contribute to the poor results of fracture neck femur. Various diseases of old age also complicate the problem.

ROLE OF GRAFTS IN BONE UNION

Historically, Mac Ewen has been credited with pioneering the clinical use of bone grafts in 1981. subsequently, reports by albee, barth & phemister established the clinical utility of bone grafts in patients with a variety of skeletal conditions. Following in the footsteps of these stalwarts, bone grafts have been used routinely for past seventy years to unite fractures, fuse joints and repair skeletal defects with the intention of grafts incorporation and providing mechanical stability.

There are numerous factors which need to be considered before bone transplantation.

1. an additional surgical incision.2. increased post operative morbidity.3. weakened donor site.4. the type of grafts, vascular status of graft and mechanical properties of graft

required also be borne in mind.

BIOPHYSICAL BEHAVIOUR

The cortical bone is relatively less osteogenic than cancellous bone. Cortical bone however exhibits superior structural properties for the extended period of time. Necrotic cortical bone retains its breaking strength during the early weeks following transplantation. This gradually losses its resistance to torsional and bending stresses when resorption is at maximum, then slowly regains its strength as bone mass and structure are restored.

In the experimental animal (dog), transplant losses half its strength as porosity becomes apparent on X ray, usually by six weeks, then regain its normal radiological density and strength by one year. In man, two years period is required for completion of internal remodeling of the transplant. Union between six to twelve months, and it is only after union, that resorption and porosity, and susceptibility to stress fracture becomes apparent. Restoration of mechanical strength requires two years.

REPAIR OF CANCELLOUS BONE

Autogenous cancellous bone differs from autogenous cortical bone by the rate of recascularisation, mechanism of creeping substitution repair and completeness of the repair. Within the first two days cancellous bone transplants are entirely covered by blood vessels and revascularization is initiated and completed within two weeks. As vascular invasion proceeds accompanying primitive mesenchymal cells differentitate into osteoblasts, that line the surface of the dead trabeculae and deposit a stream of osteoids. Which becomes annealed to and surrounds the central core of the dead bone. Finally each trabeculum, enclosed by newly deposited viable bone take on the appearance of woven bone. The bone mass is increased, subsequently the woven bone and entrapped dead bone are gradually reformed. First phase of increased bone mass produces increased radio density, second phase or resorption,which goes hand in hand with replacement by new lamellar bone,restores the original radiodensity. At the same time haemopoietic marrow

elements are gradually formed within the inter trabecular spaces. Ultimately the cancellous transplant is completely replaced by viable lamellar bone.

REPAIR OF CORTICAL BONE

Autogenous cortical bone transplant is revascularised at slower rate. Blood vessels penetrate the volkmann’s and haversian canals by the sixth day and revascualrisation occurs by one to two months. In addition, at the surface of cortical bone, vascular cellular tufts, termed “cutter heads”, by osteoclastics resorption, progressively burrow new tunnels into the bone.

In marked contrast to cancelous bone repair, the process is initiated by osteoclastic resorption rather than by osteoblastic bone deposition. Resorption begins at the outer region of the transplant. In experimental cortical bone transplants observed in dogs, the rate at which the interior of the havarsion canal are widened, is significantly increased until the sixth week “(excavation chamber)”,a phase correlated with loss of mechanical strength,then the resorptive rate gradually declines to resorptive process is at first directed towards peripherally located haversian systems, reaching the interior by the fourth weeks the interstitial lamellae remain relatively unchanged. When appropriate cavity size is obtained resorption ceases, osteoblasts appears and rebuild concentric lamellae.

The appositional phase occurs initially at twelve weeks after transplantation. The repair is at first greater at transplant host junction and secondarily the repair advances towards the centre of the transplant. The ratio of mixture of necrotic and viable bone in the cortical transplant remains basically unaltered after the process of repair has been completed. Proportion of viable new bone to necrotic old bone increases from two weeks to six months after transplantation, but then ratio appears to remain unchanged between six months and two years.

Thus it can be seen that cancellous bone is completely repaired where as cortical bone is only partially repaired and remains as an admixture of necrotic and viable bone.

MATERIAL AND METHODS

This study was carried out in the Department of Orthopaedics, Pt. J.N.M. medical college and associated Dr. B.R. Ambedkar memorial hospital Raipur retrospectively from 2002 to 2006 for incidence of fracture neck femur and prospectively from may 2006 to November 2007 for the treatment of fracture intracapsular neck femur.

All patients of fracture intracapsular neck femur with special reference to 55 to 65 years age group were the subject of the study.

Richard’s Hip compression screw with supplementary cancellous screw (manufactured by SSEPL) with autogenous iliac bone grafting, Austin Moore unipolar Endoprosthesis and Talwalkar’s bipolar hip prosthesis(manufactured by INOR) and multiple cannulated cancellous screw with washer(manufactured by SSEPL) was used in this study.

Photograph of DHS, prosthesis, cancellous screw

INSTRUMENTS :-

Apart from the general instruments for routine dissection, the list of special instruments required for unipolar or bipolar Hemiarthroplasty are as follows :-

1. Cork Screw Head Extractor.2. Head Gauge.3. Rasp (For Unipolar Or Bipolar Hemiarthroplasty)4. Tomy Bar.5. Osteotomes.6. Punch.7. Hammer.8. Murphy Skid.

the list of special instruments required for richard’s hip compression screw with supplementary cancellous screw fixation with autogenous iliac bone grafting are as follows :-

1. Threaded Guide Wires - 3.2 Mm, 2.4 Mm.2. Angle Guide 130 – 135 Degrees.3. Triple Reamer.4. Drill Bit – 3.4 Mm, 6.5 Cannulated Drill Bit. 5. Taps – Lag Screw Tap, 4.5 Tap, 6.5 Cannulated Tap.6. Insertion Wrench.7. Osteotome.8. Mallet.9. Screw Driver – 4.5, 6.5 Cannulated.10. Non Tooth Thumb Forcep.

Special instruments list for multiple cancellous screw fixation is same as above list.The detailed history of mode of injury, time lapsed between between sustaining the injury and first reporting to the hospital and treatment received before admission was recorded. History of pre existing pain in hip, difficulty in walking and associated diseases were also recorded. Patient’s general condition was assessed and detailed systemic examination was done to exclude any concomitant disease.

Affected limb was examined for deformity and shortening. Investigations like heamotological, biochemical, electrocardiogram and roentgenogram of chest were done to assess the patient for surgery and anaesthesia. The X-ray pelvis with both hips - AP view was taken to assess the type of fracture as per Garden’s classification, amount of intact calcar and associated pathology if any. X-ray affected hip with thigh – AP view in abduction and internal rotation was taken to assess the position of neck and extent of osteoporosis. X-ray affected hip with thigh lateral view was taken to assess posterior communition.

All patients with Garden’s grade II & III fresh cases with trauma surgery interval not more than three weeks and with posterior communition with intact neck with good bone quality ( no sign of osteoporosis) were treated with Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting / multiple cacellous screw fixation. Patients with Garden’s grade IV with trauma surgery interval more than three weeks with osteoporotic bone with absorption of neck were treated with Hemiarthroplasty.

PRE OPERATIVE TREATMENT :-

Above knee skin traction or skeletol traction was applied in all the cases while waiting for surgery for relieving pain, to chek the extreme rotation, and to correct the deformity.A). STEPS OF OPERATIONS (HEMIARTHROPLASTY)

Anaesthesia :

Spinal / epidural anaesthesia or general anaestheisa was used.

Position :

Patient was kept in semiprone on the sound side keeping the unaffected hip and knee flexed, with one sand bag in front and another in back of the body, thorough scrubbing, painting and draping was done.

Approach :

The fracture side was exposed by modified gibson’s approach.

Removal of head of the femur:

Head was removed with the help of cork screw head extractor and ligamentum teres was removed completely. Acetabulum was packed with a sponge while femoral preparation.

The neck was nibbled completely by bone nibbler. Seat was prepared using finger saw and sharp osteotomes to prevent splitting of calcar. The femoral canal was reamed, keeping the tomy bar parallel to the long axis of the leg. While reaming was started the entry point was kept in the centre of the medullary cavity, in relation to anterior and posterior cortex, to avoid placing of stem in varus, perforation of lateral femoral cortex or fracture of greater trochanter.

Appropriate size of the unipolar / bipolar component was determined by passing the excised femoral head through the graded template. A trial fitting of the prosthetic head was always made in the acetabulum. Then after packing cancellous bone graft,removed from head of femur into the fenestrations in the prosthesis(unipolar), prosthesis was seated into the shaft with the help of impactor.

Reduction of prosthetic head :

Gentle traction on the limb was given with the 90 degree of knee flexion when the apex of the prosthetic head comes opposite the ream of acetabulum. Then it was reduced into the acetabulum by the downward pressure by the surgeon with the help of Murphy skid and gentle external rotation maintaining traction of the limb. After reduction it was made certain that labrum was not enfolded into the joint, otherwise the component may not be fully seated and may subsequently dislocate.The stability of the prosthetic replacement was tested.

The wound was closed in layers over a negative suction drain. Wound was sealed with adhesive strapping. the limb was immobilised and kept in abduction. The splint was used only for transportation of patient to the ward and for X-ray after which it was removed. Post operatively flexion,adduction and internal rotation of the operated limb were prevented.

B). STEPS OF OPERATION (RICHARD’S COMPRESSIVE HIP SCREW WITH SUPPLEMENTARY CANCELLOUS SCREW FIXATION WITH AUTOGENOUS ILIAC BONE GRAFTING) :

Position:

The patient was kept in supine position on the fracture table with radiolucent, padded post with unaffected limb tide over foot plate.

Reduction:

Done by leadbetter technique and checked under image both in AP and cross table lateral view paying special attention to cortical contact medially and posteriorly. A slight varus or valgus, anterior or posterior tilt was considered acceptable. In no instances was open reduction considered necessary. Then maintening the reduction the affected foot is also tied over the foot plate. Thorough painting and drapping was done.

Approach:

Lateral approach to proximal shaft and trochantric region.

Techniques:

Insertion of guide wire :

Precortex drilling of lateral cortex was done with the help of 4.5 mm drill bit at a point which is approximately 2 cm below the vastus lateralis ridge or tip of lesser trochanter. Then a threaded guide wire (3.2 mm) was inserted with the help of angle guide to the neck which should be just inferior to the central sector in AP view and central in lateral view. We attempted to place the DHS preferably slightly below the centre, to achieve firm engagement in the dense calcar femorale and also for rotational cancellous screw fixation proximal to it. The tip of the guide wire should be within 10 mm of the joint. The leg screw length of the guide wire was measured with the help of measuring gauze and then guide wire was advanced to the subchondral region to provide temporary stability during reaming.

Reaming of femur :

Reaming is done with the help of power combination triple reamer through guide wire until the distal aspect of positive stop reaches the lateral cortex.

Taping of femoral head :

Attach the quick-connect T-handle to the lag screw tap and insert the tap into the reamed portion. And the wound was thorough washed and packed with sterile gauze.

Cancellous bone grafting :

Autogenous cancellous bone graft taken from same side of iliac crest from posterior third with the help of osteotome mallet and curet. The cancellous bone graft was inserted over the fracture site through the guide wire with the help of blunt forcep under image guidance.

Insertion of lag screw and plate :

The measured lag screw was inserted through guide wire with the help of insertion wrench. Then the side plate (2 hole / 3 hole) is advanced into the lag screw and the plate is secured to the shaft with plate clamp or bone holder. Drilling was done through the screw hole of plate with the help of 3.4 mm drill bit. Depth was measured with depth gauze, tapped and appropriate size of 4.5 mm cortical screw was tightened. Now traction was released and the top screw was tightened over lag screw.

Insertion of supplementary rotation screw :

A 2.4 mm threaded pin was passed under image guidance proximal to the lag screw in AP view and centrally in lateral view. Drilling was done with the help of 6.5 mm cannulated drill bit, tapped and finally appropriate size of cannulated cancellous screw with washer was tightened.

The wound was closed in layer over a negative suction drain and sealed with adhesive strapping.

C). STEPS OF OPERATIONS (MULTIPLE CANCELLOUS SCREW FIXATION)

Patient position and reduction and exposure approach was in similar manner to the above described procedure.

Techniques :

A 2.4 mm guide wire was inserted over the central sector of the neck under image guidance both in AP and lateral view. Then two more guide wire were inserted in diamond pattern parallel to the first one through diamond pattern positioning holes. Depth was measured with the help of depth gauze then insert the guide wire into the subchondral bone of femoral head. Now the drilling was done through the first guide wire with the help of 6.5 mm cannulated drill bit, tapped and then appropriate size of 6.5 mm cannulated cancellous screw with washer was inserted with the help of cannulated screw driver and confirmed it with image intensification. 2 more screw with washer were inserted in a similar technique through the remaining guide wires one by one.

The wound was closed in layer over a negative suction drain and sealed with adhesive strapping.

POST OPERATIVE CARE :

Day 1st - negative suction drain was maintained.Day 2nd- active quadriceps drill. -Negative suction drain removed. -sitting of the patient allowed with active movement of ankle and toes.Day 3rd- active movement of hip, knee by hanging the limbs by the side of the Bed.Day 4th to 9 th- quadriceps exercise continued. -active hip and knee movement continued.Day 10th- stitches were removed and walking with walker was started depending upon pain tolerance and confidence of the patient.3 weeks – gradual increasing weight bearing.

FOLLOW UP :-

Patient was followed every month for first three months followed by every three monthly for one year. Subsequently 6 monthly. Patients who did not returned up on given date were contacted personally or by questionnaire or by telephone.

At the time of each follow up, patients were followed both clinically and radiologically(AP and laterally) to see fracture related and implant related complications. Evaluation of the function of the hip was done by oxford hip score.

Oxford hip score(OHS)

OHS consist of 12 questionnaire about pain and disability. Each item has 5 response categories, and gives a score of 1-5 (low disability to high disability),scoring involve summing the total for each item to produce a final score between 12-60, with a higher score indicating greater disability.

OXFORD HIP SCORE

Please answer the following questions. Choose only one answer per question. The value for each answer is indicated to the left of the answer. Total up all of your answer to obtain a total score out of 60 points.

During the past 4 weeks…

1). How would you describe the pain you usually have in your hip?

1). None. 2). Very mild. 3). Mild. 4). Moderate. 5). Severe.

2). Have you been troubled by pain in your hip in bed at night?

1). No nights. 2). Only 1 or 2 nights. 3). Some nights. 4). Most nights. 5). Every night.

3). Have you have any sudden, severe pain-‘shooting’, ‘stabbing’, or ‘spasms’ from your affected hip?

1). No days. 2). Only 1 or 2 days. 3). Some days. 4).Most days 5).every day.

4). Have you been limping when walking because of your hip?1). Rarely/never. 2). Sometimes or just at first. 3). Often, not just at first. 4).Most of the times. 5). All of the time.

5). For how long have you been able to walkbefore the pain in your hip becomes severe(with or without a walking aid)?

1). No pain for 30 minutes or more. 2). 16 to 30 minutes 3). 5 to 15 minutes. 4). Around the house only 5). Not at all.

6). have you been able to climb a flight of stairs?1). Yes,easily. 2). With little difficulty. 3). With little difficulty. 4). With extreme difficulty. 5). No,impossible.

7). Have you been able to put a pair of socks,stockings,or tights?1). Yes,easily. 2). With little difficulty. 3). With moderate difficulty. 4). With extreme difficulty. 5). No,impossible.

8). After a meal(sat at a table), how painful it has been for you to stand up from chair because of your hip?

1). Not at all painful. 2). Slightly painful. 3). Moderately painful. 4). Very painful. 5). Unbearable.

9). Have you had any trouble getting in and out of a car using public transportation because of your hip?

1). No trouble at all. 2). Very little trouble. 3). Moderate trouble. 4). Extreme difficulty. 5). Impossible to do.

10). Have you had trouble with washing and drying yourself(all over)because of your hip?

1). No trouble at all. 2). Very little trouble. 3). Moderate trouble.4). Extreme difficulty. 5). Impossible to do.

11). Coud you do the household shopping on your own?1). Yes easily. 2). With moderate difficulty. 3). With extreme difficulty.5). No,impossible.

12). How much has the pain from your hip interfered with your usual work,including housework?

1). Not at all. 2). A little bit. 3). moderately. 4). greatly. 5). Totally.

Results: The results were graded as per as oxford hip score-

Excellent 12-20Good 21-30Fair 31-40Poor 41-60

OBSERVATIONS

The following observations are based on the study and follow up of 50 patients of fracture intracapsular neck femur that were admitted in the department of orthopaedics Pt. J.N.M. medical college and associated Dr. B.R. Ambedkar Memorial hospital, Raipur. Out of these 50 patients 31 were treated by Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting. And 15 patients were treated with Hemiarthroplasty (13 unipolar endoprosthesis non cemented,1 cemented unipolar endoprosthesis and 1 bipolar endoprosthesis) and 4 patients were treated with 3 multiple cancellous screw. The period of study was between may 2006 to November 2007. the observation are as follows:-

1). Age

Distribution of cases according to age

Age group(yrs)

Richard’s plating (31)

Hemiarthroplasty (15)3 Multiple CSF

(04)

No. %Unipolar

(14)Bipolar

(01) No. %No. % No. %

41-50 10 32.25 02 14.28 00 00 03 75

51-60 14 45.16 05 35.71 00 00 01 25

61-70 06 19.35 04 28.57 01 100 00 00

71-80 00 00.00 02 14.28 00 00 00 00

81-90 01 03.22 01 07.14 00 00 00 00

These study was done for fracture intracapsular neck femur. 47 year was the lowest age group and 85 was the highest age group for Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting, 50 years being lowest age group and 87 highest for Hemiarthroplasty and 45 years being lowest and 56 highst age group for multiple Cancellous screw fixation. Mean age for internal fixation – 59 yearsMean age for Hemiarthroplasty- 66 years

2). Sex Distribution of cases according to sex.

Sex

Richard’s plating (31)

Hemiarthroplasty (15)

3 Multiple CSF (04)

No. % No. % No. %

Male 23 74.19 06 40 03 75

Female 08 25.80 09 60 01 25

Overall more patients were males(29 ie 58%) & female patients were 18 (ie 36 %)

Male female ratio for Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting was 23:8, for Hemiarthroplasty was 6:9 and for multiple cancellous screw fixation was 3:1.

3). Side of fracture.

SideRichard’s

plating (31)Hemiarthroplasty

(15)3 Multiple CSF

(04)

No. % No. % No. %

Right 20 64.52 09 60 01 25

Left 11 35.48 06 40 03 75

Overall right side(30cases ie 60%) fracture occur more commonly than left side (20 cases ie 40%).

4). Type of fractures (anatomical classification)

TypeRichard’s

plating(37)Hemiarthroplasty(15)

Multiple CSF(4)

No. % No. % No. %

Subcapital 22 13 02

Transcervical 03 00 01

Basal 06 02 01

Overall subcapital type of fracture occurred highest (37 cases ie 74%) followed by

basal type(9 cases ie 18%) followed by transcervical (4 cases ie 8%).

5). Interval between date of trauma and date of admission

No. of daysRichard’s plating(31)

Hemiarthroplasty(15) 3 Multiple CSF(4)

No. % No. % No. %0-3 19 61.29 03 20 02 504-7 05 16.13 04 26.67 02 50

> 1 week- 2 week 02 6.45 03 20 00 0> 2 week- 3 week 03 9.68 02 13.33 00 0

> 3 week 02 6.45 03 20 00 0

Overall range between – same day of trauma to 4 months after trauma. Maximum patients were brought to the hospital within 3 days of trauma in case of internal fixation and within 1 week in case of Hemiarthroplasty.

6). Interval between date of trauma and date of surgery

IntervalRichard’s plating(31)

Hemiarthroplasty(14) 3 multiple CSF(4)

No. % No. % No. %0-3 days 1 3.22 00 0 00 04-7 days 4 12.90 00 0 01 25

>1 week-2 week 10 32.25 03 21.43 01 25>2 week-3 week 7 22.58 01 7.14 01 25

> 3 weeks 9 29.03 11 78.57 01 25

Maximum patients were treated within 10 days of trauma for internal fixation and for Hemiarthroplasty it was more than 3 weeks.

Ranges:- 1).For Richard’s compressive hip screw with supplementary

cancellous screw fixation with autogenous iliac bone grafting -- 2 -26 days.2). For multiple CSF -- 6 - 23 days3). For Hemiarthroplasty 12 days – 4.5 months.

7.) A:- Implant used for Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting

Implants No. of cases %

Richard’s plate

135 0Long barrel 03 9.8

Short barrel 26 83.87

130 0Long barrel 01 3.2

Short barrel 01 3.2

Richard’s plate 2 hole 12 38.713 hole 11 35.484 hole 08 25.81

Lag screw size

75 mm 04 12.9080 mm 01 3.2285 mm 12 38.7090 mm 08 25.8095 mm 06 19.35

Cancellous screw size

75 mm 07 22.5880 mm 11 35.4885 mm 04 12.9090 mm 06 19.35

95 mm 03 9.8

Implant most commonly used was Richard’s plate of 135 degrees. Short barrel with 2 holes , lag screw of size 85 mm and cancellous screw of size 75 mm.

B:- Prosthesis size used in Hemiarthroplasty.

diameterUnipolar Bipolar

No. of cases % No. of cases %39 00 00 01 6.6741 04 26.67 00 043 05 33.33 00 045 01 6.67 00 047 03 20 00 049 01 6.67 00 0

The size of prosthesis which was used most commonly was 43.

C). implant size for multiple cancellous screw fixation

SizeCancellous screw

No. of cases %75 05 31.2580 04 2585 03 18.7590 04 25

The size of implant most commonly used was 25 mm.

8). Period of hospital stay:-

1). For Richard’s compressive hip screw with supplementary cancellous screw fixation with autogenous iliac bone grafting was --18 days.2). for hemiarthroplasty --27 days.3). For 3 multiple SFC --21 days.

9). Modes of Trauma:-

Type of operation

Type of Trauma

Fall from height/ tumbleFall over hard

surfaceRTA

No. % No. % No. %Richard’s plating 05 16.13 18 58.06 08 25.80Hemiarthroplasty 04 26.67 08 53.33 03 203 Multiple CSF 00 0 02 50 02 50

Overall most common mode of trauma was fall over hard surface.

10). Results:-

OHS score (60)Type of operation

Richard’s plating Hemiarthroplasty 3 multiple CSFNo. % No. % No. %

Excellent (12-20) 18 64 08 53.33 02 50Good (21-30) 05 17 03 20 01 25Fair (31-60) 02 7 02 13.33 01 25

Failure 03 10 00 00 00 00Death 01 3.5 02 13.33 00 00

Overall satisfactory(excellent + good) result for richard’s plating is 81 % and for Hemiarthroplasty 73%,and for multiple cancellous screw is 75%.

11). Complications :-A). Richard’s Hip Compression Screw With Supplementary Cancellous Screw Fixation With Autogenous Iliac Bone Grafting :

Intra operative

Immediate post operative

Early post operative Delayed/radiological

Nil Failure of reduction with implant cut out

01 case

-Super ficial wound infection-deep wound infection

02 cases

nil

-Implant failure with DHS cut through

-cancellous screw backing out

-Shortening

02 cases

03 cases

nil

B). Hemiarthroplasty :

Intra operativeImmediate post

operativeEarly post operative

Delayed/radiological

Fracture of the shaft the femur

02 cases

Dislocation 01 case

-Superficial wound infection

-Deep wound infection

04 cases

02 cases

-Acetabular erosion

-stem loosening

-shortening of limb

01 case

01 case

06 cases

C). 3 Multiple Cancellous Screw Fixation :

Intra operative

Immediate post

operativeEarly post operative Delayed/radiological

Breaking of guide wire

01 case

Nil -Superficial wound infection

- deep wound infection

01 case

Nil

-Screw backing out

- non union

-shortening

01 case

01 case

Nil

12). Incidence of fracture neck femur:-

YearFracture neck femur

totalICNF Intertrochantric

2002-2003 32 37 692003-2004 40 39 792004-2005 33 42 752005-2006 38 41 782006-2007 36 45 81