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