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Letters to Editor
England Journal of Medicine less than 20ng/ml is considered
as deficient by most experts and a level of 2032 is considered
a relative insufficiency of vitamin D as intestinal absorption
of calcium increases by 4565% when the vitamin D value
increases from 20 to 32. Hollis in 2010 in defining a normal
circulating vitamin D level considered a deficiency as less than
32 based on the circulating levels of parathyroid hormone
vizaviz. vitamin D.4 In our experience, most adolescents
even with vitamin D levels less than 5ng/ml do not show
classical radiological rachitic changes. Two of our children
who had levels<5ng/ml and nine who had levels<10ng/ml
did not have radiological rachitic changes. In considering
vitamin D levels it is not the populations means, but ideal
values for optimal health such as those for serum cholesterol,
which are relevant as the mean values may depend upon the
environmental and nutritional factors in the region.
Regarding the second comment by reviewers on suggesting
a comparison with healthy children and adolescents this is
the subject of another study by us where we have compared
15 consecutive slipped capital femoral epiphysis(SCFE)
children with age, gender and habitat matched controls and
shown a significant association between subnormal vitamin
D levels and SCFE in children and adolescents from India.5
Sanjay Arora, Vivek Dutt,
Thomas Palocaren, Vrisha Madhuri
Department of Orthopaedics, Paediatric Orthopaedics Unit, Christian
Medical College,Vellore, Tamil Nadu, India
Address for correspondence: Prof. Vrisha Madhuri,
Paediatric Orthopaedics Unit, Christian Medical College, Ida Scudder Road,
Vellore632004, Tamil Nadu, India.
Email:madhuriwalter@cmcvellore.ac.in
References
1. Tripathy SK, Sen RK. Slipped upper femoral epiphysis: Outcome
after in situ fixation and capital realignment technique. Indian
J Orthop 2014;48:111.
2. AroraS, DuttV, PalocarenT, MadhuriV. Slipped upper
femoral epiphysis: Outcome after insitu fixation and capital
realignment technique. Indian J Orthop 2013;47:26471.
3. HolickMF. Vitamin D deficiency. NEngl J Med 2007;357:26681.
4. HollisBW. Assessment and interpretation of circulating
25hydroxyvitamin D and 1,25dihydroxyvitamin D in the clinical
environment. Endocrinol Metab Clin North Am 2010;39:27186.
5. MadhuriV, AroraSK, DuttV. Slipped capital femoral epiphysis
associated with vitamin D deficiency: Aseries of 15cases. Bone
Joint J 2013;95B:8514.
Four quadrant parallel
peripheral screw fixation
for displaced femoral neck
fractures in elderly patients
Sir,
We read the article titled Four quadrant parallel peripheral
screw fixation for displaced femoral neck fractures in elderly
patients by Satish etal.1 with deep interest. We would like
to congratulate the authors for this informative paper. We
would like to comment on a few points as follows:
We have been using diamondshaped configuration2 with four
screws, where we insert one screw at the apex(SuperiorS),
one at the bottom of the neck(InferiorI), and two in the
middle portion of the neck, one anteriorly(MA) and the other
one posteriorly(MP)[Figure1b]. We feel this is a superior
construct compared to the rectangular configuration, as the
distance between the screws is more, giving better rotational
control. Also, this technique allows skimming the neck cortex
and calcar femorale, giving additional stability[Figure1].
1. In the rectangular configuration, putting two screws
superiorly and inferiorly will result in the screws being
very close to each other[Figure1a]. Also, it is not possible
to skim the calcar with two screws parallel to each other.
When this is done, then chances of perforation of neck
are higher.
2. Authors have not mentioned about the patients with
posterior or medial comminution, as literature mentions
that there is increased risk of redisplacement and
avascular necrosis if the posterior cortex is comminuted.2
Fourth screw is shown to be useful in fractures with
comminution.3
3. We would like to know why this study does not include
patients of less than 50years of age.

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a b
Figure1: Schematic representation of screw construct in neck: (a)four
quadrant parallel configuration(b) diamond shaped configuration

Indian Journal of Orthopaedics | January 2014 | Vol. 48 | Issue 1 112

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Letters to Editor
Sandeep R Biraris, Darius F Soonawalla1,
Dhiraj V Sonawane2, Pradip S Nemade3
Departments of Orthopaedics, Mumbai Port Trust Hospital,
1
Soonawalla Orthopaedic Clinic, 2Grant Medical College and
Sir JJ Group of Hospitals, 3Seth GS Medical College and KEM
Hospital Mumbai, Maharashtra, India
Address for correspondence: Dr.Sandeep R Biraris,
Department of Orthopaedics, Mumbai Port Trust Hospital
Nadkarni Park, Wadala (E), Mumbai - 400037, Maharashtra, India.
Email:drsandeeprb@gmail.com
References
1. SatishBR, RanganadhamAV, RamalingamK, TripathySK. Four
quadrant parallel peripheral screw fixation for displaced femoral
neck fractures in elderly patients. Indian J Orthop 2013;47:17481.
2. HuangTW, HsuWH, PengKT, LeeCY. Effect of integrity
of the posterior cortex in displaced femoral neck fractures
on outcome after surgical fixation in young adults. Injury
2011;42:21722.
3. LyTV, SwiontkowskiMF. Management of femoral neck
fractures in young adults. Indian J Orthop 2008;42:312.
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DOI:
10.4103/0019-5413.125541
Authors reply
Sir,
We thank the readers1 for showing interest in our article
titled Four quadrant parallel peripheral screw fixation for
displaced femoral neck fractures in elderly patients.2
Four screw parallel fixation, done either in rectangular or
diamond configuration(DC), theoretically occupies same
area inside the head and neck of femur. Hence, it should
provide same degree of stability in a given case of femoral
neck fracture(FNF). We presume the authors have used the
term skimming the calcar for compression at the fracture
site. In four quadrant parallel peripheral(FQPP) screw fixation,
maximal compression is achieved by the first inferior screw
which is placed either anteriorly or posteriorly depending on
the opening at the fracture site. Other screws will subsequently
provide more fixation and close the fracture gap. We presume
the term perforation of neck means inadvertent entry of screw
through the neck cortices. The chances of neck perforation
may be more with FQPP than with DC if the neck has a wider
cross section in the central part and narrower superior and
113 Indian Journal of Orthopaedics | January 2014 | Vol. 48 | Issue 1
inferior parts(diamondshaped cross section). Considering
the neck cross section as roughly circular, the probability of
neck perforation is same for both screw configurations. As
pointed out in our earlier reply to the editors letter, DC screw
fixation may require more orientation and threedimensional
conceptualization of the neck as three screws will be always seen
in AP and lateral image intensifier images(i.e.,overcrowding of
screws in twodimensional pictures).
In our case series of 64patients, 14patients had posterior
comminution. Many comminutions were not visualized in
the initial routine radiographs, but were seen in the image
intensifier lateral view at the time of surgery. Apreoperative
CT scan may help to identify the comminuted fractures
and make a better plan. However, we have not done CT
scan in our patients. The surgical management of FNF with
comminution does not differ significantly as we do four
screw fixation in all cases irrespective of the comminution.
However, few precautions need to be taken in those cases.
Since generally surgeons consider screw fixation as the first
choice for FNFs in younger patients, we have not included
them in our study. The study has included patients aged
50years or more to specifically emphasize the point that screw
fixation can be successful in this age group also. Nevertheless,
FQPP can be done in younger patients with good outcome.
Bhava RJ Satish, Atmakuri V
Ranganadham , Karruppasamy Ramalingam,
1
Sujit Kumar Tripathy2
Departments of Orthopedic Surgery, BRJ Ortho Centre,
Coimbatore, Tamil Nadu, 1Sree Ortho Clinic, Behrampur, Odisha,
2
KMC Hospital, Manipal, Karnataka, India
Address for correspondence: Dr.Bhava RJ Satish Kumar,
BRJ Ortho Center, 218 NSR Road, Saibaba Colony,
Coimbatore, Tamil Nadu, India.
Email:drbrjorthocentre@gmail.com
References
1. BirariSR, SoonawallaDF, SonawaneDV, NemadePS. Comment
on: Four quadrant parallel peripheral screw fixation for
displaced femoral neck fractures in elderly patients. Indian J
Orthop.2014;48:112-3.
2. SatishBR, Ramalingam K, Karruppasamy R, TripathySK.
Four quadrant parallel peripheral screw fixation for
displaced femoral neck fractures in elderly patients.Indian J
Orthop.2013;47:174-81.
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