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 19th 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 12-20
Good 21-30
Fair 31-40
Poor 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

Richard’s 3 Multiple CSF

Hemiarthroplasty (15)
plating (31) (04)
Age
group(yrs) Unipolar Bipolar
No. % (14) (01) No. %
No. % No. %
14.2
41-50 10 32.25 02 00 00 03 75
8
35.7
51-60 14 45.16 05 00 00 01 25
1
28.5
61-70 06 19.35 04 01 100 00 00
7
14.2
71-80 00 00.00 02 00 00 00 00
8
07.1
81-90 01 03.22 01 00 00 00 00
4
 3 mutiple CSF
14

12

10
numbers

8 hemiarthroplasty

6
4
2
richard's plating
0

41-50
51-60
richard's plating
61-70
hemiarthroplasty
71-80
age groups 3 mutiple CSF
81-90 type of
operation

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 years
Mean age for Hemiarthroplasty- 66 years

2). Sex
Distribution of cases according to sex.

Richard’s Hemiarthroplasty 3 Multiple CSF

plating (31) (15) (04)
Sex
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 %)
 25
male
20

numbers
15
female
10

richard's plating

hemiarthroplasty

3 multiple CSF
female
male
sex

type of operation

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.

Richard’s Hemiarthroplasty 3 Multiple CSF

Side plating (31) (15) (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%).
 20

15

10
side

0
right
richard's plating

hemiarthroplasty

left
3 multiple CSF

left

right

number
type of operation

4). Type of fractures (anatomical classification)

Richard’s Multiple
Hemiarthroplasty(15)
Type plating(37) 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%).
 multiple CSF
25

20

number
15 hemiarthroplasty
10

0 subcapital richard's plating

trancervical
richard's plating
basal
hemiarthroplasty
multiple CSF
type of
operation
type of fracture

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

Richard’s
Hemiarthroplasty(15) 3 Multiple CSF(4)
No. of days plating(31)
No. % No. % No. %
0-3 19 61.29 03 20 02 50
4-7 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.
 20

15
3 multiple
10 number CSF

5
hemiarthropla
0 sty

> 3 week
>2 week-3 week
richard's

>1 week -2 week

richard's plating

plating

3-7 days
hemiarthroplasty

type of interval
0-3 days
3 multiple CSF

operation

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

Richard’s
Hemiarthroplasty(14) 3 multiple CSF(4)
Interval plating(31)
No. % No. % No. %
0-3 days 1 3.22 00 0 00 0
4-7 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 days
3). For Hemiarthroplasty 12 days – 4.5 months.
 3 multiple
CSF

hemiarthr
oplasty

richard's
plating
12
richard's plating
type of operation

10
8

number
hemiarthroplasty
6
4
3 multiple CSF 2
0
0-3 4-7 >1 >2 >3
days days w eek- 2 w eek - w eek
w eek 3 w eek
interval

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

Implants No. of cases %

Long barrel 03 9.8
135 0
Short barrel 26 83.87
Richard’s plate
Long barrel 01 3.2
130 0
Short barrel 01 3.2
2 hole 12 38.71
Richard’s plate 3 hole 11 35.48
4 hole 08 25.81
75 mm 04 12.90
80 mm 01 3.22
Lag screw size 85 mm 12 38.70
90 mm 08 25.80
95 mm 06 19.35
75 mm 07 22.58
80 mm 11 35.48
Cancellous screw 85 mm 04 12.90
size 90 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.

 Unipolar Bipolar
diameter
No. of cases % No. of cases %
39 00 00 01 6.67
41 04 26.67 00 0
43 05 33.33 00 0
45 01 6.67 00 0
47 03 20 00 0
49 01 6.67 00 0

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

C). implant size for multiple cancellous screw fixation

Cancellous screw
Size
No. of cases %
75 05 31.25
80 04 25
85 03 18.75
90 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 Trauma
Type of
Fall over hard
operation Fall from height/ tumble RTA
surface
No. % No. % No. %
Richard’s plating 05 16.13 18 58.06 08 25.80
Hemiarthroplasty 04 26.67 08 53.33 03 20
3 Multiple CSF 00 0 02 50 02 50

Overall most common mode of trauma was fall over hard surface.
 richard's plating
8

7
hemiarthroplasty
6

4 3 multiple CSF

0
RTA

richard's plating
fall over hard surface

hemiarthroplasty
fall from height/ tumble

3 multiple CSF

10). Results:-

Type of operation
OHS score (60) Richard’s plating Hemiarthroplasty 3 multiple CSF
No. % No. % No. %
Excellent (12-20) 18 64 08 53.33 02 50
Good (21-30) 05 17 03 20 01 25
Fair (31-60) 02 7 02 13.33 01 25
Failure 03 10 00 00 00 00
Death 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%.
 18
16
14 3 multiple CSF
12
hemiarthroplasty
10
8
richard's plating
6
4
2
0
richard's plating
excellent (12-20)

hemiarthroplasty
good (21-30)

fair (31-60)
3 multiple CSF

failure

death

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

Intra Immediate post

Early post operative Delayed/radiological
operative operative
Nil Failure of 01 -Super ficial 02 -Implant failure 02 cases
reduction case wound cases with DHS cut
with infection through
implant -deep wound
cut out infection nil -cancellous screw 03 cases
backing out

-Shortening nil

B). Hemiarthroplasty :

Immediate post Delayed/radiologica

Intra operative Early post operative
operative l
Fracture 02 Dislocation 01 -Superficial 04 -Acetabular 01
of the cases case wound infection cases erosion case
shaft
the -Deep wound 02 -stem 01
femur infection cases loosening case

-shortening 06
of limb cases
C). 3 Multiple Cancellous Screw Fixation :

Immediate
Intra
post Early post operative Delayed/radiological
operative
operative
Breaking 01 Nil -Superficial 01 -Screw backing 01 case
of guide case wound infection case out
wire
- deep wound Nil - non union 01 case
infection
-shortening Nil

12). Incidence of fracture neck femur:-

Fracture neck femur

Year total
ICNF Intertrochantric
2002-2003 32 37 69
2003-2004 40 39 79
2004-2005 33 42 75
2005-2006 38 41 78
2006-2007 36 45 81