Free fibular strut graft in neglected femoral neck fractures in adult

BACKGROUND: Neglected femoral neck fracture in adults still poses a formidable challenge. Existing treatment options varies from osteotomy (with or without graft) to osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularized, and nonvascularized fibula). The aim of this study was to assess outcome of nonvascularized fibular strut graft and cancellous screw fixation in neglected femoral neck fractures in the younger age group. MATERIALS AND METHODS: Medical records of 32 patients of neglected femoral neck fracture, in the age group of 22-45 years (mean 37.8 years), operated between May 1994 to December 2001, were retrospectively reviewed. After the application of inclusion and exclusion criteria, 28 patients having three years minimum follow-up (mean 4.6 years) were included. Delay between injury and operation varied from four weeks to 42 weeks (mean 16.4 weeks). Closed reduction was achieved in 17 patients; open reduction through Watson-Jones anterolateral approach was performed in the remaining 15 patients in whom closed reduction failed. The fracture was transfixed with three parallel guide wires. Appropriate sized cannulated lag screw (7 mm) was then inserted in two of the wires. Selection of the third guide wire for fibula depended on the space available in both anteroposterior and lateral view. RESULTS: Satisfactory bony union was obtained in 25 patients, of whom in four cases, the union occurred in 10-20° (mean 15°) of varus. Nonunion occurred in three patients (9.37%), and aseptic necrosis occurred in another six patients (18.75%). Of the 25 patients where union was achieved, five patients showed excellent results; 14 good and six had poor functional result, as evaluated using modified Anglen criteria. CONCLUSION: Nonvascularized fibular strut graft along with cancellous screws provides a dependable and technically less-demanding alternative procedure for neglected femoral neck fractures in young adults. Fibula being cortical provides mechanical strength besides stimulating the union and getting incorporated as biological graft.