Management of Avulsion Fracture Tibial Spine by Open Reduction and Endobutton Fixation An Outcome Study

Volume 3, Issue 4, April – 2018 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Management of Avulsion Fracture Tibial Spine by

Open Reduction and Endobutton Fixation an Outcome
Study
Dr. Sanjay Kumar Agrawal, Senior Resident Doctor GMC Kota Rajasthan India
Dr. Chetan Ram, Resident Doctor GMC Kota Rajasthan India
Dr. Balmukund Jetwal, Resident Doctor GMC Kota Rajasthan India
Abstract Background: Fracture neck of femur are Now a days, surgeons have options of hemi-
common in elder persons. Reconstruction using arthroplasty (unipolar or bipolar) and total hip replacement in
uncemented bipolar prosthesis is purpose of study to the management of femoral neck fractures in the elderly[5].
evaluate functional outcome using Harris Hip Score. Unipolar hemi-arthroplasty is out of practice in the developed
Cement causes increased morbidity and mortality in nations but common in developing nations.[3] Pain was
elderly patients, hence uncemented hemiarthroplasty is associated with unipolar due to erosion of acetabulum and
suggested. stem loosening. Bipolar prosthesis had dual-bearing system so
these complications are less.[6]
Materials and methods: This is prospective study including
thirty patients with neck of femur fractures referred to the Currently, use of modular prosthesis allows
department of Orthopaedics, GMC Kota were selected for adjustment of neck length so limb length discrepancy can be
this study. Patients with femoral neck fractures and aged manage and easier future conversion to a total hip
above 60 years were considered. arthroplasty.
Discussion: We have excellent results in 11 cases (36.67%), With superiority of prosthetic replacement over
good in 14 cases (46.67%), fair in 3 cases (10%) and poor internal fixation in elderly being well established, primary
in two cases (6.67%) according to the Harris hip rating Total Hip Replacement (THR) is being offered at many
system. Mobilization exercises in our study patients were centres as a treatment option for these fractures. Total hip
started on the second day after surgery. Limb lengthening arthroplasty is still not popular as a treatment modality for
(<1 cm) was present in two patients (6.66%). Superficial fracture neck of femur in our country because majority of the
infection was observed in one patient (3.33%). patients do well with hemi-arthroplasty and also due to the
high costs involved. It also has a higher incidence of
Conclusion: Uncemented hemiarthroplasty in fracture dislocations and higher morbidity associated with the
neck of femur in elderly is associated with less procedure[7].
complications like cardiac events. Cement related complications like thermal necrosis,
loosening, osteolysis, bone cement implant syndrome (BCIS),
I. INTRODUCTION anaphylactic reactions, reflex bradycardia, embolism,
pulmonary hypertension, hypotension, cardiogenic shock are
Hip fractures are fairly common and comprise about absent in uncemented hemiarthrplasty. Uncemented procedure
20% of the operative workload of an orthopaedic trauma [1]. gives better press fitting, better three point fixation of
Half burden of all hip fractures is fracture neck of femur. The prosthesis, less time consuming than cemented procedure.
prevalence of the fracture also doubles for each decade of life
after the fifth decade[2]. The hip is a weight bearing joint This prospective study is done to see functional
performing many functions. outcome of bipolar prosthesis in fracture neck of femur in
elderly.
As geriatric burden is increasing in our society, this
fracture and its sequelae are also increasing[3]. The treatment II. MATERIAL AND METHOD
goal of this fracture is to restore pre-fracture function with no Our study was conducted in the Orthopaedics
association of morbidity[4].Various methods of management Department , Govt Medical College and Associated group of
have been employed since ages. Management of fracture neck hospitals, Kota during the year 2015-16. 30 cases of fracture
of femur in elderly has been debatable. Open reduction and neck femur were included in this study. Age inclusion criteria
internal fixation for this fracture in elderly has unfavourable was >60 years of age having Door’s A & B with good bone
outcome because non- union and avascular necrosis of femur stock. Patients having arthritis of acetabulum were excluded.
head were common. Arthroplasty is standard treatment in
geriatric patients in most countries.
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ISSN No:-2456-2165
After thorough preoperative evaluation, informed checked by telescopy, flexion- adduction of the hip. Great care
consent was taken for surgery. After induction of either spinal is taken to achieve adequate closure of the capsule and
or epidural anaesthesia the lateral position was given to the anatomical reattachment of the rotators. All patients who
patient on the operative table with the affected side facing up, were operated were kept in supine position with the
GIBSON posterolateral surgical approach of the hip[8] was involved lower limb in 20-300 abduction.
used. The capsule is incised, and hip was dislocated by
flexion, adduction and internal rotation. Using a head Patient will be made to sit up on bed and Static
extractor and bone levers, head is delivered out of the quadriceps exercises started from 2nd day. Mobilization with a
acetabulum and the acetabulum is cleared of debris. The size walker was started between third and seventh post-operative
of the extracted head is measured by using measuring gauze, day. Patients were initially advised partial weight bearing then
and the size of prosthesis is selected. The appropriate sized later advised progress to complete weight bearing as per
prosthesis is inserted into the unreamed canal by using box patient’s tolerence. Sutures were removed on 12th -15th post
chisel. Taking care to place it in 10-15 degree of anteversion. operative day. The study patients were discharged after 5th day
The final seating of the prosthesis is by gentle blows with the or stitch removal.
help of a mallet and the inserter. Prosthesis is seated on the
calcar by direct visualization. The hip joint is reduced by Follow up was done at 6 weeks, 3 months then 3
gentle traction with external rotation and simultaneous month interval for a year (at 6 months, 9 months, one year).
manipulation of the head of the prosthesis into the Follow up evaluation was done clinico-radiologically (Harris
acetabulum. Range of movement in all directions is checked Hip Score[9], X-rays).
by taking the joint through the whole range of movements.
The stability of the prosthesis and its tendency to dislocate is
Fig 1:- Exposure To The Fracture Site

ISSN No:-2456-2165
Fig 2:- Closure Over A Suction Drain

III. RESULTS- fracture occurred on the left side in 53.33% of the patients (n =
16) and right side 46.66% (n=14).
30 eligible patients were included in this prospective
study. All the study patients were taken up for the surgical 56.66% cases (17) had mode of injury slipping on
procedure between the 4th and 17th day after the trauma, the ground, 26.66 (8) cases are due to RTA and 16.66 % (5) cases
average delay to surgery being 7 days. due to fall from height. Size of prosthesis, complications due
In this study sample there were 12 males out of to surgery and final HARRIS hip score with clinical results are
30(40%) and 18 females out of 30 patients (60%). The mean in table 1,2,3 respectively.
age was75 years (SD = 8.37), range is 63-89 years, for
females77.33 years (SD = 9.67), range is 65-89 years and for
males 64.25 years (SD = 9.8), range is 63-88 years. The
Size of the Prosthesis Number of Patients Percentage
41mm 1 3.33
43mm 9 30
45mm 15 50
47mm 5 16.66
Table 1: Size Of Prosthesis

ISSN No:-2456-2165
Complications Number of patients Percentage

Superficial infection 1 3.33
Wound Gap 0 0
Deep infection 0 0
Subluxation/dislocation 0 0
Bed sores 0 0
Limb Lengthening (<1cm) 2 6.66
Pulmonary embolism 0 0
Intra operative fracture 0 0
Table 2: Complications
No. of
Score(Harris Hip) Grading Percentage
Patients
90-100 Excellent 11 36.66

80-89 Good 14 46.66
70-79 Fair 3 10
60-69 Poor 2 6.66
Table 3: Harris Hip Score And Final Clinical Result
Fig 3:- Post-Operative

ISSN No:-2456-2165
Fig 4:- Superficial Wound Dehiscence Which Healed By Local Debridement And Secondary Suturing Under Adequate
Antibiotics Cover
Fig 5:- Immediate post-operative x-ray showing prosthesis sitting proud of calcar resulting in 1cm
lengthening of the lower limb

ISSN No:-2456-2165
Fig 6:- One year follow-up shows no subsidence of the prosthesis and patient continued to have the limb
lengthening and limp
IV. DISCUSSION In two (6.66%) patients there was limb lengthening

(<1 cm) present post- operatively. Cause of this was either
In fracture neck of femur arthroplasty is done for as miscalculation of resection of neck femur or technical errors in
early as possible return to routine activities of elderly patient seating of prosthesis over the calcar.
to prevent complications and over-dependency.
In one patient (3.33%) of our study superficial
Most of our study patients (56.66%) were injured due infection was seen. Serial dressings and adequate control of
to a slipping on ground. This is common due to poor the diabetes with antibiotics according to culture-sensitivity
neuromuscular coordination and osteoporotic bones. were done for its management. Nottage, et al. found 3.9%
All the study patients were taken up for the surgical infection rate.
procedure between the 4th and 10th day after the trauma, the The average hospital stay in our study was 13.8 days.
average delay to surgery being 7 days. Elective surgery was most of our patients were discharged after suture removal.
performed in all cases and cause of delay were poor medical Lestrange et al reported 21 days[10], Drinker and Murray et al
conditions. 23 days.[11]
In 50% of the cases 45 mm prostheses were used. Loosening of stem, periprosthetic fracture, dislocation,
This was followed in frequency by 43 mm (30%), 47 mm protrusio acetabuli were not present in any case. Comment
(16.66%) and 41 mm (3.33%) prostheses in the order of over erosion of acetabulum cannot be done because of
frequency. For pressing fit of prosthesis rasp was used to relative short follow up.
broach the canal.
Followed up was regular and done at 6wks then 3rd
The prosthesis was not modular so technical months then 3 monthly for an year (6 months, 9 months, one
difficulty encountered was limb length discrepancy. This year). Evaluation was done recording the Harris Hip Score at
problem was also due to miscalculated resection of neck. each follow-up. Average final Harris Hip Score at one year
In our study mobilization exercises were started on follow-up was 85.68 ( maximum- 93, minimum- 65.8). Out of
second day after surgery and partial weight bearing started as 30 patients excellent, good, fair and poor were 11 patients
per patients tolerance within the 72 hours. (36.66%), 14 patients (46.66%), 3 patients (10%) and 2

ISSN No:-2456-2165
patients (6.66%) respectively. Overall an excellent or good [9]. Harris WH. Traumatic arthritis of the hip after dislocation
result was present in 83.32% of the patients. and acetabular fractures: Treatment by mould
arthroplasty. An end result study using a new method of
This study has some limitations like small study result evaluation. J Bone Joint Surg Am 1969;51(4):737-
sample, relatively short duration of follow- up of one year. 55.
Because of these limitations we are in conclusive for longevity [10]. Lestrange NR. Bipolar arthroplasty for 496 hip
of the prosthesis and acetabulum erosion. fractures. Clin Orthop 1990;251:7 -18.
[11]. Nottage WM, McMaster WC. Comparison of bipolar
implants with fixed neck prosthesis in femoral neck
V. CONCLUSION fractures. Clin Orthop 1990;251:38-44.
Uncemented Bipolar prosthesis for fractures neck

of femur is suitable and avoid complications associated with
cement like thermal necrosis, loosening, osteolysis, canal
pressure induced post operative thigh pain, Bone Cement
Implant Syndrome (BCIS) – Exothermic reaction,
anaphylactic reaction, Reflex bradycardia, Embolic
phenomenon, Pulmonary hypertension, Hypotension,
Cardiogenic shock.
So this is easy and less time consuming surgical
procedure associated with early return to routine activity with
less complications in elderly.
BIBLIOGRAPHY
[1]. Singer BR, McLauchlan GJ, Robinson CM.
Epidemiology of fractures in 15,000 adults: the influence
of age and gender. J Bone Joint Surg Br 1998;80(2):243-
8.
[2]. Leighton RK, Bucholz RW, Heckman JD, Court-Brown
CM. Fractures of the Neck of the Femur. In:
Heckman JD, editor. Rockwood and Green's fracture in
Adults, 6thed. Philadelphia: Lippincott Williams &
Wilkins; 2006.p.1753-91.
[3]. Swiontowski MF. Intracapsular fractures of the hip. J
Bone Joint Surg Am 1994;76:129-38.
[4]. Ioro R, Healy WL, Lemos DW, Appleby D, Lucchesi
C, Saleh KJ, etal. Displaced femoral fractures in the
elderly: outcomes and cost effectiveness. Clin Orthop
2001;383:229-42.
[5]. Ioro R, Schwartz B, Macaulay W, Teeney SM, Healey
WL, York S et al. Surgical treatment of displaced femoral
neck fractures in the elderly: a survey of the American
Association of Hip and Knee Surgeons. J Arthroplasty
2006;21(8):1124-33.
[6]. Zofka P. Bipolar hip hemiarthroplasty. Acta Chir Orthop
Traumatol Cech 2007;74(2):99-104.
[7]. Maini PS, Talwar N, Nijhawan VK, Dhawan M. Results
of cemented bipolar hemiarthroplasty for fracture of the
femoral neck – 10 year study. Indian Journal of
Orthopaedics 2006;40(3):154-6.
[8]. Hoppenfeld S, DeBoer P.The Hip. In: Hurley
Robert,editor. Surgical Exposures in Orthopaedics – The
Anatomical Approach, 3rd ed. Philadelphia: Lippincott
Williams and Wilkins; 2002; 365-454.

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Volume 3, Issue 4, April – 2018 International Journal of Innovative Science and Research Technology

Management of Avulsion Fracture Tibial Spine by

IJISRT18AP247 www.ijisrt.com 477

Fig 1:- Exposure To The Fracture Site

IJISRT18AP247 www.ijisrt.com 478

Fig 2:- Closure Over A Suction Drain

Size of the Prosthesis Number of Patients Percentage

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Complications Number of patients Percentage

Limb Lengthening (<1cm) 2 6.66

Intra operative fracture 0 0

90-100 Excellent 11 36.66

Table 3: Harris Hip Score And Final Clinical Result

Fig 3:- Post-Operative

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IV. DISCUSSION In two (6.66%) patients there was limb lengthening

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Uncemented Bipolar prosthesis for fractures neck

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