The quadratus femoris graft in old transcervical femoral fractures.DF Delima, DD Tanna
Sixteen patients with an old transcervical femoral fracture were treated with the quadratus femoris muscle pedicle bone graft with supplementary autografting. The result was a good functional hip in 14 cases.
Keywords: Adolescent, Adult, Bone Transplantation, Child, Female, Femoral Fractures, surgery,Human, Leg, Male, Muscles, transplantation,
Intracapsular femoral fractures, though uncommon in the young adult, are associated with a high incidence of nonunion and aseptic necrosis, which can be more symptomatic than in the older age group. The reasons for fracture nonunion in this age group are well known, but characteristic of the developing countries is the problem of financial and social restraints that prevent these people from seeking medical care.
In an established nonunion, the treatment options are very much limited in this age group. Replacement arthroplasty and surface replacement arthroplasty have a high incidence of failure in the younger patients., Osteotomy with or without bone grafting does not seem to have any advantages as regards union or late segmental collapse.
The aim of this study was to determine whether old transcervical femoral fractures could be treated with the quadratus femoris muscle pedicle bone graft,, and thereby attain a sound physiological hip.
Sixteen patients of ununited transcervical femoral fractures were treated by the quadratus femoris muscle pedicle bone graft. There were 11 females and 5 males. The age ranged from 12 years to 40 years with most patients between 21 and 35 years [Table - 1].
The time interval between the fracture and grafting varied from 3 months to 10 months in 14 patients. In the remaining two patients it was 1 month and 2 months respectively.
All the fractures were displaced initially.
Ten of these fracture nonunions were untreated old fractures. The remaining 6 patients had been operated upon previously and were failures of the primary surgery.
The pregrafting clinical details of the 6 previously operated patients are shown in [Table - 2]
In all the patients a pre-operative anteroposterior radiograph of the hip was taken. No lateral or rotational views were taken. All the patients were operated upon in a semi-prone position on an ordinary table. In this manner the patient was easily tilted to a semi-supine position should it be necessary to harvest bone grafts from the anterior superior iliac crest. The Kocher-Langenbeck incision was used to expose the fracture site. No powered instruments were used to elevate the pedicle graft. The pedicle graft was elevated after drilling multiple drill holes connected with a fine osteotome. The fracture was then exposed. The bone ends were not vigorously freshened nor was multiple drilling of the fracture ends resorted to. Reduction of the fracture was by leg traction and manipulation. It was held by a single K-wire and maintained by 3-4 Austin-Moore pins. A check antero-posterior radiograph was taken to confirm reduction and the position of the implant.
The degree of posterir comminution was marked in all these fractures. Supplementary autografts from the anterior superior iliac crest were used to pack the posterior-inferior comminution [Figure - 1]. Supplementary autografts from the anterior superior iliac crest were taken by merely tilting the patient from semi-prone to the semi-supine position after rearranging the anchoring sandbags. The quadratus femoris muscle pedicle bone graft was then fixed in the femoral head after making a slot with an osteotome. The trochanteric end was fixed with a single 32 mm cortical screw [Fig. I].
Post-operatively, the patient was supported on a splint for a period of 8 weeks. Active and passive mobilisation was started in the immediate post-operative period. Partial weight bearing was allowed at 8 weeks and full weight bearing at 10 weeks.
The follow-up ranged from i year to 5 years [Table - 1], with most of the patients seen between 2 years and 4 years
(1) Radiological results
Of the 16 patients treated with the quadratus femoris muscle pedicle bone graft, there were 13 radiological unions [Figure - 2]. In patient no. 14, radiological union viz. trabecular continuity, and decrease in fracture line sclerosis, was difficult to conclude even at 18 months. However, she was symptom free on full weight bearing with no change in the position of the implant or in the fracture reduction even at 18 months.
Of the 13 radiological unions, 9 united in varus. A union was considered to be in varus when the antero-posterior alignment index was less than 150 degrees.
We have not seen a single case of late segmental collapse in any of our patients even trough some of them have been followed up for as long as 5 years.
(2) Functional results
Four patients had a fixed flexion deformity of 10 degrees. Twelve patients had external rotation restricted by 10 degrees. Functionally all the 14 patients including the one with doubtful union were able to squat.
Of the 2 failures that we had, one was considered a failure of the procedure. The end result was a reabsorption of the neck, backing out of the implant and a pseudoarthrosis. The second failure was due to infection which was treated with a girdlestone excision. Both the failures occurred in fractures where the interval between fracture and the grafting was less than 2 months.
Pin extrusion was seen in 11 patients. However, no implant failure was seen.
The lesser trochanter was fractured whilst elevating the pedicle graft in 4 patients. This was detected post-operatively and eventually proceeded to union.
We have had no post-operative nerve damage.
There is a considerable controversy as to what constitutes an ununited transcervical femoral fracture with time intervals ranging from 3 weeks to 3 months., Its importance lies in the fact that fractures greater than 12 weeks old have a poor prognosis, 10 with only one report of a good result in this time interval. Of the 16 patients treated with the quadratus femoris muscle pedicle bone graft in this study, the interval between the fracture and the pedicle grafting in 14 patients was more than 3 months. The 2 failures in this study were those whose time interval between the fracture and grafting was 2 months and 1 month respectively.
Pre-operatively only the antero-posterior radiograph of the affected hip was taken. In the earlier part of the study, rotational views were taken in an attempt to study the degree of comminution at the fracture site. The lack of correlation between radiographic conclusions and operative findings made us discontinue this routine. The quadratus femoris muscle pedicle bone graft was elevated without using any power tools. No particular care was taken to isolate the circumflex artery as we felt the pedicle was supplied by a consistent branch via the ischial tuberosity. Neither the posterior approach, the isolation of the pedicle graft or the capsular incision jeopardised the blood supply to the femoral head Supplementary autografting of the posterior comminution is essential for mechanical stability and prevention of retroversion collapse.,,,
Further the likelihood of obtaining a bony union is increased when supplementary autografting is resorted to. The chances of union are more than when only pedicle grafting or only autografting is resorted to. Autografts were taken preferably from the anterior superior iliac crest as very often with trochanteric grafts the implant hold was loosened.
The post-operative regimen was fixed and did not vary from patient to patient. Initially an attempt was made to correlate weight bearing with sign of radiographic union viz. trabecular continuity, decrease in fracture line sclerosis etc. It was difficult to interprete radiographic union in these fractures in the first 8 weeks. Hence the patients were put on a fixed post-operative regimen. We did not feel the need to change this regimen, as is evidenced in patient no. 14, where radiological union was difficult to conclude even at 18 months but the patient was symptom-free with no loss of reduction or implant failure on full weight bearing even at 16 months post-operatively.
Of the 13 radiological unions in this study, 9 united in varus (Garden alignment index less than 150 degrees) with no evidence of late segmental collapse even after 2 years. This is contrary to the commonly held view that a varus reduction is the forerunner of a nonunion and late segmental collapse.
We conclude that old transcervical femoral fractures where the interval between the fracture and grafting is more than 90 days, can still be treated by the quadratus femoris pedicle graft resulting in a physiological hip and should be considered at a time when such fractures find a solution to their treatment by replacement orthroplasty and salvage surgery in increasing dissatisfying ardour.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4][Table - 1], [Table - 2]