Clinical Article National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47

Comparative Study of Intra-capsular Fracture Neck of Femur

Treated By Two Different Methods of Screw Fixation
Mahendra SolankiA, Anand AjmeraB, Pradip BhargavaC, Amit ShahD, Anuj MundraE
AAssistant Professor, Department of Orthopaedics, MGM Medical College, Indore
BAssociate Professor, Department of Orthopaedics, MGM Medical College, Indore
CProfessor and Head, Department of Orthopaedics, MGM Medical College, Indore
DEx Resident Surgical Officer, Department of Orthopaedics, MGM Medical College,
Indore
EResident Surgical Officer, Department of Orthopaedics, MGM Medical College,
Indore
Manuscript Reference
Number: Njmdr_245_14

Abstract:
Background: Optimal method of fixation for intracapsular fracture neck femur still
eludes us as so many implants and configurations have been recommended for
it. This paper evaluates two methods of screw fixation with regard to the stability
of fixation, healing of the fracture, functional outcome & possible complications
associated with them.
Material and Methods: This retrospective & prospective study was conducted in the
Department of Orthopaedics & Traumatology, M.G.M. Medical College & associated
M. Y. Hospital, Indore from June 2005 to September 2007 in which 30 cases of neck
femur fractures were admitted and evaluated in the Orthopaedic wards and treated by
internal fixation with three cancellous screws in a triangular configuration with Apex
up or Apex down. Only medically fit skeletally mature patients between ages 17-50
years with fresh intracapsular fracture neck of femur with normal radiological bone
density and without posterior comminution with Gardens radiological classification
Grade I-Grade III were included in the study. Patients having associated secondary
degenerative osteoarthritis of hip were not included in the study.
Results: Out of 30 patients 14 patients were fixed in apex up and 16 patients were
operated for apex down configuration. In apex up 9 patients (64.3%) had excellent
or good functional outcome and in apex down 13 patients (81.25%) had excellent or
good functional outcome.
Conclusion: Achieving adequate reduction imparts inherent stability and using
triangular screw configuration with apex downwards results in lower implant failure
rate, speedy union and better functional results.

Date of submission: 22 August 2014

Date of Editorial approval: 29 August 2014
Date of Peer review approval: 10 September 2014
Date of Publication: 30 September 2014
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:

Keywords: Femoral neck fracture, osteosynthesis, triangular screw fixation

Introduction:

Dr. Mahendra Solanki,

M.S. Orthopaedics,
Assistant Professor,
Department of Orthopaedics ,
MGM Medical College, Indore
Mobile - 9425900927
Phone

No

Department

of

Orthopedics-

07312528516
Email drmahendrasolanki@gmail.com

Despite ever-increasing literature on

hip fracture, there are no authoritative
and evidence-based guidelines for the
management of displaced intra-capsular
femoral neck fractures [1]. A general lack
of consensus exists among orthopaedic
trauma surgeons in the management of

41

these fractures. The decision making in hip

fracture treatment depends on age, patients
co-morbidities,
pre-fracture
mobility
status, associated injuries, bone quality,
fracture configuration and pre-existing
degenerative status of the joint [2-6].
Several biomechanical analytical studies
have assessed the stability after simulated
fracture fixation on cadaveric femora

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47

with variable results. The conventional AO fixation using

three screws in apex proximal triangular configuration
is generally practiced by several surgeons for fixing
fracture neck femur [6,7]. In a radiographic review study
of patients who underwent cannulated cancellous screw
fixation for fracture neck femur, six different types of
screw configurations are found: Triangular configurations,
consisting of two parallel screws with a third screw placed
either superiorly, inferiorly, anteriorly or posteriorly; and
linear configurations with two or three screws in a vertical
line [8]. In a multinational survey of 298 Orthopaedic
surgeons, it is found that 73% agreed on the use of three
cannulated screws and more than half used the triangle
with base inferior construct. Patwa et al. in a biogeometric
study of Indian femurs found that inferior half of femoral
neck is narrower than superior half and recommended apex
distal configuration for screw fixation. The rationale behind
using multiple screws is manifold. They are less invasive,
preserve more cancellous bone as compared to larger hip
screws, and provide enhanced rotational stability [9 13].
Both in experimental and clinical studies, controversies exist
regarding the ideal screw fixation method that can provide
good stability and good clinical results respectively. The
purpose of the current study is to give an overview of the,
current techniques of screw insertion and placement, study
of two configuration in triangular pattern and its results,
limitations, and complications in fixation of intracapsular
femoral neck fractures in young adult patients.

Material and Methods:

This retrospective & prospective study was conducted in
the Department of Orthopedics and Traumatology, Indore
from June 2005 to September 2007 in which 30 cases of
Neck Femur fractures were admitted and evaluated in the
Orthopedic wards and treated by internal fixation with
multiple cancellous screws in two configurations Apex up
and Apex down.

Inclusion Criteria:
All skeletally mature patients between ages 17-50 years
with fresh intracapsular fracture neck of femur with
normal radiological bone density and without posterior
comminution and only patients with Gardens radiological
classification Grade I-Grade III were included.

Exclusion Criteria:
(1) Patients with Gardens Classification Grade IV, (2)
Skeletally immature patients, (3) Patients having associated
secondary degenerative osteoarthritis of hip were excluded.
There were 22 male and 8 female patients with youngest one
18 years old and the oldest one aged 50 years. Patients were
randomly categorized to the following two groups. Group I:
Apex proximal group: Three cannulated screws were fixed
in end positions of a triangle with its apex directed upwards.
Group II: Apex distal group: Three cannulated screws were
fixed in end positions of a triangle with its apex directed
downwards. Preoperative assessment of fracture geometry
was done using Gardens classification. Depending upon
the age and pattern of fracture as per x-ray, above knee skin
traction or skeletal traction was applied.
Gardens Classification: [14] It is based on the degree of
displacement seen on the anteroposterior radiograph of the
hip:
Type I: Incomplete valgus impacted fracture
Type II: Complete fracture without displacement
Type III: Complete fracture with partial displacement
Type IV: Completely displaced fracture with engagement
of the two fragment
Intra operatively pattern of reduction achieved by using
Garden alignment index as seen in anteroposterior and
lateral projections by image intensifier. All the cases were
operated under spinal anaesthesia on fracture table in supine
position under image intensifier control. Prophylactic
antibiotics were administered 30 minutes before surgery
(third generation cephalosporin).

Surgical technique:
Fracture fixed in a triangle or inverted triangle configuration
with the first screw running along calcar, controlling inferior
displacement of the head of the femur. The second screw
was placed posterosuperior, along the neck of the femur,
with the shaft of the screw being as close as possible to the
posterior cortex of the femoral neck. This screw was used
to prevent the femoral head from drifting posteriorly. A
final screw was placed anterosuperior as additional support
(Figure 1). In apex down position the first screw was placed
in centre of neck along calcar and in apex up position the

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47

Table No. 3
Functional Results in various age groups

first screw has to be placed postero-inferior along calcar so

as to accommodate a third screw anteroinferiorly (Figure 2).
Post-operatively intravenous antibiotics (Cephalosporins)
were given for 3 days followed by oral antibiotics for
another 5 days. Suction drain removed after 24 hours

Post operative protocol:

Active and passive physiotherapy of hip, knee and ankle
started according to pain tolerance of patients. Same
Postoperative protocol was followed in both the groups.
Toe touch weight bearing was initiated at 6 weeks, partial
weight bearing at 12 weeks and full weight bearing following
fracture healing. Patients were followed by X-rays taken in
true AP and true lateral views for determining the screw
configuration, fixation, healing and complications if any.
Due to financial constraints we were not able to perform
CT scan of all the patients. CT scan of representative cases
in either configuration was done to assess the biogeometry
of femoral neck and screw placement. Functional results
were evaluated after a minimum period of 6 months
postoperatively using Modified Harris hip Score [15].

Age group
17-25 yrs.
26-35 yrs.
36-45 yrs.
< 50yrs
Total

90-100

Good

60-89

Fair

30-59

Poor

<30

In our study we evaluated 30 cases and found that

percentage of Grade I and II fracture neck of femur were
significantly more (73.3 %) than grade III fracture (26.7%).
Functional results were comparable among male & female
populations (77.7% excellent or good results among males
as compared with 62.8% in Females).
Table No. 2
Functional Results in various fracture grades
Fracturegrades
Grade I
Grade II
Grade III
Total

Excellent
5
10
1
16

Good
1
3
2
6

Fair
1
1
2

Poor
2
4
6

Total
6
9
11
4
30

Table No. 4
Screw Configuration correlated to Reduction Achieved
Reduction Achieved
Anatomic
Non-anatomic
Total

Screw Configuration
Apex Up Apex Down
11
12
3
4
14
16

Total No. of
Cases
23
7
30

Table No. 5
Functional results correlated with Screw
Configuration
Functional Results

Screw
Configuration

Excellent

Good

Fair

Poor

Apex UP
Apex Down
Total

7
9
16

2
4
6

2
2

3
3
6

Total
14
16
30

There were a total 3 cases of implant failure. One case of

screw bending and two cases of screw loosening, occurred
in those patients who started early complete weight bearing
without surgeons advice or supervision.

Results:

Functional Results

Poor
1
3
2
6

Anatomic reduction and screw configuration are strong

predictors of stability of fracture and final functional results.
Among the 8 cases of poor & fair functional outcome, we
were not able to achieve anatomic reduction in 7 cases most
of which were Gardens grade III fracture

Table No. 1 Modified Harris hip Score

Excellent

Functional Results
Excellent Good
Fair
5
1
6
2
5
2
1
1
1
16
6
2

Total
6
16
8
30

Our study suggested that reduction and implant placement

both are important in predicting the functional outcome,
fixation and stability of fracture.Out of 14 patients operated
for Apex up configuration, Radiologically Delayed union
was noted in 1 patient (7.14%), Nonunion 3 patients
(21.42%) and Avascular necrosis 1 patient (7.14%). 2
patients had screw loosening and shortening were noted in
5 patients.
Out of 16 patients operated for Apex Down configuration,
Radiologically avascular necrosis was seen in 3(18.75%)
patients. 1 patient had screw bending and shortening was
noted in 3 patients.

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47

Figure 1:
Screws in apex down triangle configuration.

considerably in the ratio of 2.1:1. This finding in the

present study is contrary to various published reports which
indicate a pre-ponderance of female patients, this being
attributed to several factors such as women having a wider
pelvis with a tendency to coxa vara, low activity levels,
more prone to osteoporosis & their life expectancy is more
than males [21-23].

Figure 2:
Screws in apex up triangle configuration

The study comprises of significant number of younger

patients and high velocity trauma as common mode of
injury. This may explain the preponderance of males in
this study. In this study Vehicular accident as a mode of
injury was responsible for major group of patients (46.7%),
closely followed by Slip and fall (33.3%).

Discussion:
Since intracapsular fracture neck of femur heals by primary
healing, along with stability in coronal and sagittal planes,
absolute rotational stability is necessary across the fracture
site [16]. The commonly used screw fixation construct in
fracture neck femur may be imperfect with one or more of
technical flaws: Unacceptable reduction (less contact area),
lack of parallelism, convergence towards head center,
crowding of screws in small area, inadequate screw length,
repeated drilling into the head weakening screw purchase
and leaving fracture gap. Loading on imperfect mechanical
construct can result in uncontrolled collapse, tilting of head
into varus, loss of contact, nonunion and screw penetration
into the joint. The key therefore is to provide good stable
construct that can withstand the routine strains, still
maintain contact between the fracture ends, provide
stability and allow healing [17].
A total of 30 cases of intracapsular fracture neck of femur
were treated and fixed by three cannulated cancellous
screws fixed in two different triangular configurations i.e.
apex up and apex down were studied. The age of patients
varied from 17 yrs to 50 yrs. 75% patients were younger
than 45 yrs. Average age of the patient in this series was
33.5 yrs, which was significantly lower as compared to
various studies published [18-21]. The frequency of neck
femur fractures in relatively younger age group in this
series may be related to shorter life expectancy of the Indian
population and high velocity trauma causing the fracture in
several younger patients in the study.

Patwa et al conducted study on biogeometry of femoral

neck of implant placement and concluded that biogeometry
of the neck of femur does not accommodate two inferior
screws and thus fixation of fracture neck of femur with three
cannulated cancellous screws in apex distal configuration
is recommended. Probably two screws loosening in our
series can be explained on above study because loosening
occurred in apex up configuration.
As per Stomquivst et al different healing and complication
rates depend on the surgeons experience [24]. This was true
in particular for displaced femoral neck fractures, where the
complication rate was as high as 40% for unexperienced
surgeons compared with 27% for experienced surgeons.
In the current series, the complication rate also was high
for surgeons not familiar with this technique compared
with more experienced surgeons. Insufficient analysis
of the morphologic features of the fracture, inadequate
reduction and impaction of the fracture, and incorrect
screw positioning were responsible for early redislocation
after screw fixation.
A subtrochanteric femur fracture after cannulated screw
fixation of a femoral neck fracture is a devastating
complication. Observations of Oakey et al support the use
of an apex-distal configuration for cannulated screw fixation
of femoral neck fractures [25]. In our case not a single
case of subtrochanteric fracture was seen in apex proximal
group. From our study we conclude that if screw placement
is proper that is above the level of greater trochanter and
wider enough than chances of any complications are almost
equal as seen in apex down configuration up to gardens
grade II fracture.

Males in the present study outnumbered the females

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 41-47

Fekete et al reported a redislocation rate of 6.5% in a

series of 445 patients with cannulated screw fixation of
intracapsular hip fractures. This was not comparable with
the redislocation rate in the current series as the numbers of
patients were not enough to comment.

reduction and implant placement as independent variables

of construct stability. The initial fracture reduction achieved
is directly related to the subsequent position of screw i.e.
varus and retroverted reduction will lend themselves to
superior and anterior screw placement respectively.

Nonunion may present acutely or gradually with increasing

hip pain associated with painful and limited movements
and shortening of the leg. It may occur with or without
failure of screw fixation. Incidence of non-union of femoral
neck fractures has been reported to be between 2 and 22%
and generally become apparent within 1 year [26 30].
In the current series there was a rate of 9.9% whereas the
nonunion rate reported by Fekete et al who used the same
technique was 1.3%.

Strong association with functional outcome and high

statistical correlation with excellent or good results indicate
that achieving anatomic reduction and fixing in apex
down configuration are recommended for obtaining better
functional outcome in intracapsular fracture neck of femur
in young patient. Achieving adequate reduction imparts
inherent stability and using optimal screw configuration
(Apex down) results in lower implant failure rate, speedy
union and better functional results.

This compartively high rate of non union in our series can be

explained in terms of low number of patients in our series.
Mostly non union was seen in patients in gardens stage II
category in which nonanatomical reduction was achieved
and screws were placed in apex up configuration. 2 cases
in our study suffered from deep infection (6.6%). The rate
of infection is/significantly higher as compared with other
previous studies [21, 22].High infection rate in our series
can be attributed to delay in treatment causing increased OT
time and more surgical trauma, socioeconomic condition of
the patient and poor hygiene of the patients.
There were 3 cases with mechanical failure (1 screw
bending, 2 screw loosening) amounting for 9.9% which can
be correlated to poor reduction of fracture and improper
placement screw while fixation as both these complications
were seen in apex up configuration which can be explained
by biomechanical principle mentioned above.

Conclusion:
Anatomic reduction and Screw configuration are strong
predictors of Stability of fracture and final functional
results. When we correlated functional result with screw
configuration, we found that most patients in whom apex
down configuration was used, functional results were
excellent or good. On the other hand functional results are
almost comparable in grade I and II in apex up configuration
but in grade III screw configuration does affect the final
functional outcome.
Of course therefore, it is an oversimplification to consider

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