Fracture neck of femur with delayed presentation in young patients can be a surgical challenge. Such scenarios are rare in the developed world but not uncommon in developing countries. To present the medium term results of open reduction and internal fixation accompanied by Quadratus Femoris muscle pedicle grafting in young patients who presented with a delay after sustaining a fracture neck of femur, 42 patients with fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. A posterior approach was used in all cases. The patients were advised not to bear weight until there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor. The age of the patients, predominantly male, ranged from 24 yrs to 50 yrs. Radiological union occurred on average at 6 months. Thirty-six patients proceeded to union; six patients had non-union and needed revision surgery. Complications included varus union in 9 cases; shortening greater than 2 cms occurred in 6 cases. Quadratus Femoris muscle pedicle grafting described by Meyer in the 1970s is useful in treating fracture neck of femur. Open reduction and internal fixation of the fracture neck of femur when supplemented with Quadratus Femoris muscle pedicle graft fixation promoted the union of fracture and preserved the head the femur.
Two patients had re operation due to poor intra operative reduction which were performed by junior grade surgeon without supervision during out of hours. No fracture had displaced at follow up when compared with the intra operative X-ray when properly reduced and wired. One child had ulnar neuropraxia post operatively One child had superficial infection, which settled with oral antibiotics.
New guidelines proposed:
Patients with no N-V complications can wait till the morning trauma list. All intraoperative X-rays to be reviewed by consultants before discharging home. 3 weeks appointment for wire removal can be set at one week clinic follow up with out X-ray.
ASA 2: 66 patients mean age 82 years – MTS 6.3, comorbities 1.8, average time to theatre 36 hours. 15% had injury/implant related complications, one year mortality rate was 4.5%. ASA 3: 64 patients mean age of 84 years – MTS 3.9, comorbidities 2.7, average time to theatre of 3 days. 6.25% had injury specific complications, one- year mortality rate was 28.13%. ASA grade 4: 6 Patients mean age 83 years – MTS 5, comorbidities 3. The one-year mortality rate was 83.33%. Four patients were medically unfit to undergo any form of surgical intervention. Overall 9% of patients had complications related to the injury/implant that occurred exclusively in ASA 2 and 3 groups and the one year mortality rate was 17.22% for the entire group.