Clinical outcomes of muscle pedicle bone grafting (Meyer's Procedure) in cases of old displaced femur neck fractures: A Study Of 20 Cases
H Panchal, M Prabhakar, A Acharya, B Jadav, J Harshvardhan
autogenous cancellous bone grafting, avasculer necrosis of head of femur, displaced intracapsular fracture neck of femur, meyer's procedure, quadratus femoris muscle pedicle bone graft
H Panchal, M Prabhakar, A Acharya, B Jadav, J Harshvardhan. Clinical outcomes of muscle pedicle bone grafting (Meyer's Procedure) in cases of old displaced femur neck fractures: A Study Of 20 Cases. The Internet Journal of Orthopedic Surgery. 2007 Volume 10 Number 1.
20 patients with neglected displaced intra-capsular femoral neck fractures were included in study. They are classified according to the staging by Garden; 5 patients were in Stage III and 15 were in Stage IV. The majority of the patients were young (average age 42.8 years). The injury operation interval was ranging from 25 days to 6 months. (Average 57.7 days). All fracture is treated with Meyer's technique. Open reduction and fixation with Cannulated Cancellous screw, muscle-pedicle bone grafting using quadratus femoris supplemented with autogenous cancellous bone grafts. During the follow up period of 6 months to 4 years (average 17.11 months), we observed union in 18 (90%) patients and one case of AVN and one failure of technique. According to the Harris Hip Score –HSS, functional improvement was noted in 16 out of 20 patients, 4 patients having poor functional outcome- HSS below 60 (26.66 %, non-survival group) were recommended alternative treatment (total hip replacement or girdle stone arthroplasty).
Displaced Intracapsular fracture of the neck of the femur in young and middle aged person is really a challenge to the treating surgeon. Inspite of better reduction and good fixation the nonunion rate and AVN rate are very high with Garden type III and type IV fractures. In a weight bearing extremity, requires accurate reduction of fragments and satisfactory internal fixation of a fracture, if the complications like non-union and late segmental collapse are to be prevented. Hundreds of techniques devised for the treatment of this fracture can explain the futility of one or other method to achieve satisfactory results in all patients. As somebody has said
Materials and Methods
Selection criteria: All the patients were having displaced intracapsular fracture neck femur with injury operation interval between 25 days to maximum 6 months. The upper limit of the age of patient was 50 years. All patients belonged to Stage III and IV Gardens classification. Surgical technique: General anesthesia with endotracheal intubation in all the cases
Post-operative protocol: Boot plaster was given after operation. Patients were encouraged to do static quadriceps strengthening exercise from the next day of operation. Stitches were removed at 10th day .Non weight bearing was continued till the radiological signs of union were appreciated, usually at about 3 months, viz. trabecular continuity, decrease in fracture line sclerosis etc .Partial weight bearing was then started till sound union occurred. Gradually full weight bearing was advised in united fractures. Follow up protocol: Routine follow up was done at 6 weeks, 3 months, 6 months and then every 6 monthly. Follow up for minimum 6 months was done to access the following results: Union: Clinical and radiological, Time taken for union, Funtional assessment by Harris hip score: HSS, Complications: Early: infection, technical failure, subtrochantric fracture, lesser trochanteric fracture. Late: non union, Coxa vara, shortening, avascular necrosis of head of femur.
During study Males dominated our series, usually middle aged. Fall while walking was a common cause of fracture. Males dominated because their activities are usually outdoor and are more likely to meet with accident.
In our series, most of the patients were from middle age – group
Displaced fractures with delayed presentation were selected for the treatment by this method.
Out of these 20 patients, according to Harris Hip Score, functional results were excellent in 9 patients; good results were obtained in 5 patients and fair results in 2 patients while rest of the 4 had poor results. 18 fractures (90 %) showed signs of union while only 2 cases (10%) were not united at 6 months of minimum follow up. The average time taken for union was 15 weeks. The probable reason for non union was poor quality fixation. Results are better in patients having garden's type III fracture. . During the follow up of 6 months to 4 years (average 17.11 months), according to the Harris Hip Score –HSS, satisfactory functional improvement was noted in all 5
(100 %) patients of Gardens Stage III and 60% of patients of Stage IV cases.
The amount of posterior comminution is quite higher with high grade of fractures and thus they require more stable fixation and adjuvant cancellous bone grafting to strengthen the postero-medial cortex of femoral neck. In our series there were 85% cases with posterior comminution and we did adjuvant cancellous bone grafting from trochanter itself to fill the space. All patient shown good union except one in which implant failed.
In our series we haven't had any superficial or deep infection.
Good fixation of fracture and graft required for union of fracture.
Because of collapse, at fracture site, some shortening was present in all patients, Limb shortening up to 2 centimeters were present in 17 (85%) patients. Only one patient showed signs of AVN of femoral head at 4 years of follow up. None of the patient had infection. 5 patients developed coax vara. One patient had sub-trochanteric fracture (intra-operative while taking the graft) and the graft got fractured in one patient while elevating it.
The results were analyzed using the Harris Hip Score. Excellent to good results were obtained in 70% of cases in spite the union rate of 90%. Factors responsible for poor functional outcomes were poor reduction, poor fixation and complications like subtrochanteric fracture.
As compared with the results of similar series like Meyers  and Bakshi , we had similar rate of 10% nonunion after such procedure. While the rate of late segmental collapse (AVN) was 8% with original Meyer series and in our series it was seen in only 1 patient after 4 years follow up. Another similar series by Delima & DD Tanna  showed good functional hips in 14 patients (87.5%) out of total 16 which are identical to our series. 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.Pre-operatively only the antero-posterior radiograph of the affected hip with 15 degree of internal rotation was taken. The quadratus femoris muscle pedicle bone graft was elevated without taking ant particular care to isolate the circumflex artery. Neither the posterior approach, the isolation of the pedicle graft nor the capsular incision jeopardized the blood supply to the femoral head. Supplementary auto grafting of the posterior comminution is essential for mechanical stability and prevention of retroversion collapse.[2, 3, 4, 7] further the likelihood of obtaining a bony union is increased when supplementary auto grafting is resorted to. 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. We observed that it was difficult to interpret radiographic union in these fractures in the first 8 weeks.
We adopted the Harris hip score- HSS  for the assessment of the functional outcome. In it can be clearly demonstrated that in the present series though the union rate is satisfactory, functional outcome is not extraordinary. We can improve the results by doing accurate reduction, satisfactory rigid fixation of fracture and proper fixation of the graft. Preservation of the remaining vasculature of proximal fragment while opening the hip through posterior approach is very important. Complications like infection, subtrochantric fracture must be minimized for better results. So, with the more experience in the procedure results can be improved.