Discussion

DISCUSSION Fracture of the neck of the femur continues to be regarded as “unsolved fracture”. But its claim to this distinction becomes increasingly insecure. Since the introduction of the Smith-Petersen nail in 1931, unrelenting Endeavours have been made to solve this problem, and the literature reveals a wide variety of anatomical studies, statistical reviews, new methods of reduction, fixation and bone grafting techniques. The overall picture is one of some confusion but two elementary points of universal agreement are seen to emerge: reduction must be perfect; and fixation must be secure. No one will deny the advantage of perfect reduction in the treatment of this or any other fracture, but accurate reduction is not essential to union in fracture elsewere. Nevertheless, it is generally agreed that in fracture of the femoral neck full and accurate reduction is of particular importance. In regard to fixation many methods of treatment have been devised . Wires, nails, multiple screws and lag bolts, combined bone grafting procedure, sliding and compression devices have all been described, each striving to achieve rigid apposition of the fracture surfaces. Replacement surgery, either partial or total, remains the treatment of choice for these fractures in elderly patient (D’Arcy and Devas 1976,Devas 1977,Coats and Armour 1979, Cartlidge 1981). The struggle to find the best treatment in relatively younger patient continues as it did in earlier years. Efforts were focused on saving the femoral head in active elderly patients with special reference to 55 to 65 years of age group. This study was conducted on 46 patients of frature neck femur out of which 31 were treated by internal fixation (Richard’s compressive hip screw with supplementary cancellous screw with autogenous iliac bone grafting) and 15 patients were treated with Austin Moore Hemiarthroplasty. 8 patients (4 from each group) having follow up of less than 3 months were excluded from the study. The minimum follow up was of 3 months and maximum being 1 ½ years. Overall the average age of the patients was 63 years. The mean age of patient in internal fixation group was 59 years and that of Hemiarthroplasty group was 66 years which is lower than reported by A. B. Van Vugt, W.M. Oosterwijk, R.J.A. Goris (1993). In our study overall male female ratio was found to be 24:40. this ratio in internal fixation group was 20:7 and in Hemiarthroplasty group was 4:7. There were 7 women (26 %) in internal fixation group and 7 women (64%) in hemiarthroplasty group which was much lower than reported by Rogmark C et el(2002) with 78% in internal fixation group and 80% in arthroplasty group. Right side hip was found to be involved in majority of patients in both the groups. ============== According to anatomical classifications, most of the fracture were of subcapital type in both groups. ========= . majority of the fractures were caused by trivial trauma like sliping over floor or by lower intensity strain. This is the most common documented cause of fracture in elderly patients. (Watson jones fracture and joint injuries 6th edition.) In internal fixation group, hypertension was found as most common associated illness(5 patients) followed by diabetes mellitus (2 patients), asthma and Ca cervix(1 patient each). In hemiarthroplasty group most common associated illness was hypertension (2 patients) followed by asthma (1 patient), diabetes mellitus(1 patients) and head injury(1 patient). ====================

The maximum number of cases operated in internal fixation group were within a week (trauma-surgery interval) and average period of hospital stay was 18 days while in Hemiarthroplasty group it was more than 3 weeks (trauma-surgery interval) and 27 days respectively; which was significantly shorter in internal fixation group similar to the study reported by Rogmark C et el(2002). Common sense of implants used in internal fixation group was 135 degree DHS short barrel with 2 holes of size 85 mm and cancellous screw size was 80mm. Common size of prosthesis used in hemiarthro plasty group was 43 mm, which is smaller than used in Langen========= (1978) series. This could be due to comparatively smaller structure frame of Indian population. In our study we have started quadriceps exercise and allowed sitting from 2nd post operative day, allowed walking with walker from 10th post operative day onwards, depending on the patient’s general condition condition, associated medical illness and intra operative complications. F.E. Stinchfield Bernard (1957) in there study have started weight bearing within 48 hours.================ Complications:- we have not encountered any intra operative complication in internal fixation group while Hemiarthroplasty group, there occur fracture shaft of femur in 2 cases. Immediate post operative complications in internal fixation group was failure of reduction encountered in 1 case which was later on converted to Hemiarthroplasty, while in hemiarthroplasty group ,1 patient had dislocation of hip while shifting the patient, which was again closely reduced and limb was immobilized over Thomas splint in abduction and external rotation.================ We have found only 2 patients of operative wound infection(superficial) in internal fixation group. All of them completely healed with appropriate antibiotic after sensitivity testing. In Hemiarthroplasty group we found 5 patients of operative wound infection (3 superficial and 2 deep). All healed completely except in1 case which later on turned to septicemia and patient died. The incidence of wound sepsis as reported by======= Pain not controlled by oral analgesic (in internal fixation group) was in 4 patients(14 %) while in Hemiarthroplasty group, it was in 3 patients(27%); much higher than reported by Ahmed Kaabneh and Jim Jaffery (2007). In internal fixation group we found Delayed complications (DHS cut out ) in 2 cases, which were later on turned to Hemiarthroplasty. In Hemiarthroplasty group acetabular erosion occur in one case, stem loosening occur in one case and shortening occur in 6 cases.============= RESULTS: Overall functional outcome (calculated by Oxford hip screw) in internal fixation group is satisfactory with excellent /good result found in 74 %.of patients and poor in 4% with failure case in 11 % of cases, while in Hemiarthroplasty group- excellent /good result was found in 63%, poor result in 18 %.=========== There was significant difference in mortality between 2 operated group at interval of 1 month after operation. 2 patients (18%) died after Hemiarthroplasty, while there was 1 (3.7%) death n internal fixation group, quit similar result were found by M. Sikand, R. Wenn, C.G. Moran(2004). For internal result group the re-operation rate within one year was higher (n=3,11%) than Hemiarthroplasty group(n=0, 0%), while in study of M. Sikand et el, it was reported

7.2 % for internal fixation and 1.3 % for Hemiarthroplasty group, which were less for both groups.