Curative surgical treatment

When you see this type of reconstruction take place – through the magic of biology – the reply is clearly yes. This is why the use of natural coral to fill a bone void, both contents and container, seems to be so valuable.

Let's go back over the various techniques for reconstructing this unfortunate broken bone. Everyone agrees to the need for this repair. The bone must have its continuity restored so that the patient can walk again, but opinions diverge on how to rebuild the bone, with respect to technical resources and – which is just as important – on what should be done when there are several pieces.

In brief, bone continuity must be restored but the question is, how, which means, with what?
Which technique should we start with?

There are two schools of thought, one supporting the idea of rigid fixation and the other that of mobile fixation. One uses metal rods inserted into the bone, roughly in the shape of a Greek . The other uses one screw screwed into the head of the femur and a plate screwed outside the bone. They are linked by a hollow tube which makes an anatomical angle with the plate to which it is joined. The screw and tube-plate can slide in and out of each other. In fact, only the tube-plate slides along the length of the screw which is fixed into the head of the femur and cannot, therefore, be moved.

Without going into the arguments, neither of the two solutions suggested was concerned with the cause, i.e. the bone loss, which affected both the container (the walls) and the content (inside) of the bone. Neither of these methods regenerated bone in the bone. Neither of them took the bone into consideration. This is a simple fact.

Concerning the attitude of traumatologists with respect to various fractures, the same indifference is noted. Both techniques agreed that the two largest fragments of broken bone should be reunited, either by a nail (the Gamma nail) or by the screw-plate. Here is an example of a simple fracture with the two biggest fragments.

A fracture line (A-A') can be seen, separating a large upper fragment (1) and a large lower fragment (2). This is the main fracture line. These are the two basic fragments. They are always found in a femoral neck fracture. This is the traumatologists' only concern.

Sometimes the fracture is more complex and several other fragments may be detached from these two main pieces. The secondary lines detach them. These lines are usually neglected.

Two fragments are particularly important, however, because they are used when standing, walking and going up and down stairs. They play an essential part in the function of this weight-bearing joint. These are fragments (apophyses) which are essential to hip physiology, i.e. to correct function of this joint. They are detached by secondary lines. They are the greater and smaller trochanter attached to fragment 2.

Where are the greater and lesser trochanter located? What do they do ?

Here is an adult femur seen from the front and from the side. The two most frequently broken fragments, which are detached under muscular influence, form a sort of bony "protrusion" on each side of the two main fragments.

Front view

Side view

On the greater trochanter is an attachment for a powerful muscle which is used to stabilise the hip and pelvis. This is the middle gluteal muscle. In a word, it prevents limping and stabilises the pelvis when you stand on one leg.

When the greater trochanter is broken – into one or more pieces – the muscle drags the fragment upwards. It relaxes and loses its strength. This is responsible for limping and the bent position of the broken side when standing.

This loss of strength due to the fracture adds to the reduction in strength due to age. It therefore seems logical to reattach this muscle, which mean fastening the fragment of bone – to recover at least pre-accident strength.

The muscle used to flex the hip is attached to the lesser trochanter. It is also used to go up and down stairs. Since it is attached behind the head of the femur, the tendon acts a bit like a cord stretching under the bony "pulley" of the femur, which increases the muscle's strength.

When the lesser trochanter is broken, the muscle pulls the fragment upwards and forwards. The tendon relaxes the torn envelope to which it is attached.

It therefore loses its "pulley" function. The force of flexion falls. It would therefore seem logical to repair this fragment, even though it is technically more difficult than fixing the greater trochanter.

Neither of the two classic techniques involves fixing these two "secondary" fragments. Perhaps this is one of the reasons why there is a 75% record of functional sequelae. These sequelae include more or less pronounced limping and difficulty in going up or down stairs.

In any case, although a femoral neck fracture no longer has a "bad reputation", it can lead to extremely disabling sequelae. The high rate of these sequelae (75%) can only be lowered if the bone's continuity is fully restored to bring it as close as possible to the anatomy.

Further information on current classical treatment of femoral neck fractures
is available on theSpringer-Verlag (EJOST) and Masson (RCO) websites.

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