Four quadrant parallel peripheral screw fixation for displaced femoral neck fracture in elderly patients.

Sir,

I read the article titled “Four quadrant parallel peripheral screw fixation for displaced femoral neck fracture in elderly patients” with great interest.1 I would like to congratulate the author for his excellent work. However I have few concerns.

Firstly, author agree that bone quality and fracture configuration like posterior comminution are decision making for treatment, but he has not mentioned or taken extra precaution for these cases.

Secondly, author gave reference that area covered by fixation device is important in any fracture fixation; more the area on either side of fracture, better the stability. This fact is true for diaphyseal fracture.2 In fracture neck of femur, screws passes through fracture.

Thirdly, it is well established fact that even two screws can give almost same stability as three screws, unless there is posterior comminution where fourth screw can be placed in a diamond fashion. Otherwise chance of subtrochanteric fracture increases if two screw are placed inferiorly, crowding each other,3 which is obvious in intraoperative photograph shown in paper.

Fourth, there are long study series recommending that near anatomical reduction has to be achieved for fracture neck of femur even if it requires open reduction without doing undue manipulation because chance of avascular necrosis of femoral head and nonunion is proportional to malreduction.4

Finally, author has mentioned some well proven facts as a myth like, accurate reduction, role of synovial fluid preventing union and incidence of avascular necrosis of femoral head in fracture neck of femur. Author has tried to make what is known as “unsolved fracture” to a “solved fracture” but that need some more detail studies to disprove those facts.