|Year : 2022 | Volume
| Issue : 2 | Page : 57-64
Controversies in the management of fracture neck of femur
P Madhuchandra, KM Pawankumar, G Sunil Santhosh
Department of Orthopaedics, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Submission||26-Oct-2022|
|Date of Acceptance||30-Oct-2022|
|Date of Web Publication||09-Feb-2023|
Department of Orthopaedics, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Intracapsular fracture neck of the femur (NOF) has been termed as “unsolved” fracture. Despite the ever-increasing literature on hip fractures, current treatment guidelines are conflicting and provide no authoritative, evidence-based recommendations on the ideal timing and modality of surgical management. Studies are going on with regard to solving the mystery behind the fracture NOF, still many of the controversial issues are remaining as a big challenge to orthopedic surgeons across the world. We are trying to enlighten a few of the controversial issues here with regard to:
- Classification of fracture NOF
- Treatment for undisplaced fracture
- Timing of surgery for a young patient with a displaced fracture NOF
- Reduction techniques of the fracture
- Internal fixation (IF) or replacement for displaced fracture NOF
- Positioning of the implant for IF
- Aspiration of the hip
- Surgical approaches
- Cemented versus uncemented prosthesis
- Hemiarthroplasty versus total hip arthroplasty
- Postoperative weight-bearing and moblilization.
Keywords: Avascular necrosis, capsulotomy, fracture neck of femur, prosthetic replacement
|How to cite this article:|
Madhuchandra P, Pawankumar K M, Santhosh G S. Controversies in the management of fracture neck of femur. J Orthop Assoc South Indian States 2022;19:57-64
|How to cite this URL:|
Madhuchandra P, Pawankumar K M, Santhosh G S. Controversies in the management of fracture neck of femur. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:57-64. Available from: https://www.joasis.org/text.asp?2022/19/2/57/369408
| Introduction|| |
The complication following fracture neck of the femur (NOF) is high and the treatment is also controversial. Historically, the decision about which treatment to use has been made more on local preference, tradition, and economic situation. In Scandinavian Countries, Surgeon favors internal fixation (IF) even in elderly people and others preferring replacement. In India, Surgeons working in small towns are forced to do the best under the circumstances he is working. Sometimes it clicks and sometimes it does not. On several occasions, our young patients go in for native treatment and report late. The surgeon is forced to do a hemiarthroplasty at the age of 50 years which is not acceptable in the present scenario. An attempt has been made in this paper to review the literature regarding controversies in the management of fracture NOF.
| Classification|| |
Any classification system should provide the basis for clinical decision-making and correlate withoutcomese. Traditionally used classification systems for femoral NOF are Pauwels, Garden's, and AO/OTA.
Colles first classified NOF fractures as “incomplete” and “complete.” This makes sense because the treatment and prognosis of these two fracture types are different.
Pauwel's classified fracture NOF based on the inclination of the fracture, into three types. Pauwel's classification is not helpful in decision-making for (IF) or prosthetic replacement. On the preoperative X-ray, the inclination of the fracture line is difficult to draw exactly. On the other hand, Pauwel's type 2 and 3 can be differentiated. Once the fracture is reduced. Many authors have abandoned the Pauwels classification completely., The Pauwels angle studied in a series of 335 patients showed no predictive value for nonunions.
Garden claimed the existence of an “un-displaced” fracture (Stage 2) that should be distinguished from the impacted fracture (Stage 1). However, his publications never showed lateral X-rays with undisplaced fractures. It iss based on assumption that the more displaced the fracture more harm to vascularity with a higher rate of avascular necrosis (AVN). However, there is no significant difference in AVN rate between Garden stages 3 and 4 in studies even in the paper of Barnes Garden was co-author of this paper! Therefore, Garden classification does not help in preoperative decision-making. Finally, the inter-observer variation in Garden's system is unacceptable.,
AO/OTA classification system has poor intra- and inter-observer reliability. Pauwels and AO/OTA classification systems are reported to be of little value in determining the risk for adverse clinical outcomes.,, In conclusion, the only useful classification of NOF fractures is: undisplaced and displaced.,
| Treatment for Undisplaced Fractures|| |
In general, undisplaced fractures are treated by IF. However, literatures are there for the conservative as well as IF. Even though the impaction is not rigid in these cases, the perpendicular plane of the fracture causes so much of compression that these fractures can heal without operative stabilization.
Recumbency and traction are practiced and require a longer period of bedrest with the high rate of complications such as decubitus ulcer, thromboembolism, and mental deterioration.
Cserháti et al. only one-fourth of the nonoperatively treated patients were able to walk alone when they left the hospital. General complications in 19% and early displacement were noted in 20% of the nonoperatively treated.
IF of undisplaced fractures helps in early mobilization, especially in the elderly in whom prolonged bed occupancy will have harmful effects., Furthermore, early pain subsidence, a better quality of life, and lesser revisions when compared with conservative management. After IF of an undisplaced fracture, the main complications that may be expected are nonunion (6%–8%) and AVN of 4%.,
As per evidence-based medicine Conservative treatment should be reserved for those who present late with resolving pain, comorbid patients or else its better to do IF.
| Timing of the Surgery Does it Matter?|| |
In young patients
The timing of surgery for NOF fractures remains controversial, and the available data remain inconclusive. The justification for urgent fixation is the rapid reestablishment of vascularity, minimizing the risk of AVN.,,,
Swiontkowski et al., reported low rates of AVN (20%) and no nonunion in 27 patients aged 15–50 years and attributed this to their protocol of immediate reduction (within 8 h) and IF.
Jain et al. supported Swiontkowski et al. findings when they reported an increased rate of AVN (16%) in 38 patients (aged <60 years) treated >12 h after injury and 0% AVN in patients treated <12 h. No nonunions were reported. Using the Short-Form-36 and the Western Ontario and McMaster Universities Osteoarthritis Index instruments, Jain et al. found no difference in functional results between the patients in whom osteonecrosis developed and those without. They concluded that delayed treatment was associated with increased AVN rates, but didnot affect the functional outcome. Haidukewych et al. retrospectively reviewed a series of 73 patients between the ages 15 and 50 years, AVN developed in 23%. Thirteen (25%) of 53 patients had been treated <24 h and in 4 (20%) of the 20 patients who had been treated >24 h. They found no difference in nonunion rates (8%) between the two.
Upadhyay et al., prospective study of 92 patients showed an overall AVN rate of 16%, with no difference in those treated before or after 48 h at 2-year follow-up. Moreover, overall nonunion of 17% without any difference between the two groups.
A meta analysis of 18 retrospective studies with 547 patients (15–50 years), showed no difference between patients treated within12 hours (AVN 13.6%, nonunion 11.8%) and patients treated after 12 hours (AVN 15%, nonunion 5%).
In our opinion, it is better to operate at the earliest possible, so that patients will not be denied any benefits, whatever the controversies may be.
Timing of surgery in the elderly
The optimal timing of surgery in the elderly is controversial. In 31 clinical studies investigating the impact of surgical delay on the mortality rates following hip fractures, 13 showed no difference, while 18 reported significantly increased mortality rates. 9 recommended surgery <24 h of admission, and 11 suggested surgery be performed within 48 h. 4 advocated surgery within 72 or 96 h., Interestingly, studies that showed no significant difference in mortality following surgical delay continue to support the “operate within 24 or 48 h” notion, based on the fact that despite no significant impact on mortality, complications, pressure ulcers, and pain are significantly reduced and return to independent living is more likely when surgery is done within 48 h. Based on the current level II and level III evidence, it is better to do IF within 48 h to minimize postoperative complications
Should surgery be delayed for medical clearance?
Patients with hip fractures and associated comorbidities are shown to have raised perioperative mortality rates. However, patients whose surgery was delayed >4 days had 2.5 times the risk of dying within 30 days postoperatively.
Cluett et al. found that patients with significant cardiac comorbidities, such as myocardial infarction within the past 2 weeks, had significantly elevated 1- and 6-month mortality (45.4% and 63.5%,), suggesting that these patients would benefit through preoperative medical care.
Harty et al. delay due to antiplatelet medication increased the length of hospital stay (7.4 vs. 3.1 days, respectively) and 30-day mortality (29% vs. 4%, respectively) and suggested that such patients should be operated on early with transfusion of pooled platelets.
Bergeron et al. demonstrated that preoperative delay in managing comorbidities results in longer hospital stays but does not lead to mortality.
Bottle and Aylin found significantly increased mortality risk with surgical delays of 24–48 h.
In our opinion, it is better to evaluate the patient and take up for surgery within 24–48 h. Low spinal or lumbar plexus block helps to avoid complications.
Studies have shown that intracapsular pressure after fracture NOF is lowest when the hip is flexed and externally rotated. Therefore, extension and internal rotation should be avoided prior to capsulotomy. Hence, most clinicians avoid traction.
Most commonly fracture tables are used with the patient in the supine position. Leadbetter in 1932 described his technique for closed reduction. Since then, the reduction maneuver most widely used involves traction, internal rotation, and abduction of the limb. At no point, sudden forceful reduction maneuvers should take place nor should excessive traction and failed multiple attempts be put on the limb, which will impair capsular vessels.
The most common technique includes restoration of axial length by disimpacting the fracture in an externally rotated position. Once the correct length has been achieved, internal rotation reduces the fracture gap and adduction compresses the fracture. Over-distraction of the fracture must be avoided. The aim is to achieve an anatomical reduction or slight valgus position on the AP view and to restore the smooth curves and anteversion in the lateral view. A varus position must be avoided. The quality of the reduction is assessed by Garden's alignment index for which the reduction angle should be 160°–170° in the AP view and close to 180° in the lateral view. Failure to achieve an anatomical reduction using these methods is rare, the main cause for failure is inadequate internal rotation. Faced with suboptimal reduction, the surgeon has to decide whether to fix the fracture in this position or carry out an open reduction or proceed to arthroplasty. Only an anatomic reduction should be accepted. If not possible, one should proceed with open reduction and IF.
Upadhyay et al. compared closed versus open reduction and IF in young patients and found no difference between the two groups with regard to AVN and union.
To conclude, one should never accept nothing short of anatomical reduction. So never be hesitant to do open reduction, if not achieved by closed means.
Although studies have shown raised intracapsular pressures after fracture NOF impeding the vascularity in the femoral head, the role of capsulotomy remains controversial.
Swiontkowski et al., showed low rates of AVN (20%) with capsulotomy. Capsulotomy results in decreased intracapsular pressure resulting in improved blood flow to the femoral head and reducing femoral head ischemia.
Bonnaire et al. reported that 75% of the patients in their study had increased intra-capsular pressure. Harper et al. used a transducer and showed that aspiration of hematoma led to a significant decrease in intraosseous pressure (P = 0.037) and increase in pulse perfusion pressure (P = 0.038).
Strömqvist et al. and Holmberg using technetium-methylene diphosphonate scintimetry showed an increased uptake in the femoral head after aspiration. On the other hand, Maruenda et al. measured preoperative intracapsular pressure in 34 patients and followed for an average of 7 years after IF. Five of 6 patients in whom femoral head osteonecrosis developed had an intracapsular pressure that was less than diastolic blood pressure. Osteonecrosis may be a result of vascular damage and not of the tamponade effect.
Other variables related to osteonecrosis include the amount of fracture displacement,, disruption of the blood supply at the time of fracture, quality of the fracture reduction, or time between fracture and reduction, postoperative time to full weight-bearing, fracture nonunion, loss of fracture reduction, and associated fracture of the ipsilateral femoral shaft. There is no evidence indicating which factor is responsible for osteonecrosis. Hence, in our opinion, its better to do capsulotomy. It is easy to perform and adds minimal time and risk to the procedure. Most importantly, it may help a small subset of patients at risk of AVN.
Displaced fracture-Internal fixation or prosthetic replacement
When planning the ideal treatment strategy, the surgeon needs to consider the “biological age,” “calendar age,” the patient's prefracture mobility, bone quality, and comorbid conditions.
In any physiologically active patient <60 years, treatment goals are to preserve the femoral head, avoid AVN and achieve union. Current guidelines recommend IF for active patients <60 years as the preferred treatment option. For elderly patients, the priority is an early mobilization to minimize complications of prolonged bed rest. This goal is best achieved by a primary THR.
Literature suggests that IF generates less surgical trauma; shorter operating times with decreased blood loss; and reduced need for blood transfusion, decreased risk of wound infections, and early postoperative mortality compared to arthroplasty. However, the major drawback is significantly higher rates of reoperations due to implant failure or loss of reduction.
Swintkowski proposed IF in patients between 65 and 75 years of age “with high functional demands and good bone density.”,
The current best evidence comes from several meta-analyses of randomized controlled trials (RCTs) published in the last 10 years. These studies showed an increased risk of reoperation associated with IF (mean 35%) compared with arthroplasty (9%). Two highly powered metaanalyses gave divergent results when evaluating the risks of complications and mortality associated with these two treatment methods (IF vs. arthroplasty).The meta-analyses by Bhandari et al. (14 RCTs, 1901 patients) found significantly higher infection rates, blood loss, and an insignificant trend toward higher mortality at 4 months, whereas Rogmark and Johnell. evaluation of 14 RCTs comprising 2289 patients showed fewer complications with primary arthroplasty and no difference in mortality.
Duration of surgery, perioperative blood loss, and risk of deep wound infection was significantly lower in patients treated with IF. These benefits, however, came at the cost of significantly higher rates of operative revision: 28%–36% for IF and 10%–16% for arthroplasty.
As per current evidence-based studies, one should consider “biological age,” “calendar age” should no longer determine the fate of the femoral head. Physiologically active patients <60 years should be considered for IF, those with physiological age >60 years, with active lifestyle and less bone stock, will be benefited from total hip arthroplasty (THA), while elderly morbid patients with limited hip function and dependent living status benefit from primary hemiarthroplasty.
Internal fixation: Choice of implant
Any fracture neck fixation should ideally allow interfragmentary compression, resist displacement and ensure rotational stability during the healing process. Options are multiple compression screws, dynamic-fixed angle devices such as sliding hip screw dynamic hip screw (DHS), and static-fixed angle devices such as blade plates, dynamic condylar screws (DCS), and proximal femoral locking plates (PFLP).
Multiple compression screw in an inverted (apex distal) triangular fashion is the most common technique. The type and number of cancellous screws for effective fixation have been studied in multiple studies. A major limitation of these studies is that they are all based on osteoporotic models.
Three cancellous lag screws placed parallel to one another and perpendicular to the fracture line provide optimal compression at the fracture. Pauwels Type-I and II fracture variants are most amenable to this type of fixation. These three Cancellous lag screws should be in an inverted triangle configuration because there is less risk of subtrochanteric fracture with this apex-distal screw orientation than with apex-proximal orientation. The lower screw should be placed just superior to the calcar, with the tip in the subchondral bone close to the joint line. This gives three-point fixation at the femoral head, calcar, and the lateral cortex. The second screw is placed centrally on anteroposterior and touching the inferior cortical bone of the calcar on the lateral radiograph. Third screw best placed centrally on both views. The addition of a fourth screw has not shown added mechanical advantage, but some advocate its use when there is posterior comminution. Studies have shown that two screws do not provide adequate fixation. However, multiple screw technique is associated with uncontrolled sliding leading to varus angulation and postero-inferior displacement of the femoral head.
Other implant options
Other implant options, particularly useful in Pauwels type III fractures (known for higher rates of failure) and nonunion include the angled blade plate and the DCS. Liporace et al. looked specifically at Pauwels type III fractures and found a trend toward less fixation failure with fixed angle devices (DHS, cephalomedullary nail, DCS) as compared to cannulated screws.
Aminian et al. compared four fixation constructs in simulated Pauwels type III fractures in fresh frozen cadavers and showed superior strength of the PFLP as compared to DHS, DCS and 7.3 mm cannulated screw constructs. The authors did mention that although PFLP was the stiffest construct, the implant does not allow compression at the fracture site and affects healing.
Cut-outs of the Uppsala screw, Ullevaal-screw, screw of the gamma nail, and screw of the DHS were tested in the cadavers. The hold of these four implants in the bone did not differ., Ly and Swiontkowski et al. treated Pauwels Type-III fractures by open reduction and IF with three Cannulated screws (with 100% union). Obtaining an anatomic reduction and adequate fixation remains the key to successful treatment.
Baitner et al. found that fixation with DHS resulted in less inferior displacement, less shearing, and a greater load to failure when compared with three Cannulated cancellous screws. Bonnaire evaluated four different methods of fixation of Pauwels Type-III fractures in cadavers; DHS with derotational screw, DHS without derotational screw, cancellous screws, and a 130° angled blade-plate. They concluded that the DHS with the derotational screw is the best implant for this fracture pattern. These large compression screws, leads to the loss of the huge amount of bone, making subsequent reconstruction difficult if required, the risk of disrupting the blood supply to the femoral head if the hip screw is imperfectly placed, and its inability to adequately control rotation without an additional derotational screw.
The relative importance of dynamic compression during weight bearing at the cost of stability in unstable fractures has not been studied. Although, the theoretical benefit of fixed angle implants should be considered in high shear (Pauwel's type 3) fractures, an advantage over compression screws has not been clearly shown in studies. Although multiple screws remain the current standard, trends favoring fixed angle implants in the younger population demonstrate the need for comparative studies to ensure best practice.
Commonly used approaches for open reduction of fracture NOF are a lateral Watson-Jone's approach and an anterior Smith-Peterson's approach.
The anterolateral approach Watson-Jones, is through the interval between glutei and tensor fascia lata. It retains the advantage of the iliofemoral approach but also exposes the trochanteric region laterally. Since there is no risk to superior retinacular vessels the chances of AVN are less. The interval between Gluteus medius and tensor fascia lata is often difficult to delineate. This approach provides somewhat limited access to the hip joint along with the lateral proximal femur. With well-positioned retractors and adequate soft-tissue releases, it is possible to perform the open reduction of displaced fractures.
Smith-Petersen described an anterolateral approach. It provides the most direct access to the anterior aspect of the hip. The distal extension of the iliofemoral incision exposes the trochanteric region and the upper femur.
Smith-Peterson's approach provides an excellent direct exposure and there by reduction of the anterioromedial cortex. It iss also possible to fill up any defect if needed with bone graft.
However, a separate incision may be required for implant insertion. Chances of injuring the femoral nerve, lateral cutaneous nerve of the thigh endangering the vascularity for the head of the femur are high in Smith-Peterson approach when compared with Watson–Jone's approach.
Approach for arthroplasty
Commonly for arthroplasty, Smith-Peterson's anterior approach or posterior approach, lateral and trochanteric osteotomy approaches are used.
The anterior approach has a lower risk of postoperative dislocation but a greater chance of femur fracture during operation, more blood loss, and higher rates of myositic mass formation when compared with the posterior approach.,
The posterior approach is simpler and faster with less blood loss, but the chances of dislocation, infection, and foot drop are more.
Arthursson et al. compared long-term survival of primary THA with lateral with or without trochanteric osteotomy, and the posterolateral approaches. The lateral approach with trochanteric osteotomy had a lower probability of revision than without trochanteric osteotomy. The lower revision rate was due to fewer revisions for aseptic loosening and dislocation. They observed no differences between the lateral approach without trochanteric osteotomy and the posterolateral approach, except that there were more revisions in posterolateral approach due to dislocations.
The approach with trochanteric osteotomy has been associated with trochanteric pain, limp, and dislocation if trochanteric nonunion occurs. The rate of trochanteric nonunion after trochanteric is between 0.8% and 32% Wroblewski and Shelley, Pai 1997) The advantages are good exposure of the femur and acetabulum, facilitating cup and stem positioning, affords the possibility of tightening the abductor muscles when reinserting the trochanter. This reduces the rate of dislocation.
The lateral approach to the hip, without trochanteric osteotomy, has been blamed for an increased risk to the superior gluteal nerve as well as to the gluteus medius muscle, resulting in high rates of postoperative limp or dislocation Downing et al., Masonis and Bourne,. Increased heterotropic ossification has also been reported Mulliken et al. The exposure of the femur is more restricted than in the posterior approach, but it allows good exposure of the acetabulum and the possibility of good cup positioning.
The posterior approach is considered to have less effect on gait since the hip abductors are not dissected, but it has been associated with the highest rate of postoperative instability (Masonis and Bourne). It is difficult to expose the acetabulum for cup positioning. Increased risk of injury to the sciatic nerve, which is close to the operative field. The advantages are good exposure to the femur, shorter operation time, and less blood loss.
Cemented versus uncemented prosthesis
A number of recent randomized trials have shown the superiority of a cemented prosthesis to an uncemented one. In a recent study by Gjertsen et al., from the Norwegian registry, the uncemented prosthesis resulted in reoperations twice as the cemented prosthesis at an average follow-up of six years. This increased reoperations were attributable to periprosthetic fracture, aseptic loosening, and infection. However, the cemented prosthesis had a unique problem of intraoperative deaths from bone cement implantation syndrome. The study quotes a death rate of 0.3% and significant cardiovascular events of 0.8%. Parker et al. have come up with similar revision rates in the uncemented Austin Moore Prosthesis (AMP) group. In their study, the rate of reoperations was 3% for the cemented Thompson and 6% for AMP, they found that Thompson hemiarthroplasty led to less pain in the hip, improved return of mobility, and reduced stay in hospital compared with an uncemented AMP. Similar rates were reported in the Australian Joint Registry (2009) 4% and 6%.
Unipolar versus bipolar hemiarthroplasty
The choice between unipolar and bipolar prostheses is less clear. The main theoretical advantage of bipolar over unipolar prosthesis is the reduction of acetabular erosion and less pain due to movement taking place within the implant rather than between the head of the prosthesis and the acetabulum.
A prospective study showed no differences in Harris scores, loosening, or acetabular erosion between Moore's unipolar and Bateman's bipolar prosthesis at 3 years (van Thiel et al.1988). Recent studies disagree with this, unipolar prosthesis is found to be associated with a 64% erosion rate compared with the bipolar rate of 14% (Baker et al.,)
In our opinion, active older patients (70–79 years) would benefit more from a bipolar implant. And those >80 years with household ambulation, the unipolar prosthesis is sufficient.
Hemiarthroplasty versus total hip arthroplasty
This has been the subject of controversy in the number of recent studies. Most of the RCTs have shown that functional results of THR in fitter older individuals are very good as compared to Hemiarthroplasty.
Ravikumar and Marsh demonstrated that hemiarthroplasty was associated with greater pain (45% vs. 6%), decreased mobility (53% vs. 70%), lower Harris hip scores (55 vs. 80), and higher revision rates than THR (24% vs. 6.75%). Keating et al. evaluated patient assessed outcomes between hemi and THR at 24 months and demonstrated significant improvement in hip rating questionnaire and general health level in total arthroplasty patients. Blomfeldt et al. in their RCT comparing THR with hemiarthroplasty have found that THR is associated with better hip function compared with bipolar hemiarthroplasty. Based on the available evidence, THR is the preferred treatment for the elderly, functionally independent patients and hemiarthroplasty is reserved for older household ambulant and dementic patients with life span.
Postoperative weight bearing and mobilization
The preferred weight-bearing regimen after operative treatment of a fracture NOF remains controversial. Restricted weight-bearing can delay the functional recovery and return to independent living of elderly patients. Some surgeons are hesitant to have early unrestricted weight-bearing. It has been shown that unrestricted weight-bearing does not increase the rate of complications after IF of undisplaced fractures. Patients with displaced fractures, often are restricted to partial weight-bearing because of the risk of failure of fixation and risk of nonunion. An RCT showed slightly fewer complications of fracture healing in patients who were fully weight-bearing compared to those who were partially weight-bearing. Advising a patient to nonweight bear may even increase the forces across fracture as these may exceed those generated by weight bearing. Hence, for many patients, it would be advisible to allow weight-bearing as tolerated by them.
Evidence-based studies suggest:
- An undisplaced internally fixed fracture in an elderly, weight bearing is allowed as tolerated by them. They may not be able to do full weight bearing due to pain and can be given walking aids. As fracture heals and pain reduces, they become less reliable on walking supports
- For an younger patient with a displaced fracture with IF it is prudent to advise a period of partial weight bearing because of the potential chances of fixation failure and nonunion. Younger patients will voluntarily limit weight-bearing on the basis of the degree of discomfort that such weight-bearing causes
- For a patient with hemiarthroplasty and THR, total weight bearing is allowed once pain subsides. However, the risk of dislocation may be up to 10%, so these patients should be advised against excessive hip flexion and rotations in the first few weeks after surgery.,
| Conclusion|| |
Fracture NOF was an unsolved problem in older days. We are in a much better position to treat these patients in varying age groups to avoid complications and to make them mobile by Total hip Replacement in physiologically younger age groups. The decision-making in the problem is to suit the economic conditions of the patients and as well as the experience of the Surgeon. The surgeon must be exposed to lot of information during his training period and continue his learning through continuing medical education (CME) Programmes and by new ways of receiving information. The most successful Surgeon in life is the man who has the best information.
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Conflicts of interest
There are no conflicts of interest.
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