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Meyer Bakshi pedicle graft for ic nof

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Meyer Bakshi pedicle bone graft intracapsular femoral neck fracture

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quadratus femoris pedicle bone graft femoral neck fracture young

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Meyer Bakshi pedicle graft intracapsular neck of femur fracture technique

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PMID: 32662658

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PMID: 29198718

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https://ijos.co.in/archive/volume/10/issue/4/article/17241

Here is a detailed account of the Meyer's and Bakshi's Pedicle Bone Grafts for intracapsular neck of femur (IC NOF) fractures.

Meyer's and Bakshi's Muscle Pedicle Bone Grafts - IC NOF Fractures

These are head-preserving surgeries used primarily in young patients (typically under 50) with intracapsular femoral neck fractures - including fresh displaced fractures, neglected fractures (>3 weeks), and cases of nonunion / failed fixation.
The rationale is to augment vascular supply to the femoral head via a living bone graft carried on a muscle pedicle, thereby promoting union and preventing or treating avascular necrosis (AVN).

Meyer's Procedure (Quadratus Femoris MPBG)

Muscle used: Quadratus femoris (posterior hip muscle originating from the ischial tuberosity and inserting into the intertrochanteric crest)
Approach: Posterior approach to the hip with posterior capsulotomy
Technique steps:
  1. A posterior capsulotomy is performed and the femoral neck nonunion site is identified
  2. Fibrous tissue is cleared from the nonunion
  3. The quadratus femoris insertion on the posterior aspect of the femur is elevated, carrying a bone block of approximately 4 cm length x 1.5 cm width x 1 cm depth
  4. A trough is cut into the posterior femoral neck, bridging the nonunion site
  5. The vascularized bone block is placed into the trough and fixed with screws
  6. Internal fixation of the fracture (usually cannulated cancellous screws) is performed concurrently
The pedicle remains intact throughout, preserving the blood supply via the quadratus femoris artery (a branch of the medial circumflex femoral artery).
(Rockwood and Green's Fractures in Adults, 10th ed., p.2673)

Bakshi's Procedure (Tensor Fascia Lata / TFL MPBG)

Muscle used: Tensor Fascia Lata (TFL), arising from the anterior iliac crest
Approach: Anterolateral / Smith-Petersen approach
Technique steps:
  1. TFL with its attached bone block is elevated from the anterior iliac crest
  2. The femoral neck fracture is reduced (open or closed - CRIF with cannulated cancellous screws)
  3. The TFL-bone pedicle graft is placed at the subcapital region of the femoral neck (at the fracture site / neck-head junction)
  4. The graft is fixed with a 3.5 mm cortical screw into a slot at the subcapital neck, often using the "light bulb technique" to create a cortical window and prevent dislodgement

Key Comparison

FeatureMeyer'sBakshi's
Muscle pedicleQuadratus femorisTensor fascia lata (TFL)
ApproachPosteriorAnterolateral
Graft sitePosterior femoral neckSubcapital / anterior neck
Vascular basisMedial circumflex femoral a.Lateral circumflex femoral a. branches
Fixation of graftScrews into troughCortical screw into slot
Other described pedicles include iliopsoas and sartorius muscle grafts, though these are less commonly used.

Indications

  • Young adults (<50 years) with displaced intracapsular NOF (Garden III/IV)
  • Neglected fractures (>3 weeks old)
  • Ununited / failed internal fixation of femoral neck in young patients
  • Early AVN of the femoral head (Ficat stage I-III)

Evidence

  • A 2017 systematic review and meta-analysis (PMID 29198718) showed that quadratus femoris MPBG + hollow screw fixation was significantly superior to screw fixation alone in fracture healing rate (OR 5.43), hip function, AVN rate, and time to union
  • A 2021 study by Tüzün et al. (PMID 32662658) using Meyer's procedure in 16 patients with ununited NOF fractures reported radiological union in 7 months average, with only 6% AVN rate
  • Vallamshetla et al. (2010) reported 86% union rate using quadratus femoris graft with ORIF in 42 young patients with delayed/nonunion at mean 9 months post-injury (Rockwood and Green's, p.2673)
  • Nair et al. (PMID 24318307) similarly found MPBG as a useful adjunct in neglected/ununited fractures in young adults

Advantages over Arthroplasty in Young Patients

In patients under 40 with no major comorbidities, arthroplasty is often deferred. MPBG offers:
  • Head preservation with restored vascularity
  • Avoidance of prosthesis-related complications and the need for future revision
  • A technically reproducible, relatively low-cost procedure compared to free vascularized fibula graft
  • Can be combined with valgus osteotomy in cases with varus malunion
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