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The Treatment of Nonunion of Femoral Neck Fractures
The Treahnent of Nonunion of Femoral Neck Fractures ROBERT T. McELVENNY, M.D., F.A.C.S.*
PRELIMINARY CONSIDERATIONS
Nonunion and Delayed Union
K onunion between the femoral head and neck is of the same type experienced in bone elsewhere. Complete disengagement between head and neck is easily recognized. Fibrous union between neck and head (delayed union) is not yet routinely recognized by all. It should be, for it is the cause of false security, the common producer of aseptic necrosis of the head, and the eventual factor in most disengagements between head and neck. Many times, because of pain, the fixation material is removed months after pinning. The head later disengages from its neck. This is often spoken of as a refracture. Refracture may at times occur, but commonly it is not refracture-often it is the separation of an existing fibrous union. True, normal neck bone had never welded the head to its neck. As long as a femoral head is forced to function by metal fixation and fibrous union, holding a degree of functional position, the demand for nutriment to the head cells approaches the normal. But as long as a fibrous barrier exists between the head and neck at the fracture site that prevents the normal formation of medullary and cancellous substance that must be present to pass the blood to the head from the trochanteric and neck pools, just so long does the head get little, if any, normal nutriment. Keep this up beyond the time the head cells can exist upon their reserve, and they fail to propagate in kind. Substitution occurs, and the head as a functional unit is lost. Reduction of femoral neck fracture is improving. The fixation material is maintaining more heads upon their necks. Frank disengagement of fragments is less common than formerly. Delayed union is more common, as there are fewer frank separations. Aseptic necrosis of the femoral head is encountered more frequently than ever because more delayed unions occur than formerly.
* Assistant Professor of Orthopedic Surgery, Northu'estern University Medical School; Senior Attending Surgeon, Wesley Memorial Hospital, Chicago, Illinois. 251
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Fig. 146. A. Adequate reduction of transcervical fracture. Note how neck fragment on head has caught into the neck and is supported by the neck bone to bone. B, Rapid bony union ensues. Note how little purchase nail has in head. The motion of metal was slight as forces are bone to bone with fragments steadied by the metal.
Any motion at a fracture site refractures callus and irritates it. There follows an overproduction of callus. The first intramedullary rods used in the femoral shaft allowed rotary motion. The result was a marked overproduction of callus about the fracture site. This callus was of poor quality, and delayed union was common. Contrast with this the production of the relatively small amount of callus and the rapid union we witness today, as changing designs of the various rods have decreased, or even eliminated, this rotary motion. The same overproduction of callus at the fracture site between the femoral head and neck can be seen and picked up by serial x-rays taken of the fractured hip if delayed union is present. Delayed union between femoral head and neck is revealed as follows (Figs. 146, 147, 148): 1. Overproduction and progressive production of callus at the fracture site. 2. The settling or shifting of the femoral head in either the anteroposterior or lateral view. 3. The shifting or moving of metal. 4. Condensation at the fracture line. 5. Increased density of the head. 6. Inability of the patient to control completely and painlessly the affected extremity. The femoral head suffering delayed union may usually be saved for a
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Fig. 147. A, Inadequate reduction of transcervical fracture. Fragment on lower surface of head is below and away from the neck. It is impossible for this head to invaginate its neck and achieve support bone to bone. Six months after pinning. Weight-bearing started. B, Twelve months since pinning and 6 months since weightbearing. Patient was never without hesitancy in gait, limp. and some pain in groin. Complete internal rotation was always lacking. Note callus proliferation at arrow, condensation at fracture line, shift of head, and shift of metal. C, Eight years since pinning. True bony union has finally ensued. Too late to give a functioning head. This hip could have been saved by displacement osteotomy when delayed union showed so plainly in B.
full functional unit if delayed union is rapidly converted into bony union before nine months postpinning. The Fixation Material (Fig. 149) The Smith-Petersen nail or other flanged nails are not large enough to fill completely the neck cavity side to side and thus grab hard cortical bone. Slight rotary motion between the head and neck is often allowed
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Fig. 148. A, Inadequate reduction of transcervical fracture. Pins well placed in both planes and in head. B, Six months after pinning. Weight-bearing started. C, Ten months since pinning and 4 months since weight-bearing. All cardinal signs of delayed union are present. Osteotomy is indicated now. If patient is above 60 years of age an angulation osteotomy would be favored.
if single pins or nails are used. The addition of two smaller pins with the nail is desirable. If one uses a bone graft in addition to a nail, the graft should center the head. Bone grafts are often eccentric to the hole prepared for them and, in addition, if placed in the upper quadrant of the head, often pick up a bolus of cancellous bone as they traverse the neck, and when this bolus is driven into the head ahead of the graft, the upper quadrant of the head is either crushed or fractured, in many cases producing aseptic necrosis of this quadrant. Choosing the Type of Fracture to Pin (Fig. 150)
One may properly reduce and pin only the transcervical type of fracture. Routinely this fracture, properly reduced and fixed, offers results approaching the normal. A transcervical fracture is one that has some neck bone firmly attached to the inferior half of the femoral head. Proper reduction of this fracture presumes the invaginating of the bony mass on the inferior half of the femoral head into the medullary cavity of the neck. This achieves firm locking of the fragments, and all tipping tendencies are prevented. Multiple pin fixation in line with each other and parallel to the calcar femorale discourages rotation between the fragments. A subcapitaZ fracture is one that has no portion of neck firmly attached to the lower (inferior) half of the head. If neck is not attached to the lower half of the head, or is only present on the upper half of the head, there is no way that the neck may be shifted so that the head fragment may routinely invaginate and be held by the neck. Consequently, the two surfaces contact each other like the faces of one coin against another. The angle at which this occurs puts tremendous shearing, angulating and torque forces to work. Nothing locks these fragments but the metal fixation. The forces are transferred not from bone to bone with position
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Fig. 149. If one rodded the supracondylar fracture illustrated, a question of judgment might be raised. We, however, assume a nail will hold a similar fragment at the hip, where forces are at least as many as at the supracondylar area of the femur.
maintained by the steadying influence of metal, as in a properly reduced transcervical fracture, but are transferred bone to metal to bone. This set-up is physiologically impossible and failure is most common. Metal cannot hold bone. Bone must hold metal. Most nonunions following immediate fixation of intracapsular femoral neck fractures result from the following: 1. Pinning a sub capital fracture without osteotomy. 2. Failure to properly reduce a transcervical fracture. 3. Poor fixation of a properly treated fracture. Fear of Plaster
The fear of a plaster spica goes back to the days of indifferent care, or studied neglect or innocence. If the knee is placed in the proper position without torque or strain upon it, this is of no moment. A strain or torque placed upon any joint such as the knee, or the metacarpophalangeal joint, means trouble. If a knee is treated with the same understanding as one would use with the joints of the fingers, the results are comparable. A good hip, and a knee correctly fixed in plaster, eventually mean a fullfunctioning and useful lower extremity. Reconstructive Procedures
In the restoration of a human who has suffered a hip fracture and who
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Trans - cervical types Fig. 150. These may be adequately reduced and pinned.
is an integrated and active creature, the physician should know the most about the following: 1. How and when to pin a hip. 2. How and when to osteotomize. 3. How and when to fuse a hip the first time. 4. How and when to use prostheses. THE OSTEOTOMIES
Bone heals best when all angulating, torque and shearing forces are eliminated and in their place is substituted compression forces that intimately squeeze the bone fragments together at right angles to the fracture line or to the surface where union is desired. The purpose of osteotomy is to gain rapid bony union between the femoral head and neck. This is achieved by an osteotomy because: 1. The osteotomy changes the plane of the fracture line to bring correct compression forces into play. 2. The osteotomy exposes the greatest area of fractured surfaces to each other. 3. The osteotomy forces bone to support bone and thus lock to each other. The compression forces are directed bone to bone, not bone to metal to bone. 4. The fixation material is correctly placed to achieve the above objectives. Osteotomies are divided according to the location of the cut and according to the direction the weight thrust the body ultimately takes through the femur, its neck and its head. 1. According to cut: a. Oblique osteotomy between the trochanters and through the femoral neck. b. Oblique osteotomy between the trochanters. c. Curved osteotomy between the trochanters, or just below the lesser trochanter. 2. According to weight thrust:
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a. Displacement osteotomy. This procedure demands an oblique cut that passes between the trochanters and through the neck or only between the trochanters. b. Angulation osteotomy. This procedure is one in which the shaft is angulated upon the proximal fragment. It may be intertrochanteric or subtrochanteric in location. The Displacement Osteotomy
This procedure, in general, is the most satisfactory one for restoring painless hip motion. The medial displacement of the shaft throws the weight thrust towards the center of the body. The medial shift of the shaft cuts down the length of the lever arm of the neck. Displacement osteotomy gives relief of pain and tremendous endurance to most people, regardless of the appearance of the femoral head or hip joint. If, in degenerated hip joints, motion at the hip is above 70 degrees in the anteroposterior plane, displacement osteotomy is the first choice and gives the highest percentage of painless hips of any procedure yet devised. If, following vitallium cup arthroplasty, pain is marked but anteroposterior motion at the hip is above 70 degrees, a displacement osteotomy offers a chance of relief that is well worth taking. For uniting the femoral head to its neck, the displacement osteotomy through the neck is, in our hands, the method of choice. In using this procedure the following indications are followed: 1. The femoral head should be detached from its neck. This means that frank nonunion exists at the fracture site, or delayed union exists that heavy traction can separate. 2. All fixation material cleaving head to neck, be it metal or bone, must be removed prior to osteotomy. The principle of displacement with osteotomy through the femoral neck requires a free and movable head that, under traction, will turn upward. Mter osteotomy the head will then rotate and fall between the osteotomized neck fragments in proper position for immediate bone union. If the head is not freely movable, the displacing of the shaft will cause the neck to impinge upon the lower surface of the femoral head. This can lead to fracture of the shaft either through the neck or at the junction of neck and trochanter. The disadvantages of this procedure are: 1. The procedure requires a plaster spica for 10 weeks. 2. The patient undergoing this procedure must be capable of being an active person. The advantages of this procedure are: 1. Limb length is restored. 2. Gait is excellent.
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Fig. 151
A, Hip well pinned but inadequately reduced. B, Result 18 months after pinning, and 6 months since pin was removed because of pain. Delayed union present. Age 49 years. C, Heavy traction has separated the fibrous union. Limb is in 20 degrees internal rotation and about neutral lateral position. Hip is now opened anteriorly. Following exposure of the intertrochanteric region but leaving the hip capsule intact, a Steinmann pin is thrust through the skin from the lateral side and skewered on top of the shaft toward the femoral head. An x-ray is taken. The pin serves as a marker to show if the osteotomy is oblique enough and also where to place the drill holes to start the osteotomy (after Reich). The object is to cut through the neck obliquely and as high as possihle and still be able to displace the shaft and neck fragment. After the level
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3. Hip motion is more than adequate. 4. Pain is slight or absent, regardless of the appearance of the femoral head. 5. Union between the head and neck is practically certain, regardless of the time nonunion has been present. 6. If the procedure fails, other procedures or reconstructions are possible. The common mistakes leading to failure are: 1. Insufficient traction. If traction is not severe, length is not restored, the head is not rotated, and when traction is released the fragments are not drawn tightly together by the soft tissue. This leads to indifferent contact and many nonunions. The lack of severe traction and overpull has been the one principal reason this procedure has never had the popularity it rightly deserves. has been determined and the drill holes completed, using the pin as the guide, the pin is removed. An osteotome completes the cut by going between the drill holes, from the anteroposterior direction. If after heavy traction and wide abduction the shaft cannot be displaced, the neck fragment can be trimmed under direct vision until it does displace. It is far better to osteotomize too high at first than too low. D, Maintaining severe traction and the internal rotation, the limb has been abducted to gain displacement. The lateral edges of the wound have been raised and a Steinmann pin has been thrust through the skin and drilled into the greater trochanter until its point is visible. The pin is levered down the shaft, carrying the trochanter with it. This tilts the neck fragment that is attached up and out, to allow room for the head to settle between the neck fragments. Holding downward pull on the pin, it is drilled through the shaft until its point is felt in the region of the lesser trochanter. The greater trochanter is then tapped along the pin until it gains full contact with the shaft. Following the placing and setting of the pin, one judges whether or not the neck fragment is under and contacting the head. The pin is used as a lever to gain the desired position of internal rotation after the foot piece has been loosened to obtain the objective. Once this is determined, downward pull and internal rotation are kept on the pin while the wound is closed. Before closing, the field is inspected and the limb is moved to 15 to 20 degrees of abduction. The pin maintains the medial displacement and the internal rotation. E, Traction is now released and the hip is flexed to 20 degrees of flexion, while someone holds the pin in the desired position. The spica is run down to just above the knee on the affected side. The pin is still held until the plaster that incorporates it has set. Only then is the pin released. The projecting portion of the pin is covered with plaster and the rest of the spica is run down the limb. The pin is spun out, without disturbing the spica, 4 weeks after operation. 'When traction is released, the foot is not removed from its confines to the foot piece. The flexion of the knee and the flexion of the hip is achieved with the foot still attached to the table. Only after the pin is released by the assistant, is the foot taken from its bindings. The leg below the knee is handled as described in the text under "Hip Fusion." F, Condition of hip 12 weeks after operation and 3 days after spica has been removed. Patient is allowed up as soon as control of self is sufficient to justify ambulation. This is from 10 days to 3 weeks after plaster removal. Patient's leg was 2 inches short on this side prior to osteotomy. It is now less than 72 inch short. G, Condition of hip 6/14/56. Two years after osteotomy patient walks without hesitancy or limp and has full use of limb. Performs all rigors of normal living. No pain. Patient went back to full time work 7 months after osteotomy.
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Fig. 152. A, Fracture-dislocation of hip due to automobile accident February 1, 1942. B, Result of open reduction, and multiple pins. Reduction inadequate. C,
Result CApril24, 1942) about 3 months after open reduction and pinning. D, Osteotomy November 23, 1942. E, Condition of hip on March 4, 1943. This is one month after spica has been removed and 10 days since weight-bearing. F, Condition of hip November 3,1943. PatIent has been active with no limp, no limitation of activity as far as assuming any position in normal fashion. Gait and activity pass as normal. No pain or fatigue due to hip. Three-quarters inch short. G, Condition of hip April 6, 1956, 14 years since fracture-dislocation, and 13Y2 years since osteotomy. Patient is now aged 64 years. In spite of appearance of hip, patient has no limp and more than ample motion in all directions in this hip. She lives a normal life as far as endurance is concerned and states she has no pain at any time in the hip or leg.
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Fig. 153. A, This x-ray was taken September 21, 1943 when patient was a 9 year old girl. Fracture is due to bone cyst. Patient had been in spica 20 weeks. Osteotomy was performed in September 1943. Bone cyst not attacked. Spica remained on for 12 weeks. B, Condition of hip August 4, 1956. Patient is now aged 22 years, is married and has complete control of this limb without pain, limp or limitation of motion. The involved limb is lYz inches short, compensated for by shoes so that she walks without limp and with slight pelvic inclination. Normal and athletic activity exists.
2. Lack of internal rotation. If internal rotation of the lower fragment is not between 15 and 20 degrees, the normal anteversion of the neck may prevent the neck from getting completely under the head fragment. 3. Too much abduction of limb. If the limb is placed in more than 20 degrees of abduction in the spica, a knock knee deformity may occur. 4. Lack of sufficient displacement. The neck fragment must be displaced under the head so that the head is subtended by the neck and the neck will force the head into valgus and between the two neck fragments. This displacement is achieved by severe traction with the pelvis level and wide abduction until the shaft displaces. In abduction, the operator pushes the shaft medially. When displacement has occurred, the limb is brought to between 15 and 20 degrees of abduction, with traction maintained. 5. Fracturing of the femoral shaft. This can occur while the operator shoves the fragment to displace it. Lack of sufficient traction, or an immovable head are the common causes of this complication. If this occurs, the neck fragment can be replaced by threaded wires and screws, if the size of the broken fragment justifies it. Following replacement, the procedure if completed. 6. Faulty handling of the knee. The purposes of the Ys inch Steinmann
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Fig. 154. A, Delayed union. Tais x-ray was taken April 11, 1946. At this time it wash 7 months since hip pinningtnd one month since weight-bearing. Limp, lack of limb control, lack of internal roation, and a feeling of discomfort in the hip were evident to all. B, X-ray taken .July 18, 1946. Compare position of head upon neck with A. Overpull moved head little if at all but tipping the neck up by moving the trochanter downwards carried the head into good position. Note the obliquity of osteotomy. This view shows the condition of the hip 3 months after osteotomy and 3 weeks out of spica. Because of lack of distraction between head and neck the level of osteotomy is placed to skirt the lower border of the neck but not cut into the head. C, Condition of hip on August 8, 1949. Excellent function.
pin are: (a) to maintain internal rotation of the shaft and neck fragment; (b) to move and maintain the greater trochanter down the shaft; and (c) to take all torque and strain off the knee. 7. Allowing external rotation of the shaft while in plaster. The Steinmann pin is incorporated in the spica. It is spun out four weeks after operation. The spica should not be bivalved or altered so that knee motion may be possible. If this is allowed, the limb will externally rotate and move the neck away from the head, thus allowing the neck to bypass the head. This will produce a complete failure. 8. The spica should be to the nipple line, include the foot on the affected side, and extend to just above the knee of the normal limb. The Procedure. Figure 151 and its legend show the steps in this operation. Figures 152, 153, 154 and 157 show typical results. Angulation OsteotOlny
This operation is indicated primarily in treatment of sub capital hip fracture. It is also indicated in the treatment of delayed union between head and neck when the head is in a satisfactory relationship with its neck or can be placed in satisfactory position by severe traction. If traction separates head and neck, instead of only improving positional relationship, an oblique displacement osteotomy serves well. This procedure can be routinely used in handling all hip fractures, regardless
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Fig. 155. A, Delayed union. Patient aged 70. R, Note angle that nail enters neck and head so that osteotomy may be right below the lesser trochanter. Note stabilizing pin above nail. C, Osteotomy completed. After-care is the same as for any well fixed inter- or sub-trochanteric fracture. This procedure with the addition of one more stabilizing pin should be routine in the treatment of fresh subcapital neck fracture. The first requirement is good reduction with the head high upon the neck and the neck displaced medially as far as possible so that the head looks up and somewhat out. It is then fixed and the osteotomy follows.
of type. Whether one osteotomizes only subcapital fractures or both subcapital and transcervical types matters little, just so one obtains immediate and true bony union between femoral head and neck. The ideal angle the neck should assume following osteotomy is 145 to 155 degrees, depending upon the amount of valgus head assumed at reduction. The more valgus the less degree of osteotomy. Dr. James Dickson of Cleveland has, during the past 20 years, developed this procedure, and his results have justified his efforts. McN eur has modified the operation. Our experiences indicate that a wedge osteotomy is inferior to cuneiform, because the cuneiform can be accurately adjusted without fear of disengagement and loss of shaft position. Further, the strain upon the fixation material is much less if one uses a circular cut that leaves a projection medially upon the proximal fragment. If angulation is not sufficient, trimming of the distal fragment allows abduction to be as wide as desired. Figures 155 and 156 and legends describe the procedure. Osteotomy and Hip Fusion
To fuse a hip, raw bone surfaces and appropriate grafts must be all firmly fixed to obliterate motion at the hip and to gain correct compression forces at the areas where union must take place.
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Fig. 156. A, Evident nonunion between head and neck. B, Osteotomy well below the trochanters using a bone graft through the center of the head and neck and a spline plate for fixation of the femoral shaft. This is an excellent procedure and only goes to show that it is not a matter so much of where and how one does a thing but more a matter of who, when, and why one does something. Many times the mental conception of the operator, whether right or wrong, is what determines the way a patient goes. The osteotomy, following traction, reduction and grafting, has thrown the head and neck up so that unfavorable forces are converted into favorable compression force. The bone graft then must only stabilize~ the fragments so that forces work bone to bone. Not bone- to graft- to bone. This film is ]5 weeks since osteotomy. (Courtesy of Doctor Wm. Schnute.)
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Fig. 157. The advantages of the oblique osteotomy with pin and plaster fixation are: (1) Overpull of fragments, if possible, to get length. (2) High cut that is oblique so traction is essential to achieve displacement. This oblique surface will continue to press up and in, forcing the head to turn up and out. (3) The slanting pointed surface of the neck allows displacement under the head which discourages tipping of the head towards varus. (4) The head tends to be squeezed into and all upon the slanted under surface of the pocket formed by the tilted neck fragment above and the slanted neck surface below. (5) Pressure between fragments is considerable because overpull and the obliquity of the cut both favor compression of the fragments. (6) The pin maintains internal rotation without knee torque. If internal rotation is lost, the operation fails. The neck fragment must remain under the head. (7) The pin maintains displacement and trochanteric shift. Compression forces still work freely because the body's trunk moves down upon the fragments. (8) The spica decreases unfavorable motion and forces but allows compression forces to act. To date metal will not serve for displacement osteotomy. Many times it cuts out, allows rotation or other motions, keeps fragments apart, or length is lost. If one uses metal for displacement osteotomy, one will often "sell the day to save the hour."
After the above is accomplished, the powerful lever of the lower extremity must be prevented from working upon the fusion area. This is accomplished by a subtrochanteric cuneiform osteotomy placed through the widest part of the shaft but still missing the lesser trochanter. Performed high and correctly, there is no tendency for displacement at the osteotomy site. For greater function and best gait, the following position is advocated from actual study of the situation. This position is used for both sexes. 1. Flexion of 20 degrees. With the patient on the fracture table and the feet firmly fixed, the lower extremity should be neither in extension nor in more than 5 degrees of flexion when viewed from the side. 2. Neutral rotation. The patella should look straight up. There is enough normal rotation between the tibia and femur at the knee to give a normal carrying angle to the foot. External rotation of the femur is not desirable.
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A
B
Fig. 158. A, Hip fusion showing one method of fixing hip to pelvis. Note that graft extends between shaft and greater trochanter. Under this are other pieces of ilium that contact pelvis and bared femoral neck. Note osteotomy. 'Ve have used osteotomy for years. Doctor Fred Thompson first mentioned it to us. B, Four months after hip fusion. Hip and osteotomy are uniting together as far as time goes. Walking spica applied for 6 more weeks. It is now about 3 years since operation and patient's hip is stable and in good position.
3. Neutral lateral position. As a person stands with the feet together, the femurs deviate medially at about 15 degrees of adduction. The limb should be placed so that a line drawn from the anterior superior spine of the ilium will contact the lateral border of the patella. This position is about neutral from appearance but is actually 5 degrees of adduction, which relatively is about 10 degrees of abduction in relation to the normal femur while standing in the anatomical position. To maintain position, a double plaster spica extending from the nipple line to the toes on the affected side and to just above the knee on the normal side is applied in the following manner: The plaster is run to just above the knee on the affected side and allowed to set. The foot is then removed from restraints. The knee is bent to about 15 to 20 degrees and the normal external rotation of the tibia at the knee is allowed to occur. The foot is then carefully placed at right angles, in normal valgus attitude and normal external rotation in line with the tibia. In no way is the foot handled so that torque or deviation force can be applied to the knee. No strain of force upon the foot can be allowed. If this happens, knee motion will be sacrificed. The spica is changed at 12 weeks. The fusion at this time should be solid. A single spica is now applied and the patient is allowed up to walk
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Treatment of Nonunion of Femoral Neck Fractures with crutches. At the end of 18 to 20 weeks all support (Fig. 158). SUMMARY
IS
removed
During the past 16 years the procedures described here have been used in the treatment of active persons suffering from nonunion or delayed union between femoral head and neck. Displacement osteotomy for nonunion between femoral head and neck has been done in 21 patients. All except two have obtained good and prompt union and have practically normal gaits and full activity regardless of the appearance of the femoral head. None was included in this group whose period since osteotomy was less than five years. As mentioned before, regardless of the appearance of the femoral head, these people walk and sit well, have tremendous endurance, use no external support, and do not complain of pain in the hip. To date, no prosthesis can deliver the consistent good results that vitallium cup, osteotomy, and hip fusion have delivered to us in the resurrection of active, integrated persons who have years of life before them. Among others, Schanz, Lorenz, Haas, Smith-Petersen, McMurray, Reich, Guy Leadbetter and James Dickson have done monumental and pioneering work in this field. For the most part, their voices have gone unheeded. The application of these men's principles coupled with the addition of overpull of fragments, high accurate placement of an oblique osteotomy, the use of the Steinmann pin, and an insistence upon plaster, have in our hands produced a consistently gratifying procedure. REFERENCES Dickson, J. A.: High Geometric Osteotomy with Rotation and Bone Graft for Ununited Fractures of the Neck of the Femur. J. Bone & Joint Surg. 29: 105, 1947. Use of Osteotomy and Bone Grafting in Treatment of Ununited Fractures of Neck of Femur. J.A.M.A. 137: 1199, 1948. Biochemics: Fractures, Femoral Neck, Medical Physics. 11: 94. Year Book Publishers, Inc. 1950. The "Unsolved" Fracture. A Protest Against Defeatism. J. Bone & Joint Surg. 35: 805, 1953. Haas, Julius: The Lorenz Osteotomy and Its Use. Ergebn. d. Chir. 21: 457, 1928. Leadbetter, G. W.: Cervical-Axial Osteotomy of Femur; Preliminary Report. J. Bone & Joint Surg. 26: 713-720 (Oct.) 1944. McElvenny, R. T.: Roentgenographic Interpretation of What Constitutes Adequate Reduction of Femoral ~eck Fractures. Surg., Gynec. & Obst. 80: 97-106, 1945. Management of Intracapsular Hip Fractures. S. CLIN. NORTH AMERICA 29: 31-58, 1949. An Interpretation of Certain Factors Affecting Treatment of Intracapsular Hip Fractures. Northwestern Univ. Med. Sch. Quart. Bull. 24: 267, 1950. McMurray, T. P.: Osteoarthritis of the Hip Joint. Brit. J. Surg. 22: 716, 1934-1935.
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Mc:!'\eur, J. c.: Treatment of Subcapital Fractures of the Neck of the Femur. J. Bone & Joint Surg. 35-B: 188, 1953. Reich, R. S.: Ununited Fracture of the Neck of the Femur Treated by High Oblique Osteotomy. J. Bone & Joint Surg. 23: 141-158, 1941. Schanz, A.: About Walking Difficulties After Fracture of the Neck of the Femur. Deutsche med. Wchnschr. 51: 730, 1925. Tucker, E. J.: The Preservation of Livil'!.g Bone in Plasma. Surg., Gynec. & Obst. 96: 739, 1953. 30 N. Michigan Boulevard Chicago 2, Illinois
PRELIMINARY CONSIDERATIONS
Nonunion and Delayed Union
K onunion between the femoral head and neck is of the same type experienced in bone elsewhere. Complete disengagement between head and neck is easily recognized. Fibrous union between neck and head (delayed union) is not yet routinely recognized by all. It should be, for it is the cause of false security, the common producer of aseptic necrosis of the head, and the eventual factor in most disengagements between head and neck. Many times, because of pain, the fixation material is removed months after pinning. The head later disengages from its neck. This is often spoken of as a refracture. Refracture may at times occur, but commonly it is not refracture-often it is the separation of an existing fibrous union. True, normal neck bone had never welded the head to its neck. As long as a femoral head is forced to function by metal fixation and fibrous union, holding a degree of functional position, the demand for nutriment to the head cells approaches the normal. But as long as a fibrous barrier exists between the head and neck at the fracture site that prevents the normal formation of medullary and cancellous substance that must be present to pass the blood to the head from the trochanteric and neck pools, just so long does the head get little, if any, normal nutriment. Keep this up beyond the time the head cells can exist upon their reserve, and they fail to propagate in kind. Substitution occurs, and the head as a functional unit is lost. Reduction of femoral neck fracture is improving. The fixation material is maintaining more heads upon their necks. Frank disengagement of fragments is less common than formerly. Delayed union is more common, as there are fewer frank separations. Aseptic necrosis of the femoral head is encountered more frequently than ever because more delayed unions occur than formerly.
* Assistant Professor of Orthopedic Surgery, Northu'estern University Medical School; Senior Attending Surgeon, Wesley Memorial Hospital, Chicago, Illinois. 251
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Fig. 146. A. Adequate reduction of transcervical fracture. Note how neck fragment on head has caught into the neck and is supported by the neck bone to bone. B, Rapid bony union ensues. Note how little purchase nail has in head. The motion of metal was slight as forces are bone to bone with fragments steadied by the metal.
Any motion at a fracture site refractures callus and irritates it. There follows an overproduction of callus. The first intramedullary rods used in the femoral shaft allowed rotary motion. The result was a marked overproduction of callus about the fracture site. This callus was of poor quality, and delayed union was common. Contrast with this the production of the relatively small amount of callus and the rapid union we witness today, as changing designs of the various rods have decreased, or even eliminated, this rotary motion. The same overproduction of callus at the fracture site between the femoral head and neck can be seen and picked up by serial x-rays taken of the fractured hip if delayed union is present. Delayed union between femoral head and neck is revealed as follows (Figs. 146, 147, 148): 1. Overproduction and progressive production of callus at the fracture site. 2. The settling or shifting of the femoral head in either the anteroposterior or lateral view. 3. The shifting or moving of metal. 4. Condensation at the fracture line. 5. Increased density of the head. 6. Inability of the patient to control completely and painlessly the affected extremity. The femoral head suffering delayed union may usually be saved for a
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Fig. 147. A, Inadequate reduction of transcervical fracture. Fragment on lower surface of head is below and away from the neck. It is impossible for this head to invaginate its neck and achieve support bone to bone. Six months after pinning. Weight-bearing started. B, Twelve months since pinning and 6 months since weightbearing. Patient was never without hesitancy in gait, limp. and some pain in groin. Complete internal rotation was always lacking. Note callus proliferation at arrow, condensation at fracture line, shift of head, and shift of metal. C, Eight years since pinning. True bony union has finally ensued. Too late to give a functioning head. This hip could have been saved by displacement osteotomy when delayed union showed so plainly in B.
full functional unit if delayed union is rapidly converted into bony union before nine months postpinning. The Fixation Material (Fig. 149) The Smith-Petersen nail or other flanged nails are not large enough to fill completely the neck cavity side to side and thus grab hard cortical bone. Slight rotary motion between the head and neck is often allowed
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Fig. 148. A, Inadequate reduction of transcervical fracture. Pins well placed in both planes and in head. B, Six months after pinning. Weight-bearing started. C, Ten months since pinning and 4 months since weight-bearing. All cardinal signs of delayed union are present. Osteotomy is indicated now. If patient is above 60 years of age an angulation osteotomy would be favored.
if single pins or nails are used. The addition of two smaller pins with the nail is desirable. If one uses a bone graft in addition to a nail, the graft should center the head. Bone grafts are often eccentric to the hole prepared for them and, in addition, if placed in the upper quadrant of the head, often pick up a bolus of cancellous bone as they traverse the neck, and when this bolus is driven into the head ahead of the graft, the upper quadrant of the head is either crushed or fractured, in many cases producing aseptic necrosis of this quadrant. Choosing the Type of Fracture to Pin (Fig. 150)
One may properly reduce and pin only the transcervical type of fracture. Routinely this fracture, properly reduced and fixed, offers results approaching the normal. A transcervical fracture is one that has some neck bone firmly attached to the inferior half of the femoral head. Proper reduction of this fracture presumes the invaginating of the bony mass on the inferior half of the femoral head into the medullary cavity of the neck. This achieves firm locking of the fragments, and all tipping tendencies are prevented. Multiple pin fixation in line with each other and parallel to the calcar femorale discourages rotation between the fragments. A subcapitaZ fracture is one that has no portion of neck firmly attached to the lower (inferior) half of the head. If neck is not attached to the lower half of the head, or is only present on the upper half of the head, there is no way that the neck may be shifted so that the head fragment may routinely invaginate and be held by the neck. Consequently, the two surfaces contact each other like the faces of one coin against another. The angle at which this occurs puts tremendous shearing, angulating and torque forces to work. Nothing locks these fragments but the metal fixation. The forces are transferred not from bone to bone with position
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Fig. 149. If one rodded the supracondylar fracture illustrated, a question of judgment might be raised. We, however, assume a nail will hold a similar fragment at the hip, where forces are at least as many as at the supracondylar area of the femur.
maintained by the steadying influence of metal, as in a properly reduced transcervical fracture, but are transferred bone to metal to bone. This set-up is physiologically impossible and failure is most common. Metal cannot hold bone. Bone must hold metal. Most nonunions following immediate fixation of intracapsular femoral neck fractures result from the following: 1. Pinning a sub capital fracture without osteotomy. 2. Failure to properly reduce a transcervical fracture. 3. Poor fixation of a properly treated fracture. Fear of Plaster
The fear of a plaster spica goes back to the days of indifferent care, or studied neglect or innocence. If the knee is placed in the proper position without torque or strain upon it, this is of no moment. A strain or torque placed upon any joint such as the knee, or the metacarpophalangeal joint, means trouble. If a knee is treated with the same understanding as one would use with the joints of the fingers, the results are comparable. A good hip, and a knee correctly fixed in plaster, eventually mean a fullfunctioning and useful lower extremity. Reconstructive Procedures
In the restoration of a human who has suffered a hip fracture and who
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Trans - cervical types Fig. 150. These may be adequately reduced and pinned.
is an integrated and active creature, the physician should know the most about the following: 1. How and when to pin a hip. 2. How and when to osteotomize. 3. How and when to fuse a hip the first time. 4. How and when to use prostheses. THE OSTEOTOMIES
Bone heals best when all angulating, torque and shearing forces are eliminated and in their place is substituted compression forces that intimately squeeze the bone fragments together at right angles to the fracture line or to the surface where union is desired. The purpose of osteotomy is to gain rapid bony union between the femoral head and neck. This is achieved by an osteotomy because: 1. The osteotomy changes the plane of the fracture line to bring correct compression forces into play. 2. The osteotomy exposes the greatest area of fractured surfaces to each other. 3. The osteotomy forces bone to support bone and thus lock to each other. The compression forces are directed bone to bone, not bone to metal to bone. 4. The fixation material is correctly placed to achieve the above objectives. Osteotomies are divided according to the location of the cut and according to the direction the weight thrust the body ultimately takes through the femur, its neck and its head. 1. According to cut: a. Oblique osteotomy between the trochanters and through the femoral neck. b. Oblique osteotomy between the trochanters. c. Curved osteotomy between the trochanters, or just below the lesser trochanter. 2. According to weight thrust:
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a. Displacement osteotomy. This procedure demands an oblique cut that passes between the trochanters and through the neck or only between the trochanters. b. Angulation osteotomy. This procedure is one in which the shaft is angulated upon the proximal fragment. It may be intertrochanteric or subtrochanteric in location. The Displacement Osteotomy
This procedure, in general, is the most satisfactory one for restoring painless hip motion. The medial displacement of the shaft throws the weight thrust towards the center of the body. The medial shift of the shaft cuts down the length of the lever arm of the neck. Displacement osteotomy gives relief of pain and tremendous endurance to most people, regardless of the appearance of the femoral head or hip joint. If, in degenerated hip joints, motion at the hip is above 70 degrees in the anteroposterior plane, displacement osteotomy is the first choice and gives the highest percentage of painless hips of any procedure yet devised. If, following vitallium cup arthroplasty, pain is marked but anteroposterior motion at the hip is above 70 degrees, a displacement osteotomy offers a chance of relief that is well worth taking. For uniting the femoral head to its neck, the displacement osteotomy through the neck is, in our hands, the method of choice. In using this procedure the following indications are followed: 1. The femoral head should be detached from its neck. This means that frank nonunion exists at the fracture site, or delayed union exists that heavy traction can separate. 2. All fixation material cleaving head to neck, be it metal or bone, must be removed prior to osteotomy. The principle of displacement with osteotomy through the femoral neck requires a free and movable head that, under traction, will turn upward. Mter osteotomy the head will then rotate and fall between the osteotomized neck fragments in proper position for immediate bone union. If the head is not freely movable, the displacing of the shaft will cause the neck to impinge upon the lower surface of the femoral head. This can lead to fracture of the shaft either through the neck or at the junction of neck and trochanter. The disadvantages of this procedure are: 1. The procedure requires a plaster spica for 10 weeks. 2. The patient undergoing this procedure must be capable of being an active person. The advantages of this procedure are: 1. Limb length is restored. 2. Gait is excellent.
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Fig. 151
A, Hip well pinned but inadequately reduced. B, Result 18 months after pinning, and 6 months since pin was removed because of pain. Delayed union present. Age 49 years. C, Heavy traction has separated the fibrous union. Limb is in 20 degrees internal rotation and about neutral lateral position. Hip is now opened anteriorly. Following exposure of the intertrochanteric region but leaving the hip capsule intact, a Steinmann pin is thrust through the skin from the lateral side and skewered on top of the shaft toward the femoral head. An x-ray is taken. The pin serves as a marker to show if the osteotomy is oblique enough and also where to place the drill holes to start the osteotomy (after Reich). The object is to cut through the neck obliquely and as high as possihle and still be able to displace the shaft and neck fragment. After the level
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3. Hip motion is more than adequate. 4. Pain is slight or absent, regardless of the appearance of the femoral head. 5. Union between the head and neck is practically certain, regardless of the time nonunion has been present. 6. If the procedure fails, other procedures or reconstructions are possible. The common mistakes leading to failure are: 1. Insufficient traction. If traction is not severe, length is not restored, the head is not rotated, and when traction is released the fragments are not drawn tightly together by the soft tissue. This leads to indifferent contact and many nonunions. The lack of severe traction and overpull has been the one principal reason this procedure has never had the popularity it rightly deserves. has been determined and the drill holes completed, using the pin as the guide, the pin is removed. An osteotome completes the cut by going between the drill holes, from the anteroposterior direction. If after heavy traction and wide abduction the shaft cannot be displaced, the neck fragment can be trimmed under direct vision until it does displace. It is far better to osteotomize too high at first than too low. D, Maintaining severe traction and the internal rotation, the limb has been abducted to gain displacement. The lateral edges of the wound have been raised and a Steinmann pin has been thrust through the skin and drilled into the greater trochanter until its point is visible. The pin is levered down the shaft, carrying the trochanter with it. This tilts the neck fragment that is attached up and out, to allow room for the head to settle between the neck fragments. Holding downward pull on the pin, it is drilled through the shaft until its point is felt in the region of the lesser trochanter. The greater trochanter is then tapped along the pin until it gains full contact with the shaft. Following the placing and setting of the pin, one judges whether or not the neck fragment is under and contacting the head. The pin is used as a lever to gain the desired position of internal rotation after the foot piece has been loosened to obtain the objective. Once this is determined, downward pull and internal rotation are kept on the pin while the wound is closed. Before closing, the field is inspected and the limb is moved to 15 to 20 degrees of abduction. The pin maintains the medial displacement and the internal rotation. E, Traction is now released and the hip is flexed to 20 degrees of flexion, while someone holds the pin in the desired position. The spica is run down to just above the knee on the affected side. The pin is still held until the plaster that incorporates it has set. Only then is the pin released. The projecting portion of the pin is covered with plaster and the rest of the spica is run down the limb. The pin is spun out, without disturbing the spica, 4 weeks after operation. 'When traction is released, the foot is not removed from its confines to the foot piece. The flexion of the knee and the flexion of the hip is achieved with the foot still attached to the table. Only after the pin is released by the assistant, is the foot taken from its bindings. The leg below the knee is handled as described in the text under "Hip Fusion." F, Condition of hip 12 weeks after operation and 3 days after spica has been removed. Patient is allowed up as soon as control of self is sufficient to justify ambulation. This is from 10 days to 3 weeks after plaster removal. Patient's leg was 2 inches short on this side prior to osteotomy. It is now less than 72 inch short. G, Condition of hip 6/14/56. Two years after osteotomy patient walks without hesitancy or limp and has full use of limb. Performs all rigors of normal living. No pain. Patient went back to full time work 7 months after osteotomy.
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Fig. 152. A, Fracture-dislocation of hip due to automobile accident February 1, 1942. B, Result of open reduction, and multiple pins. Reduction inadequate. C,
Result CApril24, 1942) about 3 months after open reduction and pinning. D, Osteotomy November 23, 1942. E, Condition of hip on March 4, 1943. This is one month after spica has been removed and 10 days since weight-bearing. F, Condition of hip November 3,1943. PatIent has been active with no limp, no limitation of activity as far as assuming any position in normal fashion. Gait and activity pass as normal. No pain or fatigue due to hip. Three-quarters inch short. G, Condition of hip April 6, 1956, 14 years since fracture-dislocation, and 13Y2 years since osteotomy. Patient is now aged 64 years. In spite of appearance of hip, patient has no limp and more than ample motion in all directions in this hip. She lives a normal life as far as endurance is concerned and states she has no pain at any time in the hip or leg.
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Fig. 153. A, This x-ray was taken September 21, 1943 when patient was a 9 year old girl. Fracture is due to bone cyst. Patient had been in spica 20 weeks. Osteotomy was performed in September 1943. Bone cyst not attacked. Spica remained on for 12 weeks. B, Condition of hip August 4, 1956. Patient is now aged 22 years, is married and has complete control of this limb without pain, limp or limitation of motion. The involved limb is lYz inches short, compensated for by shoes so that she walks without limp and with slight pelvic inclination. Normal and athletic activity exists.
2. Lack of internal rotation. If internal rotation of the lower fragment is not between 15 and 20 degrees, the normal anteversion of the neck may prevent the neck from getting completely under the head fragment. 3. Too much abduction of limb. If the limb is placed in more than 20 degrees of abduction in the spica, a knock knee deformity may occur. 4. Lack of sufficient displacement. The neck fragment must be displaced under the head so that the head is subtended by the neck and the neck will force the head into valgus and between the two neck fragments. This displacement is achieved by severe traction with the pelvis level and wide abduction until the shaft displaces. In abduction, the operator pushes the shaft medially. When displacement has occurred, the limb is brought to between 15 and 20 degrees of abduction, with traction maintained. 5. Fracturing of the femoral shaft. This can occur while the operator shoves the fragment to displace it. Lack of sufficient traction, or an immovable head are the common causes of this complication. If this occurs, the neck fragment can be replaced by threaded wires and screws, if the size of the broken fragment justifies it. Following replacement, the procedure if completed. 6. Faulty handling of the knee. The purposes of the Ys inch Steinmann
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Fig. 154. A, Delayed union. Tais x-ray was taken April 11, 1946. At this time it wash 7 months since hip pinningtnd one month since weight-bearing. Limp, lack of limb control, lack of internal roation, and a feeling of discomfort in the hip were evident to all. B, X-ray taken .July 18, 1946. Compare position of head upon neck with A. Overpull moved head little if at all but tipping the neck up by moving the trochanter downwards carried the head into good position. Note the obliquity of osteotomy. This view shows the condition of the hip 3 months after osteotomy and 3 weeks out of spica. Because of lack of distraction between head and neck the level of osteotomy is placed to skirt the lower border of the neck but not cut into the head. C, Condition of hip on August 8, 1949. Excellent function.
pin are: (a) to maintain internal rotation of the shaft and neck fragment; (b) to move and maintain the greater trochanter down the shaft; and (c) to take all torque and strain off the knee. 7. Allowing external rotation of the shaft while in plaster. The Steinmann pin is incorporated in the spica. It is spun out four weeks after operation. The spica should not be bivalved or altered so that knee motion may be possible. If this is allowed, the limb will externally rotate and move the neck away from the head, thus allowing the neck to bypass the head. This will produce a complete failure. 8. The spica should be to the nipple line, include the foot on the affected side, and extend to just above the knee of the normal limb. The Procedure. Figure 151 and its legend show the steps in this operation. Figures 152, 153, 154 and 157 show typical results. Angulation OsteotOlny
This operation is indicated primarily in treatment of sub capital hip fracture. It is also indicated in the treatment of delayed union between head and neck when the head is in a satisfactory relationship with its neck or can be placed in satisfactory position by severe traction. If traction separates head and neck, instead of only improving positional relationship, an oblique displacement osteotomy serves well. This procedure can be routinely used in handling all hip fractures, regardless
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Fig. 155. A, Delayed union. Patient aged 70. R, Note angle that nail enters neck and head so that osteotomy may be right below the lesser trochanter. Note stabilizing pin above nail. C, Osteotomy completed. After-care is the same as for any well fixed inter- or sub-trochanteric fracture. This procedure with the addition of one more stabilizing pin should be routine in the treatment of fresh subcapital neck fracture. The first requirement is good reduction with the head high upon the neck and the neck displaced medially as far as possible so that the head looks up and somewhat out. It is then fixed and the osteotomy follows.
of type. Whether one osteotomizes only subcapital fractures or both subcapital and transcervical types matters little, just so one obtains immediate and true bony union between femoral head and neck. The ideal angle the neck should assume following osteotomy is 145 to 155 degrees, depending upon the amount of valgus head assumed at reduction. The more valgus the less degree of osteotomy. Dr. James Dickson of Cleveland has, during the past 20 years, developed this procedure, and his results have justified his efforts. McN eur has modified the operation. Our experiences indicate that a wedge osteotomy is inferior to cuneiform, because the cuneiform can be accurately adjusted without fear of disengagement and loss of shaft position. Further, the strain upon the fixation material is much less if one uses a circular cut that leaves a projection medially upon the proximal fragment. If angulation is not sufficient, trimming of the distal fragment allows abduction to be as wide as desired. Figures 155 and 156 and legends describe the procedure. Osteotomy and Hip Fusion
To fuse a hip, raw bone surfaces and appropriate grafts must be all firmly fixed to obliterate motion at the hip and to gain correct compression forces at the areas where union must take place.
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Fig. 156. A, Evident nonunion between head and neck. B, Osteotomy well below the trochanters using a bone graft through the center of the head and neck and a spline plate for fixation of the femoral shaft. This is an excellent procedure and only goes to show that it is not a matter so much of where and how one does a thing but more a matter of who, when, and why one does something. Many times the mental conception of the operator, whether right or wrong, is what determines the way a patient goes. The osteotomy, following traction, reduction and grafting, has thrown the head and neck up so that unfavorable forces are converted into favorable compression force. The bone graft then must only stabilize~ the fragments so that forces work bone to bone. Not bone- to graft- to bone. This film is ]5 weeks since osteotomy. (Courtesy of Doctor Wm. Schnute.)
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Fig. 157. The advantages of the oblique osteotomy with pin and plaster fixation are: (1) Overpull of fragments, if possible, to get length. (2) High cut that is oblique so traction is essential to achieve displacement. This oblique surface will continue to press up and in, forcing the head to turn up and out. (3) The slanting pointed surface of the neck allows displacement under the head which discourages tipping of the head towards varus. (4) The head tends to be squeezed into and all upon the slanted under surface of the pocket formed by the tilted neck fragment above and the slanted neck surface below. (5) Pressure between fragments is considerable because overpull and the obliquity of the cut both favor compression of the fragments. (6) The pin maintains internal rotation without knee torque. If internal rotation is lost, the operation fails. The neck fragment must remain under the head. (7) The pin maintains displacement and trochanteric shift. Compression forces still work freely because the body's trunk moves down upon the fragments. (8) The spica decreases unfavorable motion and forces but allows compression forces to act. To date metal will not serve for displacement osteotomy. Many times it cuts out, allows rotation or other motions, keeps fragments apart, or length is lost. If one uses metal for displacement osteotomy, one will often "sell the day to save the hour."
After the above is accomplished, the powerful lever of the lower extremity must be prevented from working upon the fusion area. This is accomplished by a subtrochanteric cuneiform osteotomy placed through the widest part of the shaft but still missing the lesser trochanter. Performed high and correctly, there is no tendency for displacement at the osteotomy site. For greater function and best gait, the following position is advocated from actual study of the situation. This position is used for both sexes. 1. Flexion of 20 degrees. With the patient on the fracture table and the feet firmly fixed, the lower extremity should be neither in extension nor in more than 5 degrees of flexion when viewed from the side. 2. Neutral rotation. The patella should look straight up. There is enough normal rotation between the tibia and femur at the knee to give a normal carrying angle to the foot. External rotation of the femur is not desirable.
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A
B
Fig. 158. A, Hip fusion showing one method of fixing hip to pelvis. Note that graft extends between shaft and greater trochanter. Under this are other pieces of ilium that contact pelvis and bared femoral neck. Note osteotomy. 'Ve have used osteotomy for years. Doctor Fred Thompson first mentioned it to us. B, Four months after hip fusion. Hip and osteotomy are uniting together as far as time goes. Walking spica applied for 6 more weeks. It is now about 3 years since operation and patient's hip is stable and in good position.
3. Neutral lateral position. As a person stands with the feet together, the femurs deviate medially at about 15 degrees of adduction. The limb should be placed so that a line drawn from the anterior superior spine of the ilium will contact the lateral border of the patella. This position is about neutral from appearance but is actually 5 degrees of adduction, which relatively is about 10 degrees of abduction in relation to the normal femur while standing in the anatomical position. To maintain position, a double plaster spica extending from the nipple line to the toes on the affected side and to just above the knee on the normal side is applied in the following manner: The plaster is run to just above the knee on the affected side and allowed to set. The foot is then removed from restraints. The knee is bent to about 15 to 20 degrees and the normal external rotation of the tibia at the knee is allowed to occur. The foot is then carefully placed at right angles, in normal valgus attitude and normal external rotation in line with the tibia. In no way is the foot handled so that torque or deviation force can be applied to the knee. No strain of force upon the foot can be allowed. If this happens, knee motion will be sacrificed. The spica is changed at 12 weeks. The fusion at this time should be solid. A single spica is now applied and the patient is allowed up to walk
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Treatment of Nonunion of Femoral Neck Fractures with crutches. At the end of 18 to 20 weeks all support (Fig. 158). SUMMARY
IS
removed
During the past 16 years the procedures described here have been used in the treatment of active persons suffering from nonunion or delayed union between femoral head and neck. Displacement osteotomy for nonunion between femoral head and neck has been done in 21 patients. All except two have obtained good and prompt union and have practically normal gaits and full activity regardless of the appearance of the femoral head. None was included in this group whose period since osteotomy was less than five years. As mentioned before, regardless of the appearance of the femoral head, these people walk and sit well, have tremendous endurance, use no external support, and do not complain of pain in the hip. To date, no prosthesis can deliver the consistent good results that vitallium cup, osteotomy, and hip fusion have delivered to us in the resurrection of active, integrated persons who have years of life before them. Among others, Schanz, Lorenz, Haas, Smith-Petersen, McMurray, Reich, Guy Leadbetter and James Dickson have done monumental and pioneering work in this field. For the most part, their voices have gone unheeded. The application of these men's principles coupled with the addition of overpull of fragments, high accurate placement of an oblique osteotomy, the use of the Steinmann pin, and an insistence upon plaster, have in our hands produced a consistently gratifying procedure. REFERENCES Dickson, J. A.: High Geometric Osteotomy with Rotation and Bone Graft for Ununited Fractures of the Neck of the Femur. J. Bone & Joint Surg. 29: 105, 1947. Use of Osteotomy and Bone Grafting in Treatment of Ununited Fractures of Neck of Femur. J.A.M.A. 137: 1199, 1948. Biochemics: Fractures, Femoral Neck, Medical Physics. 11: 94. Year Book Publishers, Inc. 1950. The "Unsolved" Fracture. A Protest Against Defeatism. J. Bone & Joint Surg. 35: 805, 1953. Haas, Julius: The Lorenz Osteotomy and Its Use. Ergebn. d. Chir. 21: 457, 1928. Leadbetter, G. W.: Cervical-Axial Osteotomy of Femur; Preliminary Report. J. Bone & Joint Surg. 26: 713-720 (Oct.) 1944. McElvenny, R. T.: Roentgenographic Interpretation of What Constitutes Adequate Reduction of Femoral ~eck Fractures. Surg., Gynec. & Obst. 80: 97-106, 1945. Management of Intracapsular Hip Fractures. S. CLIN. NORTH AMERICA 29: 31-58, 1949. An Interpretation of Certain Factors Affecting Treatment of Intracapsular Hip Fractures. Northwestern Univ. Med. Sch. Quart. Bull. 24: 267, 1950. McMurray, T. P.: Osteoarthritis of the Hip Joint. Brit. J. Surg. 22: 716, 1934-1935.
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Mc:!'\eur, J. c.: Treatment of Subcapital Fractures of the Neck of the Femur. J. Bone & Joint Surg. 35-B: 188, 1953. Reich, R. S.: Ununited Fracture of the Neck of the Femur Treated by High Oblique Osteotomy. J. Bone & Joint Surg. 23: 141-158, 1941. Schanz, A.: About Walking Difficulties After Fracture of the Neck of the Femur. Deutsche med. Wchnschr. 51: 730, 1925. Tucker, E. J.: The Preservation of Livil'!.g Bone in Plasma. Surg., Gynec. & Obst. 96: 739, 1953. 30 N. Michigan Boulevard Chicago 2, Illinois