Primary
Internal Fixation of Femoral Neck Fractures Arsen M.
Pankovich, MD
The principles in treatment of femoral neck fractures by primary internal fixation have been reviewed. In the rare, undisplaced stress or fatigue fracture, early internal fixation with threaded pins is recommended. Impacted fractures should be treated by primary internal fixation in patients who do not follow orders and patients whose general condition is poor and would require early weight bearing. Displaced fractures may be treated by primary internal fixation at any age and regardless of the patient's general condition. The following principles are emphasized: early operation, anatomical reduction and slight valgus in some cases, compression and impaction of fragments, and firm immobilization of fragments with a device that has a sliding mechanism and provides lateral cortical fixation.
neck fractures continue to be a formidable and to the orthopedic surgeon. Liter¬ ature concerning the biomechanics and vascular supply of the hip, the mechanisms of injury, the management and healing of the fractures, the epidemiology, and early and late complications is abundant. Yet, it is all too confusing to read sometimes contradictory statements and to look for principles that are often lost in the woods of statistics, technical details, and speculations. This article reviews the present concepts and methods of primary internal fixation of femoral neck fractures and presents recent experience at Cook County Hospital.
Femoral challenging problem
GENERAL PRINCIPLES
The ideal method in treating femoral neck fractures would provide firm immobilization of facture fragments in anatomical position, allow early weight bearing, and prevent the two most common local complications: nonun¬ ion and avascular necrosis. In order to appreciate the dif¬ ficulties in achieving this goal, it is necessary to underAccepted
for publication July 25, 1974. From the Division of Orthopedic Surgery, Cook County cago. Reprint requests to Division of Orthopedic Surgery, Cook tal, Chicago, IL 60612 (Dr. Pankovich).
Hospital, ChiCounty Hospi-
stand certain details of femoral neck and head anatomy, the mode of healing of the fractures, the types of frac¬ tures and their pathology, and basic principles and re¬ quirements of treatment. Anatomical Considerations
The
capsule of the hip joint, along with its ligamentous enforcements, is attached on the femur anteriorly to the intertrochanteric line and posteriorly about 1 to 1.5 cm proximal to the intertrochanteric crest (Fig 1). Therefore, the base of the femoral neck is intracapsular anteriorly and extracapsular posteriorly. From the femoral attach¬ ments of the capsule originate ascending fibrous bands, retinacula, that are attached to the intracapsular portion of the femoral neck and extend to the cartilaginous rim of
the femoral head. Retinacula contain blood vessels and are covered with synovia. Blood supply to the femoral neck and head is derived from the extracapsular arterial ring at the base of the femoral neck (Fig 1). The anterior portion of the arterial ring is derived from the lateral femoral circumflex artery and the posterior portion from the medial femoral circum¬ flex artery. Ascending cervical arteries, from the arterial ring, perforate the capsule and become retinacular ar¬ teries. Posterosuperior retinacular arteries are more nu¬ merous (three to eight) than posteroinferior (one to three); there are very few arteries on the anterior surface. Trueta and Harrison1 suggested the existence of separate epiphysial and metaphysial retinacular arteries that, in adults, anastomose across the old epiphysial line. Most investiga¬ tors now agree that the femoral head is primarily supplied by the posterosuperior retinacular arteries. Postero¬ inferior arteries supply primarily the metaphysial portion of the neck. The contribution of the artery of the ligamen¬ tum teres that is usually derived from the obturator ar¬ tery is not quite clear. It seems that it supplies primarily
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Fig 1.—Femoral neck with capsular attachments and retinacula (dotted lines) and arterial ring with retinacular arteries. Note greater number of vessels and extracapsular location of base of neck posteriorly (right). In anterior view (left), three Pauwels frac¬ ture
types
are
indicated.
2.—Bilateral stress fractures in elderly patient. Top, In May varus of femoral heads was evident and sclerosis in subcapi¬ tal areas indicated healing at fracture sites. Patient refused treat¬ ment and continued to bear weight. Bottom, In February 1968, frac¬ tures are healed in marked varus.
Fig
1962,
the
area of the head around the fovea capitis where the ligamentum teres is attached.1 Banks' correlated histo¬ logical viability of the femoral head with its vascular sup¬ ply and concluded that avascular necrosis developed if all retinacular vessels were damaged, regardless of the state of vessels in the ligamentum teres. Due to proximity of the retinacular arteries to the bone, they may be injured in any fracture of the femoral neck -
and the outcome may be avascular necrosis of the femoral head. Some cases of late development of avascular necro¬ sis could be explained on the basis of inadequate blood supply, ie, chronic ischemia through the remaining, intact arteries.4 Conversely, in displaced fractures, some arteries may be spared and still provide adequate blood flow. Ex¬ tracapsular location of the base of the neck posteriorly ex¬ plains the low incidence of avascular necrosis of basilar neck fractures. Finally, the adult femoral neck has no functional peri¬ osteum. This has direct bearing on the type of healing of these fractures. There being no periosteal callus, the heal¬ ing depends entirely on the endosteal callus. Absence of cartilage, proliferation of fibrous tissue and small vessels, and laying down of fibrous bone are the main features of the endosteal callus. If the head is viable, the endosteal callus is laid down on both sides of the fracture. The endosteal callus forms only on the neck side if the head is nonviable, although the fracture may heal. This type of fracture healing, by endosteal callus, was coined by F. C. McLean as healing by primary intention. Since the heal¬ ing is dependent on the state of vascularity of the femoral head and even more so on the integrity of callus vessels, rigid immobilization and close apposition of the frag¬ ments are imperative until callus is completely consoli¬ dated.4 :> Nonunion will therefore develop if these condi¬ tions are not met. '
Types of
Fractures
The division of femoral neck fractures into three cate¬ gories—stress, impacted, and displaced—is of practical im-
portance.
Stress or Fatigue Fractures.—These fractures are rare and occur in all age groups. In younger individuals, frac¬ tures are usually seen following strenuous activity. In older persons and patients with underlying bone disease, such as osteoporosis and osteomalacia, there is pre¬ disposition to stress fractures (Fig 2). Two types were de¬ scribed by Devas." In the transverse type, the initial infrac¬ tion is in the superior cortex of the neck with tendency for complete fracture and displacement. In the compression type, the area above the calcar is the site of initial infrac¬ tion; this type shows less tendency for displacement.
Impacted Fractures.—According to Linton,7 and, more recently, Klenerman and Marcuson," impacted fractures represent the first stage in the displacement of all intra¬ capsular fractures. They explained the mechanism of the 8
fracture to be external rotation of the femur. The femoral head is thus fixed by the iliofemoral ligament while the posterior and superior neck buckles over the acetabular rim. Extension of the fracture goes along the cervical trabeculae and calcar, usually at some distance from the head and often in spiral fashion. Further rotation pro¬ duces impaction of the neck into the head. An impacted fracture may become "disimpacted" and converted to a displaced fracture. Displaced Fractures.—As mentioned above, the mecha¬ nism of the fracture is the same for impacted and dis¬ placed fractures. However, in displaced fractures, rotation¬ al force completely disrupts anterior and inferior cortices of the neck and then the pull of the muscles on the distal fragment displaces the neck proximally. The distance from the head to the point of fracture through the inferior neck determines the angle of inclina¬ tion that is the basis of Pauwels1" classification (Fig 1). Stability or lack of it has been related to these fracture types, the higher angle indicating less stable fracture.
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Fig 3.—Impacted fracture, Pauwels type Right, Six weeks after internal fixation with
II. Left, At admission. four Knowles pins.
Some authors identify Pauwels type I fracture (less than 35°) with impacted fractures. However, after dis¬ placement it may be clear that they should be classified as types II (35° to 60°) or III (60° to 90°). Impacted and dis¬ placed fractures, then, can have angle of inclination of any degree and be classified as any one of the three Pau¬ wels types.
Fig 4.—Lateral views at surgery. Top, Inadequate reduction: retroversion of femoral head and anterior separation. Bottom, Following open reduction, fragments are in anatomical position; note marked posterior wall comminution and spiral fashion of fracture.
PRINCIPLES AND METHODS OF INTERNAL FIXATION
Deyerle' admirably accounted for the historical evolu¬ tion of the principles in the treatment of intracapsular fractures from the days of Sir Astley Cooper. Although many attitudes and ideas have changed, certain basic principles remain. Stress Fractures
Devas" considered the transverse type before dis¬ placement as an emergency and advised the use of three pins and early ambulation. Devas" and Blickenstaff and Morris11 advised no treatment of the compression type and Devas stated that these fractures will heal even if the patient continues full weight bearing. At Cook County Hospital we currently internally fix all stress fractures, transverse and compression, as a means of increasing the reliability of the treatment in patients who do not follow orders.
Fig 5.—Impacted fracture, Pauwels type II. Left, At admission; note marked valgus of femoral head. Right, Two years later ad¬ vanced changes of avascular necrosis are noted: sclerosis, cystic areas, and collapse of articular surface. Fig 6.—Displaced fracture, Pauwels type II. Left, At admission. Right, Six weeks after insertion of sliding nail plate device, fracture is clinically and radiologically healed; note improper placement of nail that should lay on calcar.
Impacted Fractures There is much controversy in the literature concerning
the treatment of impacted fractures of the femoral neck. Recently, Hilleboe et al12 reviewed the subject and argued in favor of conservative treatment. In their series of 37 patients they allowed early non-weight-bearing crutch walking soon after hospitalization. Most of the fractures were thought to be sufficiently healed by 12 to 16 weeks, when full weight bearing was started. Their indication for conservative treatment was roentgenographic evidence of valgus position of the head, the neck fragment under the head, and apposition of the fragments. Four fractures dis-
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Fig 7.—Displaced fracture, Pauwels type II. Top, At admission, showing marked comminution of superior neck. Bottom left, One week after internal fixation with multiple pins-plate system. Bottom right, Three and a half months after surgery. Resorption at fracture site and backing out of pins are evident. Radiologically fracture was healed and patient was bearing weight without pain.
impacted at an average of 18 days and avascular necrosis developed in three. In Crawford's13 series of 50 patients, only four fractures became disimpacted and aseptic necro¬ sis developed in three. Proponents of internal fixation of impacted fractures cite better results with this method. A somewhat higher incidence of disimpaction (10% to 15%) was noted when conservative methods were employed, although the inci¬ dence of aseptic necrosis was approximately the same (6% to 10%).14» In comparing the operative with nonoperative methods, one gains the impression that the operative method gave only slightly better results, so the patient's general condi¬ tion and social habits, rather than roentgenograms alone, should determine the mode of treatment. An older indi¬ vidual, feeble and in poor condition, or an unreliable alco¬ holic should be treated by internal fixation to decrease the possibility of disimpaction when ambulation is started and after the patient leaves the hospital. At Cook County Hospital we prefer internal fixation of all impacted frac¬ tures with four Knowles pins (Fig 3). Triflange nails are not recommended for these fractures because of the possi¬ bility of producing disimpaction.
Displaced
Fractures
Most authors agree that displaced femoral neck frac¬ tures require either internal fixation or prosthetic replace¬ ment. In many centers the tendency is to use age and the
patient's general condition
as criteria for the type of pro¬ cedure to be done. Internal fixation is recommended for patients below the age of 65 to 70 years who are in good general condition and prosthetic replacement is recom¬ mended for patients above that age with less favorable general conditions. Reasoning for the use of these criteria is that older patients should have a "definitive" procedure and avoid long non-weight bearing and subsequent proce¬ dures if avascular necrosis and/or nonunion develop. How¬ ever, complications following prosthetic replacement, such as painful and migrating prosthesis, infection, dislocation, and fracture of the femur, are all very difficult to treat. Early Operation.—Many patients are in their best health at the time of injury and delaying the surgery may mean deterioration of their general condition, particularly de¬ velopment of cardiopulmonary complications, thrombophle¬ bitis, and decubitus ulcers. Therefore, surgery should be planned on a semi-emergency basis, only to allow for the basic evaluation. However, certain patients will not be in the condition to undergo surgery within 24 hours of ad¬ mission and it will be necessary to afford them vigorous
Fig 8.—Sliding screw compression plate device in place six following surgery. Fracture of femoral neck is clinically and radiologically healed. months
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medical treatment. On the other hand, there is some evi¬ dence indicating that delay in reduction and internal fix¬ ation will increase the incidence of avascular necrosis and delayed union.41" Most investigators agree that reduction and internal fixation should be done within 12 to 24 hours of the injury when medically feasible. Reduction.—It is not always quite clear from the litera¬ ture what is meant by accurate, proper, or adequate reduc¬ tion. Banks11 considered the fracture fragments ade¬ quately reduced if they were in anatomical position or in valgus, sometimes with 2 to 3 mm of separation at the calcar. On the other hand, valgus reduction where the distal fragment is placed under the proximal fragment in order to provide bony support is considered proper and de¬ sirable by many authors.4-51718 Most authors agree that varus and rétroversion positions of the femoral head are undesirable and give predictably many complications, re¬ gardless of the type of the internal fixation device. The study of Christophe et al19 compared the results of varus, valgus, and anatomical position of the femoral head fol¬ lowing reduction and nailing. There were no cases of asep¬ tic necrosis or nonunion in 25 patients where the head was in anatomical position as opposed to four cases of nonun¬ ion and seven cases of aseptic necrosis in 30 patients with valgus reduction and nine cases of nonunion and eight cases of aseptic necrosis in 28 patients with varus reduc¬ tion. Firm fixation in anatomical reduction seems to af¬ ford the best conditions for fracture repair, although slight valgus may be desirable if it provides closer apposi¬ tion of fracture fragments. Should close manipulation fail to obtain adequate reduction, open reduction is imperative
(Fig 4).
and Impaction.—The principle of in contact-compression treatment of fractures has been well demonstrated over the years-" and more recently reemphasized by the Swiss Association for the Study of Internal Fixation.2' In femoral neck fractures this prin¬ ciple can also be applied.22 Contact compression is achieved either by a sliding or a compression mechanism in the fix¬ ation device. Some authors have promulgated "the prin¬ ciple of impaction," particularly of more comminuted frac¬ tures.4'5-'7'23'24 The idea stemmed from impacted fractures, which are often stable and heal almost invariably. Impac¬ tion, which is usually produced by several blows to the lat¬ eral cortical plate, may accomplish better contact and compression of noncomminuted cortices and firm internal fixation will facilitate healing of comminuted parts. Im¬ paction in slight valgus will provide greater stability of fracture fragments in addition to their closer apposition. However, excessive valgus is undesirable and known to be associated with a high incidence of avascular necrosis (Fig
Contact-Compression
5).
Firm Immobilization.—In order to keep firm fixation of fragments in the position of reduction, certain re¬ quirements have to be met. First, the appliance should provide for sliding, to accommodate for possible and not uncommon résorption of the neck at the fracture site.
the
investigators look on this résorption as indicating inadequate fixation. Second, firm lateral cortex fixation of Some
Fig 9.—Femoral head and pins are being inserted.
neck
as seen on
television
screen
while
appliances is necessary to prevent loosening in the lateral
fracture site.4·5 best inserted into the femoral neck at an angle to the shaft of about 150° to 160° since it has been shown that this is the weight-bearing axis for most hips and therefore shearing force on the appliance would be minimal.23 Methods of Internal Fixation.—Triflanged nails with or without side plates, lag screws, regular screws, spikes, partially threaded nails at their tips with or without side plates, and sliding nails have all been advocated during the past 40 years. Many of these devices are only of histor¬ ical significance and are not presently employed. Some de¬ vices such as the Smith-Petersen nail and Moore and Knowles pins are still in use although they fail to meet the optional requirements for firm fixation in displaced frac¬ tures. Only three systems available at present meet these requirements, two of which are currently under evaluation cortex that would allow motion at the
Third, nails and pins
are
County Hospital. Sliding Triflange Nail Plate.—The main features of the system are relatively small triflange nails connected to the sliding mechanism below the fracture and fixation with a small plate to the femoral shaft (Fig 6). The nail plate angle is 155°. There are several modifications of this nail based essentially on the same principle. This system was described by Massie25 after he modified a similar de¬ vice by Pugh.2" Massie4-23 emphasized the need for early fixation, surgi¬ cal impaction, lateral cortical fixation, high nail-shaft angle, and distal and posterior placement of the nail in the neck. He reported an increase of healing rate and decrease
at Cook
in number of nonunions and early avascular necrosis. He also pointed to asymptomatic and late cases of avascular necrosis that he explained on the basis of repeated micro-
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trauma and chronic ischemia.
Multiple Pins-Plate System.—The main features of this system are partially threaded pins (eight to 12) that are inserted at 140° through a lateral cortical plate (Fig 7). Deyerle27 described this system. He reported two cases of avascular necrosis and only one case of delayed union in 35 displaced fractures,5 and emphasized valgus reduction, im¬ paction, and lateral cortical fixation. Metz et al28 reported 11.6% avascular necrosis and 4.7% nonunion in 43 patients
than two years. Screw Sliding Compression Plate.-This system was de¬ scribed by Schumpelick and Jantzen2" in 1955 and has been used primarily for intertrochanteric fractures. Main fea¬ tures of this system are similar to the Massie nail except that the nail is replaced by a screw (Fig 8). In addition to a shaft plate and a sliding mechanism, compression may be accomplished by a special screw in the sliding mecha¬ nism. Clawson3" reported 13% nonunion and 30% avascular necrosis in 26 patients and advised against use of this sys¬ tem in very old patients as in his series (average age, 76 years). He recommended it for younger patients and em¬ phasized anatomical reduction and impaction. observed
more
RESULTS
displaced fractures of the femoral neck, where fix¬ ation problems are significant, we have initiated a trial of treatment using a multiple pin and plate system (Deyerle). A total of 15 such hips have been treated since
out complications. Of the remaining six fractures, avascu¬ lar necrosis developed in two although the fracture healed, nonunion developed in two in addition to avascular necro¬ sis, nonunion developed in one, and osteomyelitis in an¬ other. The most frequent mistakes were inadequate re¬ duction and inappropriate placement of the nail (Fig 6). Most critical was reduction, which was found to be inade¬ quate in all failed cases.
CONTRAINDICATIONS TO PRIMARY INTERNAL FIXATION In discussing their indications for prosthetic replace¬ ment in femoral neck fractures, Hinchey and Day31 cited poor general health contraindicating second operation,
Parkinson disease, spastic hemiplegia, severe hip arthritis, the need for early ambulation, physiological age over 70, and pathological fracture. Although these indications for prosthetic replacement have changed over the last decade, they may be used as a list of relative contraindications to primary internal fixation. Severe hip arthritis and patho¬ logical fractures are absolute contraindications. With bet¬ ter understanding of the principles of internal fixation and availability of better appliances, the list of relative contraindications may one day become shorter. CONCLUSIONS
In
Jan
1,
1973.
Although long-term results cannot be stated, the advan¬ tages of the system are already apparent. The procedure is relatively simple to perform providing that an image in¬ tensifier is available (Fig 9). All patients were allowed to ambulate as soon as their general condition permitted, usually in the first week. This may account for absence of thrombophlebitis, decubitus ulcers, and cardiopulmonary problems. Reduction was less than adequate in eight cases and yet in no case so far has there been breakage of the nails or gross displacement. In one patient, pins had to be backed out five months following surgery, and the marked pain he was having almost completely subsided; the frac¬ ture is radiologically healed. Resorption of the neck devel¬ oped in three patients, but no pins penetrated into the joint and patients are reporting no pain. In three cases, the fracture line is still visible six months following sur¬ gery; these patients continue to bear weight without pain. In one instance, the patient is complaining of moderate pain and the fracture line is visible five months following surgery. Of the remaining seven patients with adequate reduction and fixation, fractures have healed in four pa¬ tients and the fracture line is still visible in three patients two to four months following surgery although these pa¬ tients have no pain on weight bearing. Obviously, more cases are needed and longer follow-up required before any conclusions can be drawn. Review of the results of internal fixation with sliding triflanged nails (Massie) performed in 1971 and 1972 was done. In 16 Massie nailings, which were done primarily in patients under 60 years of age, ten fractures healed with-
It has often been said that no replacement prosthesis will ever function as well as the patient's own normal femoral head. This is still true. Primary internal fixation of femoral neck fractures will work to that end. Unfortu¬ nately, the incidence of nonunion and avascular necrosis is still high and their occurrence unpredictable. It has been demonstrated that these complications can be reduced, al¬ though not eliminated, if the principles of internal fix¬ ation are carefully followed. It is left to future investigators to work in two critical areas: (1) To develop methods capable of differentiating between viable and nonviable femoral head within the first 12 to 24 hours of injury and thus establish objective indications for internal fixation and prosthetic replace¬ ment. (2) To develop better devices for internal fixation. Only when this is accomplished will the "unsolved" frac¬ ture become a "solved" one. Saul S. Haskell, MD, gave permission to report the case shown in Fig 8. The sliding screw compression device shown in Fig 8 was supplied by the Richards Manufacturing Company, Inc.
References 1. Trueta J, Harrison MHM: The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg 35-B:442-461, 1953. 2. Sevitt S, Thompson RG: The distribution and anastomosis of arteries supplying the head and neck of the femur. J Bone Joint Surg 47-B:560-573, 1965. 3. Banks HH: Healing of the femoral neck fracture, in Proceedings of the Conference on Aseptic Necrosis of the Femoral Head. St. Louis, Surgery Study Sections, National Institutes of Health, 1964, pp 465-482. 4. Massie WK: Treatment of femoral neck fractures emphasizing long-term follow-up observations on aseptic necrosis. Clin Orthop 92:16-62, 1973. 5. Deyerle WM: Plate and peripheral pins in hip fractures: Twoplane reduction, total impaction, and absolute fixation. Curr Prac
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/08/2015
Orthop Surg 3:173-207, 1966. 6. Devas MB: Stress fractures of the femoral neck. J Bone Joint Surg 47-B:728-738, 1965. 7. Linton P: Types of displacement in fractures of femoral neck and observations on impaction of fractures. J Bone Joint Surg 31\x=req-\ B:184-189, 1949. 8. Linton P: On the different types of intracapsular fractures of the femoral neck. Acta Chir Scand 90 (suppl 86):1-122, 1944. 9. Klenerman L, Marcuson RW: Intracapsular fractures of the
neck of the femur. J Bone Joint Surg 52-B:514-517, 1970. 10. Pauwels F: Der Schenkelhalsbruch ein mechanisches Problem: Grundlagen des Heilungvorganges Prognose und kausale Therapie. Z Orthop Chir 63:32-33, 1935. 11. Blickenstaff LD, Morris JM: Fatigue fracture of the femoral neck. J Bone Joint Surg 48-A:1031-1047, 1966. 12. Hilleboe JW, Staple TW, Lansche EW, et al: The nonoperative treatment of impacted fractures of the femoral neck. South Med J 63:1103-1109, 1970. 13. Crawford HB: Conservative treatment of impacted fractures of the femoral neck. J Bone Joint Surg 42-A:471-479,1960. 14. Banks HH: Factors influencing the result in fractures of the femoral neck. J Bone Joint Surg 44-A:931-964, 1962. 15. Bentley G: Impacted fractures of the neck of the femur. J Bone Joint Surg 50-B:551-561, 1968. 16. Soto-Hall R, Johnson LH, Johnson RA: Variations in intraarticular pressure of hip joint in injury and disease: Probable factor in avascular necrosis. J Bone Joint Surg 46-A:509-516, 1964. 17. Cotton FJ, Morrison GM: Hip fractures: Valgus position\p=m-\ accidental or engineered. J Bone Joint Surg 20:461-468, 1938. 18. McElvenny RT: Management of intracapsular hip fractures. Surg Clin North Am 29:31-58, 1949. 19. Christophe K, Howard LG, Potter TA, et al: A study of 104
consecutive cases of fracture of the hip. J Bone Joint Surg 35\x=req-\ A:729-735, 1953. 20. Eggers GWN, Shindler TO, Pomerat CM: The influence of the contact-compression factor on osteogenesis in surgical fractures. J Bone Joint Surg 31-A:693-716, 1949. 21. Miller ME, Allgower M, Willenegger H: Manual on Internal Fixation. New York, Springer-Verlag, 1970. 22. Charnley J: Treatment of fractures of neck of femur by compression. Acta Orthop Scand 30:29-48, 1960. 23. Massie WK: Fractures of the hip. J Bone Joint Surg 46\x=req-\ A:658-690, 1964. 24. Deyerle WM: Multiple-pin peripheral fixation in fractures of the neck of the femur: Immediate weight-bearing. Clin Orthop
1965. 25. Massie WK: Functional fixation of femoral neck fractures: Telescoping nail technic. Clin Orthop 12:230-255, 1958. 26. Pugh WL: A self-adjusting nail-plate for fractures about the hip joint. J Bone Joint Surg 37-A:1085-1093, 1955. 27. Deyerle WM: Absolute fixation with contact compression in hip fractures. Clin Orthop 13:279-298, 1959. 28. Metz Jr CW, Sellers TD, Feagin JA, et al: The displaced intracapsular fracture of the neck of the femur. J Bone Joint Surg 52-A:113-127, 1970. 29. Schumpelick W, Jantzen PM: A new principle in the operative treatment of trochanteric fractures of the femur. J Bone Joint Surg 37-A:693-698, 1955. 30. Clawson DK: Intracapsular fractures of the femur treated by the sliding screw plate fixation method. J Trauma 4:753-756, 1964. 31. Hinchey JJ, Day PL: Primary prosthetic replacement in fresh femoral-neck fractures. J Bone Joint Surg 46-A:223-240, 1964.
39:135-156,
50 Years Ago in the Archives of
Surgery
Endometrial Carcinoma of the Ovary Arising in Endometrial Tissue in That Organ
"Endometrial tissue in the ovary is of common occurrence. The evidence obtained would indicate that it usually develops from implantation of bits of uterine mucosa escaping through the tubes during a retrograde menstrual flow from the uterine cavity. Tubal epithelium also may possibly become implanted on the ovary. It is difficult to disprove that endometrium-like tissue may not occasionally arise from the true surface epithelium of the ovary; I have seen a few specimens which might be so interpreted. The evidence [is] in favor of malignant changes in endometrial tissue in the ovary as a ." source of some, and possibly of many, ovarian carcinomas. .
Sampson
JA: Arch
Surg 10:1-72, 1925.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/08/2015
.
Internal Fixation of Femoral Neck Fractures Arsen M.
Pankovich, MD
The principles in treatment of femoral neck fractures by primary internal fixation have been reviewed. In the rare, undisplaced stress or fatigue fracture, early internal fixation with threaded pins is recommended. Impacted fractures should be treated by primary internal fixation in patients who do not follow orders and patients whose general condition is poor and would require early weight bearing. Displaced fractures may be treated by primary internal fixation at any age and regardless of the patient's general condition. The following principles are emphasized: early operation, anatomical reduction and slight valgus in some cases, compression and impaction of fragments, and firm immobilization of fragments with a device that has a sliding mechanism and provides lateral cortical fixation.
neck fractures continue to be a formidable and to the orthopedic surgeon. Liter¬ ature concerning the biomechanics and vascular supply of the hip, the mechanisms of injury, the management and healing of the fractures, the epidemiology, and early and late complications is abundant. Yet, it is all too confusing to read sometimes contradictory statements and to look for principles that are often lost in the woods of statistics, technical details, and speculations. This article reviews the present concepts and methods of primary internal fixation of femoral neck fractures and presents recent experience at Cook County Hospital.
Femoral challenging problem
GENERAL PRINCIPLES
The ideal method in treating femoral neck fractures would provide firm immobilization of facture fragments in anatomical position, allow early weight bearing, and prevent the two most common local complications: nonun¬ ion and avascular necrosis. In order to appreciate the dif¬ ficulties in achieving this goal, it is necessary to underAccepted
for publication July 25, 1974. From the Division of Orthopedic Surgery, Cook County cago. Reprint requests to Division of Orthopedic Surgery, Cook tal, Chicago, IL 60612 (Dr. Pankovich).
Hospital, ChiCounty Hospi-
stand certain details of femoral neck and head anatomy, the mode of healing of the fractures, the types of frac¬ tures and their pathology, and basic principles and re¬ quirements of treatment. Anatomical Considerations
The
capsule of the hip joint, along with its ligamentous enforcements, is attached on the femur anteriorly to the intertrochanteric line and posteriorly about 1 to 1.5 cm proximal to the intertrochanteric crest (Fig 1). Therefore, the base of the femoral neck is intracapsular anteriorly and extracapsular posteriorly. From the femoral attach¬ ments of the capsule originate ascending fibrous bands, retinacula, that are attached to the intracapsular portion of the femoral neck and extend to the cartilaginous rim of
the femoral head. Retinacula contain blood vessels and are covered with synovia. Blood supply to the femoral neck and head is derived from the extracapsular arterial ring at the base of the femoral neck (Fig 1). The anterior portion of the arterial ring is derived from the lateral femoral circumflex artery and the posterior portion from the medial femoral circum¬ flex artery. Ascending cervical arteries, from the arterial ring, perforate the capsule and become retinacular ar¬ teries. Posterosuperior retinacular arteries are more nu¬ merous (three to eight) than posteroinferior (one to three); there are very few arteries on the anterior surface. Trueta and Harrison1 suggested the existence of separate epiphysial and metaphysial retinacular arteries that, in adults, anastomose across the old epiphysial line. Most investiga¬ tors now agree that the femoral head is primarily supplied by the posterosuperior retinacular arteries. Postero¬ inferior arteries supply primarily the metaphysial portion of the neck. The contribution of the artery of the ligamen¬ tum teres that is usually derived from the obturator ar¬ tery is not quite clear. It seems that it supplies primarily
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Fig 1.—Femoral neck with capsular attachments and retinacula (dotted lines) and arterial ring with retinacular arteries. Note greater number of vessels and extracapsular location of base of neck posteriorly (right). In anterior view (left), three Pauwels frac¬ ture
types
are
indicated.
2.—Bilateral stress fractures in elderly patient. Top, In May varus of femoral heads was evident and sclerosis in subcapi¬ tal areas indicated healing at fracture sites. Patient refused treat¬ ment and continued to bear weight. Bottom, In February 1968, frac¬ tures are healed in marked varus.
Fig
1962,
the
area of the head around the fovea capitis where the ligamentum teres is attached.1 Banks' correlated histo¬ logical viability of the femoral head with its vascular sup¬ ply and concluded that avascular necrosis developed if all retinacular vessels were damaged, regardless of the state of vessels in the ligamentum teres. Due to proximity of the retinacular arteries to the bone, they may be injured in any fracture of the femoral neck -
and the outcome may be avascular necrosis of the femoral head. Some cases of late development of avascular necro¬ sis could be explained on the basis of inadequate blood supply, ie, chronic ischemia through the remaining, intact arteries.4 Conversely, in displaced fractures, some arteries may be spared and still provide adequate blood flow. Ex¬ tracapsular location of the base of the neck posteriorly ex¬ plains the low incidence of avascular necrosis of basilar neck fractures. Finally, the adult femoral neck has no functional peri¬ osteum. This has direct bearing on the type of healing of these fractures. There being no periosteal callus, the heal¬ ing depends entirely on the endosteal callus. Absence of cartilage, proliferation of fibrous tissue and small vessels, and laying down of fibrous bone are the main features of the endosteal callus. If the head is viable, the endosteal callus is laid down on both sides of the fracture. The endosteal callus forms only on the neck side if the head is nonviable, although the fracture may heal. This type of fracture healing, by endosteal callus, was coined by F. C. McLean as healing by primary intention. Since the heal¬ ing is dependent on the state of vascularity of the femoral head and even more so on the integrity of callus vessels, rigid immobilization and close apposition of the frag¬ ments are imperative until callus is completely consoli¬ dated.4 :> Nonunion will therefore develop if these condi¬ tions are not met. '
Types of
Fractures
The division of femoral neck fractures into three cate¬ gories—stress, impacted, and displaced—is of practical im-
portance.
Stress or Fatigue Fractures.—These fractures are rare and occur in all age groups. In younger individuals, frac¬ tures are usually seen following strenuous activity. In older persons and patients with underlying bone disease, such as osteoporosis and osteomalacia, there is pre¬ disposition to stress fractures (Fig 2). Two types were de¬ scribed by Devas." In the transverse type, the initial infrac¬ tion is in the superior cortex of the neck with tendency for complete fracture and displacement. In the compression type, the area above the calcar is the site of initial infrac¬ tion; this type shows less tendency for displacement.
Impacted Fractures.—According to Linton,7 and, more recently, Klenerman and Marcuson," impacted fractures represent the first stage in the displacement of all intra¬ capsular fractures. They explained the mechanism of the 8
fracture to be external rotation of the femur. The femoral head is thus fixed by the iliofemoral ligament while the posterior and superior neck buckles over the acetabular rim. Extension of the fracture goes along the cervical trabeculae and calcar, usually at some distance from the head and often in spiral fashion. Further rotation pro¬ duces impaction of the neck into the head. An impacted fracture may become "disimpacted" and converted to a displaced fracture. Displaced Fractures.—As mentioned above, the mecha¬ nism of the fracture is the same for impacted and dis¬ placed fractures. However, in displaced fractures, rotation¬ al force completely disrupts anterior and inferior cortices of the neck and then the pull of the muscles on the distal fragment displaces the neck proximally. The distance from the head to the point of fracture through the inferior neck determines the angle of inclina¬ tion that is the basis of Pauwels1" classification (Fig 1). Stability or lack of it has been related to these fracture types, the higher angle indicating less stable fracture.
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Fig 3.—Impacted fracture, Pauwels type Right, Six weeks after internal fixation with
II. Left, At admission. four Knowles pins.
Some authors identify Pauwels type I fracture (less than 35°) with impacted fractures. However, after dis¬ placement it may be clear that they should be classified as types II (35° to 60°) or III (60° to 90°). Impacted and dis¬ placed fractures, then, can have angle of inclination of any degree and be classified as any one of the three Pau¬ wels types.
Fig 4.—Lateral views at surgery. Top, Inadequate reduction: retroversion of femoral head and anterior separation. Bottom, Following open reduction, fragments are in anatomical position; note marked posterior wall comminution and spiral fashion of fracture.
PRINCIPLES AND METHODS OF INTERNAL FIXATION
Deyerle' admirably accounted for the historical evolu¬ tion of the principles in the treatment of intracapsular fractures from the days of Sir Astley Cooper. Although many attitudes and ideas have changed, certain basic principles remain. Stress Fractures
Devas" considered the transverse type before dis¬ placement as an emergency and advised the use of three pins and early ambulation. Devas" and Blickenstaff and Morris11 advised no treatment of the compression type and Devas stated that these fractures will heal even if the patient continues full weight bearing. At Cook County Hospital we currently internally fix all stress fractures, transverse and compression, as a means of increasing the reliability of the treatment in patients who do not follow orders.
Fig 5.—Impacted fracture, Pauwels type II. Left, At admission; note marked valgus of femoral head. Right, Two years later ad¬ vanced changes of avascular necrosis are noted: sclerosis, cystic areas, and collapse of articular surface. Fig 6.—Displaced fracture, Pauwels type II. Left, At admission. Right, Six weeks after insertion of sliding nail plate device, fracture is clinically and radiologically healed; note improper placement of nail that should lay on calcar.
Impacted Fractures There is much controversy in the literature concerning
the treatment of impacted fractures of the femoral neck. Recently, Hilleboe et al12 reviewed the subject and argued in favor of conservative treatment. In their series of 37 patients they allowed early non-weight-bearing crutch walking soon after hospitalization. Most of the fractures were thought to be sufficiently healed by 12 to 16 weeks, when full weight bearing was started. Their indication for conservative treatment was roentgenographic evidence of valgus position of the head, the neck fragment under the head, and apposition of the fragments. Four fractures dis-
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Fig 7.—Displaced fracture, Pauwels type II. Top, At admission, showing marked comminution of superior neck. Bottom left, One week after internal fixation with multiple pins-plate system. Bottom right, Three and a half months after surgery. Resorption at fracture site and backing out of pins are evident. Radiologically fracture was healed and patient was bearing weight without pain.
impacted at an average of 18 days and avascular necrosis developed in three. In Crawford's13 series of 50 patients, only four fractures became disimpacted and aseptic necro¬ sis developed in three. Proponents of internal fixation of impacted fractures cite better results with this method. A somewhat higher incidence of disimpaction (10% to 15%) was noted when conservative methods were employed, although the inci¬ dence of aseptic necrosis was approximately the same (6% to 10%).14» In comparing the operative with nonoperative methods, one gains the impression that the operative method gave only slightly better results, so the patient's general condi¬ tion and social habits, rather than roentgenograms alone, should determine the mode of treatment. An older indi¬ vidual, feeble and in poor condition, or an unreliable alco¬ holic should be treated by internal fixation to decrease the possibility of disimpaction when ambulation is started and after the patient leaves the hospital. At Cook County Hospital we prefer internal fixation of all impacted frac¬ tures with four Knowles pins (Fig 3). Triflange nails are not recommended for these fractures because of the possi¬ bility of producing disimpaction.
Displaced
Fractures
Most authors agree that displaced femoral neck frac¬ tures require either internal fixation or prosthetic replace¬ ment. In many centers the tendency is to use age and the
patient's general condition
as criteria for the type of pro¬ cedure to be done. Internal fixation is recommended for patients below the age of 65 to 70 years who are in good general condition and prosthetic replacement is recom¬ mended for patients above that age with less favorable general conditions. Reasoning for the use of these criteria is that older patients should have a "definitive" procedure and avoid long non-weight bearing and subsequent proce¬ dures if avascular necrosis and/or nonunion develop. How¬ ever, complications following prosthetic replacement, such as painful and migrating prosthesis, infection, dislocation, and fracture of the femur, are all very difficult to treat. Early Operation.—Many patients are in their best health at the time of injury and delaying the surgery may mean deterioration of their general condition, particularly de¬ velopment of cardiopulmonary complications, thrombophle¬ bitis, and decubitus ulcers. Therefore, surgery should be planned on a semi-emergency basis, only to allow for the basic evaluation. However, certain patients will not be in the condition to undergo surgery within 24 hours of ad¬ mission and it will be necessary to afford them vigorous
Fig 8.—Sliding screw compression plate device in place six following surgery. Fracture of femoral neck is clinically and radiologically healed. months
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medical treatment. On the other hand, there is some evi¬ dence indicating that delay in reduction and internal fix¬ ation will increase the incidence of avascular necrosis and delayed union.41" Most investigators agree that reduction and internal fixation should be done within 12 to 24 hours of the injury when medically feasible. Reduction.—It is not always quite clear from the litera¬ ture what is meant by accurate, proper, or adequate reduc¬ tion. Banks11 considered the fracture fragments ade¬ quately reduced if they were in anatomical position or in valgus, sometimes with 2 to 3 mm of separation at the calcar. On the other hand, valgus reduction where the distal fragment is placed under the proximal fragment in order to provide bony support is considered proper and de¬ sirable by many authors.4-51718 Most authors agree that varus and rétroversion positions of the femoral head are undesirable and give predictably many complications, re¬ gardless of the type of the internal fixation device. The study of Christophe et al19 compared the results of varus, valgus, and anatomical position of the femoral head fol¬ lowing reduction and nailing. There were no cases of asep¬ tic necrosis or nonunion in 25 patients where the head was in anatomical position as opposed to four cases of nonun¬ ion and seven cases of aseptic necrosis in 30 patients with valgus reduction and nine cases of nonunion and eight cases of aseptic necrosis in 28 patients with varus reduc¬ tion. Firm fixation in anatomical reduction seems to af¬ ford the best conditions for fracture repair, although slight valgus may be desirable if it provides closer apposi¬ tion of fracture fragments. Should close manipulation fail to obtain adequate reduction, open reduction is imperative
(Fig 4).
and Impaction.—The principle of in contact-compression treatment of fractures has been well demonstrated over the years-" and more recently reemphasized by the Swiss Association for the Study of Internal Fixation.2' In femoral neck fractures this prin¬ ciple can also be applied.22 Contact compression is achieved either by a sliding or a compression mechanism in the fix¬ ation device. Some authors have promulgated "the prin¬ ciple of impaction," particularly of more comminuted frac¬ tures.4'5-'7'23'24 The idea stemmed from impacted fractures, which are often stable and heal almost invariably. Impac¬ tion, which is usually produced by several blows to the lat¬ eral cortical plate, may accomplish better contact and compression of noncomminuted cortices and firm internal fixation will facilitate healing of comminuted parts. Im¬ paction in slight valgus will provide greater stability of fracture fragments in addition to their closer apposition. However, excessive valgus is undesirable and known to be associated with a high incidence of avascular necrosis (Fig
Contact-Compression
5).
Firm Immobilization.—In order to keep firm fixation of fragments in the position of reduction, certain re¬ quirements have to be met. First, the appliance should provide for sliding, to accommodate for possible and not uncommon résorption of the neck at the fracture site.
the
investigators look on this résorption as indicating inadequate fixation. Second, firm lateral cortex fixation of Some
Fig 9.—Femoral head and pins are being inserted.
neck
as seen on
television
screen
while
appliances is necessary to prevent loosening in the lateral
fracture site.4·5 best inserted into the femoral neck at an angle to the shaft of about 150° to 160° since it has been shown that this is the weight-bearing axis for most hips and therefore shearing force on the appliance would be minimal.23 Methods of Internal Fixation.—Triflanged nails with or without side plates, lag screws, regular screws, spikes, partially threaded nails at their tips with or without side plates, and sliding nails have all been advocated during the past 40 years. Many of these devices are only of histor¬ ical significance and are not presently employed. Some de¬ vices such as the Smith-Petersen nail and Moore and Knowles pins are still in use although they fail to meet the optional requirements for firm fixation in displaced frac¬ tures. Only three systems available at present meet these requirements, two of which are currently under evaluation cortex that would allow motion at the
Third, nails and pins
are
County Hospital. Sliding Triflange Nail Plate.—The main features of the system are relatively small triflange nails connected to the sliding mechanism below the fracture and fixation with a small plate to the femoral shaft (Fig 6). The nail plate angle is 155°. There are several modifications of this nail based essentially on the same principle. This system was described by Massie25 after he modified a similar de¬ vice by Pugh.2" Massie4-23 emphasized the need for early fixation, surgi¬ cal impaction, lateral cortical fixation, high nail-shaft angle, and distal and posterior placement of the nail in the neck. He reported an increase of healing rate and decrease
at Cook
in number of nonunions and early avascular necrosis. He also pointed to asymptomatic and late cases of avascular necrosis that he explained on the basis of repeated micro-
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trauma and chronic ischemia.
Multiple Pins-Plate System.—The main features of this system are partially threaded pins (eight to 12) that are inserted at 140° through a lateral cortical plate (Fig 7). Deyerle27 described this system. He reported two cases of avascular necrosis and only one case of delayed union in 35 displaced fractures,5 and emphasized valgus reduction, im¬ paction, and lateral cortical fixation. Metz et al28 reported 11.6% avascular necrosis and 4.7% nonunion in 43 patients
than two years. Screw Sliding Compression Plate.-This system was de¬ scribed by Schumpelick and Jantzen2" in 1955 and has been used primarily for intertrochanteric fractures. Main fea¬ tures of this system are similar to the Massie nail except that the nail is replaced by a screw (Fig 8). In addition to a shaft plate and a sliding mechanism, compression may be accomplished by a special screw in the sliding mecha¬ nism. Clawson3" reported 13% nonunion and 30% avascular necrosis in 26 patients and advised against use of this sys¬ tem in very old patients as in his series (average age, 76 years). He recommended it for younger patients and em¬ phasized anatomical reduction and impaction. observed
more
RESULTS
displaced fractures of the femoral neck, where fix¬ ation problems are significant, we have initiated a trial of treatment using a multiple pin and plate system (Deyerle). A total of 15 such hips have been treated since
out complications. Of the remaining six fractures, avascu¬ lar necrosis developed in two although the fracture healed, nonunion developed in two in addition to avascular necro¬ sis, nonunion developed in one, and osteomyelitis in an¬ other. The most frequent mistakes were inadequate re¬ duction and inappropriate placement of the nail (Fig 6). Most critical was reduction, which was found to be inade¬ quate in all failed cases.
CONTRAINDICATIONS TO PRIMARY INTERNAL FIXATION In discussing their indications for prosthetic replace¬ ment in femoral neck fractures, Hinchey and Day31 cited poor general health contraindicating second operation,
Parkinson disease, spastic hemiplegia, severe hip arthritis, the need for early ambulation, physiological age over 70, and pathological fracture. Although these indications for prosthetic replacement have changed over the last decade, they may be used as a list of relative contraindications to primary internal fixation. Severe hip arthritis and patho¬ logical fractures are absolute contraindications. With bet¬ ter understanding of the principles of internal fixation and availability of better appliances, the list of relative contraindications may one day become shorter. CONCLUSIONS
In
Jan
1,
1973.
Although long-term results cannot be stated, the advan¬ tages of the system are already apparent. The procedure is relatively simple to perform providing that an image in¬ tensifier is available (Fig 9). All patients were allowed to ambulate as soon as their general condition permitted, usually in the first week. This may account for absence of thrombophlebitis, decubitus ulcers, and cardiopulmonary problems. Reduction was less than adequate in eight cases and yet in no case so far has there been breakage of the nails or gross displacement. In one patient, pins had to be backed out five months following surgery, and the marked pain he was having almost completely subsided; the frac¬ ture is radiologically healed. Resorption of the neck devel¬ oped in three patients, but no pins penetrated into the joint and patients are reporting no pain. In three cases, the fracture line is still visible six months following sur¬ gery; these patients continue to bear weight without pain. In one instance, the patient is complaining of moderate pain and the fracture line is visible five months following surgery. Of the remaining seven patients with adequate reduction and fixation, fractures have healed in four pa¬ tients and the fracture line is still visible in three patients two to four months following surgery although these pa¬ tients have no pain on weight bearing. Obviously, more cases are needed and longer follow-up required before any conclusions can be drawn. Review of the results of internal fixation with sliding triflanged nails (Massie) performed in 1971 and 1972 was done. In 16 Massie nailings, which were done primarily in patients under 60 years of age, ten fractures healed with-
It has often been said that no replacement prosthesis will ever function as well as the patient's own normal femoral head. This is still true. Primary internal fixation of femoral neck fractures will work to that end. Unfortu¬ nately, the incidence of nonunion and avascular necrosis is still high and their occurrence unpredictable. It has been demonstrated that these complications can be reduced, al¬ though not eliminated, if the principles of internal fix¬ ation are carefully followed. It is left to future investigators to work in two critical areas: (1) To develop methods capable of differentiating between viable and nonviable femoral head within the first 12 to 24 hours of injury and thus establish objective indications for internal fixation and prosthetic replace¬ ment. (2) To develop better devices for internal fixation. Only when this is accomplished will the "unsolved" frac¬ ture become a "solved" one. Saul S. Haskell, MD, gave permission to report the case shown in Fig 8. The sliding screw compression device shown in Fig 8 was supplied by the Richards Manufacturing Company, Inc.
References 1. Trueta J, Harrison MHM: The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg 35-B:442-461, 1953. 2. Sevitt S, Thompson RG: The distribution and anastomosis of arteries supplying the head and neck of the femur. J Bone Joint Surg 47-B:560-573, 1965. 3. Banks HH: Healing of the femoral neck fracture, in Proceedings of the Conference on Aseptic Necrosis of the Femoral Head. St. Louis, Surgery Study Sections, National Institutes of Health, 1964, pp 465-482. 4. Massie WK: Treatment of femoral neck fractures emphasizing long-term follow-up observations on aseptic necrosis. Clin Orthop 92:16-62, 1973. 5. Deyerle WM: Plate and peripheral pins in hip fractures: Twoplane reduction, total impaction, and absolute fixation. Curr Prac
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/08/2015
Orthop Surg 3:173-207, 1966. 6. Devas MB: Stress fractures of the femoral neck. J Bone Joint Surg 47-B:728-738, 1965. 7. Linton P: Types of displacement in fractures of femoral neck and observations on impaction of fractures. J Bone Joint Surg 31\x=req-\ B:184-189, 1949. 8. Linton P: On the different types of intracapsular fractures of the femoral neck. Acta Chir Scand 90 (suppl 86):1-122, 1944. 9. Klenerman L, Marcuson RW: Intracapsular fractures of the
neck of the femur. J Bone Joint Surg 52-B:514-517, 1970. 10. Pauwels F: Der Schenkelhalsbruch ein mechanisches Problem: Grundlagen des Heilungvorganges Prognose und kausale Therapie. Z Orthop Chir 63:32-33, 1935. 11. Blickenstaff LD, Morris JM: Fatigue fracture of the femoral neck. J Bone Joint Surg 48-A:1031-1047, 1966. 12. Hilleboe JW, Staple TW, Lansche EW, et al: The nonoperative treatment of impacted fractures of the femoral neck. South Med J 63:1103-1109, 1970. 13. Crawford HB: Conservative treatment of impacted fractures of the femoral neck. J Bone Joint Surg 42-A:471-479,1960. 14. Banks HH: Factors influencing the result in fractures of the femoral neck. J Bone Joint Surg 44-A:931-964, 1962. 15. Bentley G: Impacted fractures of the neck of the femur. J Bone Joint Surg 50-B:551-561, 1968. 16. Soto-Hall R, Johnson LH, Johnson RA: Variations in intraarticular pressure of hip joint in injury and disease: Probable factor in avascular necrosis. J Bone Joint Surg 46-A:509-516, 1964. 17. Cotton FJ, Morrison GM: Hip fractures: Valgus position\p=m-\ accidental or engineered. J Bone Joint Surg 20:461-468, 1938. 18. McElvenny RT: Management of intracapsular hip fractures. Surg Clin North Am 29:31-58, 1949. 19. Christophe K, Howard LG, Potter TA, et al: A study of 104
consecutive cases of fracture of the hip. J Bone Joint Surg 35\x=req-\ A:729-735, 1953. 20. Eggers GWN, Shindler TO, Pomerat CM: The influence of the contact-compression factor on osteogenesis in surgical fractures. J Bone Joint Surg 31-A:693-716, 1949. 21. Miller ME, Allgower M, Willenegger H: Manual on Internal Fixation. New York, Springer-Verlag, 1970. 22. Charnley J: Treatment of fractures of neck of femur by compression. Acta Orthop Scand 30:29-48, 1960. 23. Massie WK: Fractures of the hip. J Bone Joint Surg 46\x=req-\ A:658-690, 1964. 24. Deyerle WM: Multiple-pin peripheral fixation in fractures of the neck of the femur: Immediate weight-bearing. Clin Orthop
1965. 25. Massie WK: Functional fixation of femoral neck fractures: Telescoping nail technic. Clin Orthop 12:230-255, 1958. 26. Pugh WL: A self-adjusting nail-plate for fractures about the hip joint. J Bone Joint Surg 37-A:1085-1093, 1955. 27. Deyerle WM: Absolute fixation with contact compression in hip fractures. Clin Orthop 13:279-298, 1959. 28. Metz Jr CW, Sellers TD, Feagin JA, et al: The displaced intracapsular fracture of the neck of the femur. J Bone Joint Surg 52-A:113-127, 1970. 29. Schumpelick W, Jantzen PM: A new principle in the operative treatment of trochanteric fractures of the femur. J Bone Joint Surg 37-A:693-698, 1955. 30. Clawson DK: Intracapsular fractures of the femur treated by the sliding screw plate fixation method. J Trauma 4:753-756, 1964. 31. Hinchey JJ, Day PL: Primary prosthetic replacement in fresh femoral-neck fractures. J Bone Joint Surg 46-A:223-240, 1964.
39:135-156,
50 Years Ago in the Archives of
Surgery
Endometrial Carcinoma of the Ovary Arising in Endometrial Tissue in That Organ
"Endometrial tissue in the ovary is of common occurrence. The evidence obtained would indicate that it usually develops from implantation of bits of uterine mucosa escaping through the tubes during a retrograde menstrual flow from the uterine cavity. Tubal epithelium also may possibly become implanted on the ovary. It is difficult to disprove that endometrium-like tissue may not occasionally arise from the true surface epithelium of the ovary; I have seen a few specimens which might be so interpreted. The evidence [is] in favor of malignant changes in endometrial tissue in the ovary as a ." source of some, and possibly of many, ovarian carcinomas. .
Sampson
JA: Arch
Surg 10:1-72, 1925.
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.
