Treatment of Old Ununited Fracture of the Neck of the Femur by Transplantation of the Head of the Femur to the Trochanter

E. G. Brackett, May Sung New
1917 Boston Medical and Surgical Journal  
No attempt is made in this communication to review the literature on this subject, or to discuss the various methods of treating this condition, for it has been thoroughly done many times. It will deal only with the old fractures of the neck of the femur, at a period from some months to several years after the injury, when there has already been absorption of practically the entire neck, and when the partly atrophied head consists only of the articular portion, not projecting beyond the
more » ... beyond the acetabulum, and must be regarded somewhat in the light of a sequestrum. It can derive a certain amount of nourishment from the joint fluids in which it is bathed, and also some from the non-vascular fibrous attachment, when such exists, but this union to the head fragment is often found, on operation, to be slight, and hardly enough to be the channel of much nourishment, and the actual bleeding of the bone when it is cut seems to be always questionable. It surely is very different from the dead sequestrum, but it is also very different from the bleeding cut surface of normal bone. This nutritive defect of the head is one of the most important factors to be reckoned with in the attempts to procure firm union between two fragments so long separated, for we must bring about conditions sufficiently favorable for the fragment to become thoroughly living again. The principle in the treatment of this condition in the fresh cases, when nutrition is good, and in the long-standing, when nutrition is necessarily poor, must be radically different. The retention by nail has practically been discarded, as well as the 'use of graft for retention, as the atrophied head is too soft to withstand any force put upon it, for the purpose of retention or fixation. The use of the graft as a carrier or trellis for osteoblastic stimulus, unless a firm apposition is obtained, is nearly as futile, for the graft, once detached from its bed, becomes dead bone, one end of which is fastened into live bone and the other into a fragment of questionable viability. It is reasonable to expect that the first end should live, but it is expecting a good deal that this insert, which itself must be renourished from its attachment into the femoral shaft, can carry its regenerative power across the bridge between the two and into the old head, at least partly dead, and restore it tc normal activity. On attempting to freshen the surfaces of the two fragments, it is necessary tc hollow the femoral surface of the head, for there is usually not enough of the head to make a flat fresh surface without encroaching on the cartilage edge of the articular surface ; nor is there enough left of the neck to fashion a convex surface which will protrude into the newly made concavity of the head; therefore, any attempt to appose these two freshened surfaces results in approximately placing a cupped or mushroomshaped head on a flat surface of the shaft, with only the edges of the head, at the best, in contact. If the leg is abducted, the upward riding troehanter pulls the neck surface away from the head, and prevents the firm contact which is necessary for a strong bony union. If, on the other hand, the leg is placed in the position of extension, then the small graft or peg, driven into the head, too soft to be relied upon to withstand any degree of force, must be relied upon to withstand the strong upward thrust of the thigh muscles. The fact is, by these usual methods, a firm bony union in these old cases of fracture of the neck of the femur, ununited after a long time, is not at all common. It has been found difficult to look up the results of operation on the old fracture cases. The pretty constant failure to obtain a .firm bony union has not been an encouragement to go through the experience of the long convalescence added to the operation. Twenty-four cases have been studied, among which are some for which I have to thank the general surgical services of the Massachusetts General Hospital for the privilege of using. Of these (24), one has a useful leg. This report is by letter; it is (4?) years since the operation. It has not been possible to get an x-ray, but the patient writes that his leg is strong and useful, and that he has no pain. The operation was freshening the surfaces, no peg or graft was used. The man was younger than the average in these cases, being in the thirties, therefore at a time when the bone repair is more active. This is the only case of this series in which a satisfactory result was obtained. Results such as these, combined with the fact that these patients are permanently out of commission for any activity, is sufficient reason for advocating active surgical measures, even if they are radical. The method here considered treats the femoral head as if it were a real sequestrum. "We know that an entirely dead bone becomes vitalized if grafted on to living cancellar bone, and this seemed to be a solution to the problem here. The details were as to where to place the old head, and how. The thrust of weight-bearing from the shaft to the head should be as direct as possible, and yet have enough obliquity to adapt itself to the weight-bearing plane of the acetabulum. To accomplish this, the head is placed on the inner side of the top of the sawedoff troehanter, and in this way the thrust is passed directly from the shaft to the head, so that there is little or no distraction strain in weight-bearing, and the head has its most favor-
doi:10.1056/nejm191709131771103 fatcat:a5hca54iwve6tgnxc6fb6q5mkm