Treatment of the displaced femoral neck fracture, as reflected inActa Orthopaedica Scandinavica

The publication of Acta Orthopaedica Scandinavica started in1930, at the same time as “modern” treatment of the displaced femoral neck fracture was introduced by Sven Johansson (1932), who began his paper: “Scarcely any form of fracture has attracted so much discussion as fractures of the neck of femur, particularly those in the medial region”. Acta (with a change of name to Acta Orthopaedica in 2005) has devoted much space and interest to hip fracture, especially during the last 2 decades. Much has been published about the epidemiology in different geographical areas, for example, and rehabilitation. This report will focus on the treatment and outcome. The early years Before nailing was introduced, the commonest treatment in the Scandinavian countries was according to Whitman or Whitman-LOfberg, since Otto LOfberg introduced and modified the method in Sweden. The fracture was reduced with extension, internal rotation, and abduction. Then the hip was immobilized in plaster for months. It is difficult to get a clear idea of the results. It seems that several fractures healed, but the mortality was high. LOfberg practiced his method until 1946, when he retired from the Department of Surgery in MalmO (Lindqvist 1951). By then the orthopedists who practiced nailing had gradually taken over. In 1931, Smith Petersen published in Archives of Surgery a new nail with 3 flanges, which was supposed to cause less pressure necrosis and to be rotationally stable. Smith Petersen believed that it was absolutely necessary to reduce the fracture openly. Sven Johansson (Gothenburg, Sweden), impressed by the design, aimed at a method using closed reduction: “Only by this means would the operation be relatively slight—so slight that, even having regard to the advanced age at which most of these fractures occur, it seemed to me to be justified” (Johansson 1932). He invented a technique resembling the one used today. He made a central canal in the Smith Petersen nail and invented a targeting device (Figure 1). After closed reduction and calculation with the help of external landmarks on the patient and a targeting device, a guide pin was introduced from the trochanter and into the femoral head. The position was checked with radiographs in two planes and if it was acceptable, the nail was “knocked in” (Figure 2). The position was again checked with radiographs and finally the fracture was compressed with a specially designed hammer (Figure 3). Dr Johansson presented his paper at the Nordic Orthopaedic Association, describing the first 9 cases: “…so encouraging to me, not least because of the advantage to the patients in the simplified aftertreatment, that I have not hesitated to already describe the method now for other surgeons and orthopaedists to try it”. Figure 1. Patient on extension table with the targeting device assembled. Figure 2. Guide pin in position and the final result. Figure 3. The compression hammer. More nails Slipping of the nail was a common complication. The nail lost its hold and slipped out because of resorption of bone in the fracture area and around the nail. Rydell (1964) invented the “spring-loaded nail” (Figure 4). It had 4 flanges and was hammered in over a guide pin, which was removed and replaced by a spring pin. This pin had a curved end, which extruded through a hole in the nail in order to prevent slippage. The Rydell nail predominated until Hansson (1982) introduced the hook pin (Figure 5), simply a Rydell nail with flanges removed and with the same spring pin. It was primarily used for fixation of slipped capital femoral epiphysis. For neck fractures, 2 pins were used to prevent rotation of the head fragment. The pins were not hammered in but gently inserted through predrilled channels. A less gentle method was multiple pinning (Figure 6) (Kofoed and Alberts 1980). It was thought that the better stability obtained from multiple pins would facilitate revascularization of the femoral head. Figure 4. The spring-loaded nail. Mounted on the nail is a small compression plate, which was abandoned later. Figure 5. Hook pins. Figure 6. Multiple pinning. Sliding nail/screw-plate Charnley was a forerunner also in the field of fracture treatment. He invented a sliding screw-plate for fixation of neck fractures (Figure 7). His paper from 1961 contains a detailed analysis of fixation and failure with his and contemporary methods of fixation. His device was a prototype of the sliding fixations used nowadays for trochanteric fractures. It appears that it was not widespread in the Scandinavian countries, but another sliding nail-plate (Figure 8) was used in Denmark (Frandsen and Jorgensen 1977). Figure 7. Sliding screw-plate. Figure 8. Sliding nail-plate. Screws Several types of screws were introduced as an alternative to single-nail fixation. Some of them will appear later in this report, but the commonest were of Swedish design: the von Bahr screw and the Uppsala screw (Rehnberg and Olerud 1989). A guide pin was used for the Uppsala screw and the tip was self-tapping “to allow subchondral fixation” in the femoral head (Figure 9). Figure 9. Uppsala (left) and von Bahr screws. Comparisons of outcome With increasing options for internal fixation, it became necessary to compare the results of treatment. Was any one method superior? Sliding nail/screw vs. pins/screws. Frandsen and Andersen (1981) compared the Smith Petersen nail with sliding nail-plate. The patients were allocated to the 2 groups according to the date of admission. 83/131 fractures healed in the Smith Petersen group and 89/118 healed in the nail-plate group, a statistically significant difference. In a randomized trial, Madsen et al. (1987) compared sliding screw-plate with 4 ASIF cancellous screws. The rate of union (84%) was better in the screw group. Elmerson et al. (1995) compared hook pins with sliding screw-plate in a randomized study of 222 patients, and they found that the failure rate after 2 years was 38% with hook pins and 46% with screw-plate, which was a not statistically significant difference. Sorensen et al. (1992) randomized between sliding screw-plate and Gouffon screws. The study involved only 73 patients, but even so it clearly favored the use of a screw plate.