Medial Circumflex Research Articles

A variant deep femoral artery passing anterior to femoral vein: an anatomical observation with implication in femoral vein cannulation.

The common femoral artery (CFA) typically gives rise to its superficial and deep branches, with the deep femoral artery (DFA) being the largest and most substantial of these branches. This case study presents a rare variation of the DFA characterized by an unusual branching pattern and its specific relationship with the femoral vein within the subinguinal region. In nutshell, the DFA and the medial femoral circumflex artery shared a common origin from the medial aspect of the CFA. The DFA assumed an unusual course, initially passing anterior to the femoral vein above the saphenofemoral junction, followed by a spiraling trajectory around the medial aspect of the femoral vein before running posteriorly. The embryological origins and clinical implications of this anatomical variation are thoroughly examined. This unusual vascular relationship in the subinguinal region may potentially result in arterial injury during femoral vein cannulation or formation of arteriovenous fistula after the procedure.

Assessment of trochanteric vascularity using quantitative magnetic resonance imaging in a cadaveric model

AbstractPurposeFew studies have assessed trochanteric vascularity despite its implications for bone healing and surgical approaches. This study aimed to assess the regional arterial contributions of the medial femoral circumflex artery (MFCA) versus the lateral femoral circumflex artery (LFCA) to trochanteric vascularity.MethodsTen adult human cadaveric pelvises to mid‐femur specimens were obtained. One hip was randomly assigned experimental (either MFCA or LFCA MRI‐contrast infusion) and contralateral as control (MFCA and LFCA magnetic resonance imaging [MRI]‐contrast infusion). Vascular dissection was performed for MFCA and LFCA cannulation. Pre‐ and post‐contrast 3T MRI was completed, and intra‐osseous contributions were quantified by region: greater trochanter (GT), intertrochanteric (IT), lesser trochanter (LT) and subtrochanteric (ST). A polyurethane compound mixed with barium sulfate was injected into the LFCA cannula, and into the MFCA cannula for the contralateral hip. Computed tomography (CT) imaging was completed to assess terminal branch locations.ResultsMFCA provided the majority of arterial contributions to the full trochanteric region (68.5% MFCA, 31.5% LFCA; standard deviation [SD]: 10.7%, p < 0.001). Over 70% of arterial contributions to ST, LT and IT regions are derived from MFCA. GT contributions were more balanced (52.5% MFCA, 47.5% LFCA; SD: 33.7%; p = 0.853). Significant differences were found between MFCA and LFCA contributions in all regions except for the GT. CT revealed multiple consistent MFCA and LFCA trochanteric terminal branches.ConclusionsMFCA provided the dominant trochanteric arterial supply, which highlights MFCA's importance to overall hip vascularity. LFCA's trochanteric contribution was smaller but still provided trochanteric contributions, especially the GT region. Knowledge of trochanteric arterial contributions can be beneficial for optimizing surgical approaches and fixation to protect terminal branches during trochanteric fracture, nonunion treatment and trochanteric osteotomies.Level of EvidenceNot applicable.

Is choice of approach associated with risk of avascular necrosis in pediatric septic hip?

Septic arthritis of the hip in children and adolescents is a common condition requiring timely diagnosis and intervention. Surgical irrigation and debridement is typically performed through the anterior approach because of concerns about injury to the medial femoral circumflex artery leading to avascular necrosis. While there are multiple studies investigating the sequelae of anterior and medial approaches for reduction of developmental dislocation of the hip, none have compared these approaches for the pediatric septic hip. We hypothesize that there will be no significant difference in the rate of avascular necrosis when comparing the medial and anterior approaches to the septic hip in pediatric patients. A retrospective review was performed of pediatric septic hips treated with irrigation and debridement through either a medial or anterior approach at a single institution over an 18-year period of time. The primary outcome measure was the development of avascular necrosis. Thirteen of 164 patients (7.9%) developed avascular necrosis. Avascular necrosis was noted in 9 of 101 patients who had anterior approach and 4 of 63 patients who underwent medial approach (p = 0.76). The average age for patients developing avascular necrosis was 10.0 years old versus 6.8 years old in patients who did not develop avascular necrosis (p = 0.01). The average follow-up was 3.3 years in patients with avascular necrosis versus 1.5 years for patients who did not develop avascular necrosis (p = 0.01). Medial approach to the pediatric septic hip does not increase the rate of avascular necrosis compared to the anterior approach. Retrospective comparison study, Level III.

Hip Preservation and Capanna Reconstruction for Pediatric Proximal Femur Ewing Sarcoma: A Report of 2 Cases.

This is a first report describing preservation of the femoral head by transcervical resection of proximal femoral Ewing sarcoma in 2 pediatric patients. A unique Capanna reconstruction supported joint salvage. At 1 year, Pediatric Outcomes Data Collection Instrument and Pediatric Toronto Extremity Salvage Score outcomes were excellent. Surveillance magnetic resonance imaging was without evidence of recurrence or impaired perfusion to the femoral head. We demonstrate the feasibility of hip joint preservation and maintenance of femoral head viability after transcervical resection of pediatric proximal femur bone sarcomas while preserving the medial circumflex femoral artery. This technique may be a preferred option over joint sacrifice and endoprosthetic replacement in young patients when tumor margins permit.

Angiographic Anatomy of the Prostatic Artery in the Korean Population: A Bicentric Retrospective Study.

The aim of this study was to analyze the origins of prostatic arteries (PAs) in the Korean population and compare them with those reported in the literature. From April 2018 to February 2024, 108 male (mean age ± standard deviation: 71.6 ± 9.7 years) with lower urinary tract symptoms (n = 102) or refractory hematuria (n = 6) underwent prostatic artery embolization (PAE). Computed tomography and angiography images were retrospectively reviewed. The branching pattern of the internal iliac artery (IIA) was classified according to the Yamaki system. The origin of the PA was categorized using the de Assis definition, and the incidence of each type was recorded. A systematic literature review was conducted and the most common types of PA were investigated. PAE was successfully implemented on 211 of the 216 pelvic sidewalls. PA cannulation failed in five sidewalls due to a steno-occlusive state. The most common IIA type was type A, in which the IIA was divided into the superior gluteal artery and gluteal-pudendal trunk (77%). Of 226 PAs analyzed, including 15 in 211 sidewalls exhibiting dual PAs, the most common PA origin was the internal pudendal artery (type IV, 35%), followed by the superior vesical (type I, 25%) and obturator (type III, 21%) arteries. Anterior division of IIA (type II) was less common (10%). Type V (uncommon origins) occurred in 8% of cases, including five distal internal pudendal arteries, four quadfurcations, three inferior gluteal arteries, three trifurcations, two medial femoral circumflex arteries, and two rectal arteries. Two of the five patients with surgically or endovascularly altered anatomy were successfully treated via PAs originating from the medial femoral circumflex arteries. Globally, type I is the most common PA type. In the Korean population, the most common IIA pattern and PA origin were types A and IV, respectively.

An In Vivo Radiologic Description of Periacetabular Vascularization in a Healthy Subject and a Literature Review of its Clinical Implications.

The aim of this study is to provide a radiologic description of periacetabular vascularization. A computed tomography angiography was used to analyze the vascularization patterns of the periacetabular region, describing for the first time "in vivo" the periacetabular branches of the superior and inferior gluteal artery, obturator artery, and of the medial circumflex femoral artery. The analysis revealed the possibility of visualizing clearly all the previously described vessels of the aforementioned arteries. Both acetabular and supra-acetabular arteries, the rami of the OA directed to the lamina quadrilateral, and the rami of the IGA directed to the posterior wall were identified. In conclusion, understanding the periacetabular vascularization patterns is pivotal for effective clinical decision-making in pelvic trauma, and conservative and reconstructive surgery of the hip. The radiologic description provided in this study, along with the associated literature review, offers valuable insights into the clinical implications of periacetabular vascularization.

Perfusion Changes in Acute Septic Arthritis of the Hip Joint During Infancy Using Doppler USG.

To quantitatively assess vascularity changes of acute septic hips in infants using Doppler ultrasonography. To compare these findings with asymptomatic hips, and establish a correlation for accurate diagnosis between these findings. In this prospective case-control study, we included all children under 1year of age with a diagnosis of acute septic arthritis of the hip in the case group. For the control group, we enrolled apparently healthy, full-term neonates and infants not affected with any hip pathology. Doppler ultrasound of the medial femoral circumflex artery of the hip joint was done using a single Phillips HDI 5000 sonography machine. Following parameters were studied: peak systolic velocity (PSV), resistive index (RI), pulsatility index (PI), and systolic to diastolic ratio (SD ratio). Doppler signals and spectral waveforms were obtainable in 100% of hips in both groups. A statistically significant difference was found between the cases and controls with respect to their PSVs, RIs, PIs and SD ratios. The most striking difference was found between the PSVs of the two groups, whose mean was 6.18 in the control group and 11.8 in the case group. No significant correlation between age/gender and any of the 4 parameters was found. Doppler parameters are useful in raising suspicion of onset in the diagnosis of septic arthritis. No correlation was found between age or gender and any parameter in control group. These baseline values can be held valid for all children below the age of 7months.

High Origin of Profunda Femoris Artery - A Case Report

Profunda Femoris Artery arises from lateral aspect of femoral artery 3.5cm distal to inguinal ligament. Profunda femoris Artery gives lateral circumflex and medial circumflex femoral arteries from lateral and medial aspect of femoral artery respectively. Following variation was reported in left lower limb of a 62-year male cadaver, during routine dissection of Rachana Shareera dissection class. Profunda Femoris Artery arises from lateral aspect of femoral artery 1.5 cm distal to inguinal ligament, runs laterally and down words parallel to femoral artery, the profunda femoris passed beneath rectus femoris, sartorius and vastus medialis successively in its course, later pierced adductor magnus, 5.5 cm above knee joint.

Doppler ultrasonography can be used to evaluate the arterial blood supply of hip joints in skeletally immature cats.

To investigate hemodynamics and morphology of hip joint vasculature in cats with the use of color and pulsed-wave Doppler ultrasonography. 30 client-owned healthy skeletally immature cats presented for routine examinations between September 7, 2022, and March 25, 2023. Cats between 3.5 to 18 months old with healthy hip joints and Hct within reference ranges (26% to 44.2%) were eligible for inclusion. Color and pulsed-wave Doppler ultrasonography was performed without sedation. Peak systolic velocity (PSV), mean diastolic velocity (MDV), resistance index (RI), and pulsatility index (PI) were measured for major arteries of the hip joints. Intermediate pulsatility, resistance to flow, and pandiastolic anterograde flow were evident for all arteries evaluated for each joint except for the ligamentum capitis ossis femoris artery (LCOFA). Spectral waveforms for the LCOFA showed a low-resistance pattern with continuous forward diastolic flow. No significant differences were found in the mean PI or MDV between the left and right sides for the ascending branch of the lateral circumflex femoral artery or in the mean PI of the ascending branch of the medial circumflex femoral artery. Mean PSV of the LCOFA was lower (but nonsignificantly) for left hip joints vs right hip joints, whereas other values were often higher on cats' left side vs their right. This study provided insight into the morphology and hemodynamics of the femoral head vasculature in skeletally immature cats and showed Doppler ultrasound values to study the clinically normal blood supply to hip joints in cats.

Medial fascia lata perforator flap: Anatomical basis and clinical application as a pedicled or free flap

Adipofascial flaps have proven to be an excellent tool for multipurpose reconstruction as free or pedicled flaps. The anatomical studies in this field are now focused on improving esthetics in reconstruction while maintaining a minimal donor site morbidity. An anatomical cadaver study has been carried out to investigate the medial thigh region as a potential donor site for adipofascial flaps.Eighteen thighs from fresh cadavers were dissected and a new territory with autonomous vascular supply was defined through vascular injection, anatomical dissection, transillumination, and angiography. Cutaneous access was made in a “T” shape. The fascia harvests had to be centered on the adductor longus and gracilis muscles bearing in mind the position of the flap pedicle. The fascial flap was isolated from adductor longus and gracilis muscles and isolated on his pedicle (medial circumflex femoral artery).After our anatomical study, we used the flap in 2 clinical cases. The results of our anatomical study and clinical cases confirmed the suitability and reliability of a new flap: the “Medial Fascia Lata Flap.” Flap size ranged from 20 to 25 cm and has the advantage of preserving the functionality of the thigh muscles. The study showed that the “Medial Fascia Lata Flap” is easy to harvest, and the resulting scar is concealed. In consideration of its suitability, reliability and aesthetical advantages, it could be proposed as a good option in selected cases.

Variations of the obturator nerve and implications in obturator nerve entrapment treatment: an anatomical study.

Obturator nerve entrapment or idiopathic obturator neuralgia is an unfamiliar pathology for many physicians which can lead to diagnostic errancy. This study aims to identify the potential compression areas of the obturator nerve to improve therapeutic management. 18 anatomical dissections of lower limbs from 9 anatomical cadavers were performed. Endopelvic and exopelvic surgical approaches were utilized to study the anatomical variations of the nerve and to identify areas of entrapment. On 7 limbs, the posterior branch of the obturator nerve passed through the external obturator muscle. A fascia between the adductor brevis and longus muscles was present in 9 of the 18 limbs. The anterior branch of the obturator nerve was highly adherent to the fascia in 6 cases. In 3 limbs, the medial femoral circumflex artery was in close connection with the posterior branch of the nerve. Idiopathic obturator neuropathy remains a difficult diagnosis. Our cadaveric study did not allow us to formally identify one or more potential anatomical entrapment zones. However, it allowed the identification of zones at risk. A clinical study with staged analgesic blocks would be necessary to identify an anatomical area of compression and would allow targeted surgical neurolysis.

Prostatic Artery Perfusion from the Medial Circumflex Femoral Artery

Prostatic Artery Perfusion from the Medial Circumflex Femoral Artery

Assessment of the local blood supply when femoral neck fracture occurs:advances in the anatomy research and its clinical application

The stability of internal fixation of femoral neck fractures can be obtained through surgical techniques, the configuration of screws and bone grafting, etc. However, the blood supply injury caused by fractures could not be completely reversed by the current medical management. Hence, the comprehensive evaluation of the residual blood supply of the femoral neck, to perioperatively avoid further iatrogenic injury, has become a hotspot. The anatomy of the extraosseous blood supply of the femoral neck has been widely reported, while its clinical application mostly involved the assessment of the medial circumflex femoral artery and retinacular arteries. However, further studies are needed to explore the prognosis of patients with these artery injuries, with different degrees, caused by femoral neck fractures. Direct observations of nutrient foramina in vivo are not possible with current clinical technologies, but it is possible to make reasonable preoperative planning to avoid subsequent femoral head necrosis based on the distribution features of nutrient foramina. The anatomy and clinical application studies of the intraosseous blood supply focused on the junction area of the femoral head and neck to probe the mechanism of femoral head necrosis. Thus, the intraosseous blood supply of other regions in the femoral neck remains to be further investigated. In addition, a blood supply evaluation system based on a three-level structure, extraosseous blood vessels, nutrient foramina, and intraosseous vascular network, could be explored to assist in the treatment of femoral neck fractures.

Biomechanical research of medial femoral circumflex vascularized bone-grafting in the treatment of early-to-mid osteonecrosis of the femoral head: a finite element analysis

PurposeHip preservation therapy of early ONFH (Osteonecrosis of the femoral head) has emerged as one of the hot areas of research. We have optimized the procedure of traditional MFCVBG (medial femoral circumflex vascularized bone grafting) by using specialized surgical tools and used the finite element analysis to guide the implantation position of the bone flap during surgery and validate the biological mechanical stability of the modified MFCVBG.MethodsThis study was based on the data of a male patient with left hip (ARCO stage IIB, JIC type C) hormonal ONFH. Harris score (HHS), anteroposterior and lateral hip radiographs, frog position hip radiographs and SPECT/CT of femoral head flow imaging were performed postoperatively to evaluate clinical efficacy. The patient’s CT data were used to establish upper femur finite element model of the normal group, osteonecrosis group and postoperative group, respectively. The force on the femoral structure of each group was analyzed under four different loads in the gait cycle of 0.5 times the body weight (0.5 G, standing on two feet), 2.75 G (standing on one foot), 4 G (walking with the middle foot on the ground) and 7 G (walking with the toe off the ground) to validate the biological mechanical stability of the modified MFCVBG, predict femoral head collapse risk, simulate of the different healing conditions of postoperative bone flap, and analyze the postoperative effect of non-ideal surgical model.ResultsAccording to the follow-up results, the bone flap and the inner wall of decompression channel healed well, no osteonecrosis progression, no local collapse or micro-fracture occurred in the femoral head, and the articular surface was intact and the necrosis was well repaired. According to the result of the finite element analysis, compared with the osteonecrosis group, the overall stress and displacement peak of the upper femur and the cortical bone stress peak of the femoral head in the postoperative group and normal group were significantly reducing; modified MFCVBG can significantly improve the biomechanical stability of necrotic femoral head and reduce the risk of femoral head collapse; there was no obvious abnormal stress distribution in the greater trochanter and intertrochanter region after the flap was removed; the bone flap of the complete removal of necrotic focus + long bone flap group was directly placed at the bottom of the decompression passage, and the bone flap cortical bone can provide substantial mechanical support; in theory, patients can try to reduce the load with crutches or walking aids and carry out appropriate flat activities to effectively promote the early postoperative recovery.ConclusionsThe modified MFCVBG resulted in good efficacy, safety and feasibility. The necrotic focus should be completely removed during the operation, and the long bone flap should be placed directly under the subchondral bone. For patients with better bone healing ability, a more positive attitude can be taken to promote early postoperative weight-bearing.

Freestyle Anterolateral Thigh Flap and Perforator Variations

Introduction: Anterolateral thigh (ALT) flap has become an increasingly popular reconstructive option, especially for head-and-neck and extremity defects. In addition to the many advantages of the ALT flap, there are also some disadvantages such as individual variations in the number and location of cutaneous perforators. Doppler ultrasonography (USG) is one of the most frequently used methods to overcome variations in perforator anatomy. However, the Doppler device may obtain false results so some clinics use the “freestyle” harvesting technique for ALT flap. The aim of the study is to examine experience with freestyle ALT flap harvesting and to evaluate the perforator variations. Materials and Methods: Between 2018 and 2021, 59 ALT flaps were harvested by the same microsurgical team for head-and-neck reconstructions. Of 59 patients, 23 were female and 36 were male. Cases were performed without using preoperative or peroperative imaging techniques. Results: In 2 (3%) of 59 patients, different septocutaneous flap options were used because suitable perforators could not be found in both thigh regions. For 57 ALT flaps, the rate of descending branch of lateral circumflex femoral artery (LCFA) perforators was 73%, transverse/ascending branch was 17%, aberrant perforators other than classical branches of LCFA was 7%, and the perforator from medial circumflex femoral artery was 1%. Partial necrosis due to perfusion problem was experienced in one flap and total necrosis was in two flaps. Conclusion: The advantages of the freestyle technique, such as allowing the evaluation of all perforators and designing flaps according to the appropriate perforator, provide great flexibility and convenience to the surgeon. With this, surgical problems caused by inaccurate results obtained by devices such as Doppler USG are excluded.

A rare bifurcation of the external iliac artery into femoral and deep femoral arteries

The current cadaveric report describes a quite rare unilateral bifurcation of the external iliac artery (EIA) into two femoral arteries (FAs) of almost equal diameter and parallel course, at the level of the inguinal ligament (IL). The variant FAs were identified on a 75-year-old formalin-embalmed female cadaver, derived from a body donation program after a signed informed consent. The EIA bifurcated into a FA and a deep femoral artery (DFA). The DFA extremely high origin was identified at the IL level. Both lateral and medial circumflex femoral arteries originated from the DFA. The in-depth knowledge of the FA variant origin is of paramount importance to vascular surgeons and interventional radiologists during vessel catheterization and attempts to interpret the angiographic findings. In particular, the DFA's high origin from the EIA and the coexistence of two FAs in a parallel course may pose problems to clinicians during angiographic procedures leading to diagnostic errors. The DFA high origin may also complicate femoral arterial and venous puncture and femoral nerve blocks, due to the close neurovascular relationship. There is a possibility for the FA to be mistaken for a vein leading to accidental intra-arterial injection and consequently thrombosis. Thus, variable arterial pattern is important to be identified preoperatively using Doppler ultrasound imaging.

Morphological Investigation of Deep Femoral Artery Variations using Multidetector Computed Tomography Angiography

Purpose The deep femoral artery (DFA) is the largest and thickest branch of the femoral artery (FA), separated from the posterior lateral surface of the FA. This study aimed to analyze the anatomy of DFA using multidetector computed tomography (MDCT) angiography images to improve for its clinical applications. Materials and methods Eight hundred right and left DFA MDCT angiography images from 400 individuals, 302 males (75.5%) and 98 females (24.5%), were included. Results It was determined that the DFA originates from six different aspects of the FA. The DFA was found to most commonly originate from the posterolateral aspect of the FA, with an incidence of 53%. The DFA originated from the posterior, lateral, medial, anterolateral, and posteromedial aspects at an incidence of 35.3%, 9.8%, 1%, %0.5, and 0.37%, respectively. The average distance between the DFA’s origin and the midpoint of the inguinal ligament (IL) was 43.07 mm across both genders. The average distance between the DFA’s origin and the midpoint of the IL was 43.07 mm. The average diameters of the DFA, medial circumflex femoral artery (MCFA), and lateral circumflex femoral artery (LCFA) were 5.62 mm, 3.01 mm, and 3.44 mm, respectively. The average distance between the DFA and MCFA was 14.64 mm, while between the DFA and LCFA, it was 19.05 mm. Conclusion Knowledge regarding the anatomical variants and morphology of the DFA will enhance the accuracy of decision-making during interventional procedures and operations in the femoral region, as well as aid in the prevention of iatrogenic injuries.

Favorable Outcome Twenty-Two Months after Delbet Type Ib Capital Femoral Transepiphyseal Fracture and Posterior Column Acetabular Fracture in a Fifteen-Year-Old Male

Case A fifteen-year-old male patient sustained a posteriorly dislocated right capital femoral Delbet type Ib epiphyseal fracture-separation and a right acetabular posterior column fracture after a low-energy trip and fall. The capital femoral epiphysis was closed reduced and fixed with cannulated screws on an urgent basis. He underwent acetabular osteosynthesis via a Kocher-Langenbeck approach two days thereafter. Twenty-two months after injury, he was weight-bearing on the right lower extremity without radiologic evidence of avascular necrosis or clinical evidence of pain or functional deficit. Conclusion Fracture-separation of the capital femoral epiphysis comprises only 8% of skeletally immature femoral neck fractures in the Delbet and Colonna classification. Prognosis is worse with ipsilateral hip dislocation due to the risk of avascular necrosis from disruption of the medial femoral circumflex artery. Urgent referral to a trauma center and treatment by appropriate specialists enables good long-term results after this uncommon traumatic injury pattern.

A Novel Clinically Based Classification System for the Profunda Femoris Artery and the Circumflex Femoral Arteries

The profunda femoris artery (PFA) supplies important collateral branches to both the ipsilateral internal iliac artery and the distal superficial femoral artery (SFA). The size and patency of these collateral pathways can determine the risk of pelvic malperfusion, spinal cord ischemia, and lower extremity limb loss following vascular interventions. Despite its importance, the anatomy of the PFA is rarely characterized in clinical studies involving the pelvic or lower extremity circulation. This discussion may be limited by the lack of a comprehensive classification system. Our objective was to describe the most common PFA anatomic variants and present a classification system based on its branching patterns. We dissected 155 fixed and nonfixed femoral artery systems from 88 cadavers. Seventy-seven female and 78 male femoral exposures were performed. Vessel diameters, branch configurations, and relative distances between the inguinal ligament, PFA, lateral circumflex femoral artery (LCFA), and medial circumflex femoral artery (MCFA) were recorded. The mean diameters of the common femoral artery, SFA, and PFA were 10.3mm, 8.0mm, and 6.9mm in males and 8.9mm, 6.9mm, and 6.1mm in females, respectively (P<0.05). The mean distances from the inguinal ligament for PFA, MCFA, and LCFA were 41mm, 41.7mm, and 52.5mm, respectively. No significant differences were noted relative to laterality or fixation. We developed a clinically applicable classification system based on the orientation of the PFA, LCFA, and MCFA. Six PFA, 5 LCFA, and 5 MCFA variations were identified and ranked by frequency. The 5 most common combinations accounted for 56.1% of our cadaver series. The anatomic orientation of the PFA and its branches is highly variable. We propose a novel classification system of this rich collateral system to facilitate consistent communication in academic and clinical vascular surgery.

In the fixation of adult femoral neck fractures, does percutaneous hematoma drainage have an effect on bone union?

Background/Aim: Major blood circulation of the femur head is provided by retrograde flow from the medial femoral circumflex artery. The biggest problem here is uncertainty that the fracture hematoma disrupts the feeding of the femoral head. The aim of this study was to evaluate the effect on bone union of percutaneous hematoma punction in femoral neck fractures in patients aged