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==Overview==
==Overview==
Surgical intervention is not recommended for the management of [disease name].
Surgery is the mainstay of treatment for neck of femur fracture. It is a surgical emergency as the risk of avascualr necrosis and non union increases as time passes by. The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty.


OR
==Surgery==
*Surgery is the mainstay of treatment for neck of femur fracture.
*The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty.
*In addition, the timing of surgery is also extremely vital.
*Recent studies have shown that the incidence of avascular necrosis and nonunion is decreased by fixation within 12 hours after injury.
 
===Types of Surgery===
*Femoral Neck Pinning
*Sliding Hip Screw
*Prosthetic Replacement
**Partial Hip Replacement
**Total Hip Replacement
 
===Femoral Neck Pinning===
 
'''Indications'''
*Valgus impacted neck of femur fracture
*Garden type I or II in the elder individuals.
*Displaced neck of femur fracture in young patient
 
'''Implant'''
*Cannulated cancellous screw
 
'''Technique'''
*Three cannulated screws placed in an inverted triangular pattern.
*The emphasis is particularly placed on screws buttressing the inferior and posterior neck cortices.
*The starting point is at or above the level of lesser trochanter to avoid fracture.
 
'''Positioning'''
The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.
 
'''Order of Screw placement'''
The order of screw placement is as follows:
*1st - Inferior screw along calcar
*2nd - Posterior and superior screw
*3rd - Anterior and superior screw
 
===Sliding Hip Screw===
*It is biomechanically superior to cannulated screws.
*Additional cannulated screw should be placed above the sliding hip screw to prevent rotation.
*It allows dynamic compression at fracture site during axial loading.
*But, it can cause shortening of femoral neck.
 
'''Indications'''
*Basicervical fracture
*Vertical fracture pattern in a young patient


Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
'''Implant'''
*Richard screw with barrel plate


OR
'''Positioning'''
The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.


The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
'''Technique'''
*A small, about 5-10 cms incision is made just lateral to the inferior aspect of the greater trochanter.
*Dissection is taken through skin and fascia; no significant anatomic structures are at risk in this direct lateral approach.
*The exact point of incision can be determined under fluroscopy by using a guide pin and determining trajectory of screw placement.
*The goal for guide pin placement is for the tip of the pin to be in a central location in both AP and lateral views and deeply inserted in to the subchondral bone of the femoral head.
*The '''tip apex distance''', which is the summed value on AP and lateral radiographs is aimed to be less than 25 mm.
*The guide wire is measured and the reamer set to the appropriate depth.
*The lag screw is then placed, followed by the appropriate angled side plate.


OR
===Prosthetic Replacement===


The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
===Approaches===


OR
'''Anterior Smith Peterson Apporach'''
*A 10 cms skin incision made beginning just distal to anterior inferior iliac spine.
*This is followed by incising the deep fascia.
*Develop an interval between tensor fascia lata and sartorious.
The thigh must be externally rotated while dissecting the plane.
*Sartorius along with Lateral femoral cutaneous nerve are retracted medially.
*The tendinous portion of rectus femoris is identified and elevated off the hip capsule.
*The capsule is incised and the femoral neck is exposed.


Surgery is the mainstay of treatment for [disease or malignancy].
'''Anterolateral Watson-Jones Approach'''
*A skin incision is started approximately 2 cms posterior and distal to anterior superior iliac spine and down toward tip of greater trochanter.
*The incision curved distally and extended 10 cms along anterior surface of femur.
*The deep fascia is incised.
*Then develop an interval between gluteus medius and tensor fascia lata.
*The anterior aspect of gluteus medius and minimus are retracted posteriorly to visualize anterior hip capsule.
*Then the capsule is incised with a Z-shaped incision.
*The capsular incision must remain anterior to lesser trochanter at all times in order to avoid injury to medial femoral circumflex artery.


==Indications==
'''Psterior Southern or Moore Approach'''
*A skin incision is made 10 to 15 cms, curved, beginning one inch posterior to posterior edge of greater trochanter and 7 cm above and posterior to greater trochanter and continue down the shaft of femur.
*An incision is made on fascia lata to uncover vastus lateralis distally.
*The fascial incision is lenghtened in line with skin incision.
*The fibers of gluteus maximus are split in proximal incision.
*Then, internally rotate the hip to place the short external rotators on stretch.
*The stay sutures are placed in piriformis and obturator internus tendon.
*Piriformis and obturator internus are detached close to femoral insertion and reflected backwards to protect the sciatic nerve.
*The capsule is incised with a longitudinal or T-shaped incision.
*The hip is finally dislocated with internal rotation.


*Surgical intervention is not recommended for the management of [disease name].
===Hemiarthroplasty===
OR
*The posterior approach has increased risk of dislocations.
*Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either:
*The anterolateral approach has increased risk of abductor weakness.
**[Indication 1]
**[Indication 2]
**[Indication 3]
*The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either:
**[Indication 1]
**[Indication 2]
**[Indication 3]


==Surgery==
'''Indications'''
*Debilitated elderly patients
*Metabolic bone disease
 
'''Implant'''
*Unipolar prosthesis - Austin Moore prosthesis
*Bipolar prosthesis
 
'''Technique'''
*The femoral neck is exposed.
*The head and neck of femur are excised.
*The head sized is measured.
*The femoral canal is reamed and prepared.
*The trial implant are placed and sizing is confirmed.
*The decision on cemented Vs. non cemented is determined based on age and bone quality.
*The final implant is placed and reduction is done.
The wound is closed in layers.
 
===Total Hip Arthroplasty===
*Total hip replacement provides the best results of any form of prosthetic replacement for displaced femoral neck fracture.
*But has a higher risk of dislocation compared to hemiarthroplasty.
 
'''Indications'''
*Patients with preexisting hip osteoarthritis
*Garden type III or IV in patient less than 85 years
 
'''Implants'''
===Femoral component===
*Cemented 
*Press-fit (uncemented) 
**Tapered stems
**Porous coated stems
**Modular stems
 
===Acetabular components===
*Cemented
**Polyethylene
**Metal
*Press-fit (uncemented)
**Metal
===Bearing surfaces=== 
*Polyethylene
*Metal
*Ceramic
 
'''Technique'''
*The anterolateral approach is usually preferred.
*Use of a larger head in the setting of a femoral neck fracture is usually advised.


*The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
===Postoperative Care===
OR
*Patients should sit up and get out of bed as soon as possible after surgery, preferably on the day of the operation.
*Surgery is the mainstay of treatment for [disease or malignancy].
*Early ambulation is associated with accelerated recovery and shorter length of stay.
*Physical therapy for chest and passive range of motion is recommended.  


==Contraindications==
===Complications===
*Periprosthetic fracture
*Implant breakage
*Implant cut out
*Dislocation
*Osteonecrosis
*Non union
*Complications Of Prolonged Recumbency such as:
**Hypostatic pneumonia
**Pressure sores
**Deep venous thrombosis
**Pulmonary embolism
**Cardiac failure due to weakening of the cardiac muscle and poor venous return
**Muscle wasting 
**Common peroneal nerve palsy
**Stiffening of joints
**Osteoporosis
**Urinary tract infections
**Depression


==References==
==References==

Revision as of 21:23, 17 February 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Surgery is the mainstay of treatment for neck of femur fracture. It is a surgical emergency as the risk of avascualr necrosis and non union increases as time passes by. The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty.

Surgery

  • Surgery is the mainstay of treatment for neck of femur fracture.
  • The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty.
  • In addition, the timing of surgery is also extremely vital.
  • Recent studies have shown that the incidence of avascular necrosis and nonunion is decreased by fixation within 12 hours after injury.

Types of Surgery

  • Femoral Neck Pinning
  • Sliding Hip Screw
  • Prosthetic Replacement
    • Partial Hip Replacement
    • Total Hip Replacement

Femoral Neck Pinning

Indications

  • Valgus impacted neck of femur fracture
  • Garden type I or II in the elder individuals.
  • Displaced neck of femur fracture in young patient

Implant

  • Cannulated cancellous screw

Technique

  • Three cannulated screws placed in an inverted triangular pattern.
  • The emphasis is particularly placed on screws buttressing the inferior and posterior neck cortices.
  • The starting point is at or above the level of lesser trochanter to avoid fracture.

Positioning The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.

Order of Screw placement The order of screw placement is as follows:

  • 1st - Inferior screw along calcar
  • 2nd - Posterior and superior screw
  • 3rd - Anterior and superior screw

Sliding Hip Screw

  • It is biomechanically superior to cannulated screws.
  • Additional cannulated screw should be placed above the sliding hip screw to prevent rotation.
  • It allows dynamic compression at fracture site during axial loading.
  • But, it can cause shortening of femoral neck.

Indications

  • Basicervical fracture
  • Vertical fracture pattern in a young patient

Implant

  • Richard screw with barrel plate

Positioning The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.

Technique

  • A small, about 5-10 cms incision is made just lateral to the inferior aspect of the greater trochanter.
  • Dissection is taken through skin and fascia; no significant anatomic structures are at risk in this direct lateral approach.
  • The exact point of incision can be determined under fluroscopy by using a guide pin and determining trajectory of screw placement.
  • The goal for guide pin placement is for the tip of the pin to be in a central location in both AP and lateral views and deeply inserted in to the subchondral bone of the femoral head.
  • The tip apex distance, which is the summed value on AP and lateral radiographs is aimed to be less than 25 mm.
  • The guide wire is measured and the reamer set to the appropriate depth.
  • The lag screw is then placed, followed by the appropriate angled side plate.

Prosthetic Replacement

Approaches

Anterior Smith Peterson Apporach

  • A 10 cms skin incision made beginning just distal to anterior inferior iliac spine.
  • This is followed by incising the deep fascia.
  • Develop an interval between tensor fascia lata and sartorious.

The thigh must be externally rotated while dissecting the plane.

  • Sartorius along with Lateral femoral cutaneous nerve are retracted medially.
  • The tendinous portion of rectus femoris is identified and elevated off the hip capsule.
  • The capsule is incised and the femoral neck is exposed.

Anterolateral Watson-Jones Approach

  • A skin incision is started approximately 2 cms posterior and distal to anterior superior iliac spine and down toward tip of greater trochanter.
  • The incision curved distally and extended 10 cms along anterior surface of femur.
  • The deep fascia is incised.
  • Then develop an interval between gluteus medius and tensor fascia lata.
  • The anterior aspect of gluteus medius and minimus are retracted posteriorly to visualize anterior hip capsule.
  • Then the capsule is incised with a Z-shaped incision.
  • The capsular incision must remain anterior to lesser trochanter at all times in order to avoid injury to medial femoral circumflex artery.

Psterior Southern or Moore Approach

  • A skin incision is made 10 to 15 cms, curved, beginning one inch posterior to posterior edge of greater trochanter and 7 cm above and posterior to greater trochanter and continue down the shaft of femur.
  • An incision is made on fascia lata to uncover vastus lateralis distally.
  • The fascial incision is lenghtened in line with skin incision.
  • The fibers of gluteus maximus are split in proximal incision.
  • Then, internally rotate the hip to place the short external rotators on stretch.
  • The stay sutures are placed in piriformis and obturator internus tendon.
  • Piriformis and obturator internus are detached close to femoral insertion and reflected backwards to protect the sciatic nerve.
  • The capsule is incised with a longitudinal or T-shaped incision.
  • The hip is finally dislocated with internal rotation.

Hemiarthroplasty

  • The posterior approach has increased risk of dislocations.
  • The anterolateral approach has increased risk of abductor weakness.

Indications

  • Debilitated elderly patients
  • Metabolic bone disease

Implant

  • Unipolar prosthesis - Austin Moore prosthesis
  • Bipolar prosthesis

Technique

  • The femoral neck is exposed.
  • The head and neck of femur are excised.
  • The head sized is measured.
  • The femoral canal is reamed and prepared.
  • The trial implant are placed and sizing is confirmed.
  • The decision on cemented Vs. non cemented is determined based on age and bone quality.
  • The final implant is placed and reduction is done.

The wound is closed in layers.

Total Hip Arthroplasty

  • Total hip replacement provides the best results of any form of prosthetic replacement for displaced femoral neck fracture.
  • But has a higher risk of dislocation compared to hemiarthroplasty.

Indications

  • Patients with preexisting hip osteoarthritis
  • Garden type III or IV in patient less than 85 years

Implants

Femoral component

  • Cemented
  • Press-fit (uncemented)
    • Tapered stems
    • Porous coated stems
    • Modular stems

Acetabular components

  • Cemented
    • Polyethylene
    • Metal
  • Press-fit (uncemented)
    • Metal

Bearing surfaces

  • Polyethylene
  • Metal
  • Ceramic

Technique

  • The anterolateral approach is usually preferred.
  • Use of a larger head in the setting of a femoral neck fracture is usually advised.

Postoperative Care

  • Patients should sit up and get out of bed as soon as possible after surgery, preferably on the day of the operation.
  • Early ambulation is associated with accelerated recovery and shorter length of stay.
  • Physical therapy for chest and passive range of motion is recommended.

Complications

  • Periprosthetic fracture
  • Implant breakage
  • Implant cut out
  • Dislocation
  • Osteonecrosis
  • Non union
  • Complications Of Prolonged Recumbency such as:
    • Hypostatic pneumonia
    • Pressure sores
    • Deep venous thrombosis
    • Pulmonary embolism
    • Cardiac failure due to weakening of the cardiac muscle and poor venous return
    • Muscle wasting
    • Common peroneal nerve palsy
    • Stiffening of joints
    • Osteoporosis
    • Urinary tract infections
    • Depression

References

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