Neck of femur fracture surgery: Difference between revisions
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*The capsular incision must remain anterior to lesser trochanter at all times in order to avoid injury to medial femoral circumflex artery. | *The capsular incision must remain anterior to lesser trochanter at all times in order to avoid injury to medial femoral circumflex artery. | ||
''' | '''Posterior 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. | *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. | *An incision is made on fascia lata to uncover vastus lateralis distally. |
Revision as of 21:29, 17 February 2019
Neck of femur fracture Microchapters |
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Neck of femur fracture surgery On the Web |
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Risk calculators and risk factors for Neck of femur fracture surgery |
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.
Posterior 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