Neck of femur fracture surgery

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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.

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