Neck of femur fracture surgery
Jump to navigation
Jump to search
|
Neck of femur fracture Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Neck of femur fracture surgery On the Web |
|
American Roentgen Ray Society Images of Neck of femur fracture surgery |
|
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 avascular 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. The types of surgery include femoral pinning, sliding hip screw and prosthetic replacement.
Surgery
 |
- Surgery is the mainstay of treatment for neck of femur fracture.[1][2][3]
- 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.[4][5]
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.[6][7]
- 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.[8]
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.[9]
- 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
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.[8]
Technique
- A small, about 5-10 cms incision is made just lateral to the inferior aspect of the greater trochanter.[10][11]
- 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 fluoroscopy 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.[12]
- 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
The various approaches to the hip include:[13][14]
Anterior Smith Peterson Apporach
- A 10 cms skin incision made beginning just distal to anterior inferior iliac spine.[15]
- This is followed by incising the deep fascia.
- Develop an interval between tensor fascia lata and sartorius.
- 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.[16]
- 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.[17]
- 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.[18]
- 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.[19]
- 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.[20]
- But has a higher risk of dislocation compared to hemiarthroplasty.[21][22][23]
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.[24]
- 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.[25]
- Early ambulation is associated with accelerated recovery and shorter length of stay.[26]
- Physical therapy for chest and passive range of motion is recommended.
Complications
Complications of surgery include:[27][28]
- 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
- ↑ Mears SC (2014). "Classification and surgical approaches to hip fractures for nonsurgeons". Clin Geriatr Med. 30 (2): 229–41. doi:10.1016/j.cger.2014.01.004. PMID 24721363.
- ↑ Mallick A, Parker MJ (2004). "Basal fractures of the femoral neck: intra- or extra-capsular". Injury. 35 (10): 989–93. doi:10.1016/j.injury.2003.10.019. PMID 15351664.
- ↑ Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG (2008). "Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year". Injury. 39 (10): 1164–74. doi:10.1016/j.injury.2008.01.048. PMID 18555253.
- ↑ Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM (2009). "Length of stay, mortality, morbidity and delay to surgery in hip fractures". J Bone Joint Surg Br. 91 (7): 922–7. doi:10.1302/0301-620X.91B7.22446. PMID 19567858.
- ↑ Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekström W, Cederholm T; et al. (2008). "Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients". J Bone Joint Surg Am. 90 (7): 1436–42. doi:10.2106/JBJS.G.00890. PMID 18594090.
- ↑ Kloen P, Rubel IF, Lyden JP, Helfet DL (2003). "Subtrochanteric fracture after cannulated screw fixation of femoral neck fractures: a report of four cases". J Orthop Trauma. 17 (3): 225–9. PMID 12621266.
- ↑ Zlowodzki M, Weening B, Petrisor B, Bhandari M (2005). "The value of washers in cannulated screw fixation of femoral neck fractures". J Trauma. 59 (4): 969–75. PMID 16374290.
- ↑ 8.0 8.1 Anglen J, Banovetz J (1994). "Compartment syndrome in the well leg resulting from fracture-table positioning". Clin Orthop Relat Res (301): 239–42. PMID 8156681.
- ↑ Ma JX, Kuang MJ, Xing F, Zhao YL, Chen HT, Zhang LK; et al. (2018). "Sliding hip screw versus cannulated cancellous screws for fixation of femoral neck fracture in adults: A systematic review". Int J Surg. 52: 89–97. doi:10.1016/j.ijsu.2018.01.050. PMID 29471156.
- ↑ Dargan DP, Callachand F, Diamond OJ, Connolly CK (2016). "Three-year outcomes of intracapsular femoral neck fractures fixed with sliding hip screws in adults aged under sixty-five years". Injury. 47 (11): 2495–2500. doi:10.1016/j.injury.2016.09.013. PMID 27637999.
- ↑ Hardinge K (1982). "The direct lateral approach to the hip". J Bone Joint Surg Br. 64 (1): 17–9. PMID 7068713.
- ↑ Baumgaertner MR, Solberg BD (1997). "Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip". J Bone Joint Surg Br. 79 (6): 969–71. PMID 9393914.
- ↑ Moretti VM, Post ZD (2017). "Surgical Approaches for Total Hip Arthroplasty". Indian J Orthop. 51 (4): 368–376. doi:10.4103/ortho.IJOrtho_317_16. PMC 5525517. PMID 28790465.
- ↑ Petis S, Howard JL, Lanting BL, Vasarhelyi EM (2015). "Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes". Can J Surg. 58 (2): 128–39. PMC 4373995. PMID 25799249.
- ↑ Smith-Petersen MN. A new supra-articular subperiosteal approach to the hip joint. Am J Orthop Surg. 1917;15:592–5.
- ↑ Mjaaland KE, Svenningsen S, Fenstad AM, Havelin LI, Furnes O, Nordsletten L (2017). "Implant Survival After Minimally Invasive Anterior or Anterolateral Vs. Conventional Posterior or Direct Lateral Approach: An Analysis of 21,860 Total Hip Arthroplasties from the Norwegian Arthroplasty Register (2008 to 2013)". J Bone Joint Surg Am. 99 (10): 840–847. doi:10.2106/JBJS.16.00494. PMID 28509824.
- ↑ MOORE AT (1957). "The self-locking metal hip prosthesis". J Bone Joint Surg Am. 39-A (4): 811–27. PMID 13438939.
- ↑ Zeni J, Madara K, Witmer H, Gerhardt R, Rubano J (2018). "The effect of surgical approach on gait mechanics after total hip arthroplasty". J Electromyogr Kinesiol. 38: 28–33. doi:10.1016/j.jelekin.2017.11.004. PMC 5808892. PMID 29149623.
- ↑ Veldman HD, Heyligers IC, Grimm B, Boymans TA (2017). "Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck: a systematic review and meta-analysis of current generation hip stems". Bone Joint J. 99-B (4): 421–431. doi:10.1302/0301-620X.99B4.BJJ-2016-0758.R1. PMID 28385929.
- ↑ Tol MC, van den Bekerom MP, Sierevelt IN, Hilverdink EF, Raaymakers EL, Goslings JC (2017). "Hemiarthroplasty or total hip arthroplasty for the treatment of a displaced intracapsular fracture in active elderly patients: 12-year follow-up of randomised trial". Bone Joint J. 99-B (2): 250–254. doi:10.1302/0301-620X.99B2.BJJ-2016-0479.R1. PMID 28148669.
- ↑ Wang Z, Bhattacharyya T (2017). "Outcomes of Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fracture: A Medicare Cohort Study". J Orthop Trauma. 31 (5): 260–263. doi:10.1097/BOT.0000000000000814. PMC 5407395. PMID 28431409.
- ↑ Rockwood, Charles (2010). Rockwood and Green's fractures in adults. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781605476773.
- ↑ Azar, Frederick (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. ISBN 9780323374620.
- ↑ Travis EC, Tan RS, Funaki P, McChesney SJ, Patel SC, Brogan K (2015). "Clinical outcomes of total hip arthroplasty for fractured neck of femur in patients over 75 years". J Arthroplasty. 30 (2): 230–4. doi:10.1016/j.arth.2014.09.011. PMID 25311164.
- ↑ Oldmeadow LB, Edwards ER, Kimmel LA, Kipen E, Robertson VJ, Bailey MJ (2006). "No rest for the wounded: early ambulation after hip surgery accelerates recovery". ANZ J Surg. 76 (7): 607–11. doi:10.1111/j.1445-2197.2006.03786.x. PMID 16813627.
- ↑ Koval KJ, Sala DA, Kummer FJ, Zuckerman JD (1998). "Postoperative weight-bearing after a fracture of the femoral neck or an intertrochanteric fracture". J Bone Joint Surg Am. 80 (3): 352–6. PMID 9531202.
- ↑ Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH (1995). "Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip". J Bone Joint Surg Am. 77 (10): 1551–6. PMID 7593064.
- ↑ de Jong L, Klem TMAL, Kuijper TM, Roukema GR (2017). "Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur". Bone Joint J. 99-B (8): 1088–1094. doi:10.1302/0301-620X.99B8.BJJ-2016-1119.R1. PMID 28768787.