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Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty

Planning

B

Preoperative Plan

1

Radiographic templating of fracture

  • evaluate AP Pelvis, AP/Lat hip and femur for degree of fracture displacement

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • hip cemented hemiarthroplasty system

2

Room setup and equipment

  • standard OR table
  • sterile hoods with circulating fans for surgical team
  • hip positioners or bean bag
  • check back table to make sure correct equipment available

3

Patient positioning

  • lateral decubitus with operative extremity facing up
  • axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, Foley in place
  • in obese patients place towel or pad between positioners and skin
  • check to make sure operative leg can be flexed to 90° with positioners in place
  • arms stacked on top of each other with blankets underneath and in between, taped down to arm boards
  • prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area
  • bovie pad on contralateral thigh or abdomen
  • foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep

Technique

D

Posterior Approach to the Hip

1

Mark out GT and anterior/posterior borders of femur and anterior bow of femur

  • mark out the anatomy of GT

2

Mark incision posterior to midline of GT down shaft of femur

  • incision is curved posterior to edge of GT, aimed towards PSIS proximally
  • 1/3 of incision proximal to GT, 2/3 distal to GT (~10-15cm long)

3

Perform dissection

  • use 10 blade for skin incision
  • curve incision posterior aiming for posterolateral corner of GT
  • incise fascia 2-3 cm with knife just posterior to midline of GT

4

Expose the fascia lata

  • insert 2 self retainers (Wheatlanders, Oberhills for larger patients) at 1/3 and 2/3 aspect of incision
  • cauterize bleeders in subcutaneous tissue
  • use knife down to fascia lata

5

Develop fascial plane

  • use Cobb and dry lap to sweep soft tissue
  • abduct leg 30° to relax TFL
  • place Hibbs retractor proximally

6

Incise fascia 2-3cm with knife just posterior to midline of GT

  • start distal and move proximal with cautery
E

Deep Dissection of Posterior Approach to the Hip

1

Place Charnley retractor

  • place the long blade anterior and the short blade posterior
  • need to retract glut medius and minimus anteriorly while just glut max posterior

2

Split glut max

  • with blunt dissection using index fingers in center of decussating fibers, expose trochanteric bursa on lateral margin of GT
  • femoral neck fractures will often have hemorrhagic bursa and ill defined anatomy
  • leg stays abducted until short external rotators (SERs) visualized
  • internally rotate hip to place SERs on stretch

3

Dissect SERs with Bovie

  • incise soft tissue and bursa off of posterior aspect of GT with leg extended to keep sciatic nerve out of field
  • identify SERs (piriformis and obturator internus, gamelli) and quadratus distally (can often feel piriformis tendon proximally)
  • dissect SERs directly off of bone with Bovie
  • start distally just proximal to quadratus and move proximally
  • extend proximally along posterior aspect of abductors, extend distally until quadratus femoris (will bleed due to medial femoral circumflex artery)
  • sciatic nerve is located in fat deep to piriformis and superficial and posterior to SERs

4

Tag SERs with #5 ethibond

  • place #5 Ethibond tag sutures (x3) into SERs and anterior capsule
  • place hemostat on each pair grab enough soft tissue for repair later on

5

Release capsule

  • release capsule using longitudinal or T-shaped incision

6

Dislocate hip

  • use flexion, adduction and internal rotation
  • leg perpendicular to ground, 90-90°
F

Femoral Head Extraction

1

Make preliminary neck cut

  • use sagital saw to get more room to remove femoral head

2

Remove femoral head via corkscrew or ring shaped tenaculum

  • cauterize soft tissue away and clean off with Cobb

3

Choose implant size

  • use native femoral head to measure size for templating implant head size (typically 46-52mm)
G

Canal Preparation

1

Elevate the femur

  • use proximal femoral retractor (double prong, equal prongs on either side) and place under GT to help elevate femur and protect soft tissues
  • can use Hibbs or #1 acetabular retractor to get better calcar exposure

2

Make neck cut 0.5-1cm proximal to lesser trochanter

  • use box cutter to start, then canal finder then lateralizing reamer to make sure you are down canal and not in varus

3

Broach up sizes from small to larger

  • start at 10, then 11, 12 (typically 12-13 size stem final)
  • want snug fit but don’t need to overtighten
  • cement will fill void between implant and bone
  • need to hit broaches with same power to evaluate if it’s advancing
  • watch calcar for evidence of fracture
  • place leg in extension and internal rotation to visualize the calcar

4

Trial implants

  • extend the leg and hyper internal rotation to get max exposure of proximal femur, then heads, reduce with traction and external rotation

5

Check for stability, range of motion and leg lengths

H

Cement Insertion

1

Dislocate hip, remove trials, size and place cement restrictor (typically 11-12mm)

  • place cement restrictor 15cm down from neck cut (length may vary depending on stem being used)

2

Clean and dry canal using epinephrine soaked sponge

  • suction out canal

3

Insert cement in retrograde fashion pressurized with gun

  • place sponge in acetabulum to block cement extrusion
  • cement typically takes 3.5-4.5min to reach appropriate consistency for insertion

4

Cover tip of stem with extra cement

I

Final Implants

1

Use stem pusher and Tommy bar to control depth and anteversion

  • place in 10-15° anteversion (angled posterior for increased anteversion)
  • add 5-10° if worried about posterior dislocation
  • hold in place until cement hard (~15min)

2

Trial head and neck size (typically +7, +10.5)

  • engage Morse taper, allow cement to dry, and relocate hip

3

Confirm Implant Position and Extremity

  • check final anteversion of stem and impingement, leg lengths, rotation when hip dislocates anterior and posterior
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • pulsatile irrigate acetabulum and deep tissues
  • cauterize peripheral bleeding vessels

2

Deep closure

  • repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures
  • tie to either glut medius anteriorly or through bone on posterior aspect of GT
  • close TFL with #1 Ethibond figure of 8 sutures

3

Superficial closure

  • need use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

4

Dressing and immediate immobilization

  • soft incision dressings over hip

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • document distal neurovascular status
  • identify patient comorbidities and ASA status (predictor of mortality)
  • pre-injury mobility is the most significant determinant for post-op survival
  • household ambulators with assistive devices, low demand patients are ideal for cemented hemiarthroplasty
  • community ambulators without assistive devices may receive THA instead of hemiarthroplasty
  • make sure patient has Foley urinary catheter in place
  • elderly patients with hip fractures should be definitively managed as soon as medically cleared
  • within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality

2

Order basic imaging studies

  • order AP Pelvis, AP/Lat hip and femur

3

Perform operative consent and lists potential complications

  • describe complications of surgery including
  • describes pros and cons of nonoperative treatment
  • superficial / deep infection
  • mortality (14-36% at 1 year post-op)
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • change dressings POD2

2

Appropriate medical management and medical consultation

3

Initiate physical therapy POD1

  • weight-bearing as tolerated, physical therapy
  • posterior hip precautions

4

Discharges patient appropriately

  • pain meds
  • DVT prophylaxis
  • schedule follow up appointment in 2weeks
  • outpatient PT
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • determine the mechanism of injury
  • examine extremity for shortening, external rotation, and ipsilateral injuries
  • check neurovascular status
  • document presence of underlying osteoarthritis
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • AP Pelvis, AP/Lat hip and femur for degree of fracture displacement

3

Interact with consultants regarding optimal patient management

  • timing of surgery
  • medical management
  • assess risk for thromboembolic disease

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • staples/sutures removed
  • continue physical therapy and range of motion exercises
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Comprehensive assessment of fracture patterns on imaging studies

2

Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral

3

Arranges for long term management of geriatric patients

  • management of bone health
  • discharge planning to long term care

4

Modifies and adjusts post-operative treatment plan as needed

5

Provides prohylaxis and manages thromboemblotic disease

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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