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Femoral Neck Fracture ORIF with Dynamic Hip Screw

Planning

B

Preoperative Plan

1

Template intramedullary nail and cephalomedullary screws

  • measure the size of the hip screw

2

Surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case.
  • list potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • DHS system

2

Room setup and equipment

  • radiolucent fracture table (Jackson fracture)
  • c-arm fluoroscopy

3

Patient positioning

  • make sure patient has Foley urinary catheter in place
  • patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder
  • padded post deep into groin, move genitals and Foley catheter out of the way
  • ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board
  • prep and drape entire leg up to iliac crest to make sure adequate working area
  • c-arm from contralateral side at 45° towards hip
  • take initial fluoro AP/Lat of hip to examine femoral neck
  • mark position of C-arm to ensure proper positioning during remainder of case (~15° tilt for correct AP xray of hip)

Technique

D

Lateral Approach to the Hip

1

Mark and make the incision

  • make straight lateral incision two finger breadths below the vastus ridge to a point 5-7 cm distally

2

Dissect down to the IT band

  • perform subperiosteal dissection to sweep the subcutaneous tissue from either side of the IT band

3

Incise the fascia lata

  • make an incision in line with the fascia lata

4

Place retractors

  • place Charnley retractor deep to the IT band
  • use blunt dissection between the vastus lateralis and the IT band to remove the adhesions

5

Retract the vastus lateralis anteriorly

6

Expose the bone

  • elevate the posterior portion of the vastus lateralis off to expose bone
  • use a periosteal elevator too bluntly split the posterior 20% of the vastus directly down to bone, and then elevate it off the bone

7

Place Benet retractors

  • insert 2 large Bennet retractors over the anterior edge of the femur, and rest the retractor handles underneath the previously applied Charnely retractor
  • use a periosteal elevator to strip the remaining tissue from the lateral aspect of the femur
E

Fracture Reduction and Guidepin Placement

1

Reduce the fracture

2

Determine the degree of anteversion

  • determine the amount of anteversion by placing the DHS/DCS guide pin anteriorly along the femoral neck with the use of the appropriate DHS angle guide

3

Place the pin

  • gently hammer the pin into the femoral head
  • this anteversion pin will later allow the correct placement of the central guide pin in the center of the femoral head

4

Align the DHS angle guide

  • align the appropriate DHS angle guide along the axis of the femoral shaft

5

Place the DHS angle guide on the femur

  • point the guide tube toward the center of the femoral head

6

Place the guidepin

  • it is recommended to predrill the lateral cortex with a 2.0 mm drill bit due to the density of the bone
  • insert a DHS/DCS guide pin through the appropriate DHS angle guide
  • this should be parallel to the anteversion pin and directed toward the center of the femoral head
  • this point of introduction will vary with the barrel angle
  • when the 135 degree barrel angle is used, enter the guide pin through the proximal femur approximately 2.5 cm distal to the vastus ridge
F

Confirm Placement of the Guidepin and Insertion of Depth Measurement

1

Confirm the placement of the guidepin

  • use image intensification to confirm the placement of the DHS/DCS guide pin under image intensification
  • the pin must lie along the axis of the femoral neck in both the AP and lateral views and parallel to the anteversion pin

2

Remove the anteversion pin

3

Check guidepin insertion depth

  • slide the direct measuring device over the guide pin to determine guide pin insertion depth
  • the calibration on the device provides a direct reading
  • calculate the reaming depth, tapping depth and lag screw length
  • subtract 10 mm from the reading

4

Assemble the appropriate DHS triple reamer

G

Reaming

1

Set and place the reamer

  • set the reamer to the correct depth
  • insert the DHS triple reamer into the power drive using the large quick coupling attachment
  • slide the reamer over the guide pin to simultaneously drill for the plate/barrel junction to the preset depth
  • when reaming into the dense bone, continuously irrigate the DHS triple reamer to prevent thermal necrosis
  • if needed tap to the predetermined depth using the Tap Assembly
  • tapping depth can be seen through the window in the short centering sleeve
H

Lag Screw Placement

1

Assemble the lag screw insertion assembly

2

Place the assembly

  • slide the assembly over the guide pin and into the reamed hole
  • seat the long centering sleeve in the hole to the center and stabilize the assembly

3

Insert the lag screw

  • insert the lag screw by turning the handle clockwise until the 0 mark on the assembly aligns with the lateral cortex
  • the threaded tip of the lag screw should lie 10 mm from the medial cortex
  • the lag screw may be inserted an additional 5 mm in porotic bone for increased holding power

4

Remove the handle

  • before removing the assembly, align the handle so it is in the same plane as the femoral shaft
  • this allows proper placement of the DHS plate onto the lag screw
I

DHS Plate Placement

1

Place the DHS plate

  • remove the DHS wrench and long centering sleeve
  • slide the appropriate DHS plate onto the guide shaft /lag screw assembly
  • loosen and remove the coupling screw and guide shaft

2

Remove the guidepin

  • use the power drive in reverse with the Jacobs chuck attachment to withdraw the guide pin

3

Place the DHS impactor

  • gently seat the plate with the DHS impactor
  • the vastus ridge may be chiseled to further seat the plate on the bone

4

Fix the plate to the bone

  • fix the DHS plate to the femur with 4.5 mm cortex screws using AO ASIF standard screw insertion technique
  • for further intraoperative compression of the trochanteric fracture, the DHS compression screw may be inserted into the lag screw
J

Wound Closure

1

Irrigation and hemostasis

  • flush out nail insertion site, lag screw, and interlocking screw sites with saline bulb irrigation
  • cauterize peripheral bleeding vessels

2

Close the deep fascia

  • close fascia lata and IT band with 0-vicryl

3

Close the superficial layers

  • subcutaneous and skin closure with 2-0 vicryl and staples

4

Soft incision dressings over hip, proximal and distal femur

Patient Care

K

Preoperative H & P

1

Perform focus orthopaedic history and physical

  • perform careful extremity exam
  • document distal neurovascular status
  • identify associated injuries and comorbidities
  • identify patient comorbidities and ASA status (predictor of mortality)
  • screen medical studies to identify and contraindications for surgery

2

Order basic imaging studies

  • order AP pelvis, ap and lateral of affected hip

3

Perform operative consent including lists potential complications

  • describe complications of surgery including
  • medical complications including death
  • definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality
  • varus collapse with screw cut out
  • AVN of the femoral head
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
  • remove dressings POD 2

2

Inpatient physical therapy

  • start range of motion exercises of the hip and knee

3

Appropriate medical management and medical consultation

4

Discharges patient appropriately

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

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • check neurovascular status
  • compare extremity to contralateral limb
  • concomitant and associated orthopaedic injuries

2

Appropriately interprets basic imaging studies

  • interpret AP pelvis and lateral radiographs of the affected hip

3

Recognition / evaluation of fragility fractures

  • order appropriate workup and/or consult

4

Interacts with consultants regarding optimal patient management

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

5

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

6

Provides post-operative management and rehabilitation; WB status

  • 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
  • repeat xrays of femur
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • repeat xrays of femur
  • 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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