Hip Fracture - Operative Planning - Wheeless' Textbook of Orthopaedics

- PreOp Management:
- etiology of fracture:
- arrhythmia, osteoporosis, pathologic hip fractures, seizure, stroke,
- ref: Osteoporosis and proximal femoral fractures in the female elderly of Jerusalem.
- fall producing a direct blow;
- lateral rotation of extremity
- head is firmly fixed by anterior capsule & iliofemoral ligaments while the neck rotates posteriorly;
- posterior cortex impinges on acetabulum, and the neck fractures; (look for marked posterior comminution of the neck)
- "The path was worn and slippery. My foot slipped from under me, knocking the other out of the way,
but I recovered and said to myself, It's a slip and not a fall." - Abraham Lincoln.
- functional status:
- ambulation status
- medications:
- medical conditions;
- dementia:
- elderly patients w/ documented dementia have an especially high risk of complications from hip fracture surgery;
- these patients are especially sensitive to even small doses of narcotics, and there is some evidence that these patients are
sensitive to the relative hypotension from spinal anesthesia (decrease cerebral perfusion);
- dementia should be expected to worsen during the perioperative period which increases the likelihood of poor feeding and aspiration;
- ref: The Influence of Cognitive Function on Outcome After a Hip Fracture.
- exam:
- r/o dental, GI, & GU pathology;
- decubit
- shortening and external rotation
- skin abrasions and ipsilateral trauma;
- r/o previous hip surgery (complicating incisions)
- internal rotation of limb almost always elicits pain in region of hip and groin when a femoral neck fracture is present;
- consider consequences of immobilization:
- crush syndrome:
- in patients who have lain for more than 6 hours before being transported to the hospital, over 70% will have elevated CPK;
- ref: Crush syndrome after proximal femoral fracture. A. Garg et al. (Presentation at the 15th Annual Orthopaedic Trauma Association);
- deep venous thrombosis
- hypercalcemia
- constipation
- dementia

- Radiographs for Femoral Neck Fractures:
- Accetable Reduction Parameters:
- Sigh Index
- Garden I & II:
- Garden III & IV:
- Garden's Alignment Index:
- AP & Lateral of Ipsilateral Femur + Internal Rotation View;
- Lateral x-ray: of affected limb on the stretcher while good limb is flexed upto obtain the proper angle;
- lateral view: scrutinized for post. femoral neck comminution;
- do not order frog leg pts suspected of having a hip frx;

- Operative Planning:
- Anesthesia, Medical Complications and Timing for Femoral Neck Frx:
    - Operative Choices: (requires inclusive operative consent)
- cannulated screws (or pins or sliding hip screw): - this technique requires adeqate closed reduction;
         - open reduction:
- hemiarthroplasty:
- indications:
- inadequate reduction;
- displaced frx which is several days old;
- pre-existing hip disease (DJD, RA, AVN);
- total hip replacement:
- indicated for patients w/ rheumatoid arthritis and/or concomitant hip arthrosis;
- patients should be aware of a relatively high complication rate (10% will dislocate);
- risk of dislocation was dramatically reduced using the Hardinge approach (3/40 hips) versus the posterior approach (4/17 hips);
              - references:
- A comparison of total hip arthroplasty and hemiarthroplasty for treatment of acute fracture of the femoral neck.
- Secondary total hip replacement after fractures of the femoral neck.
- Total hip arthroplasty after acute displaced femoral neck fractures.
- Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement.
- Total hip arthroplasty following failed internal fixation of hip fractures.
- Treatment of intracapsular hip fractures with total hip arthroplasty in rheumatoid arthritis. Asai et al. Bull Hosp Joint Dis. Vol 53. 1993. p 29-33.
- The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison.
- Treatment of acute femoral neck fractures with total hip arthroplasty.
- Failure of internal fixation of displaced femoral neck fractures in rheumatoid arthritis. E Bogoch et al. JBJS. Vol 73-B. 1991. p 7-10.
- Total hip arthroplasty for the treatment of an acute fracture of the femoral neck. BP Lee MD et al. JBJS Vol 80-A. No 1. Jan 1998. p 70.

- Hip Frx in Young Adults:
- expect AVN rate of about 20%;
- controversey as to whethere these patients require emergent reduction and pinning along with capsulotomy (to avoid hematoma and increase
                      in intra-articular pressure);
- references:
- Displaced stress fractures of the femoral neck in young male adults: a report of twelve operative cases.
- Intracapsular fractures of the femoral neck in young patients.
- Femoral-neck fractures in young adults.
- Femoral neck frx in skeletally mature patients, fifty years old or less.
- Femoral neck fractures in young adults.
- Fractures of the femoral neck in patients between the ages of twelve and forty-nine years.
- Fractures of the femoral neck in patients between the ages of twelve and forty-nine years.
- Vascularized iliac bone graft for displaced femoral neck fractures in young adults. MC Chang MD et al. Orthopedics. May 1999. Vol 22. No 5. p 493.
- Operative Treatment of Femoral Neck Fractures in Patients Between the Ages of Fifteen and Fifty Years.
- Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction.
- comparative studies:
- Clinical study on internal fixation of femoral neck fractures.
- The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison.
- A biomechanical study of two methods of internal fixation of unstable fractures of the femoral neck. A preliminary study.
- Basicervical fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques.
- Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur. A prospective randomised study.
- Nailing versus prosthesis for femoral-neck fractures. A critical review of long-term results in two hundred and thirty-nine consecutive private patients.
- Randomized Comparison of Reduction and Fixation, Bipolar Hemiarthroplasty, and THA. Treatment of Displaced Intracapsular Hip Frx in Healthy Older Pts.
         - Renal Failure:
                      - Analysis of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis
                      - Intracapsular hip fractures in end-stage renal failure.
                      - Life expectancy and functional prognosis after femoral neck fractures in hemodialysis patients
                      - Hip fractures in end-stage renal disease patients: incidence, risk factors, and prevention
                      - Operative treatment of hip fractures in patients with renal failure

- Post Op Management:
    - DVT occurance in hip frx surgery
    - decubiti /pressure ulceration
    - osteoporosis work up:
            - liver function tests and levels of calcium, albumin, 25-hydroxyvitamin D, intact PTH, and thyroid-stimulating hormone in all patients and
a total serum testosterone level in men;
             - vitamin d: 400-800 U/day (in order to address the 4-8% of hip frx patients who have osteomalacia);
         - calcium supplementation: - note that standard supplements may cause constipation;
             - bisphosphonates:
             - references:
                       - Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture
                       - Zoledronic Acid and Secondary Prevention of Fractures
    - complications:
- Factors predisposing to healing complications after internal fixation of femoral neck fracture. A stepwise logistic regression analysis.
- A prospective assessment of nutritional status and complications in patients with fractures of the hip.
    - urinary tract infection:
            - Extended use of indwelling urinary catheters in postoperative hip fracture patients.
            - Extended use of urinary catheters in older surgical patients: a patient safety problem?
            - Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data.

The classic. The treatment of fractures of the neck of the femur by immediate reduction and permanent fixation. By Nicholas Senn. 1889.
Clinical Orthopaedics & Related Research. (218):4-11, 1987 May.

Operative Treatment of Hip Fractures in Patients with Renal Failure. DM Klein, MD et al. CORR. No 350. p 174-178. May 1998.

Recommendations for Optimal Care of the Fragility Fracture Patient to Reduce the Risk of Future Fracture