From the Guidelines
The surgical procedure for intertrochanteric femur fracture fixation using dynamic hip screw (DHS) plating involves several critical steps, with the choice of anesthesia being either spinal or general, as deemed appropriate by the practitioner, according to the AAOS clinical practice guideline summary 1. The procedure begins with the patient being positioned supine on a fracture table with the affected limb in slight adduction to facilitate lateral access to the proximal femur.
- Key considerations include:
- Sterile preparation and draping of the affected limb
- A lateral incision from the greater trochanter extending distally along the femoral shaft
- Incision of the fascia lata and reflection of the vastus lateralis anteriorly to expose the lateral femoral cortex Fracture reduction is achieved using traction and rotation under fluoroscopic guidance, with particular attention to restoring the neck-shaft angle and correcting any varus deformity, as these factors significantly impact morbidity, mortality, and quality of life.
- The reduction process involves:
- Insertion of a guide wire from the lateral femoral cortex into the femoral head, aiming for central placement in both AP and lateral views
- Reaming of the femoral head to the appropriate depth for the lag screw
- Insertion of the lag screw over the guide wire, followed by attachment of the DHS plate to the lag screw
- Securing the plate to the femoral shaft using cortical screws Throughout the procedure, fluoroscopic imaging confirms proper implant positioning and fracture reduction, which is crucial for minimizing complications and ensuring optimal outcomes.
- Postoperative care includes:
- Protected weight-bearing as tolerated with physical therapy
- Progression to full weight-bearing based on clinical and radiographic evidence of healing, usually within 6-12 weeks This technique provides stable fixation through the sliding capability of the lag screw, allowing controlled impaction at the fracture site during weight-bearing, which promotes bone healing while maintaining anatomic alignment, ultimately reducing morbidity and improving quality of life 1.
From the Research
Step-by-Step Procedure for Fracture Fixation by DHS Plating
The following steps outline the procedure for fracture fixation using Dynamic Hip Screw (DHS) plating:
- Preoperative preparation: The patient is prepared for surgery, and the type of anesthesia to be used is determined 2, 3, 4.
- Positioning: The patient is positioned on a fracture table to allow for proper alignment and stabilization of the affected limb.
- Incision and dissection: A skin incision is made, and the tissue is dissected to expose the fracture site.
- Reduction: The fracture is reduced, and the bone fragments are aligned properly.
- Plate fixation: The DHS plate is fixed to the bone using screws, ensuring proper alignment and stability.
- Lag screw insertion: The lag screw is inserted through the plate and into the bone to provide additional stability.
- Wound closure: The wound is closed, and the patient is taken to the recovery room.
Considerations for Anesthesia
The choice of anesthesia for DHS plating surgery is crucial, with both regional and general anesthesia having their advantages and disadvantages:
- Regional anesthesia: May be associated with more peri-operative complications compared to general anesthesia 3.
- General anesthesia: May be preferred for certain patients, especially those with multiple comorbidities 2, 4.
- The decision on the type of anesthesia should be made on a case-by-case basis, taking into account the patient's individual needs and medical history 2, 3, 4.
Postoperative Care
After the surgery, the patient requires proper postoperative care to ensure a smooth recovery:
- Pain management: The patient is given pain medication to manage postoperative pain.
- Mobilization: The patient is encouraged to mobilize as soon as possible to prevent complications such as deep vein thrombosis.
- Follow-up: The patient is scheduled for follow-up appointments to monitor the healing progress and remove any sutures or staples.
Complications and Outcomes
The outcomes of DHS plating surgery can vary, with some patients experiencing complications such as:
- Residual pain: Patients treated with DHS plating may experience more residual pain compared to those treated with other methods 5.
- Implant irritation: Some patients may experience implant irritation or other complications related to the hardware used in the surgery 5.
- The overall outcome of the surgery depends on various factors, including the patient's age, medical history, and the severity of the fracture 5, 6.