What is the step-by-step procedure for treating an intracapsular (within the joint capsule) fracture of the femoral (thigh bone) neck using Dynamic Hip Screw (DHS) plating?

From the Guidelines

Dynamic Hip Screw (DHS) plating is not the recommended treatment for intracapsular femoral neck fractures. Instead, these fractures are typically treated with arthroplasty (hemiarthroplasty or total hip replacement) or multiple cannulated screws, as evidenced by the most recent and highest quality study 1. DHS is primarily used for extracapsular fractures like intertrochanteric fractures. For intracapsular femoral neck fractures, the blood supply to the femoral head is compromised, leading to high rates of avascular necrosis and nonunion if treated with internal fixation methods like DHS, as noted in 1.

Key Considerations

• In younger patients (typically under 60), preservation of the native femoral head is attempted using multiple cannulated screws placed parallel to each other.
• For older patients, arthroplasty is preferred due to the high risk of fixation failure and subsequent reoperation.
• The choice between hemiarthroplasty and total hip replacement depends on the patient's activity level, pre-existing arthritis, and life expectancy, with cemented arthroplasty improving hip function and reducing residual pain postoperatively, as seen in 1.
• The use of cemented femoral stem is recommended, along with the administration of tranexamic acid to reduce blood loss and the need for transfusion, as supported by 1.

Anesthesia and Surgical Approach

• Either spinal or general anesthesia is appropriate for patients with a hip fracture, with a strong recommendation for its use, as stated in 1.
• Regional anesthesia for hip fracture surgery requires blockade of the lateral cutaneous nerve of the thigh, as mentioned in 1.
• The surgical approach should prioritize minimizing blood loss and promoting optimal recovery, with the use of tranexamic acid and careful consideration of the patient's overall health and activity level.

Outcome Prioritization

The primary goal in treating intracapsular femoral neck fractures is to minimize morbidity, mortality, and improve quality of life, which is best achieved through arthroplasty or multiple cannulated screws, rather than DHS plating, as supported by the most recent and highest quality evidence 1.

From the Research

Step-by-Step Procedure for Fracture Intracapsular Neck of Femur by DHS Plating

• The treatment of intracapsular femoral neck fractures using dynamic hip screw (DHS) fixation is a surgical approach that aims to stabilize the fracture and promote healing 2.
• The procedure typically involves the following steps:
  • Closed reduction of the fracture to achieve anatomical alignment.
  • Insertion of a 135-degree sliding hip screw with a short thread, directed to the head centre, and a two-hole side plate 2.
  • Use of an anti-rotation screw may be considered, although its effectiveness in preventing late complications is debated 2, 3.
• The goal of the procedure is to achieve bone union without complications, which was achieved in 73.4% of patients within 12 months of surgery in one study 2.
• The quality of fracture reduction is crucial, as unsatisfactory reduction is associated with a higher risk of late complications, including avascular necrosis and non-union 2.
• The timing of surgery is also important, with studies suggesting that treatment within 24 hours of injury may reduce the risk of avascular necrosis 3.

Considerations and Controversies

• The choice of surgical approach for intracapsular femoral neck fractures is controversial, with some studies suggesting that arthroplasty options may outperform internal fixation in terms of function, quality of life, and reoperation rates 4, 5.
• The use of DHS fixation is economical and available, but its effectiveness may be limited in patients with poor bone quality or displaced fractures 2.
• The role of anti-rotation screws in preventing late complications is unclear, and further study is needed to determine their effectiveness 2, 3.

Patient Selection and Outcomes

• Patient selection is critical, with factors such as age, bone quality, and functional status influencing the choice of surgical approach 4, 5.
• Outcomes following DHS fixation for intracapsular femoral neck fractures can be variable, with studies reporting rates of bone union, avascular necrosis, and non-union ranging from 73.4% to 26.6% 2.
• Further study is needed to determine the optimal surgical approach for intracapsular femoral neck fractures and to identify factors that influence outcomes 4, 5.