From the Guidelines
The surgical procedure for treating intertrochanteric femur fractures (ICNF) using dynamic hip screw (DHS) plating involves several critical steps, with the most recent and highest quality study guiding the approach 1, 2.
Preoperative Considerations
Before proceeding with the surgery, it is essential to consider the patient's overall health and potential risks associated with the procedure. According to the study by the American Academy of Orthopaedic Surgeons 1, either spinal or general anesthesia is appropriate for patients with a hip fracture, with a strong recommendation for following this approach unless a clear and compelling rationale for an alternative is present.
Surgical Procedure
The surgical procedure involves the following steps:
- Positioning the patient supine on a fracture table with the affected limb in slight adduction to facilitate access to the lateral aspect of the proximal femur.
- Making a lateral incision from the greater trochanter extending distally along the femoral shaft, followed by incising the fascia lata and reflecting the vastus lateralis anteriorly to expose the lateral femoral cortex.
- Achieving fracture reduction using traction and rotation under fluoroscopic guidance, with particular attention to restoring the neck-shaft angle and correcting any varus deformity.
- Inserting a guide wire from the lateral femur into the femoral head, positioned centrally in both AP and lateral views, ideally in the lower half of the femoral head.
- Reaming the femoral head to the appropriate depth for the lag screw, followed by inserting the lag screw over the guide wire.
- Attaching the DHS plate to the lateral femoral shaft using cortical screws.
- Obtaining final fluoroscopic images to confirm proper implant position, fracture reduction, and hardware placement.
Postoperative Management
Postoperative management includes wound closure in layers and early mobilization with weight-bearing restrictions based on fracture stability, as recommended by the American Academy of Orthopaedic Surgeons 2. It is also crucial to consider pressure care, particularly in older patients, to avoid the development of pressure sores and/or neuropraxia, as highlighted in the study by the Association of Anaesthetists of Great Britain and Ireland 3.
Key Considerations
- The procedure should be performed in a timely manner, ideally within 24 to 48 hours after admission, as recommended by the American Academy of Orthopaedic Surgeons 2.
- The choice of anesthesia should be based on the patient's individual needs and medical history, with either spinal or general anesthesia being appropriate, as stated in the study by the American Academy of Orthopaedic Surgeons 1.
- The surgical approach should be tailored to the patient's specific fracture pattern and overall health, with a strong recommendation for arthroplasty for displaced femoral neck fractures, as recommended by the American Academy of Orthopaedic Surgeons 2.
From the Research
Step-by-Step Procedure for Fracture Fixation by DHS Plating
The dynamic hip screw (DHS) is a widely used implant for the fixation of intertrochanteric fractures. The procedure involves the following steps:
- Preoperative preparation: The patient is prepared for surgery, and the affected limb is positioned to allow for easy access to the fracture site 4.
- Incision and dissection: A skin incision is made, and the fascia is dissected to expose the fracture site 5.
- Reduction of the fracture: The fracture is reduced, and the fragments are aligned properly 6.
- Insertion of the DHS: The DHS is inserted into the femoral head, and the side plate is attached to the femoral shaft 4.
- Fixation of the fracture: The fracture is fixed using the DHS, and the stability of the fixation is checked 7.
- Closure: The wound is closed, and the patient is taken to the recovery room 5.
Postoperative Care
After the surgery, the patient is monitored for any complications, and the following postoperative care is provided:
- Pain management: The patient is given pain medication to manage postoperative pain 8.
- Mobilization: The patient is mobilized as soon as possible to prevent complications such as deep vein thrombosis 5.
- Follow-up: The patient is followed up regularly to check the progress of fracture healing and to remove any sutures or staples 4.
Complications
The potential complications of DHS plating include:
- Screw cut-out: The screw can cut out of the femoral head, leading to loss of fixation 4.
- Implant failure: The implant can fail, leading to loss of fixation and fracture instability 6.
- Infection: The patient can develop an infection, which can lead to serious complications 5.
- Avascular necrosis: The patient can develop avascular necrosis of the femoral head, which can lead to fracture nonunion 7.
Outcome
The outcome of DHS plating for intertrochanteric fractures is generally good, with a low complication rate and high rate of fracture healing 8. The patient can expect to regain mobility and function, although the extent of recovery may vary depending on the individual case 4.