What are the steps for treating an Intracapsular Neck of Femur (INF) fracture using valgus osteotomy and Dynamic Hip Screw (DHS) plating?

From the Guidelines

Valgus osteotomy with Dynamic Hip Screw (DHS) plating is a recommended treatment for intracapsular neck of femur fractures, particularly in younger patients, as it improves the biomechanical environment and reduces the risk of nonunion or avascular necrosis. The procedure involves several key surgical steps, including positioning the patient supine on a fracture table with the affected limb slightly adducted to facilitate lateral approach 1. After standard surgical preparation, a lateral incision is made over the greater trochanter extending distally. The vastus lateralis is reflected anteriorly to expose the lateral femoral cortex.

Key Steps in the Procedure

• A wedge-shaped osteotomy is created below the fracture site, typically removing a laterally-based wedge of bone to achieve the desired valgus correction (usually 20-30 degrees) 1.
• This realigns the fracture to convert shear forces into compressive forces, promoting healing and reducing the risk of complications.
• After reduction, a guide wire is inserted from the lateral femur into the femoral head, followed by reaming and insertion of an appropriately sized lag screw.
• The DHS plate is then attached to the lag screw and secured to the femoral shaft with cortical screws.
• Intraoperative fluoroscopy confirms proper implant position and fracture reduction, ensuring optimal outcomes.

Post-Osteotomy Care

The osteotomy site is typically bone grafted using the removed wedge to promote healing. This technique is particularly useful for younger patients with displaced femoral neck fractures where preserving the native femoral head is preferred over arthroplasty, as it improves the biomechanical environment by changing the fracture orientation to promote healing and reduce the risk of nonunion or avascular necrosis 1. Rapid diagnosis and treatment of hip fractures is critical, as delays are associated with increased cost, complication rate, length of hospital stay, and short- and long-term mortality 1.

From the Research

Procedure Overview

The treatment of Intracapsular Neck of Femur (INF) fractures using valgus osteotomy and Dynamic Hip Screw (DHS) plating involves several steps. The goal of this procedure is to achieve stable fixation and promote union of the fracture.

Preoperative Steps

• Evaluate the patient's overall health and medical history to determine the best course of treatment 2, 3, 4
• Assess the fracture type and severity using imaging studies such as X-rays and CT scans 5, 6
• Plan the surgical approach and osteotomy technique based on the fracture characteristics and patient's anatomy 2, 3, 4

Surgical Steps

• Perform a valgus osteotomy to correct the deformity and improve the alignment of the femur 2, 3, 4, 6
• Use a dynamic hip screw (DHS) and a plate (such as a 120 degrees double angle barrel plate or a 135º single-angled barrel plate) to stabilize the fracture and promote union 3, 6
• Ensure proper positioning and fixation of the implant to avoid complications such as implant cut-through or avascular necrosis 2, 3, 4

Postoperative Steps

• Monitor the patient's progress and assess the fracture union using regular follow-up X-rays and clinical evaluations 2, 3, 4, 6
• Manage any postoperative complications such as pain, infection, or implant failure 2, 3, 4, 6
• Provide rehabilitation and physical therapy to help the patient regain mobility and strength in the affected hip 3, 6

Key Considerations

• The choice of implant and osteotomy technique may vary depending on the fracture type, patient's age, and surgeon's preference 2, 3, 4, 6
• The procedure should be performed by an experienced surgeon with expertise in orthopedic trauma and reconstruction 2, 3, 4, 6
• The patient's overall health and medical history should be carefully evaluated to minimize the risk of complications and optimize the outcome 2, 3, 4, 6

Potential Complications

• Avascular necrosis (AVN) of the femoral head 2, 3, 4, 6
• Implant failure or cut-through 2, 3, 4, 6
• Infection or deep vein thrombosis 2, 3, 4, 6
• Nonunion or malunion of the fracture 2, 3, 4, 6

Outcomes

• The outcome of the procedure can be excellent, good, or poor, depending on various factors such as the fracture type, patient's age, and surgeon's expertise 2, 3, 4, 6
• The procedure can provide stable fixation and promote union of the fracture, allowing the patient to regain mobility and strength in the affected hip 2, 3, 4, 6
• The choice of implant and osteotomy technique can affect the outcome, and the surgeon should carefully evaluate the patient's individual needs and preferences 2, 3, 4, 6