What is the step by step procedure for a hip fracture treated with valgus osteotomy and Dynamic Hip Screw (DHS) plating?

From the Guidelines

The treatment of a hip fracture with valgus osteotomy and Dynamic Hip Screw (DHS) plating involves a systematic surgical procedure aimed at realigning the femoral neck and providing stable fixation, and should be performed under either spinal or general anesthesia as deemed appropriate by the practitioner 1. The procedure begins with patient positioning in the supine position on a fracture table.

• The choice of anesthesia, either spinal or general, is based on the patient's overall health and the surgeon's preference, with both options being considered appropriate for patients with a hip fracture 1. After standard surgical preparation and draping,
• a lateral approach to the proximal femur is performed with an incision starting from the greater trochanter extending distally along the femoral shaft. The fascia lata is incised, and the vastus lateralis is reflected anteriorly to expose the lateral femoral cortex.
• Once exposure is achieved, the fracture site is identified and the valgus osteotomy is performed by removing a laterally-based wedge of bone from the subtrochanteric region. This osteotomy changes the angle of the femoral neck to a more valgus position, which improves the biomechanical forces across the fracture site by converting shear forces to compressive forces.
• A guide wire is then inserted under fluoroscopic guidance from the lateral femur into the femoral head, ensuring central placement in both anteroposterior and lateral views. The femoral head is then reamed over the guide wire to the appropriate depth for the lag screw.
• The DHS lag screw is inserted over the guide wire, followed by attachment of the side plate to the femoral shaft using cortical screws. Intraoperative fluoroscopy confirms proper implant position and fracture reduction.
• The wound is irrigated, hemostasis achieved, and closure performed in layers with drains as needed. Postoperatively, patients typically begin protected weight-bearing within 24-48 hours based on fracture stability, with gradual progression to full weight-bearing over 6-12 weeks. This procedure is particularly beneficial for younger patients with femoral neck fractures in varus position, as the valgus reorientation improves the mechanical environment for healing while the DHS provides stable fixation during the recovery process.

From the Research

Step-by-Step Procedure for Fracture Hip by Valgus Osteotomy with DHS Plating

The procedure for treating a hip fracture with valgus osteotomy and Dynamic Hip Screw (DHS) plating involves several key steps:

• Preoperative preparation: This includes administering prophylactic antibiotics, particularly against Staphylococcus aureus, and thromboembolic prophylaxis, preferably with low-molecular-weight heparin, as noted in 2 and 3.
• Surgical approach: The choice of surgical approach depends on the type and location of the fracture, as well as the patient's overall condition, according to 3.
• Valgus osteotomy: This involves cutting and realigning the femur to improve the alignment and stability of the hip joint, as described in 4.
• DHS plating: The dynamic hip screw is used to fixate the osteotomy and provide stable fixation for the fracture, allowing for early mobilization and rehabilitation, as discussed in 5 and 4.
• Secure placement of the DHS: It is essential to ensure secure placement of the DHS within the femoral head to achieve stable fixation and promote healing, as emphasized in 5.
• Postoperative care: This includes early mobilization, rehabilitation, and monitoring for potential complications, such as delirium, joint infection, and venous thromboembolism, as highlighted in 2, 3, and 6.

Key Considerations

• Fracture stability: The stability of the fracture is dependent on the status of the posteromedial cortex, and the DHS provides a means of achieving stable fixation, as noted in 5.
• Patient selection: The decision to use valgus osteotomy with DHS plating depends on the individual patient's condition, including the type and location of the fracture, as well as their overall health and mobility, according to 3 and 4.
• Surgical technique: The technical aspects of the procedure, including the placement of the DHS and the performance of the osteotomy, are critical to achieving a successful outcome, as discussed in 5 and 4.

Outcomes and Complications

• Healing rates: The use of valgus osteotomy with DHS plating has been shown to result in high healing rates for femoral neck nonunions, as reported in 4.
• Complications: Potential complications of the procedure include osteonecrosis, joint infection, and venous thromboembolism, which must be carefully monitored and managed, as highlighted in 2, 3, and 6.