What is the step-by-step procedure for treating an intertrochanteric femur fracture using bipolar hemiarthroplasty and total hip ball and socket (Total Hip Replacement, THR)?

Surgical Procedure for Intertrochanteric Femur Fracture Using Bipolar Hemiarthroplasty and Tension Band Wiring

For unstable intertrochanteric femur fractures in elderly patients, bipolar hemiarthroplasty with tension band wiring technique is recommended as it allows for early mobilization and weight-bearing, reducing morbidity and mortality associated with prolonged immobilization. 1, 2

Preoperative Evaluation

• Assess fracture pattern and stability using radiographic imaging
• Evaluate patient's comorbidities, functional status, and bone quality
• Differentiate between pathologic and traumatic fractures
• Consider bone scan if metastatic disease is suspected
• Optimize medical conditions prior to surgery

Anesthesia Considerations

• Spinal/epidural anesthesia is preferred when not contraindicated as it may reduce postoperative confusion 3
• Regional anesthesia requires blockade of the lateral cutaneous nerve of the thigh, femoral, obturator, sciatic, and lower subcostal nerves 3
• Consider peripheral nerve blockade for postoperative pain control

Step-by-Step Surgical Procedure

1. Patient Positioning and Preparation

• Position patient in lateral decubitus position on the unaffected side
• Apply proper padding to bony prominences
• Prepare and drape the hip region using standard aseptic technique
• Mark anatomical landmarks including greater trochanter and surgical approach

2. Surgical Approach

• Make a posterolateral (Moore) approach or direct lateral (Hardinge) approach
• Incise skin, subcutaneous tissue, and fascia lata
• Split gluteus maximus fibers in line with their direction
• Identify and protect the sciatic nerve
• Expose the short external rotators and posterior capsule
• Tag and divide the short external rotators and piriformis
• Incise the hip capsule in a T-shaped manner

3. Femoral Head Resection

• Dislocate the femoral head
• Identify the femoral neck and perform osteotomy at appropriate level
• Remove the femoral head
• Preserve the fractured trochanteric fragments for later reattachment

4. Femoral Canal Preparation

• Identify the femoral canal
• Ream the canal progressively to appropriate size
• Perform trial reduction with broach to determine appropriate implant size
• Check for leg length and stability

5. Implantation of Bipolar Prosthesis

• Prepare the femoral canal for cementation if using cemented technique
• Insert cement restrictor if using cemented technique
• Inject bone cement into the canal in retrograde fashion
• Insert the femoral stem with proper version (10-15° anteversion)
• Attach the appropriate bipolar head to the femoral stem
• Reduce the hip joint

6. Trochanteric Fragment Fixation with Tension Band Wiring

• Identify and prepare the greater and lesser trochanteric fragments
• Drill holes in the trochanteric fragments and proximal femur for wire passage
• Pass stainless steel wires through the holes in a figure-of-eight configuration
• Reduce the trochanteric fragments to their anatomical position
• Tighten the wires to secure the fragments to the proximal femur 4
• Verify reduction and fixation under fluoroscopy

7. Closure

• Repair the short external rotators and posterior capsule
• Close the wound in layers (fascia, subcutaneous tissue, skin)
• Apply sterile dressing

Postoperative Management

• Initiate early mobilization to reduce complications 3
• Begin weight-bearing as tolerated in most cases
• Provide appropriate pain management
• Implement wound care protocols
• Monitor for complications including infection, dislocation, and wire breakage

Follow-up Protocol

• Radiographic evaluation at 6 weeks, 3 months, 6 months, and 1 year
• Assess fracture healing, implant position, and potential complications
• Evaluate functional recovery using Harris Hip Score

Expected Outcomes

• Studies show 76-87% good to excellent functional outcomes with bipolar hemiarthroplasty for unstable intertrochanteric fractures 2, 5
• Early ambulation typically within the first postoperative week 6
• Reduced risk of complications associated with prolonged immobilization

Potential Complications

• Wire breakage (reported in approximately 11.5% of cases) 4
• Non-union of greater trochanter
• Dislocation of the prosthesis
• Infection
• Leg length discrepancy
• Acetabular erosion (rare)

This surgical approach is particularly beneficial for elderly patients with osteoporosis and unstable intertrochanteric fractures, as it allows for immediate postoperative weight-bearing and mobilization, reducing the complications associated with prolonged bed rest 2, 5.