From the Guidelines
The operative procedure for removal of cannulated compression (CC) screws from a femur neck fracture involves several key steps, prioritizing minimal invasion and maximizing fluoroscopic guidance to ensure accurate screw removal and minimize complications. When managing a fracture of the femoral neck with cannulated screw removal, the primary goal is to alleviate pain, restore function, and prevent further morbidity, as highlighted in the management of patients older than 50 years with a fragility fracture 1. The procedure typically starts with the patient positioned supine on a fracture table under appropriate anesthesia, with the affected hip elevated on a radiolucent platform. After sterile preparation and draping, the surgeon locates the previous incision site, typically on the lateral thigh, and makes a 3-5 cm incision along the old surgical scar. Dissection through subcutaneous tissue and fascia lata is followed by splitting the vastus lateralis in line with its fibers to expose the lateral femoral cortex where the screws were inserted. Using fluoroscopic guidance, as recommended for stable non-displaced fractures managed with cannulated fixation in a percutaneous manner 1, the surgeon identifies the screw heads, which may be covered by bone overgrowth requiring osteotome clearance. A specific cannulated screw removal set is used, ensuring the correct screwdriver bit matches the screw head design, and each screw is removed by turning counterclockwise after confirming proper engagement with the screwdriver. If a screw is stripped or difficult to remove, specialized extraction tools may be needed, emphasizing the importance of careful preoperative planning and having the necessary equipment available. After all screws are removed, the wound is irrigated with normal saline, and the surgeon checks for any bone defects that might require bone grafting, considering the overall bone quality and the patient's specific condition. The wound is then closed in layers using absorbable sutures for deep tissues and either staples or nylon sutures for skin, with post-operative care focusing on pain management, early mobilization, and physical therapy to enhance recovery and quality of life. Given the limited strength of options for managing stable femoral neck fractures, including hemiarthroplasty, internal fixation, or nonsurgical care 1, the decision for cannulated screw removal should be made on a case-by-case basis, considering the patient's age, activity level, and overall health status, to optimize outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Operative Procedure Steps for Cannulated Screw Removal
The operative procedure steps for a fracture of the femoral neck managed by cannulated (cc) screw removal are as follows:
- Preoperative planning: This involves evaluating the fracture and deciding on the best approach for screw removal and fixation 2.
- Removal of existing screws: This is done to allow for the passage of new fixation devices, such as a Trochanteric Fixation Nail-Advanced Proximal Femoral Nailing System (TFNA) 2.
- Insertion of new fixation devices: This may involve the use of fully threaded cannulated screws to minimize femoral neck shortening 3.
- Confirmation of screw placement: This can be done using imaging techniques, such as radiographs and computed tomography scans 2, 3.
- Postoperative care: This involves allowing the patient to bear weight and monitoring for complications, such as avascular necrosis and non-union 4.
Considerations for Screw Removal and Fixation
When removing cannulated screws and fixing a fracture of the femoral neck, the following considerations should be taken into account:
- The use of fully threaded cannulated screws can decrease femoral neck shortening 3.
- The presence of posterior comminution may influence the rate of avascular necrosis 4.
- The time interval from injury to surgery may also influence the rate of avascular necrosis 4.
- The use of robot-assisted orthopaedic surgery can provide a more minimally invasive and precise treatment method 5.
- The technique of using a cannulated screw as a drill guide and sleeve can simplify the procedure and minimize soft tissue dissection 6.