What is the operative procedure step by step for managing an intertrochanteric fracture using Dynamic Hip (DH) screw plating?

From the Guidelines

The operative procedure for managing an intertrochanteric fracture with Dynamic Hip Screw (DHS) plating involves several key steps, prioritizing stable fixation and controlled collapse at the fracture site to promote healing while maintaining the femoral head-neck relationship.

Key Steps in the Operative Procedure

• The patient is positioned supine on a fracture table with the affected limb in slight adduction and internal rotation to facilitate fracture reduction.
• A lateral approach is used, making an incision starting approximately 2 cm below the greater trochanter and extending distally for about 10-15 cm along the lateral thigh.
• The fascia lata is incised in line with the skin incision, and the vastus lateralis is reflected anteriorly to expose the lateral femoral shaft.
• Once exposure is achieved, the fracture is reduced under fluoroscopic guidance using traction and manipulation.
• A guide wire is then inserted from the lateral femoral shaft into the femoral head, aiming for the inferior-central position in the femoral head on both AP and lateral views, as recommended by recent guidelines 1.
• The guide wire position is confirmed with fluoroscopy, ensuring it is centrally placed in the femoral head with appropriate tip-apex distance (ideally less than 25mm).
• After measuring the required screw length, the femoral head is reamed over the guide wire to the appropriate depth.
• The lag screw is then inserted over the guide wire until it reaches the predetermined depth.
• The DHS plate (typically 135° angle) is attached to the lag screw and secured to the lateral femoral shaft with cortical screws.
• Final fluoroscopic images are obtained to confirm adequate reduction and proper implant position.
• The wound is thoroughly irrigated, hemostasis is achieved, and the incision is closed in layers.
• Postoperatively, patients typically begin weight-bearing as tolerated with assistive devices, progressing based on fracture healing and stability, with careful management of intra-operative blood pressure and consideration of age-appropriate anesthesia doses, as suggested by recent research 1.

Considerations for Optimal Outcomes

• The choice of surgical technique, such as the use of a sliding hip screw for stable intertrochanteric fractures, is supported by strong evidence 1.
• The importance of careful peri-operative care, including the management of intra-operative hypotension, cannot be overstated, as it is associated with significant increases in postoperative mortality 1.
• Recent guidelines emphasize the need for standardized anaesthesia techniques and continuous quality improvement initiatives to monitor peri-operative performance and improve patient outcomes 1.

From the Research

Operative Procedure for Managing Intertrochanteric Fracture using Dynamic Hip (DH) Screw Plating

The operative procedure for managing an intertrochanteric fracture using Dynamic Hip (DH) screw plating involves several steps. Although the provided studies do not give a step-by-step guide, we can infer the general process from the information given:

• Preoperative planning: This includes evaluating the patient's condition, assessing the fracture type, and selecting the appropriate implant size and type 2, 3, 4.
• Reduction and fixation: The fracture is reduced, and the dynamic hip screw is inserted to stabilize the fracture. The screw is typically placed in the femoral head, and the side plate is attached to the femoral shaft 5, 6.
• Compression and stabilization: The dynamic hip screw allows for controlled compression of the fracture, promoting healing and stabilization of the fracture site 2, 6.
• Postoperative care: Patients are typically monitored for complications, such as screw cut-out or fracture nonunion, and undergo rehabilitation to regain mobility and strength 2, 3, 4.

Key Considerations

Some key considerations when using dynamic hip screw plating for intertrochanteric fractures include:

• Implant selection: The choice of implant, such as a standard DHS or a locking DHS, can affect the outcome of the procedure 2.
• Surgical technique: The surgical technique used can impact the stability and healing of the fracture 6.
• Patient factors: Patient factors, such as bone quality and age, can influence the outcome of the procedure 3, 4.

Comparison with Other Treatments

Dynamic hip screw plating has been compared to other treatments, such as proximal femoral nailing and locking compression plating, in terms of outcomes and complications 3, 4. The choice of treatment depends on various factors, including the fracture type, patient condition, and surgeon preference.

Biomechanical Effects

The biomechanical effects of dynamic hip screw plating have been studied, with results showing that it can provide stable fixation and promote healing of intertrochanteric fractures 5, 6. However, the biomechanical effects can vary depending on the implant design and surgical technique used.

Some of the key findings from the studies include:

• The dynamic hip screw can provide better stress distribution and stability than other implants, such as the triangle support fixation plate 5.
• The use of a locking side plate can reduce the risk of screw cut-out and improve the outcome of the procedure 2.
• The limited dynamic hip screw technique can provide better biomechanical effects than the standard dynamic hip screw technique 6.