Pre-operative planning

Intracapsular left hip fracture

Diagnosis: Intracapsular left hip fracture

Aim: To minimize patient discomfort,
To restore hip function,
And allow rapid mobilization by obtaining early anatomic
reduction
Anesthesia: Spinal anesthesia

Position: Right lateral position

Surgery: Modular bipolar hemiarthroplasty

Implants:

Approach: Anterolateral approach(Watson-jones)

Skin incision about 7-10 cm proximal of the lateral part of the

greater trochanter (directed towards the tubercle of the iliac crest –
the posterior landmark of tensor fascia lata origin). Distally, the
incision extends along the femur about 10 cm below the greater

trochanter.
Expose the fascia lata sharply. Incise the fascia lata over the femur
and extend this incision proximally along the posterior border of the
tensor fascia lata.

With the greater trochanter and the gluteus medius muscle exposed,
retract the tensor fascia lata anteriorly and the gluteus medius
muscle posteriorly. Expose the interval between the gluteus medius
and the tensor fascia lata and extend it proximally over the hip joint.
This can be best done by blunt dissection.
Be aware of vessels running across this interval. They require
ligation or cautery.

Exposure of hip capsule

Place a Hohmann retractor into the bone proximal to the hip
capsule. Additional retractors anteriorly and posteriorly will open
the dissected interval.
External rotation of the leg improves access to the hip capsule .
Anterior release of vastus lateralis
The origin of the vastus lateralis muscle should be released from the
anterior inferior trochanteric region to expose the underlying hip
capsule. Retract the muscle inferiorly.
Adjust the retractors as necessary, and debride periarticular fat to
expose the hip capsule.

Make an T-shaped incision in the capsule,

and place two retraction sutures, anteriorly and posteriorly. Protect
the acetabular labrum.
This capsulotomy shows the anterior femoral head and neck. Lateral
traction and repositioning of the leg can improve visualization.
The incision can be extended distally over the proximal vastus
lateralis to allow insertion of screws or DHS for femoral neck
fracture fixation.
For hemiarthroplasty, the acetabular labrum should be preserved,
as it improves stability.
Next, remove the femoral head. Use a “corkscrew” (threaded
handle), as illustrated, retracting the distal femur, and dividing the
ligamentum teres as necessary.
An additional osteotomy of the femoral neck is usually required to
obtain correct neck length and to fit the flange of the prosthesis (if
there is one).
Inspect the acetabulum and remove small bone fragments. If
arthrosis of the acetabulum is observed, a total hip prosthesis might
be preferable to a hemiprosthesis.
To determine the diameter of the femoral head component, measure
the removed femoral head. The chosen size should be confirmed by
manually testing the fit of a trial femoral head prosthesis within the
acetabulum

Osteotomy of the femoral neck

Choose the correct level for the definitive osteotomy, which

determines the height of the prosthesis. The remaining femoral neck
should be long enough to maintain equal leg lengths, as well as
proper soft-tissue tension.
The orientation of the osteotomy depends on the chosen prosthesis.
It usually begins in the fossa below the greater trochanter. If the
prosthesis has a flange, the osteotomy must match this. The
osteotomy should also be perpendicular to the axis of the femoral
neck, so the prosthetic anteversion is correct
Correct rotation of the prosthesis, using an anterolateral approach, with
the patient in the lateral decubitus position

Exposure of the proximal femur is accomplished by careful

placement of the involved limb in an externally rotated and flexed
position with the lower leg hanging over the edge of the operating
table. To maintain sterility, the lower leg is inserted into an
envelope or pocket made from a sterile sheet. The assistant holds
the patient’s leg perpendicular to the table surface, which is thus the
plane of the knee axis. Proper anteversion is achieved by externally
rotating the femoral prosthesis, so its neck is aimed approximately
15° anteriorly to the knee axis (or table surface).
Medullary preparation

The femoral awl is inserted, initially laterally, in the femoral neck,

and rotated to match the femoral neck anteversion (approximately
15°). The lateral starting point helps avoid varus malposition.
Intramedullary cancellous bone is progressively removed, usually
with a series of rasps, until the prosthesis fits appropriately within
the medullary canal.
Although the size of the femoral stem was estimated with
preoperative planning, it should be confirmed definitively by the fit
of the rasp within the medullary canal.
Choice of the right stem size

If an uncemented implant is used, the stem of the prosthesis should

snugly fill the prepared medullary cavity.
If cement is used, the stem size should be somewhat smaller than
the prepared medullary cavity to allow for an appropriate layer of
cement.

Introduction and correct position of the prosthesis in the frontal plane

The prosthesis is introduced into the prepared femoral medullary
canal. Because both the femur and the prosthesis are eccentrically
loaded, bending forces are acting on the prosthetic head, forcing the
prosthetic stem in varus. The prosthesis – cemented or uncemented
- should be inserted in valgus orientation, with the proximal stem
laterally, and its distal tip close to the medial femoral cortex.
This illustration shows a cemented femoral stem with correct valgus
alignment on the left and excessive varus on the right.

Cementing technique

Since new cementing techniques have been introduced, the long-

term results of the cemented prosthesis have been considerably
improved.
A cement restrictor, placed a centimeter or so below the prosthesis,
allows the cement to be pressurized so that it flows into the
cancellous bone rather than into the distal femur.
Before inserting cement, clean the canal with irrigation and an
appropriate brush. Place a temporary dry sponge in the canal, to be
removed just before the cement is inserted.
By mixing the cement liquid and powder in a low-pressure
container, air bubbles are avoided, and the cement is stronger.
Prosthesis insertion

Before the cement hardens, the prosthesis is inserted with correct

rotation (anteversion) and valgus alignment. It must be placed to
the appropriate, predetermined depth. Once the stem is seated,
allow the cement to set undisturbed. Trim off any excessive cement,
and carefully remove all cement fragments from the hip joint and
surrounding wound.
Assembly of the prosthesis

For a hemiarthroplasty, use a trial femoral head prosthesis on the

cemented stem to confirm both diameter and neck length. The latter
affects both leg length soft-tissue tension, and hip stability.
For total hip arthroplasty a similar trial prosthesis is used to check
length and offset. Head size, however, is determined by the
preoperatively selected acetabular component. Total hip prostheses
with larger heads tend to be more stable.

With the hip reduced, confirm range of motion and stability. Adjust
the neck and head if necessary.
Once satisfactory, attach the definitive femoral head to the stem, and
reduce the hip. Confirm complete reduction, stability, and range of
motion
Post-operative Management:
First 6 weeks, the patient should avoid  adduction across the midline, hip
flexion of more than 80° to 90°.

Full weight bearing can usually be allowed immediately (cemented

prosthesis). The patient should begin with a walker (walking frame) and be
instructed in safe transfers and gait.