For education

2. Femoral neck fractures at a glance
Apley
 20 % # NOF is associated with # SOF
 Mortality rate in elderly is as high as 20 % at 4
months after injury
 Among survivors over 80 years , about 50 % fail to
resume independent walking
 30 % of displaced fractures – AVN
 10 % of undisplaced fractures – AVN
 AVN in > 45 yrs – THR
 > 30 % all # NOF – nonunion ; high risk in severely
displaced fractures

3. Displaced intracapsular femoral
neck fractures in the elderly have
a high risk of :
Failed fixation
Non-union
Avascular necrosis
Hemiarthroplasty
Reduces the need for
reoperation
Early weight bearing
Bigger operation
Possible serious complications

4. Stronger indications : Campbell
1. A fracture that cannot be satisfactorily reduced or
fixed with stability, especially with posterior
comminution
2. # NOF that lose fixation several weeks after
operation ( Failure )
3. Some pre-existing lesions of the hip
4. Malignancy
5. Neurological disorders

5. Stronger indications : Campbell
6. Old , undiagnosed fractures
7. # NOF with complete dislocation of femoral head
8. A patient who probably cannot withstand two
operations
9. Patients with psychoses or mental deterioration

6. Indication for hemiarthroplasty :
Handbook
 Comminuted, displaced femoral neck fracture
in the elderly
 Pathologic fracture
 Poor medical condition
 Poorer ambulatory status before fracture
 Neurologic condition (dementia, ataxia,
hemiplegia, parkinsonism)

7. HEMIARTHROPLASTY:Handbook
CONTRAINDICATIONS
Active sepsis
Active young person
Pre-existing acetabular disease (e.g.,
rheumatoid arthritis)

8. Carefully plan with sufficient detail
Select the prosthesis with radiographic templates
and appropriate x-rays of the normal & injured hip
Besides the selected prosthesis, possible alternatives
should be available in the operating room
Radiologically measured femoral head size is 10 % smaller than the actual size.

9. Position of the patient
Position - the true lateral position
The afftected limb is placed uppermost
Pads – to protect the bony prominences of
the legs and pelvis ( under the LM and
knee of the bottom leg
A pillow - between the knees
Drape the limb free to leave room for
movement during the procedure

10. Posterior approach : Skin incision
Incision – 10 cm distal to PSIS
Extension - distally and laterally parallel with the fibers of the G.
maximus to the posterior margin of the GT
Direct the incision distally 10 to 13 cm parallel with the femoral
shaft
Bony landmarks are
PSIS , GT & the shaft of
the femur

11. SUBCUTANEOUS INCISION
Direct the incision distally
10 to 13 cm parallel with
the femoral shaft

12. Skin & subcutaneous incision

13.  There is no true internervous plane
 Split the fibers of the G. maximus ( procedure that does not
cause significant denervation of the m/s )

14. • Retract the G. maximus to reveal the fatty layer
over the short external rotators of the hip

15. Blunt dissection using fingers

16. Blunt dissection in muscle plane

17. Push the fat posteromedially to expose the insertions of the short
rotators
Note that the sciatic nv is not visible
It lies within the substance of the fatty t/s
Place your retractors within the substance of the G. maximus
superficial to the fatty t/s

18. Charnley ‘s seft retaining retractor

19. • Internally rotate the femur to bring the
insertion of the short rotators of the hip as far
lateral to the sciatic nerve as possible
• Detach the short rotator muscles close to
their femoral insertion
• Reflect them backward, laying them over the
sciatic nerve to protect it

20. Assistant handles the leg like that : flexion ,
adduction & internal rotation

21. Rotators come into view : surgeon’s finger
is hooking up of bunch of rotators

22. Dissection of rotators using diarthermy

25. Opening the capsule : Capsulotomy using inverted T
shape or longitudinal or H shape incision ( AO )

26. • The operation begins with adequate exposure
of the fracture site through a sufficient
capsular incision
• For hemiarthroplasty, the acetabular labrum
should be preserved, as it improves stability.

27. Fractured site comes into view

28. Fractured neck of femur

29. • Next, remove the femoral head
• Use a “corkscrew” (threaded handle), as
illustrated, retracting the distal femur, and
dividing the ligamentum teres as necessary

31. Osteotomy of the neck with nippler

34. After removal of the head
• Gauze roll is kept in the joint

35. 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
IM cancellous bone is progressively removed, usually with a
series of rasps, until the prosthesis fits appropriately within the
medullary canal

36. Reaming

37. Reaming again & again

38. Measure the head ‘s size
If head size is 44 mm , choose 43
mm head size
 Bigger prothesis size –
dislocation
Smaller prothesis size – 2’ OA

39. 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

40. 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.

41. • 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

42. Pitfall : Short femoral neck
• Too short a femoral neck can result in
insufficient muscle tension, which may
increase the risk of a postoperative dislocation
of the prosthesis, or hip abductor weakness
• Usually, at least a centimeter or two of neck
should remain proximal to the lesser
trochanter
• Plan carefully according to the prosthetic
design

43. Wash out the joint with N/S &
never miss to remove the gauze roll

44. Suction by assistant

45. The prosthesis must be correctly aligned in the femoral
transverse plane
The neck of the femoral component should usually be co-axial
with the femoral neck, as in the illustration
"β” - the angle of anteversion of the femoral neck, and of the
prosthesis
Avoid excessive anterior rotation (anteversion), and especially
posterior rotation (retroversion), as the latter predisposes to
dislocation of the prosthetic hip

46. Correct rotational alignment
• Achieve by cutting the femoral neck
perpendicularly to its axis (to accept a flange
on the prosthesis)
• Maintain the desired anteversion while
preparing the femoral medullary canal with
rasps and broaches

47. As shown by flexing the knee to 90°
An assistant holds the leg internally rotated, so that the tibia is
perpendicular to the table surface
The anteversion angle of the femoral neck and prosthesis (β =
approximately 15° ) is then estimated as illustrated

48. Measure the anteversion

49. 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

50. Start to insert ; assistant steadies the
angle

54. Traction by assistant

55. Assistant is maintaining steady traction while the
surgeon manages to put the prothesis into the joint

56. With the hip reduced, confirm range of motion and stability
Confirm complete reduction, stability, and range of motion

59. • Then capsular repair
• D/T insertion
• Myoplasty
• Close layer by layer

60. THANK YOU !