This document discusses femoral neck fractures in the elderly and treatment options. Displaced femoral neck fractures have a high risk of failed fixation, non-union, and avascular necrosis. Hemiarthroplasty reduces reoperation needs and allows early weight bearing, but is a bigger operation with possible serious complications. Strong indications for hemiarthroplasty include fractures that cannot be fixed stably, fractures that lose fixation after initial operation, and patients who cannot withstand two operations. Careful planning and technique are important to achieve proper alignment and positioning of the prosthesis.

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 !