PROCEDURE 18 Femoral Neck Fractures: Arthroplasty

Richard A. Boyle, James P. Waddell

Indications

Displaced intracapsular fractures of the femoral neck

• Absolute: elderly, osteoporotic bone, pathologic fracture, evidence of antecedent symptomatic arthritis

• Relative: younger, more active patients; fractures occurring over 6 hours prior

Failed internal fixation, malunion, nonunion, and osteonecrosis

PITFALLS

• Unrecognized fracture displacement

• Complex fracture patterns, including intertrochanteric or calcar extension

Controversies

• When to attempt internal fixation instead of arthroplasty

• Use of monopolar, bipolar, or total hip arthroplasty—differing physiologic ages, osteopenic bone, presence of acetabular degradation

• Use of cemented or uncemented components

• Use of larger femoral heads with total hip arthroplasty

• Use of hard-on-hard bearing surfaces

• Surgical approach

Treatment Options

• Cemented or uncemented components with a monopolar, bipolar, or total hip articulation may be used, with varying articulation sizes and materials available.

• Approaches include anterolateral, direct lateral, and posterior (described here). General wisdom dictates that the approach used should be that with which the surgeon is most comfortable or familiar.

PEARLS

• Pressure mat on operating table

• Anterior support superior enough to allow full hip flexion for femoral canal exposure

• Posterior support superior enough to allow adequate exposure

Examination/Imaging

True anteroposterior (Fig. 1) and lateral plain radiographs should be obtained.

Occasionally computed tomography is required to elucidate complex fracture patterns and to assess posteromedial calcar.

FIGURE 1

Surgical Anatomy

Anatomic structures specific to the posterior approach to the hip are noted here.

Piriformis tendon plus short external rotators are taken down, and repaired on closure (Fig. 2).

Posterior capsule

• A capsulotomy is performed, and the posterior capsule repaired where possible.

• The capsule is often torn secondary to the fracture.

The surgeon must be aware of the proximity of the sciatic nerve.

FIGURE 2

Positioning

The patient is placed in the lateral decubitus position on a padded table with supports (Fig. 3):

• Anteriorly, the pubic symphysis or anterior superior iliac spine

• Posteriorly, the lumbosacral junction/upper sacrum

A pillow is placed between the legs, and the contralateral hip and knee are flexed.

The upper body is strapped securely with an axillary roll on the dependent side, with pressure areas supported and well padded.

FIGURE 3

PITFALLS

• Ensure true pelvic perpendicularity for acetabular alignment (with total hip arthroplasty).

• Preparation and draping of the limb and buttock must be posterior and superior enough to allow wound exposure.

Equipment

• Pressure mat

• Side supports

• Bolsters or bean bag

Portals/Exposures

A lateral longitudinal incision is made, centered on the greater trochanter with the proximal portion curved or angled posteriorly (Fig. 4).

The fascia lata is split distally in line with the femur, tensor, and gluteus maximus and proximally in line with the muscle fibers (Fig. 5).

The inferior edge of the gluteus medius is identified and retracted superiorly to expose the piriformis tendon and superior joint capsule (Fig. 6).

The leg is gently adducted and internally rotated.

The piriformis is released at or near its attachment deep to the posterior margin of the greater trochanter in the surgical view, and can be tagged for later identification and repair (Fig. 7).

The remaining short external rotators are likewise released and separated from the posterior joint capsule (Fig. 8).

An arcuate capsulotomy is performed, with maintenance of capsular tissue when possible.

Further internal rotation exposes the femoral neck.

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

FIGURE 8

PEARLS

• A difficult internal rotation may require further release of the quadratus femoris and hip capsule toward the inferior neck.

• Tagging the incised capsular margins aids exposure, acts as a reduction guide, and helps prevent infolding of soft tissue on reduction; it also allows identification for repair.

PITFALLS

• Regular anatomy can be distorted. Careful identification of key structures is vital, including the sciatic nerve, which can be displaced into proximity with the femoral neck.

Instrumentation

• Standard hip arthroplasty instrumentation is used.

Controversies

• Maintenance of the piriformis where possible—it can make exposure more difficult.

Procedure

STEP 1: FEMORAL NECK CUT AND EXCISION OF FEMORAL HEAD

The femoral neck is cut at the desired height, which is determined by preoperative templating specific to the chosen implant. Cutting the neck first allows for easier exposure and removal of femoral head (Fig. 9).

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