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Key Techniques in Orthopaedic Surgery

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risk of
inadvertently sewing in the drain.
28. Make two drill holes in the posterolateral aspect of
the greater trochanter approximately 1 cm apart (it
may be easier to make these drill holes prior to
reducing the hip).
29. Pull the tagging sutures of the posterior capsule and
short external rotators through the holes. Tie the
capsule sutures to each other; then tie the short
external rotator sutures to each other (Fig. 20–10).
30. If possible, repair the quadratus femoris muscle-
31. Repair the tendinous insertion of the gluteus max-
imus with absorbable sutures.
32. Close the deep fascial layer in a meticulous fashion
with multiple absorbable sutures (normally zero or
number one).
33. Close the subcutaneous tissue in a layered fashion
with interrupted absorbable sutures (normally num-
ber one, zero and 2-0 sutures).
34. Close the skin with staples, nylon, or prolene.
35. Apply a sterile dressing and a compressive bandage
to the hip.
36. Transfer the patient off the operating table taking
care to avoid excessive hip rotation or flexion.
Transfer the patient to recovery room.
37. Obtain a radiograph in the recovery room to ensure
the hip is reduced.
Suggested Readings
Huo MH, Waldman BJ. Cemented total hip
replacement. In: Craig EV, ed. Clinical Orthopaedics.
Baltimore, MD: Lippincott Williams & Wilkins, 1999,
pp. 522–534.
Nestor BJ, Buly RL. Cementless total hip arthroplasty.
In: Craig EV, ed. Clinical Orthopaedics. Baltimore, MD:
Lippincott Williams & Wilkins, 1999, pp. 535–548.
Pellicci PM, Padgett DE. Atlas of Total Hip Replacement.
New York, NY: Churchill Livingstone, 1995.
Sharrock NE, Minco R, Urquhart B, Salvati EA. The
effect of two levels of hypotension on intraoperative
blood loss during total hip arthroplasty performed
under lumbar epidural anesthesia. Anesth Analg
2 0 TOTA L H I P A RT H R O P L A S T Y 1 3 3
Compression screw and side plate
1. Intertrochanteric hip fracture (Fig. 21–1A)
2. Low femoral neck fracture (“base of neck” fracture)
Multiple cannulated screws
1. Impacted femoral neck fracture (Fig. 21–1B)
2. Displaced femoral neck fracture (in younger patient
after “satisfactory” reduction)
1. Medical contraindications
2. Nonambulatory patient (relative—must individualize)
Preoperative Preparation
1. Hip radiographs
2. Appropriate medical and anesthetic evaluation
3. Document status of preoperative neurovascular
Special Instruments, Position, 
and Anesthesia
1. The patient is placed supine on the fracture table
(Fig. 21–2).
2. All pressure points should be padded.
3. The procedure can be done with general, spinal or
epidural anesthesia.
Tips and Pearls
1. Assess the adequacy of the fracture reduction after
positioning the patient on the fracture table, but
prior to prepping and draping. Use fluoroscopy in
two planes to evaluate the reduction.
2. Most intertrochanteric fractures can be reduced
with longitudinal traction and internal rotation.
3. Femoral neck fractures may require live fluoroscopy
to aid reduction.
4. Administer intravenous antibiotics appropriate for
the hospital’s bacterial flora prior to skin incision.
5. Take care to ensure adequate padding of the feet
and lower extremities.
6. Position the noninjured extremities so they do not
interfere with the fluoroscopy. Commonly, the con-
tralateral lower extremity is positioned in a flexed
and abducted position. The ispilateral upper extrem-
ity is taped across the anterior chest wall.
What To Avoid
1. If possible, avoid a varus hip reduction.
2. For intertrochanteric fractures, attempt to avoid
medial displacement of the proximal fragment and
concurrent lateral displacement of the femoral shaft.
3. For impacted femoral neck fractures, avoid exces-
sive traction, which could serve to disimpact the
fracture fragments.
1 3 4
C H A P T E R 2 1
Internal Fixation of Hip Fracture
Steven H. Stern
4. Avoid placing the cannulated screws below the level
of the lesser trochanter. This can result in a “stress
riser” in the lateral femoral cortex and increase the
risk of a subtrochanteric fracture.
5. Avoid allowing the guidepin to penetrate through
the femoral head into the soft tissues of the pelvis.
Postoperative Care Issues
1. When medically possible, attempt to mobilize the
patient in the postoperative period. If the medical
condition permits, the patient should be placed in a
sitting position as expeditiously as possible.
2. Consider utilizing some form of deep-vein thrombosis
prophylaxis. Options include warfarin, low-molecu-
lar weight heparin, and intermittent pneumatic
3. Depending on the fracture stability, adequacy of the
reduction and the patient’s bone quality, ambula-
tion can commence either with non-weight bearing
(NWB), toe-touch weight bearing (TTWB) or weight
bearing as tolerated (WBAT).
4. Reassessment of the distal neurovascular examina-
tion should be done after surgery.
Operative Technique
Compression screw and side plate
1. Position the patient supine on the fracture table.
The patient should be positioned directly against
the groin post. Pad the extremities. Most fractures
can be reduced with a combination of traction and
internal rotation. The degree of internal rotation can
be assessed by evaluating knee rotation (Fig. 21–2).
2. Prior to prepping and draping the patient, evaluate
the fracture using biplanar fluoroscopy. It is impor-
tant prior to draping to assess the patient’s position
to ensure that the fluoroscopic C-arm adequately
obtains satisfactory AP and lateral hip images. Opti-
mize the fracture reduction at this time.
3. Prepare and drape the patient and extremity per the
hospital’s standard sterile protocol. Commonly, a
large plastic drape (“shower curtain”) is utilized.
4. Obtain an AP hip fluoroscopic image to assist in
positioning the skin incision. Place a metal clamp
or Steinman pin on the anterior thigh so it serves as
a visible landmark on the fluoroscopic image.
5. Make a skin incision along the lateral aspect of the
thigh. Palpate the femur to ensure that the incision
is positioned in the femur’s AP mid-point. The skin
incision should be approximately 15 cm in length.
The incision’s proximal pole should extend 1 to 
2 cm proximal to the lesser trochanter (Fig. 21–3).
6. Carry the dissection directly through the subcuta-
neous tissue. Maintain adequate hemostasis. Identify
the tensor fascia lata (Fig. 21–4).
7. Sharply incise the tensor fascia lata longitudinally.
Place retractors deep to the tensor fascia lata.
Identify the vastus lateralis.
8. Retract the vastus lateralis anteriorly. Sharply incise
the fascia of the vastus lateralis longitudinally. This
incision is positioned to allow dissection through
the posterior one-third of the vastus lateralis. Take
care to incise only the fascia and not the muscle
(Fig. 21–5).
9. Use a periosteal elevator to bluntly dissect through
the muscle fibers of the vastus lateralis. Carry the
dissection down to the femur. Place a Bennett retrac-
tor over the anterior femur so it lies against the
medial femoral cortex. Use it to retract the soft tis-
sues medially to enhance visualization (Fig. 21–6).
10. Use a medium- (~3.5 mm—commonly, the drill bit
that will be used later in the procedure for the cor-
tical screws is used) size drill bit to locate the opti-
mal starting point on the lateral femoral cortex 
for the compression screw. Optimize the superior-
inferior starting hole position by evaluating AP
fluoroscopic hip images. Generally, the starting
hole should be at or below the level of the lesser
trochanter. Palpate the femur to ensure that the
starting hole is midway between the anterior and
posterior femoral cortex (Fig. 21–6).
11. Drill the hole through