Surgery is the mainstay of treatment for neck of femur fracture. It is a surgical emergency as the risk of avascular necrosis and non union increases as time passes by. The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty. The types of surgery include femoral pinning, sliding hip screw and prosthetic replacement.

• Surgery is the mainstay of treatment for neck of femur fracture.^[1][2][3]
• The decision-making process for determining the best surgical procedure uses both the fracture type and the patient’s activity level to choose between internal fixation and arthroplasty.
• In addition, the timing of surgery is also extremely vital.
• Recent studies have shown that the incidence of avascular necrosis and nonunion is decreased by fixation within 12 hours after injury.^[4][5]

• Femoral Neck Pinning
• Sliding Hip Screw
• Prosthetic Replacement
  • Partial Hip Replacement
  • Total Hip Replacement

Indications

• Valgus impacted neck of femur fracture
• Garden type I or II in the elder individuals.
• Displaced neck of femur fracture in young patient

Implant

• Cannulated cancellous screw

Technique

• Three cannulated screws placed in an inverted triangular pattern.^[6][7]
• The emphasis is particularly placed on screws buttressing the inferior and posterior neck cortices.
• The starting point is at or above the level of lesser trochanter to avoid fracture.

Positioning

The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.^[8]

Order of Screw placement

The order of screw placement is as follows:

• 1st – Inferior screw along calcar
• 2nd – Posterior and superior screw
• 3rd – Anterior and superior screw

• It is biomechanically superior to cannulated screws.^[9]
• Additional cannulated screw should be placed above the sliding hip screw to prevent rotation.
• It allows dynamic compression at fracture site during axial loading.
• But, it can cause shortening of femoral neck.

Indications

• Basicervical fracture
• Vertical fracture pattern in a young patient

Implant

• Richard screw with barrel plate

Positioning

The patient is scissored on a fracture table with the non-operative hip extended and the operative hip slightly flexed to allow for lateral imaging.^[8]

Technique

• A small, about 5-10 cms incision is made just lateral to the inferior aspect of the greater trochanter.^[10][11]
• Dissection is taken through skin and fascia; no significant anatomic structures are at risk in this direct lateral approach.
• The exact point of incision can be determined under fluoroscopy by using a guide pin and determining trajectory of screw placement.
• The goal for guide pin placement is for the tip of the pin to be in a central location in both AP and lateral views and deeply inserted in to the subchondral bone of the femoral head.
• The tip apex distance, which is the summed value on AP and lateral radiographs is aimed to be less than 25 mm.^[12]
• The guide wire is measured and the reamer set to the appropriate depth.
• The lag screw is then placed, followed by the appropriate angled side plate.

The various approaches to the hip include:^[13][14]

Anterior Smith Peterson Apporach

• A 10 cms skin incision made beginning just distal to anterior inferior iliac spine.^[15]
• This is followed by incising the deep fascia.
• Develop an interval between tensor fascia lata and sartorius.
• The thigh must be externally rotated while dissecting the plane.
• Sartorius along with Lateral femoral cutaneous nerve are retracted medially.
• The tendinous portion of rectus femoris is identified and elevated off the hip capsule.
• The capsule is incised and the femoral neck is exposed.

Anterolateral Watson-Jones Approach

• A skin incision is started approximately 2 cms posterior and distal to anterior superior iliac spine and down toward tip of greater trochanter.^[16]
• The incision curved distally and extended 10 cms along anterior surface of femur.
• The deep fascia is incised.
• Then develop an interval between gluteus medius and tensor fascia lata.
• The anterior aspect of gluteus medius and minimus are retracted posteriorly to visualize anterior hip capsule.
• Then the capsule is incised with a Z-shaped incision.
• The capsular incision must remain anterior to lesser trochanter at all times in order to avoid injury to medial femoral circumflex artery.

Posterior Southern or Moore Approach

• A skin incision is made 10 to 15 cms, curved, beginning one inch posterior to posterior edge of greater trochanter and 7 cm above and posterior to greater trochanter and continue down the shaft of femur.^[17]
• An incision is made on fascia lata to uncover vastus lateralis distally.
• The fascial incision is lenghtened in line with skin incision.
• The fibers of gluteus maximus are split in proximal incision.
• Then, internally rotate the hip to place the short external rotators on stretch.
• The stay sutures are placed in piriformis and obturator internus tendon.
• Piriformis and obturator internus are detached close to femoral insertion and reflected backwards to protect the sciatic nerve.
• The capsule is incised with a longitudinal or T-shaped incision.
• The hip is finally dislocated with internal rotation.

• The posterior approach has increased risk of dislocations.^[18]
• The anterolateral approach has increased risk of abductor weakness.

Indications

• Debilitated elderly patients
• Metabolic bone disease

Implant

• Unipolar prosthesis – Austin Moore prosthesis
• Bipolar prosthesis

Technique

• The femoral neck is exposed.^[19]
• The head and neck of femur are excised.
• The head sized is measured.
• The femoral canal is reamed and prepared.
• The trial implant are placed and sizing is confirmed.
• The decision on cemented Vs. non cemented is determined based on age and bone quality.
• The final implant is placed and reduction is done.
• The wound is closed in layers.

• Total hip replacement provides the best results of any form of prosthetic replacement for displaced femoral neck fracture.^[20]
• But has a higher risk of dislocation compared to hemiarthroplasty.^[21][22][23]

Indications

• Patients with preexisting hip osteoarthritis
• Garden type III or IV in patient less than 85 years

Implants

• Cemented
• Press-fit (uncemented)
  • Tapered stems
  • Porous coated stems
  • Modular stems

• Cemented
  • Polyethylene
  • Metal
• Press-fit (uncemented)
  • Metal

• Polyethylene
• Metal
• Ceramic

Technique

• The anterolateral approach is usually preferred.^[24]
• Use of a larger head in the setting of a femoral neck fracture is usually advised.

• Patients should sit up and get out of bed as soon as possible after surgery, preferably on the day of the operation.^[25]
• Early ambulation is associated with accelerated recovery and shorter length of stay.^[26]
• Physical therapy for chest and passive range of motion is recommended.

Complications of surgery include:^[27][28]

• Periprosthetic fracture
• Implant breakage
• Implant cut out
• Dislocation
• Osteonecrosis
• Non union
• Complications Of Prolonged Recumbency such as:
  • Hypostatic pneumonia
  • Pressure sores
  • Deep venous thrombosis
  • Pulmonary embolism
  • Cardiac failure due to weakening of the cardiac muscle and poor venous return
  • Muscle wasting
  • Common peroneal nerve palsy
  • Stiffening of joints
  • Osteoporosis
  • Urinary tract infections
  • Depression