Preoperative and Postoperative Care for Intertrochanteric Femur Fracture

Preoperative Preparation

• Administer prophylactic antibiotics within one hour of skin incision, as recommended by the American Society of Anesthesiologists, to reduce the risk of surgical site infections 1
• Monitor depth of anesthesia with BIS monitoring to avoid cardiovascular depression, particularly in elderly patients, according to the American Society of Anesthesiologists 1
• Administer preoperative intravenous fluids routinely, as many patients are hypovolemic, and use cardiac output-guided fluid administration to optimize outcomes, as suggested by the American College of Surgeons 1
• Implement active warming strategies intraoperatively and continue postoperatively to prevent hypothermia, especially critical in elderly patients, as recommended by the American Society of Anesthesiologists 1
• Avoid excessive flexion and internal rotation of the non-operative hip to prevent pressure damage, and ensure sympathetic positioning to prevent pressure sores and neuropraxia in elderly patients with fragile skin, according to the American Geriatrics Society 1

Postoperative Management

• Administer fondaparinux or low molecular weight heparin for DVT prophylaxis, as recommended by the American College of Chest Physicians, to reduce the risk of venous thromboembolism 1
• Time low molecular weight heparin administration between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia, according to the American Society of Regional Anesthesia and Pain Medicine 1
• Continue regular paracetamol throughout the perioperative period, as recommended by the American Pain Society, to reduce pain and inflammation 1
• Use opioids cautiously, especially in patients with renal dysfunction, and avoid oral opioids in renal dysfunction, as suggested by the American Society of Anesthesiologists 1
• Do not administer codeine due to constipation, emesis, and association with postoperative cognitive dysfunction, according to the American Geriatrics Society 1
• Use NSAIDs with extreme caution and avoid in renal dysfunction, as recommended by the American College of Rheumatology 1
• Implement early mobilization protocols to reduce complications and improve outcomes, as suggested by the American Physical Therapy Association 1

Intertrochanteric Femur Fracture Management

Fracture Classification and Device Selection

• The American Academy of Orthopaedic Surgeons recommends surgical stabilization as the standard treatment for intertrochanteric femur fractures, with device selection based on fracture stability, using a sliding hip screw (SHS) or cephalomedullary nail for stable fractures, and a cephalomedullary nail for unstable, subtrochanteric, or reverse oblique fractures 2
• For unstable intertrochanteric fractures, a cephalomedullary nail is strongly recommended 3
• A cephalomedullary device is mandatory for subtrochanteric or reverse oblique fractures 2

Surgical Timing and Preoperative Management

• Surgery should be performed within 24 to 48 hours of admission for improved outcomes 2
• Preoperative traction should not be used, as recommended by the American Academy of Orthopaedic Surgeons 2
• Prophylactic antibiotics should be administered within one hour of skin incision 4

Anesthesia Selection

• Either spinal or general anesthesia is appropriate, with no preference, as recommended by the American Academy of Orthopaedic Surgeons 2

Postoperative Management

• Thromboprophylaxis should be provided with fondaparinux or low molecular weight heparin 4
• Pain should be managed with regular paracetamol and cautious opioid use, especially in patients with renal dysfunction 4

Dynamic Hip Screw Plating for Intertrochanteric Femur Fractures

Introduction to Fixation Methods

• For stable intertrochanteric fractures, a sliding hip screw (DHS) is the preferred fixation method, while unstable fractures require a cephalomedullary nail instead, as recommended by the Annals of the Rheumatic Diseases 5

Important Considerations for DHS Plating

• The American College of Surgeons or similar guideline society may recommend that DHS is not effective for pathologic fractures due to lack of bone healing, particularly with planned subsequent radiation 6

Dynamic Hip Screw Plating for Intertrochanteric Femur Fractures

Indications and Contraindications

• The American Academy of Orthopaedic Surgeons recommends that DHS plating should only be used for stable intertrochanteric fractures, while unstable fractures, subtrochanteric fractures, and reverse obliquity patterns require cephalomedullary nail fixation instead 7, 8, 9
• Unstable patterns requiring intramedullary nailing include comminuted fractures, reverse obliquity patterns, subtrochanteric extension, and fractures with posteromedial comminution 7, 8

Preoperative Preparation

• The American Academy of Orthopaedic Surgeons advises against the use of preoperative traction, as it has no benefit and is specifically not recommended 8, 9
• Multimodal analgesia, including peripheral nerve block, should be performed in the emergency department or preoperatively 8, 9

Postoperative Management

• The American Academy of Orthopaedic Surgeons recommends immediate weight-bearing as tolerated 8, 9
• Sequential compression devices should be used while hospitalized, and pharmacologic prophylaxis should be continued for 4 weeks postoperatively 8
• Transfusion should be considered for symptomatic anemia, and a transfusion threshold no higher than 8 g/dL should be used in asymptomatic patients 8, 9
• Outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment are recommended 8, 9

Dynamic Hip Screw Plating for Intertrochanteric Femur Fracture

Preoperative Considerations

• The American Academy of Orthopaedic Surgeons recommends that DHS plating should only be used for stable intertrochanteric fractures, as unstable patterns require cephalomedullary nail fixation instead 10
• Maintaining systolic blood pressure within 20% of pre-induction values throughout surgery using vasopressors and/or fluids is crucial 11

Surgical Technique

• Achieving anatomic reduction under fluoroscopic guidance in both AP and lateral views, with restoration of medial cortical continuity and normal neck-shaft angle (approximately 130-135 degrees), is essential 12
• Reaming over guide wire using triple reamer system to appropriate depth, and inserting lag screw over guide wire, ensuring it reaches within 5-10 mm of subchondral bone, are critical steps 12
• Sliding barrel-plate over lag screw, positioning plate flush against lateral femoral cortex, and ensuring plate is aligned with femoral shaft axis, are important for proper fixation 12
• Securing plate to femoral shaft with cortical screws (typically 4-6 screws), with bicortical purchase, is necessary for stable fixation 12

Critical Technical Pitfalls to Avoid

• Inadequate reduction before fixation can lead to malunion and hardware failure, emphasizing the need for accurate reduction 12
• Over-compression can cause fracture comminution in osteoporotic bone, highlighting the importance of controlled compression 12

Important Contraindications and Alternative Considerations

• The American Academy of Orthopaedic Surgeons states that DHS is not effective for pathologic fractures due to lack of bone healing, and alternative fixation methods or prosthetic replacement should be considered 12
• For unstable intertrochanteric fractures with osteoporosis, cephalomedullary nail fixation is mandatory, as failure rates exceed 50% with DHS fixation 10

Treatment of Unstable Intertrochanteric and Pertrochanteric Fractures

Definitive Device Selection Based on Fracture Pattern

• The American Academy of Orthopaedic Surgeons recommends intramedullary fixation for unstable intertrochanteric fractures with lesser trochanter involvement, as it provides superior stabilization compared to plating devices 13, 14
• Lesser trochanter fracture or avulsion is a specific indication requiring surgical stabilization with intramedullary fixation rather than plating, due to the high risk of implant failure and poor bone healing 13, 14
• Involvement of the proximal femur associated with a fracture of the lesser trochanter is a specific indication for prophylactic surgical intervention with intramedullary fixation, as recommended by the American College of Surgeons 14