Surgical Management of Intertrochanteric Femoral Fractures

Pre-operative Considerations

The American Academy of Orthopaedic Surgeons recommends surgery within 24-48 hours of admission for better outcomes in elderly patients with intertrochanteric femoral fractures 1
Either spinal or general anesthesia is appropriate for this procedure, with spinal anesthesia potentially reducing postoperative confusion in elderly patients 1, 2
Tranexamic acid should be administered at the start of the procedure to reduce blood loss and need for transfusion in patients undergoing bipolar hemiarthroplasty 1

Proper padding of bony prominences is crucial to prevent pressure injuries in patients positioned in lateral decubitus during surgery 2

The gluteus maximus muscle should be split in the direction of the muscle fibers to minimize damage during the posterior approach 2
The sciatic nerve should be identified and protected throughout the procedure to prevent nerve damage 3

A two-step osteotomy technique may be used for intertrochanteric fractures, with the first osteotomy at the base of the femoral neck 3

The femoral canal should be exposed and any fracture debris removed to ensure proper implant placement 3
Trial reduction with provisional implants should be performed to assess stability, leg length, and offset 3

Cemented femoral stems are recommended for elderly patients with osteoporosis, as suggested by the American Academy of Orthopaedic Surgeons 1, 2, 4
The femoral canal should be thoroughly cleaned and dried before cement application, and the cement restrictor should be inserted at the appropriate depth 3
The final stem should be inserted with 5-10° of anteversion and held in position until the cement hardens 3

The abductor mechanism should be properly tensioned to ensure stability and prevent dislocation 2

The hip should be reduced by gentle traction and internal rotation, and the range of motion and stability should be tested to ensure no impingement or dislocation 3

The posterior capsule and short external rotators should be repaired to reduce dislocation risk, although the specific technique may vary 2
The wound should be closed in layers, and a sterile dressing should be applied 2

Appropriate VTE prophylaxis should be administered to prevent venous thromboembolism in patients after bipolar hemiarthroplasty 3

Meticulous sterile technique and appropriate perioperative antibiotics are crucial to prevent infection in patients undergoing bipolar hemiarthroplasty 2