Hip fracture surgery
Internal fixation by screws is applied to undisplaced fractures; a joint prosthesis is only suitable for patients in whom sufficient consolidation of the bones is not expected.
The procedure should be performed on the day of the accident or the day after.
In younger patients, displaced fractures lying in the joint capsule are usually set up (repositioned) and fixed internally, in older people, the femoral head is replaced by an endoprosthesis.
The internal fixation represents the minor surgical trauma and is ideal as a first treatment approach, but carries the risk of further hip surgery.
Patients with pre-existing joint disease, medium or high levels of activity and a good life expectancy should consider a total endo prosthesis (TEP) of the hip instead of a hemi-endo prosthesis (HEP) as initial treatment.
The National Institute for Health and Clinical Excellence (NICE) recommends the insertion of an artificial hip joint (partial or full denture) in patients with displaced, intracapsular fractures.
An indication for a full denture is present in patients with displaced, intracapsular hernia if all of the following criteria are met:
- Patients are able to walk on their own, possibly with the help of a walking stick.
- They have no cognitive deficits.
- Their physical condition allows for anesthesia and surgery.
The following complications may occur: infections, bleeding, lack of consolidation, axis malposition of bone fragments and avascular necrosis of the bones.
The risk of postoperative complications is high in elderly patients; these include pneumonia, heart attack, stroke, deep vein thrombosis, pulmonary embolism and bedsores.
Extracapsular femoral neck fractures
About half of all hip fractures are located outside the joint capsule (proximal, extracapsular femoral fractures).
These fractures should be treated surgically if there are no contraindications.
As a rule, fractures outside the joint capsule are treated by internal fixation, but implantation of an artificial hip joint may also be necessary (if internal fixation appears inadequate, especially in the case of unstable fractures).
There is limited scientific evidence available and does not show any significant differences in the results of conservative treatment compared to surgical treatment in extracapsular femoral fractures. Nevertheless, the surgical intervention can be linked to shortened bedridden and better rehabilitation.
Insulated, trochanteric demolition fractures
A sudden, strong force can lead to a tear (avulsion) of the middle gluteal muscle attachment from the large rolling hill (trochanter major) or the lumbar iliac muscle (iliopsoas muscle) from the small rolling hill (trochanter minor).
Initial treatment: effective pain therapy.
Follow-up treatment: gradual, passive mobilisation and symptomatic treatment.
Subtrochanteric fractures include the proximal (close-to-body) femoral shaft at the level of the rolling hills and the slightly lower lying area.
As a rule, these fractures in young people are caused by considerable violence and accompanied by other serious injuries. In elderly patients and those suffering from osteoporosis or metastatic pathologies, a subtrochanteric fracture can develop as a result of minor trauma.
Such fractures are treated by intra- or extramedullary osteosynthesis. It turned out that the intramedullary method has a longer lasting fixation and fewer operations with poor results.
The National Institute for Health and Clinical Excellence prefers extramedullary implants with sliding screws in the hip to intramedullary nails for the treatment of trochanteric fractures located at the height and above the small rolling hill.
The bed must be low enough for the feet to touch the floor when sitting on the edge of the bed.
All sources of danger are to be condemned from the house.
The patient must learn to prevent falls. There must be no loose cables and cords in the passage areas.
Carpets should be removed, small pets do not roam freely around the house.
Irregular flooring and steps in the room entrance must be leveled. The living area should be well lit.
The bathroom also needs to be overhauled in terms of safety. Useful are grab bars in the bath, shower and next to the toilet, as well as a non-slip tub and shower insert.
Do not carry objects when walking, hands may be necessary for support.
What is needed should be stored in easily accessible places.
Organize the living area in such a way that no stairs have to be climbed; Here are some tips and advice:
- Move the bed or bedroom to the ground floor.
- A toilet or mobile toilet should be located on the floor where most of the day is spent.
- If you have no help in the house for the first 1-2 weeks, you can ask the doctor about outpatient nursing staff. This person can check the security in the house and give advice on how to carry out everyday activities.
- Follow the doctor’s or physiotherapist’s instructions to know when to put weight on the leg again.
For a while, loading the leg will be impossible; the patient must know how to correctly handle the walking stick, forearm crutches and walker.
- The exercises for muscle strengthening and mobility must be carried out further.
- Be careful not to maintain the same position for too long; the position shall be changed at least once per hour.
Return to sport
In case of traumatic femoral fractures, the clinic must be visited for regular check-ups: after 2 weeks, 6 weeks, 3 months, 6 months and 1 year after the accident.
A femoral fracture would have to be consolidated in 3 months. When the formation of the bone callus is complete, treatment focuses on active and passive rehabilitation to regain range of motion and strength. The progressive strengthening of the entire musculature of the lower limb must be continued until 95% of the performance of the healthy side is achieved.
Sport-specific rehabilitation begins when normal strength levels have been regained. The athlete would have to have reached his original, athletic performance level within a year. Long-term symptoms include: weakness of the hamstring, fatigue when walking and standing, intermittent pain and inability to resume work.
In the case of femoral fractures, at least 6 weeks are necessary for the bone to heal before the patient can resume his activities. The return to sport must be gradual over the course of several weeks. If symptoms become noticeable again during training, the patient should return to the previous treatment phase for another 3 weeks.