Indications: The patient is a 69-year-old black female who fell landing on her right hip. She was seen in the emergency room where physical exam and x-ray revealed an intertrochanteric right femoral fracture. She was admitted to Dr. Loyds service after an orthopedic consultation and pre-operative clearance for surgery she was taken for ORIF. Operation in Detail: After adequate pre-operative evaluation, pre-operative medication, and signing the informed consent, the patient was taken to the operating room and administered a general endotracheal anesthetic with prominences well-padded.
She underwent an uneventful reduction and was placed on traction through a well-padded boot. Her left lower extremity was flexed and abducted at the hip. All boney prominences and the peroneal nerve were well-padded. Fluoroscopic AP and lateral images revealed a good reduction of her intertrochanteric femoral fracture. The right hip was then sterilely prepared with Betadine scrub and solution and draped into the sterile field. She was administered IV preoperative antibiotics. A straight lateral approach to the proximal femur was made. Dissection was carried through the skin and subcutaneous tissue. Hemostasis was obtained with electrocautery.
The fascia lata was divided in line with the skin incision. The fascia over the vastus lateralis was divided in line with the skin incision, and the vastus lateralis was divided in line with its fibers, revealing the lateral aspect of the proximal femur which was retracted with the Bennett and Hohmann retractors without complication. A guide pin was placed along the anterior neck to give the proper amount of antiversion. Using the 135 drill guide a guide pin was placed through the lateral aspect of the proximal femur across the fracture site and into the center of the head and neck as demonstrated by AP and lateral fluoroscopic C-arm images.
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This was then measured and 85 mm was found to be the appropriate length. The core was cut for the sliding screw without complication using a preset Remer set at 85mm the tap was then used to tap the way for the proximal screw and an 85mm sliding screw was inserted across the fracture site into the head and neck without complication. A 4-hole, 135 degree side plate was then attached. We slide it over the DePuy sliding screw and attached it the the proximal femur using a Lowman turkey-claw clamp.
With the fixation in place AP and lateral fluoroscopic images throughout the fracture site and hardware position confirmed good reduction and good placement of the hardware. At this point the side plate was then secured to the proximal femur using the 3-2 drill bit to drill a hole measuring the approximate length with the depth gauge and placing 4 to 5 cortical screws of the appropriate length without complication. At this point the compression screw was inserted. All traction was left off and the compression screw was tightened impacting the fracture nicely. All screws were then tightened with the screw driver.
The Lowman was removed as was all hardware. Multiple views in the AP and lateral plains of the fracture site and hardware for placement confirmed good reduction and good hardware placement for her intertrochanteric femoral fracture. With open reduction internal fixation complete the wound was copiously irrigated with antibiotic solution. Hemostasis was obtained with electrocautery. The fascia over the vastus lateralis was closed with a running suture of zero Vicryl. A Hemovac drain was left between the fascia lata and the vastus lateralis connected to a separate stab wound.
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The fascia lata was closed with a running suture of zero Vicryl with at few interrupted sutures. Care was taken to make sure that the drain was not sutured into the wound. The subcutaneous tissue was closed with staples. A sterile dressing was applied and the patient was returned to the recovery room via stretcher. The patient tolerated the procedure well. There were no complications. Blood loss was negligible, no replacement. Lap, needle, and sponge counts were correct x2 and she returned to the recovery room in good condition where she was neurovascularly in tack.
