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n tips & techniques
Section Editor: Steven F. Harwin, MD
Hybrid Anterolateral Approach for Open
Reduction and Internal Fixation of Femoral
Neck Fractures
Bryan G. Vopat, MD; Alan H. Daniels, MD; Craig R. Lareau, MD; Melissa A. Christino, MD; Patrick M. Kane, MD;
Roman A. Hayda, MD; Christopher T. Born, MD
Abstract: Displaced femoral neck fractures in physiologically young patients are best treated with anatomic reduction
and stable fixation. Several surgical approaches to the femoral neck have previously been described, although they are
fraught with disadvantages such as poor visualization, the
need for 2 incisions, and risk of injury to the lateral femoral cutaneous nerve and branches of the medial femoral circumflex artery. The authors’ hybrid anterolateral approach
to the hip allows for excellent visualization of femoral neck
fractures and for placement of plate and/or screw constructs
through a single incision. This surgical technique additionally minimizes risk to neurovascular structures. [Orthopedics.
2015; 38(7):430-434.]
D
isplaced femoral neck
fractures in physiologically young adults are usually
high-energy injuries best treated with open reduction and internal fixation to allow mainte-
The authors are from the Division of Orthopaedic Trauma, Department
of Orthopaedic Surgery, Warren Alpert Medical School of Brown University
and Rhode Island Hospital, Providence, Rhode Island.
Drs Vopat, Daniels, Lareau, Christino, Kane, and Hayda have no relevant financial relationships to disclose. Dr Born is a paid consultant for
and has received grants from Stryker and holds stock in Illuminos and Biointraface.
Correspondence should be addressed to: Bryan G. Vopat, MD, Division
of Orthopaedic Trauma, Department of Orthopaedic Surgery, Warren Alpert
Medical School of Brown University and Rhode Island Hospital, 593 Eddy
St, Providence, RI 02903 ([email protected]).
Received: November 27, 2013; Accepted: June 2, 2014.
doi: 10.3928/01477447-20150701-03
430
nance of an active lifestyle and
ensure the highest percentage
of a successful clinical outcome.1 Adequate visualization
of the femoral neck is required
to achieve anatomic reduction
in order to optimize postoperative outcomes. Nonetheless,
femoral head osteonecrosis
and fracture nonunion are not
uncommon, resulting in significant disability.1 Osteonecrosis
after femoral neck fracture is
reported to occur at a rate between 12% and 86% in young
patients.2-5 Therefore, an open
approach is often indicated
in young patients to achieve
anatomic reduction and potentially decrease the rate of
osteonecrosis.
Access to the hip is required
for optimal treatment of femoral neck, femoral head, and acetabular fractures, arthroplasty,
and irrigation and debridement
of septic arthritis. A variety of
approaches to the hip have been
described, including anterior,6
anterolateral (Watson-Jones),
lateral, transtrochanteric, and
posterior techniques, performed
through 1 or 2 incisions.
A recently described technique involves a 2-incision
approach, using a modified
Smith-Petersen interval (superficial: sartorius/tensor fascia latae [TFL]; deep: rectus
femoris/gluteus medius) for
reduction of the femoral neck
fracture, and a separate lateral
incision for placement of fixation.7 However, this technique
has several disadvantages, including risk of lateral femoral
cutaneous nerve (LFCN) injury and detachment of the rectus femoris tendon. Another
technique involves a 1-incision
approach in the Watson-Jones
interval (TFL/gluteus medius)
through which the femoral
neck is directly reduced and
fixated.1 Disadvantages of this
approach include difficulty in
visualizing and obtaining anatomic reduction of the fracture
and risk of injury to the blood
supply of the femoral head.7
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n tips & techniques
Figure 1: Skin incision marked. The anterior–superior iliac spine (ASIS) is
palpated and marked. Incision begins 2 cm distal and 3 cm lateral to the ASIS
and runs in line with the femur approximately 15 cm.
The purpose of this article
is to describe a hybrid approach using a single 15-cm
incision that allows access to
the femoral neck through the
Smith-Petersen interval in a
medial window, and access to
the lateral proximal femur for
introduction of a compression
hip screw device or screw fixation through a lateral window.
This approach allows excellent
visualization of the femoral
neck without endangering the
LFCN or branches of the medial femoral circumflex artery
or detaching the rectus femoris
tendon.
Surgical Technique
The patient is positioned
supine on a radiolucent table
or a fracture table, and a folded
blanket (bump) is placed underneath the ipsilateral flank.
The ipsilateral shoulder is adducted with the arm flexed and
positioned across the chest.
The contralateral leg may be
placed in a well leg holder to
assist with lateral fluoroscopy,
which is especially helpful for
obese patients. The fluoroscope is positioned on the contralateral side from the injury
and oblique to the hip. The
machine is rotated to match
the version of the femoral
neck, so a true lateral view of
the femoral neck can be visualized. Radiographs must be
obtained prior to draping to
ensure adequate visualization
of the fracture.
The anterior–superior iliac
spine is palpated and marked.
An incision is made that starts
2 cm distal and 3 cm lateral
to the anterior–superior iliac
spine. This incision is curved
posterolateral and then distal in line with the shaft of
the proximal femur (Figure
1). The distal aspect of the
incision allows for implantation of hardware. The entire
incision is approximately 15
cm long. The skin is incised
and subcutaneous dissection
is performed sharply down
to the level of the fascia over
the TFL muscle. This fascia is
Figure 2: Superficial dissection. The tensor fascia is split, exposing the deep
interval between the tensor fascia and rectus femoris, and is developed bluntly.
An Allis clamp is used to help elevate the tensor fascia. Abbreviation: TFL, tensor
fascia latae.
Figure 3: Care is taken to identify and protect the lateral femoral cutaneous
nerve (LFCN). The nerve is 3 cm from the interval in this patient, but the distance may vary. Abbreviation: TFL, tensor fascia latae.
split in the midsubstance of the
TFL muscle with a scalpel and
divided proximally and distally using dissecting scissors.
Distally, the fascial incision
is curved slightly posteriorly
to incise the iliotibial band
for later access to the lateral
femoral shaft. Proximally, an
Allis clamp is used to elevate
the medial edge of the divided
TFL fascia and blunt finger
dissection is used to separate
the tensor muscle from the
fascia medially, establishing
the deep interval between the
tensor and rectus femoris (Figure 2). Approaching this plane
through the tensor fascia lateral to this interval facilitates
identification and protection
of the LFCN (Figure 3).
Once the interval between
the tensor and rectus is developed, the femoral neck can be
palpated. A Deaver retractor
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B
A
Figure 4: The femoral neck is palpated through the tensor fascia and rectus femoris (RF) interval and exposed with a Deaver retractor superior and Cobra retractor inferior to the neck. A Cobb elevator is used to elevate the indirect head of the RF (A). A T-shaped capsulotomy further exposes the femoral head (*) and neck
(^) (B). Abbreviation: TFL, tensor fascia latae.
Figure 5: Cobra retractors placed inside the capsulotomy. The femoral head
(*) and neck (^) are now well visualized.
is placed superiorly around
the neck, just superomedial to
the greater trochanter. When
placing the retractor around
the fracture, care is taken to
avoid further comminution.
Lateral retraction of the tensor
allows the interval to be developed further to the level of the
joint capsule. The fat overlying the hip capsule is then excised with a rongeur and the
reflected head of the rectus is
432
elevated off of the joint capsule medially. A Cobra retractor is then placed inferiorly on
the femoral neck, protecting
the lateral femoral circumflex
vessels. A T-shaped capsulotomy is then performed on the
proximal aspect of the femoral
neck. One limb is placed parallel to the femoral neck and
the other perpendicular to this
first limb, with the top of the
“T” over the acetabulum to
minimize the risk of disruption of the blood supply to the
femoral head (Figure 4). This
is done with a scalpel to avoid
thermal damage to the cartilage and circumflex vessels
caused by electrocautery.
After the capsulotomy is
made, 2 Cobra retractors are
placed inside the capsule—one
superiorly and one inferiorly.
The medial window approach is
now complete, allowing excellent visualization of the femoral
neck, including the subcapital
region (Figure 5). The fracture
hematoma is then irrigated and
the fracture can be reduced under direct visualization.
Attention can then be
turned to the distal aspect of
the approach where the iliotibial band had been split.
Deep to the iliotibial band, the
vastus lateralis is split in line
with its fibers and the muscle
is elevated off the proximal
lateral femur with a Cobb elevator, exposing the femur for
hardware insertion. Retractors
can then be placed around the
femur for visualization and
placement of fixation devices.
This lateral window is separated from the medial window
by the tensor muscle and the
medial aspect of the vastus
lateralis (Figure 6).
For the fracture reduction, a
bone-hook or a 5-mm Schanz
pin can be applied to the distal fracture segment through
the lateral window, allowing
disimpaction of the fracture
site. The femoral neck is then
reduced under direct visualization. Next, 2.0-mm Kirschner
wires or threaded guide pins
for cannulated screws are
placed to provisionally fix the
femoral neck through the lateral window. Reduction can then
be verified using fluoroscopy.
Final fracture stabilization is
performed. Surgeon preference at the authors’ institution
consists of fracture fixation
with either a compression hip
screw construct with a derotational screw, or 3 cannulated
partially threaded cancellous
screws placed through the lat-
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n tips & techniques
eral window. A compression
hip screw construct is preferable for younger patients,
especially those who may
not adhere to recommended
weight-bearing restrictions,
because of its superior biomechanical strength.8 Direct
visualization of the fracture
should be continued during
screw placement to ensure the
maintenance of anatomic fracture reduction (Figure 7).
Discussion
This modified anterolateral
approach allows for direct visualization of femoral neck
fractures and for placement of
the implants through a single
approach with 2 windows.
This technique is an adaptation of the approaches described by Matta et al,9 Molnar and Routt,7 and Ly and
Swiontkowski,1 and provides
excellent femoral neck visualization without risk to the
LFCN of the medial femoral
circumflex artery.
The original Smith-Petersen
surgical exposure exploits the
internervous plane between the
sartorius and the TFL muscles;
however, it risks injury to the
LFCN.6 Molnar and Routt7
described a modified SmithPetersen approach to visualize
femoral neck fractures. However, they used the sartorius/
tensor fascia interval, which
still places the LFCN at risk.
The Watson-Jones exposure divides vessels at the base
of the femoral neck, placing
the superior and inferior retinacular branches of the medial
femoral circumflex artery at
risk, which may increase the
risk of avascular necrosis.10,11
Additionally, the WatsonJones technique does not provide optimal visualization of
subcapital fractures,7 whereas
the current authors’ approach
allows excellent access to and
exposure of these fractures.
The current authors’ approach uses a modification
described by Matta et al,9 in
which tensor fascia is incised
over the tensor in line with the
skin incision, using blunt dissection to gain access to the
medial aspect of the tensor
within the sheath of the incised
aponeurosis, developing the
interval between the tensor and
sartorius superficially. The approach that the current authors
describe does elevate some of
the rectus fibers, but does not
require a full tenotomy as described by Molnar and Routt.7
The current authors’ approach
is similar to other anterior approaches to the hip, allowing
the rectus femoris muscle to
remain mostly intact.9,12-16
This approach allows for
visualization of the reduction
along with placement of the
lateral plate and sliding screw
construct similar to which Ly
and Swiontkowski1 described.
However, the current authors’
approach allows visualization of the modified SmithPetersen interval (superficial:
sartorius/TFL; deep: rectus
femoris/gluteus medius) and
placement of lateral hardware
through a single incision.
A major concern associated
with this injury is avascular necrosis of the femoral head. Ly
and Swiontkowski1 examined
the rate of avascular necrosis
after femoral neck fracture in
the literature and found the
Figure 6: Medial and lateral windows are developed. The medial window allows
visualization of the femoral head (*) and neck (^). The lateral window allows
visualization of the femur shaft (#) for placement of hardware.
A
B
Figure 7: Anteroposterior (A) and lateral (B) radiographs 2 weeks postoperatively showing anatomic reduction of the femoral neck and fixation with a compression hip screw and derotational screw.
average to be 23% (range, 3%32%). Multiple causes have
been hypothesized for this
complication, including intracapsular injury, initial injury
to the femoral head blood supply, inadequate reduction, and
iatrogenic injury to the blood
supply.1 In this approach, care
is taken to avoid injury to the
superior retinacular branches
of the medial femoral circumflex artery when placing the
Deaver retractor superior to
the neck. However, the current
authors believe that the most
important factor in preventing
avascular necrosis is achieving an anatomic reduction.
Proper visualization and surgical technique is essential to
achieve this reduction.
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The main disadvantage
of this approach is the larger
incision, which is needed for
insertion of a sliding screw
and plate. However, a parallel
screw construct can be inserted either using a more limited
distal incision or percutaneously. Biomechanically, it
has been shown that a sliding
screw and side plate is stronger than 3 screws for vertically oriented fractures.8,17 This
has been found to be even
more important when comminution is present.18 These fracture characteristics are typical
for the current authors’ physiologically young patients,
who sustain these injuries via
high-energy mechanisms such
as motor vehicle accidents or
falls from heights. Therefore,
this is the current authors’
preferred surgical technique
when direct visualization of
femoral neck fractures and
excellent stability are needed
due to vertically oriented and
comminuted, displaced femoral neck fractures in physiologically young patients, for
whom a hemiarthroplasty or
total hip arthroplasty is suboptimal. This is in contrast to
434
older patients with low-energy
injuries, for whom a percutaneous approach, hemiarthroplasty, or total hip arthroplasty
are reasonable treatment strategies.19
Conclusion
The hybrid anterolateral
approach to the hip allows
for excellent visualization of
femoral neck fractures through
a medial window, and for
placement of plate and screw
constructs through a lateral
window. This single-incision
surgical technique minimizes
risk to the LFCN and branches
of the medial femoral circumflex artery, which may be
placed at risk with other surgical approaches.
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