Keyhole Sliding Hip Screw Fixation for Stable Intertrochanteric Hip Fractures: A Novel Technique

Intertrochanteric hip fractures are common orthopaedic injuries and the incidence is growing with increasing life expectancy. Several randomized controlled studies have shown the advantages of intramedullary devices over hip screw fixation in unstable intertrochanteric fractures. However, the proven advantage of the intramedullary device in stable intertrochanteric fractures, OTA (Orthopaedic Trauma Association) classification 31-A1 and some 31-A2 fractures are in less blood loss compared with standard hip screw fixation.

B. Shivashankar et al describe a novel minimally invasive technique of hip screw fixation that use a keyhole size incision to fix stable intertrochanteric fractures using sliding hip screw. The less invasive nature and potentially reduced blood loss makes this technique an attractive option for stabilizing stable intertrochanteric hip fractures.

The patient is positioned on a fracture table and a closed reduction of the fracture is achieved. Under image intensifer control, a four-holed 135° barrel plate is placed on the thigh such that it would be at the anticipated level on anteroposterior (AP) view under the image intensifer. Two vertical lines from just proximal to the second hole and just distal to the third hole are drawn across the lateral aspect of the thigh. These vertical lines can be brought closer to each other, as the surgeon gains experience with this technique, to about 2.5 cm. The greater trochanter is identifed and marked. In the lateral view, the long axis of the femoral shaft is identifed and marked between the two vertical lines. This line marked the proposed skin incision.

Subcutaneous fat and fascia lata are incised in line with the incision. The incision in the fascia lata extended about 1–2 cm beyond the proximal and distal ends of the skin incision. The fascia over vastus lateralis muscle is divided in line with the muscle fibers which are then split with the tips of a pair of scissors. A periosteal elevator is used to clear the lateral surface of the femur to accommodate the hip screw plate.

A 135° hip screw guide is introduced into the surgical wound and a guidewire is passed through it under image intensifer guidance. Lag screw length is indirectly measured, and the device-specific cannulated reamer passed over the guidewire. The appropriate length lag screw is passed over the guidewire in the standard fashion. The lag screw introducer is removed leaving just the guidewire in the lag screw. A four-holed 135° barrel plate, with the barrel facing laterally, is introduced into the wound deep to the Vastus lateralis muscle. Once the whole of the plate is inside the wound, a strong forceps is used to rotate the barrel 180° and then, the barrel end of the plate is pushed under the vastus lateralis. The guidewire is subsequently removed from the lag screw and reinserted into it through the barrel of the plate. The screw introducer is then glided over the guidewire and reengaged to the lag screw. The plate is then slid over the lag screw. All the cortical screws are introduced into the plate through the percutaneous method. The final wound measured between 2.5 and 4 cm.

The authors have used this technique in over 60 cases. In the author's experience, no patient has ever required blood transfusion as a consequence of surgical blood loss. The wound healing complications and infection have never been encountered. No patients have ever required an extension of the surgical wound for implant positioning.

The authors recommended that -

With the careful and atraumatic splitting of the vastus lateralis bleeding from the muscle is minimal.

While drilling and reaming for the lag screw, a novel protector sleeve ("Solapur sleeve") which can accommodate instruments upto 15 mm like double reamer to be passed through this without damaging the surrounding soft tissues.

The authors opined that - this technique is a useful minimally invasive method for operative management of simple intertrochanteric fractures and has negligible blood loss.

Key Words: Proximal femur fracture, Intertrochanteric fracture, Pertrochanteric fracture, Minimally invasive Technique, Indian Journal of Orthopaedics, B. Shivashankar, Sudhir Shah

Further reading:

Keyhole Sliding Hip Screw Fixation for Stable Intertrochanteric Hip Fractures: A Novel Technique

B. Shivashankar, Sudhir Shah, Gunasekaran Kumar, Sandeep Kumar.

Indian Journal of Orthopaedics (2022) 56:1101–1107

https://doi.org/10.1007/s43465-022-00624-5