Techniques in Orthopaedics:
Tips and Pearls
Department of Orthopedic Surgery, Bnai Zion Medical Center, Haifa, Israel
The author is a designing surgeon for Efratgo Ltd.
Address correspondence and reprint requests to Yechiel Gotfried, MD, MS, Department of Orthopaedic Surgery, Bnai Zion Medical Center, P.O. Box 4940, Haifa 31048, Israel. E-mail: firstname.lastname@example.org.
A nonanatomic reduction of displaced—unstable subcapital femoral fractures has been described. The rationale of this approach is based on biomechanical consideration. Definitions used in this method include: negative buttress—in which the lower medial edge of the proximal fracture part (femoral neck and head) is protruding medially to the upper medial edge of the distal femoral neck part; positive buttress—in which the upper medial edge of the distal femoral neck part is protruding medially to the distal medial edge of the proximal fracture part. Because observations have shown that negative buttress is associated with a higher failure rate of reduction, negative buttress should be avoided. Negative buttress allows easier displacement of the reduced femoral head into the varus; positive buttress acts in the opposite way. Hence, the goal of the Gotfried reduction is to create a positive buttress reduction while at the same time reduce the fracture in the valgus. With the patient positioned on a fracture table, the procedure includes 3 stages: (1) desimpaction; (2) reduction; and (3) reconstruction. The author uses this technique when preservation of the femoral head, after subcapital fractures, is desired.
The patient is positioned on a fracture table; all reduction maneuvers are performed under close image intensifier monitoring. The procedure includes 3 stages (Figs. 1–6).
1. Desimpaction: at this stage, gradual, increased traction is applied in 2 directions: first, laterally (using a towel that is wrapped around the upper thigh) and, second, longitudinally (on the leg with the help of the fracture table). When fracture desimpaction is achieved, the next stage follows (Fig. 4).
2. Reduction: while under traction in both directions, the lower limb is brought into adduction and internal rotation. Usually, 40 to 45 degrees of adduction is required (Fig. 5). Attention is given not to interfere with the c-arm of the image intensifier. Internal rotation is highly individual and case dependent. A 180-degree fracture alignment, on the lateral view, should be achieved. If a 160 to 180-degree alignment cannot be achieved, open reduction is indicated.
3. Reconstruction: while in adduction and internal rotation, release of longitudinal and lateral traction is performed. The lower limb remains with no traction at the time of internal fixation. The goal of this stage is a positive buttress and valgus reduction as well as a 180 degrees lateral alignment of the fracture (Figs. 6–8).
Reduction evaluation is performed only on postoperative x-ray and not on the last image at the end of surgery:
Ambulation: it is not within the scope of this presentation to recommend any kind of internal fixation and, thus, postoperative ambulation. The author’s preferred method is the use of the PH Nail (Physiological Hip Nail, (Fig. 8) wherein, in patients with optimal reduction, weight bearing is not restricted and such patients are allowed to bear weight as much as they can tolerate. In young, active patients with optimal reduction, partial weight bearing is allowed for 6 to 8 weeks after surgery. In any case, ambulation starts with walking aids under the guidance of physiotherapy.
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The goal of traditional reduction of displaced subcapital femoral fractures is to restore prefracture anatomy. Many studies repeatedly emphasize that anatomic reduction is the key for successful and uneventful fracture union.2 Nevertheless, fracture nonunion and failure of fixation remain major complications. As fracture reduction is a significant component in the prognosis of uneventful fracture healing, efforts should be devoted to improvements in reduction. Avoiding varus position and negative buttress alignment are required for positive postreduction fracture stability.1 It follows that reduction in valgus and positive buttress alignment would have a positive effect on postoperative fracture stability. These considerations are the rationale for the Gotfried subcapital femoral unstable fracture reduction.
Two issues are central to the chapter on reduction of subcapital femoral fractures: (A) reduction technique; and (B) grading the quality of reduction. A variety of methods involve closed reduction of displaced subcapital femoral fractures, aiming to achieve restoration of prefracture anatomy.2 As the proximal femoral anatomy is the objective, grading the quality of reduction is in fact based on measuring the proximity to, or deviation from, the anatomy.3 In contrast, if a nonanatomic reduction is used, the grading parameters are different. A different method of grading of the quality of reduction is, therefore, also presented here.
1. Weinrobe M, Stankewich CJ, Mueller B*, Tencer AF. Predicting the mechanical outcome of femoral neck fractures fixed with cancellous screws: an in vivo study. J Orthop Trauma. 1998;12:27–36
3. Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86:1711–1716
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