Hip > Stress Fractures > Treatments

    Open Reduction and Internal Fixation

Preparing for Surgery

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring ahealthy recovery. Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable, especially in rare cases.

   Try to arrange for someone to take home any equipment you will need when you get home from the hospital. This may include a walker, crutches, ice packs or coolers, or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   If possible, discontinue the use of any anti–inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, try to refrain from smoking for at least a week prior to surgery.

   Make sure the orthopedist performing the surgery is board–certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

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At most medical centers, you will go to "patient admissions" to check in for your open reduction–internal fixation surgery. There may be a separate department for overnight inpatient surgery check–in, so be sure to ask your doctor. In the trauma setting you will go directly to the emergency room. After you have checked in to the hospital or clinic, or in the case of a traumatic injury, after you leave the emergency room, you will go to a holding area where the final preparations are made. The paperwork is completed and your hip and thigh area may be shaved (this is not always necessary). You will wear a hospital gown and remove all of your jewelry. You will meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. In general, you should not eat for eight hours before surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Wear a loose pair of shorts or sweatpants that will fit comfortably over your hip bandage when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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When an open reduction and internal fixation is performed:

   A six to ten inch incision is made over the top of the thighbone, called the greater trochanter. The incision usually is curved in a boomerang or banana shape.

   Damaged cartilage and loose bone chips are removed.

   The femoral neck and head are properly positioned (reduction) in the socket joint of your hipbone to ensure smooth hip movement.

   The neck of your femur, which may have fractured along various lines and in multiple pieces, is reconstructed. The fractured bones are fixed in place with small nails, pins, or screws, restoring the original straight shape to the branch on the inside of your thighbone.

   Any damaged soft tissues, including the joint capsule that surrounds the hip joint, are sewn together tightly to help hold the hip joint in place.

   Incisions are closed with 30 to 40 staples, a bandage is placed over the incisions, and the patient is taken to the recovery room.

   After surgery, there is a small risk of avascular necrosis (destruction of the femoral head) and of post-traumatic arthritis. Both of these may lead to more surgery, including total hip replacement.

After surgery to repair your stress fracture, you usually will stay in the recovery room for at least two hours while the anesthetic wears off. Your hip will be bandaged with white gauze pads and tape and may have ice on it. You may have lost a significant amount of blood during surgery and there may be a small amount of bleeding afterward. Depending on your age and the volume of red blood cells in your blood stream, blood may need to be replaced in the recovery room through an IV. You will be given adequate pain medicine, either orally or through an IV (intravenous) line, as well as instructions for what to do over the next couple of days. Antibiotics and blood thinners (anticoagulants) also may be administered to help avoid infection and blood clots. You should try to move your feet, ankles, and knees while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the recovery room and be admitted for a three to five night stay.

Post-op in Hospital

After surgery to repair an intertrochanteric fracture, some patients remain in the hospital for as long as five days. Some patients may have to stay longer and in rare cases may need to be transferred to rehabilitation centers or nursing homes. Nurses typically apply a fresh bandage two days after surgery. The bandage may need to be replaced once or twice while at home and the nurses can teach you to change the bandage yourself. You may be instructed to use a wedge-shaped foam pillow called a hip abduction pillow that help keeps your legs spread apart and held in a proper position. There will likely be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. Though physicians generally limit bearing weight on your leg, you will be instructed to sit up and move around to help circulate blood. Beginning in the hospital, you probably will need to use a walker or crutches while the fractured bones heal for between three and 12 months. Your physician, nurse, or a physical therapist will teach you to use your walker or crutches and begin gentle rehabilitation exercises to avoid muscle atrophy. Your physician usually takes X-rays of your hip before you leave the hospital. In addition, you will be given an appointment to return for a checkiup and more X-rays every eight to 12 weeks until your hip heals. Most patients receive a prescription for pain medication. You will be unable to drive a car, so be sure to have arranged a ride home.

Here is what you can expect and how you can cope while recovering at home from open reduction-internal fixation surgery:

   After this procedure, there is usually pain and discomfort for about two weeks. If needed, take pain medication as instructed. The pain tends to decrease each day after surgery. Check with your doctor if unexpected pain arises.

   Staples are usually removed about two to three weeks after surgery. You may need to change your bandage yourself once or twice during the first week at home after surgery as instructed by the nurses in the hospital. You can normally stop using bandages when the wound is dry.

   Keep your staples dry. Depending on your surgeon's advice, the time you are instructed to keep the incision dry varies, usually from two to three weeks.

   Gently move your toes, ankles, and knees as much as possible to help circulate blood.

   A balanced diet, iron supplements, and proper hydration may help restore healthy tissue.

   A fractured hip can make it difficult to move around your house and perform even simple household tasks like cooking, bathing, and laundry. Try to have friends or family members available to visit you once or twice a day for several weeks. If you live alone, your insurance company decides whether you qualify for a nurse. Otherwise, you can hire help through a social worker at the hospital who can put you in contact with nursing and therapy agencies in your area.

   Expect to begin range of motion and walking exercises within two days of surgery. You should not remain sedentary because you run the risk of developing blood clots and bedsores. Your physician usually refers you to a physical therapist who can help you learn to walk after surgery. This usually takes three to six weeks.

   Because some people can regain strength without supervised physical therapy, your physician will evaluate your ability to walk and prescribe further physical therapy as needed.

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Physical therapy may be helpful during the first three to six weeks after surgery as you learn to use your walker or crutches. Many patients prefer easier–to–use walkers or "quad–canes" – devices consisting of four canes connected by handles. Range of motion is extremely important. Movement may be painful at first, but it is important to avoid stiffening in your hip. For the first few weeks, your physical therapist may help you move your hip in different directions to stretch out the joint. Partial weight bearing can begin as soon as possible after surgery. Full weight bearing is generally delayed until an X-ray shows that your femoral neck has healed and an MRI confirms you have not developed avascular necrosis, a dangerous loss of blood supply. This may not occur for three to 12 months. However, you should move around with the aid of a walker as much as possible. You usually also practice stair climbing using handrails to support your weight. Rehab may progress to resistive exercises – those involving weights – to keep the muscles around your hip strong. You may continue visiting a physical therapist or you may be able to strengthen your hip on your own, depending on your physician's advice. In some cases, general cardiovascular exercise may adequately strengthen hip muscles. Typical hip strengthening exercising involve leg exercises while sitting or laying down that do not involve bending the hip or taking steps with extra weight on your arms or torso. Patients under age 65 should eventually be able to resume functional activities like stair climbing, single leg support, swimming, and driving. You may be able to begin more vigorous activities as your hipbone heals and your leg gets stronger. Patients over age 65 may have more difficulty returning to activities and restoring full health to their hip after a fracture.

Once your hip stress fracture has healed, building muscle strength around your hip can help you avoid further injury. You also may consider training with a physical therapist or coach to increase your balance and coordination, which can help decrease the chances of accidental falls. If your physician feels you are at risk for future femoral neck fractures, you may be instructed to cut back or avoid repetitive stress activities like long distance running. Physicians generally recommend cross–training after a stress fracture to avoid putting the same type of stress on your hips every day. You should alternate your running workouts with cycling, swimming, or other cardiovascular activities. Slowly increase the intensity and duration of your workouts. Try to avoid drastic increases in your athletic activities. Another way to help prevent further hip injuries is to avoid stressing your hip during daily activities. After a hip stress fracture, take it easy on your hips whenever possible during the day to save them for activities and exercise. Avoid stairs when there is an elevator, take the shortest path when walking, and consider wearing athletic shoes designed to absorb shock. In general, you should avoid participating in activities in old, worn–out shoes. Running shoes typically wear out after 250 to 300 miles of running. Running on softer surfaces, like grass or cushioned tracks, may also decrease your risk or recurring hip stress fractures. If your stress fracture was caused by anatomical problems, like differences in your leg length or twisting in your shinbone, your physician may prescribe orthotic devices to wear in your shoes. Orthotics can help properly transfer weight through your hips and provide you with a more normal stride.

Stress fractures in your femoral neck, the branch on the inside of your upper thighbone that runs from the femoral head at the hip joint to the top of the thighbone, may require surgery if the bone is at risk of further damage. The surgery usually is performed as soon as possible after the stress fracture is diagnosed. Small pins or screws are used to reinforce weakened thighbone areas.