When the neck of the femur is fractured it needs surgical repair. There is a surgical procedure, that was developed many decades ago, that removes the non-functional head, and allows the body to form a false joint. This procedure is called a Femoral Head Ostectomy (FHO). Ostectomy means removal, so the head of the femur, where the ball joint is located, is completely removed.
We also use this procedure when there is a hip dislocation (called a subluxation) and the hip will not stay in the socket, even when we put it back in and put on a special bandage called an Ehmer sling. We also use this surgery for pets with hip dysplasia that will not be undergoing the more extensive hip replacement surgery called a Total Hip.
These are the radiographs of a young German Shepherd that was hit by a car. It was brought to us for a limping problem on the left rear leg. A thorough physical and orthopedic exam revealed some swelling at the left knee. This is a VD (venture-dorsal) view of the pelvis.
Do you see the problem?
The wing of the ileum and the acetabulum are fractured. You can also see that the neck of the femur has been fractured. Compare the problem area above in the red circle to the other side.
This purple line like gives you a conceptual idea of where the neck of the femur will be cut during the FHO surgery. The exact angle during the procedure is different, and is customized for each bone.
This fracture is 3 week old, and there is swelling and scar tissue around the fracture that is not apparent on this radiograph. Also, this is a large breed dog with large muscles and tendons surrounding the fracture. In a difficult case like this, especially in a young dog that has a long life ahead, we have an orthopedic specialist come to our hospital to perform the surgery. He has special equipment, and over 45 years of experience, to make this a successful surgery with a pain free and active dog that is not limping for the rest of its left.
Before any surgery is performed, our surgeon Dr. Paul Cechner, consults with the owner to go over all of the options. This includes post operative care, which is an important part to make sure adequate healing occurs.
Long before surgery we perform a blood panel and a chest radiograph to make sure there are no other problems from the initial trauma that are not apparent on physical exam. This is important to know before surgery to minimize the risk of anesthesia, and to make sure all problems are corrected. Our patients do not talk to us, and they have high pain thresholds compared to us humanoids, so they don’t always show symptoms and we need to be thorough. We do not want any surprises on the day of surgery.
It is important to take a chest radiograph prior to surgery to make sure the heart and lungs look normal
Once the consultation was performed we put this dog on a pain and anti-inflammatory NSAID called Rimadyl until the day of surgery. Our patient was brought into the hospital the night before surgery and intravenous fluids were started and a pain patch was applied. On the day of surgery another examination was performed by one of our veterinarians to make sure everything is OK. At this point the surgery is a go and our surgeon prepares.
Our patient is anesthetized and the leg is shaved outside of our surgery room
While our patient’s leg is shaved our surgeon starts the scrubbing process with a surgical hand scrub to make sure this is an aseptic procedure
Our patient is brought into surgery, and before anything else is done, is hooked up to our anesthetic monitor and the IV fluid pump (at the top of this picture) is set for the correct amount of fluids to be given during the procedure. These fluids are critical to minimize anesthetic risk.
Once our patient is stable and under the proper plane of anesthesia, our surgical assistant goes through the multi step process to scrub the leg. This is a crucial step to minimize the risk of infection after the surgery, so we are thorough and methodical in our approach to this part of the procedure. As you view the following pictures you will realize that preparation is a key part of this surgery.
The first step is to tape the leg up in this position
The first scrub of the leg occurs with the leg in this position
He continues scrubbing the leg after our surgeon does an initial draping
Once our surgeon is satisfied with the initial surgical scrub,s he does his own final scrub with a special antiseptic
It is called DuraPrep
It is applied directly over the area of the incision
After the DuraPrep our surgeon drapes the leg with it still hanging. In the background is our anesthetist monitoring anesthesia.
The top of the leg is wrapped in sterile aluminum foil and the tape is cut to bring the leg down
This is the position of the leg during the surgery
The foil is wrapped with a special sterile tape
The appearance of the foot before the final draping
Another drape without a hole is put over the surgical field
Our surgeon makes a custom opening in the drape specific for this surgery
He checks the exact location of where his incision will be before proceeding any further
The next step in the preparation involves and aseptic barrier called Ioban
It is adhered right to the skin where the incision will be
The surgical preparation is now complete and our surgeon is ready to make the skin incision to start the surgery
His sterile bone cutting tool is now opened up
He palpates the landmark for the skin incision
Let the surgery begin!
Once through the skin the next layer encountered is the subcutaneous (under the skin) layer, sometimes abbreviated as SQ.
The surgical approach goes between several important muscles and tendons in order to gain access to the joint where the fracture is located. These include the biceps femoris muscle, the tensor fascia latae muscle, the superficial gluteal muscle, the deep gluteal muscle, and the vastus lateralis muscle. The muscles and tendons are not cut in order to gain this access to the joint. Careful dissection is performed in this area to preserve the normal anatomy, and not interfere with important nerves and blood vessels This is one of the most difficult parts of the procedure, and where the experience of our surgeon comes into play.
After much careful dissection Dr. Cechner has the head of the femur exposed in the center of this photo. It is difficult to see because it is covered in scar tissue. On the left is the special oscillating saw that will cut through the neck of the femur. The opening is small, so our surgical assistant on the right is using a retractor for better visualization.
The oscillating saw gives a quick and precise cut with minimal bone trauma
The appearance of the head of the femur just before the cut is complete
A special rongeur is used to smooth off the bone incision
Now the long process of suturing everything back together begins
The postoperative radiograph
Our patient stayed overnight with pain injections administered that were in addition to the pain patch. He went home the next day with antibiotics and oral pain medications The skin sutures were removed in 14 days. After several weeks of confinement, and several weeks of moderate use, he is doing great! Our thanks to Dr. Paul Cechner for doing such a great job.
If you would like to learn much more about how we do surgery at the Long Beach Animal Hospital, including pre-anesthetic testing, anesthesia, and surgical concepts, please visit our Surgical Services web page.