Surgical Techniques

Surgical TechniquesAntegrade Femoral Nail

 

1.  Trochanteric Entry Antegrade Femoral Nail

 

Position

- GA, IV ABx

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for II access

 

Entry

- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP II view

- check entry point on lateral II view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail

 

Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length

 

Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated

 

Femoral Shaft Fracture Standard Displacement Lateral

 

Ream

- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail

 

Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with II at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture

 

Locking

 

Proximal

- usually proximal locking first

- screw should purchase cortex of lesser trochanter

 

Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002

 

Distal

- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed

 

Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002

 

2.  Retrograde Nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- distal 1/3

- floating knee

- obesity

 

Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- can remove to allow proximal locking

- ensure II for AP proximally locking

 

Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail

 

Pass guide wire

- measure length

 

Ream & insert nail

- distal locking performed

- proximal AP locking under II control