Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation radiolucent fracture table contralateral leg dropped down in fracture boot or raised up with thigh holder Positioning supine with feet padded with webril in fracture boots c-arm from contralateral side at 45° angle towards hip take fluoro AP/Lat and mark location and positioning of C-arm for xrays Reduction reduction before prep/drape using traction, abduction/adduction, and internal/external rotation Approach lateral approach to hip incision 3-4cm above greater trochanter (GT) in line with femur, split fascia lata Guidewire Insertion start point is on tip of GT on AP xray and in center of GT on Lat xray insert entry reamer (~15mm) over starting guidewire then long balltip wire Reaming size 9mm reamer then ream 1.0-1.5mm above size of final nail Nail Insertion insert nail over guidewire, follow anterior bow of femur and mallet in using strikeplate Lag Screw and Interlocking Screws drill, measure, and insert lag screw watching for fracture compression tip-apex distance <25mm on AP+Lat get perfect circles of two distal interlock screws, drill and insert Postoperative weight-bearing as tolerated, physical therapy, immediate range of motion exercises to hip and knee, DVT prophylaxis Planning & Preparation Extremity Exam before case need to check if intertrochanteric fracture is stable (will resist medial compressive loads) vs. unstable on AP/Cross table Lat xrays unstable fracture patterns include reverse obliquity, large posteromedial fragment, subtrochanteric extension (will collapse into varus or displace shaft medially) document distal neurovascular status Associated Injuries & Comorbidities identify patient comorbidities and ASA status (predictor of mortality) make sure patient has Foley urinary catheter in place definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality Equipment & Positioning Equipment cephalomedullary nailing system (Stryker Gamma, Synthes TFN) can use sliding hip screw in stable intertrochanteric fractures in ambulatory patients contraindications to sliding hip screw include reverse obliquity fractures and lack of lateral femoral wall c-arm fluoroscopy radiolucent fracture table (Jackson fracture) Position patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder padded post deep into groin, move genitals and Foley catheter out of the way ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board prep and drape entire leg up to iliac crest to make sure adequate working area OR Setup and C-arm radiolucent fracture table c-arm from contralateral side at 45° towards hip take initial fluoro AP/Lat of hip to examine femoral neck mark position of C-arm to ensure proper positioning during remainder of case (~15° tilt for correct AP xray of hip) Approaches Lateral Hip plan out lateral approach to hip, incision 3-4cm above GT in line with femur cautery through subcutaneous tissue, sharp through fascia lata Surgical Technique Fracture Reduction before prepping and draping, perform fracture reduction using traction, abduction/adduction, and internal/external rotation to loosen fracture fragments then move into anatomic alignment apply inline traction first to distract fracture, then adduct and internally rotate leg, check fluoro AP/Lat then release a little traction to get fracture reduced in difficult cases may need to make mini anterolateral incision after between TFL and gluteus medius to indirectly feel reduction, can use bone hook to help with reduction Approach mark out GT and AP/Lat axis of femur using xray holding guidewire against skin guidewire entry point is ~3-4cm (3-4 fingerbreadths) above GT, poke through skin with wire or make 3-4cm incision with 10blade through skin cauterize through subcutaneous tissue and fascia, fascial incision should be distal to skin incision to allow proper nail entry point spread muscle with hemostat to make sure you are directly onto bone Guidewire Insertion guidepin start point is on GT tip of bone, needs to be in center of medullary canal on AP xray and center of GT on Lat xray, mallet in then recheck on xray if difficulty with guidewire start point use cannulated awl to get better control and position on GT or gattling gun attachment for small wire adjustments use power to insert guidepin to proximal canal, check fluoro to make sure pin is in center of medullary canal, do not want to ream out of proximal canal use conical entry reamer (~15mm) with soft tissue protector and ream until it hits the stop plate push soft tissue protector and reamer in against patient abdomen to ream more in center of canal, patient body habitus and bed want to push you medial start with reamer on bone to avoid capturing muscle and fascia, check on fluoro be careful when inserting and removing reamer as it can be contaminated by surrounding OR equipment Measurement remove starting guidewire and reamer together push long balltip guidewire past fracture site using T-handle (with slight bend at tip), mallet to distal aspect of femur, check on fluoro AP/Lat insert guidewire to mid-shaft of femur if using short nail or to distal femur if using long nail use radiolucent ruler over wire to measure appropriate nail length (i.e. 70kg male, 6' tall, typically 420mm if using long nail) check proximal fluoro on GT to make sure ruler is sitting flush on bone Reaming if using short nail it’s possible to insert nail without further reaming since the entry reamer is 15mm in diameter nail might get tight near start of canal, short nail can use targeting guide for distal interlock screws as well for long nail start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer push through entry hole before reaming to avoid reaming out anterior cortex check chatter from reamer feedback and diaphyseal fit on fluoro AP ream 1.0-1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail for 70kg male, 6’ tall) don’t stop reamer in canal (avoids reamer head from getting stuck) Nail Insertion build nail on backtable and make sure targeting guide lines up with holes in nail, check sleeves for each interlock hole tighten top locking screw with pumpkin screwdriver to lock together screw in strikeplate insert nail completely and seat fully, check seating in distal femur hold nail by handle, not the targeting guide, mallet or manually advance to fracture site, check on fluoro AP/Lat insert nail over guidewire, follow anterior bow of femur (drop hand from ceiling down to floor 90°, handle parallel to the femur), mallet in using strikeplate lateral radiograph of the knee is the appropriate view to assess nail insertion remove long balltip guidewire Lag Screw check on AP fluoro to see where intertrochanteric lag screw will be located, want it to be in line with inferior border of femoral neck and end up in center of head remove strike plate and use triple sleeve into lag screw hole mark skin with trochar, 10blade for skin incision, cauterize subcutaneous tissue and fascia insert trochar guide down to bone and lock into place with targeting sleeve remove inner sleeve and drill guidepin into femoral neck and head, check on fluoro throughout to ensure proper trajectory want tip-apex distance <25mm on fluoro AP+Lat, center-center on AP and lat xrays once final guidepin placed, measure screw length (threads at tip don’t count) lock in drill to proper length, if concern regarding head spinning can insert additional kwire outside of nail as derotational pin remove inner sleeve and insert drill, slowly progress as drill approaches femoral head articular surface insert appropriate length lag screw and tighten final handle should be parallel or perpendicular to nail compress through targeting guide and watch fracture on fluoro insert set screw from top of nail to lock in position of lag screw remove targeting guide by loosening bolt on top of nail with T-handle Distal Interlocking Screws move to midshaft femur or distal femur depending on nail length and take Lat fluoro for perfect circles technique for interlocking screws c-arm now needs to be perpendicular to patient leg once distal interlock holes appear as perfect circles, use hemostat handle to localize holes, mag x2 in with fluoro 10blade through skin and IT band, hemostat spread down to bone place drill through lat cortex hole, then make drill perpendicular to C-arm beam and drill through first cortex and nail stop at 2nd cortex, measure (add 5mm to length to add 2nd cortex thickness), and then drill 2nd cortex while still in perfect circles lat fluoro, complete 2nd distal interlock screw and measure (more distal screw 10-15mm longer than proximal interlock screw) c-arm to AP position to get out of the way, insert both interlock screws Confirm Nail Position and Extremity Check take final AP/Lat of distal and proximal aspects of nail and fracture Closure Irrigation & Hemostasis strongly flush out nail insertion site, lag screw, and interlocking screw sites with saline bulb irrigation cauterize peripheral bleeding vessels Tissue Closure close fascia lata and IT band with 0-vicryl subcutaneous and skin closure with 2-0 vicryl and staples Dressing soft incision dressings over hip, proximal and distal femur Postoperative Care Immediate Post-op weight-bearing as tolerated, physical therapy foley catheter out when ambulating DVT prophylaxis immediate range of motion exercises to hip and knee 2 Weeks wound check staples/sutures removed continue physical therapy and range of motion exercises repeat xrays of femur Complications Document Complications implant failure and cutout (tip-apex distance <25mm on AP+Lat) anterior perforation of distal femoral cortex and/or femoral head and neck during lag screw placement post-operative abductor weakness and limp stress fracture in femur (when short cephalomedullary nail used)