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Prophylactic Femoral Intramedullary Nailing

Planning

B

Preoperative Plan

1

Template instrumentation

  • measure diameter of intramedullary canal and approximate length.

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • antegrade femoral intramedullary nailing system
  • recon nailing system if femoral neck protection needed

2

Room setup and equipment

  • table options
  • radiolucent flat top table
  • fracture table
  • c-arm fluoroscopy
  • c-arm from contralateral side perpendicular to patient if on flat top table
  • c-arm from contralateral side at 45° towards hip if on fracture table
  • take initial biplanar flouroscopic images of hip to examine femoral neck

3

Patient positioning

  • if using flat top table, patient is supine with small bump under ipsilateral hip
  • patient's waist brought to edge of bed
  • ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board
  • if using fracture table
  • 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
  • if traction pin in place, can remove prior to prep and drape, or alternatively can leave in place to use for traction during case (place sterile endcaps if using traction pin)
  • prep and drape entire leg up to iliac crest to make sure adequate working area

Technique

D

Lateral Approach to the Hip

1

Make incision approximately 3 cm above GT in line with femur

  • move incision superior if patient obese

2

Dissect down to greater trochanter

  • use cautery through subcutaneous tissue and sharp dissection through the fascia lata
  • palpate tip of greater trochanter.
E

Guidewire Entry

1

Identify the guidepin starting point

  • starting point is on GT tip of bone
  • needs to be in center of medullary canal on AP radiograph and center of GT on lateral image
  • starting point can be different if trochanteric height/offset different
  • if difficulty with guidewire start point, use cannulated awl to get better control

2

Insert guidepin

  • Insert guidepin down to lesser trochanter and check biplanar images

3

Use entry reamer

  • place and push soft tissue protector so that reaming is parallel to femur
  • soft tissue tends to force eccentric medial reaming
F

Reaming and Nail Placement

1

Ream intramedullary canal

  • start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer
  • push through entry hole before reaming to avoid eccentric reaming
  • check chatter from reamer feedback and diaphyseal fit on AP radiograph
  • ream 1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail)
  • don’t stop reamer in canal (avoids incarceration of reamer head)

2

Build nail

  • build nail on backtable and make sure targeting guide lines up with holes in nail

3

Place nail into intramedullary canal

  • insert nail over guidewire, follow anterior bow of femur
  • start with handle pointing up and rotate down to parallel with femur as the nail is seated
  • hold nail by handle, not the targeting guide,

4

Advance nail in intramedullary canal

  • manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet
  • insert nail completely and seat fully, check seating in distal femur
  • lateral radiograph of the knee is the appropriate view to assess nail insertion unless using recon-style fixation (need AP hip view to determine depth of nail)

5

Remove long balltip guidewire

G

Proximal Interlocking Screws

1

Identify interlocking screw placement

  • use AP fluoroscopic view to see where interlock screws will be located
  • for recon style fixaton: inferior femoral neck screw to be along inferior neck

2

Place interlocking screw

  • incise skin, subcutaneous tissue and fascia at tip of trocar, spread down to bone
  • push guides down to bone, remove innermost sleeve, and insert K-wire or drill bit in inferior trocar
  • check wire or drill bit position on AP and lateral images
  • depending on the nailing system, repeat process for in the superior trocar

3

Remove top jig locking screw from nail and remove handle and targeting guide

H

Distal Locking Screws

1

Obtain perfect circles

  • obtain C-arm lateral images for perfect circle technique
  • move the C-arm or the leg as a unit to avoid iatrogenic malrotation
  • use scalpel to locate incision site
  • incise through skin and IT band
  • use hemostat to spread down to bone

2

Drill holes for interlocking screws

  • place drill on lateral cortex in the center of the hole
  • make drill perpendicular to C-arm beam and drill through cortices and nail
  • Place interlocking screws
  • use depth gauge for length and place first screw
  • repeat this technique for a second screw if needed

3

Take final biplanar imaging of distal and proximal aspects of nail and fracture

4

Take hip through a range of motion to assess for fracture

  • static or dynamic fluoroscopic evaluation is needed
I

Wound Closure

1

Irrigation, hemostasis, and drain

  • strongly flush out nail insertion site and interlocking screw sites with saline bulb irrigation
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Close deep fascia

  • close fascia lata and IT band with 0-vicryl

3

Close superficial fascia and skin

  • subcutaneous and skin closure with 3-0 vicryl and suture or staples

4

Dressings

  • soft incision dressings over hip, proximal and distal femur

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness
  • screen medical studies to identify and contraindications for surgery

2

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

3

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

4

Perform operative consent

  • describe complications of surgery including
  • Infection
  • nonunion
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • intravenous antibiotics
  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • inpatient physical therapy
  • start range of motion exercises of the hip and knee
  • weight bear as tolerated
  • wound care
  • remove dressings POD 2
  • appropriately orders and interprets basic imaging studies
  • check radiographs of the femur in post op
  • appropriate medical management and medical consultation
  • inpatient physical therapy
  • start range of motion exercises of the hip and knee
  • weight bear as tolerated

2

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
  • wound care
M

Outside Evaluation and Management

1

Obtain focused history and performs focused exam

  • history
  • past history of cancer or radiation
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • check radiographs
  • start formal physical therapy
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • hardware failure
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • MRI
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
O

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

3

Discusses prognosis and end of life care with patient and family

 

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