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Intertrochanteric Fracture ORIF with Cephalomedullary Nail

Planning

B

Preoperative Plan

1

Template intramedullary nail and cephalomedullary screws

  • measure diameter of intramedullary canal

2

Surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case.
  • list potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • cephalomedullary nailing system (Stryker Gamma, Synthes TFN)

2

Room setup and equipment

  • radiolucent fracture table (Jackson fracture)
  • c-arm fluoroscopy

3

Patient positioning

  • make sure patient has Foley urinary catheter in place
  • 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
  • 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)

Technique

D

Closed Fracture Reduction

1

Obtain closed reduction

  • apply inline traction first to distract fracture, then adduct and internally rotate leg, check fluoro AP/Lat
  • release a little traction to get fracture reduced

2

Make open incision if unable to obtain reduction

  • 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
E

Dissection Down to Tip of Greater Trochanter

1

Mark the anatomy of the femur

  • mark out GT and AP/Lat axis of femur using xray holding guidewire against skin

2

Dissect down to the starting point

  • 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
F

Guidewire Placement & Reaming

1

Identify guidepin starting point

  • start point is on the medial tip of GT
  • 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

2

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

3

Ream the 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
  • 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

4

Remove starting guidewire and reamer together

5

Advance guidewire

  • 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

6

Determine nail length

  • 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
  • if using short nail it’s possible to insert nail without further reaming since the entry reamer is 15mm in diameter

7

Ream the canal

  • 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)
G

Nail Insertion

1

Build nail on backtable

  • 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

2

Insert nail completely and seat fully, check seating in distal femur

  • 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
  • mallet or manually advance to fracture site, check on fluoro AP/Lat
  • hold nail by handle, not the targeting guide,

3

Check nail insertion

  • lateral radiograph of the knee is the appropriate view to assess nail insertion

4

Remove long balltip guidewire

H

Lag Screw Placement

1

Identify location of 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

2

Expose the femoral

  • 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 less than 25mm on fluoro AP+Lat, center-center on AP and lat xrays

3

Determine lag screw length

  • 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

4

Drill hole for the lag screw

  • remove inner sleeve and insert drill, slowly progress as drill approaches femoral head articular surface

5

Insert lag screw

  • 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

6

Remove targeting guide by loosening bolt on top of nail with T-handle

I

Distal Locking Screw Insertion

1

Set up for perfect circles

  • 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

2

Expose the femur

  • use a 10blade through skin and IT band, hemostat spread down to bone

3

Drill holes through bone

  • place drill through lateral 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)

4

Insert the interlocking screws

  • insert both interlock screws with C-arm to AP position to get out of the way

5

Confirm nail position and extremity check

  • take final AP/Lat of distal and proximal aspects of nail and fracture
J

Wound Closure

1

Irrigation and hemostasis

  • flush out nail insertion site, lag screw, and interlocking screw sites with saline bulb irrigation
  • cauterize peripheral bleeding vessels

2

Close the deep fascia

  • close fascia lata and IT band with 0-vicryl

3

Close the superficial layers

  • subcutaneous and skin closure with 2-0 vicryl and staples

4

Soft incision dressings over hip, proximal and distal femur

Patient Care

K

Preoperative H & P

1

Perform focus orthopaedic history and physical

  • perform careful 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
  • identify associated injuries and comorbidities
  • identify patient comorbidities and ASA status (predictor of mortality)
  • screen medical studies to identify and contraindications for surgery

2

Order basic imaging studies

  • order AP pelvis, ap and lateral of affected hip

3

Perform operative consent including lists potential complications

  • describe complications of surgery including
  • 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)
  • medical complications including death
  • definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2

2

Inpatient physical therapy

  • start range of motion exercises of the hip and knee
  • weight bear as tolerated

3

Appropriate medical management and medical consultation

4

Discharges patient appropriately

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

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • check neurovascular status
  • compare extremity to contralateral limb
  • concomitant and associated orthopaedic injuries

2

Appropriately interprets basic imaging studies

  • interpret AP pelvis and lateral radiographs of the affected hip

3

Recognition / evaluation of fragility fractures

  • order appropriate workup and/or consult

4

Interacts with consultants regarding optimal patient management

  • timing of surgery
  • medical management
  • assess risk for thromboembolic disease

5

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

6

Provides post-operative management and rehabilitation; WB status

  • postop: 2-3 Week postoperative visit
  • wound check
  • diagnose and management of early complications
  • staples/sutures removed
  • continue physical therapy and range of motion exercises
  • repeat xrays of femur
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • repeat xrays of femur
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Comprehensive assessment of fracture patterns on imaging studies

  • recognizes reverse obliquity fractures

2

Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral

3

Arranges for long term management of geriatric patients

  • management of bone health
  • discharge planning to long term care

4

Modifies and adjusts post-operative treatment plan as needed

5

Provides prohylaxis and manages thromboemblotic disease

O

Complex Evaluation and Management

1

Develops unique, complex post-operative management plans

 

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