Summary The HIP-G Proximal Femur Nail is an intramedullary nail system for treatment of fractures, revisions, and tumor stabilizations in the proximal femur, including combined injury patterns affecting the shaft area (long nails) Key system concepts include a two-portal proximal fixation concept for rotational stability intra- and post-operatively, and a DyCon® screw pair intended to function as a dynamically controlled force carrier system in the femoral neck/head Controlled dynamization is provided via the inferior DyCon® Set Screw engaging the groove of the Lag Screw, allowing scalable lateral dynamization (0mm static to 10mm dynamic+) while inhibiting medial migration via full contact area between screws Indications All nails stable and unstable pertrochanteric fractures intertrochanteric fractures Additionally for long nails subtrochanteric fractures pathological fractures nonunions and malunions Contraindications (general, as described) special circumstances such as infection or marked local inflammation conditions requiring physician risk/benefit consideration, including dependence on patient bone quality for adequate fixation until bony healing occurs compromised vascularity excessive stresses on bone/implant (e.g., severe obesity) or degenerative diseases interfering systemic conditions such as infection demonstrated allergy or foreign body sensitivity to any implant materials Anatomy Osteology proximal femur landmarks relevant to trochanteric entry nailing include the greater trochanter femoral neck/head calcar region proximal diaphysis inferior femoral neck cortex (Adam’s arch/calar region) is a critical zone when planning inferior trajectories near the neck cortex Muscles abductors (gluteus medius/minimus) attach to the greater trochanter and influence trochanteric tenderness and lateral approach dissection planes iliopsoas insertion on the lesser trochanter can contribute to flexion/external rotation of proximal fragments in subtrochanteric patterns short external rotators and gluteal musculature contribute to deforming forces and can complicate reduction in unstable patterns Ligaments hip capsule and iliofemoral/pubo-femoral/ischiofemoral ligaments contribute to hip stability and can limit reduction maneuvers ligamentum teres contributes minimally to adult femoral head perfusion compared with retinacular vessels Nerves sciatic nerve is at risk with excessive traction, aggressive posterior retraction, or malpositioning superior gluteal nerve is relevant to proximal lateral dissection planes and abductor function lateral femoral cutaneous nerve may be irritated with proximal lateral incisions and retraction Blood supply medial femoral circumflex artery (deep branch) supplies most of the femoral head via retinacular vessels intracapsular displacement and excessive manipulation can threaten perfusion in femoral neck–adjacent injuries Preoperative Planning Imaging obtain pelvic overview imaging and longitudinal imaging of the affected femur with the hip joint in a/p and (if feasible) lateral projections Approach Position patient supine on a table that allows unobstructed fluoroscopy and a freely adjustable extension device via foot fixation position the healthy leg rotated to the opposite side with ~90° hip/knee flexion and supported secure the arm on the affected side across the body alternative lateral position is possible (e.g., shaft fractures), acknowledging potentially more difficult proximal reduction Localize incision using fluoroscopic marking for trochanter access in a/p, place a drill-wire transverse to the body axis resting on the trochanter tip in projection in lateral, place drill-wire centrally in femoral axis and mark longitudinally above the horizontal line Perform a proximal lateral incision for trochanter entry create ~2–3cm incision starting ~2–4cm proximal to the trochanteric apex (soft tissue dependent) sharply split fascia longitudinally; elevate musculature to palpate the anterior-to-posterior trochanteric ridge divide the ridge into thirds; usual entry point is at the junction of the anterior third and middle third Technique Reduction & canal opening reduction achieve closed reduction (length, axis, rotation) under fluoroscopy open reduction is required if displaced subtrochanteric patterns are irreducible. entry point place drill-wire centrally in the femoral axis (check valgus path in A/P) correction use parallel holes in the conical sleeve if repositioning is needed opening advance tissue protection sleeve to the trochanter ream over the drill-wire until the depth stop hits the sleeve if the canal is narrow, use a ball-tip guide wire and ream over it Nail insertion & setup selection match nail to length, diameter, and CCD angle (120°/125°/130°) insertion attach nail to targeting arm and double-check the holding bolt is fully tightened advance nail with slight rotation sleeves insert K-wire sleeves through the master sleeve until they firmly contact the lateral cortex secure via the ratchet mechanism Two-portal drill-wire placement superior (lag screw) center the femoral head in lateral view drill wire to a central position final tip should be ~5mm below the bone-cartilage transition in A/P view inferior (DyCon set screw) place the inferior wire parallel to the first anchor it 5-10mm shorter than the superior wire Lag screw insertion measurement measure length via ruler drilling depth = measured value minus 5mm drilling remove superior K-wire sleeve (keep inferior wire in for stability) drill over the superior wire until the stop is reached insertion insert cannulated lag screw align markings on the driver with the sleeve final positioning is adjustable in 1.6mm increments remove driver and superior wire Set screw fixation (DyCon or Axial) DyCon (inferior) replace inferior K-wire sleeve with the set screw sleeve drill until the stop insert DyCon screw it will automatically "push off" the driver at the 5mm dynamization depth Axial (top-down) insert via the nail holding bolt pathway tighten until it engages the lag screw groove do not back out Distal locking short/intermediate (guided) use the targeting module drill with Ø4.2mm bit through the sleeve (ratchet seated on bone) add length for the medial cortex and insert Ø5mm screw long nails (freehand) obtain "perfect circles" on fluoroscopy static use two round holes dynamic use the lower position of the elongated hole Completion & optional steps disassembly remove sleeves and unscrew the nail holding bolt only after all locking is complete closure verify final implant position and screw lengths via fluoroscopy before wound closure end caps (optional) used only if nail extension or scar tissue protection is required Technical specifications Nail lengths short 180mm intermediate 240mm long 260–480mm (multiple lengths) Nail diameter short distal diameter 10mm intermediate distal diameters 10mm 12mm long distal diameters 9mm 10mm 12mm 14mm CCD angles available 120° 125° 130° Anteversion 12° anteversion of femoral neck (as described for system concept/rotation control) Proximal geometry/features include proximal diameter Ø15.7mm 4° lateral bend two proximal portals for lag screw (superior) and set screw (inferior) trajectories self-retaining mechanism for DyCon® Set Screw (as described) Antecurvature short and intermediate nails use average femoral antecurvature of 1100mm long nails have length-dependent antecurvatures distal locking options include Ø5mm screws horizontally oriented true M-L configuration static and dynamic locking options Screws Lag screw diameter Ø10.5mm lengths 70–130mm (5mm increments) Dycon® set screw (inferior set screw of dycon® screw pair) controlled lateral dynamization control (0–10mm) while inhibiting medial migration via screw-to-screw contact 1:1 relationship with lag screw short dycon® set screw can be used universally when needed/preferred Axial set screw can be used alone or with dycon® set screw if used alone, medial movement of lag screw is blocked and lateral movement is free depending on remaining groove length of lag screw Distal locking screws diameter Ø5.0mm lengths 25–120mm End cap screws 0mm 5mm 10mm 15mm 20mm