Updated: 10/4/2016

Prophylactic Femoral Intramedullary Nailing

Preoperative Patient Care


Outside Evaluation and Management


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


Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic


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


Makes informed decision to proceed with operative treatment

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


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

Advanced Evaluation and Management


Appropriately orders and interprets advanced imaging studies/lab studies

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


Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty


Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)


Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling

Preoperative H & P


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


Orders basic imaging studies

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


Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention


Perform operative consent

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

Operative Techniques


Preoperative Plan


Template instrumentation

  • measure diameter of intramedullary canal and approximate length.


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

Room Preparation


Surgical instrumentation

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


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


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

Lateral Approach to the Hip


Make incision approximately 3 cm above GT in line with femur

  • move incision superior if patient obese


Dissect down to greater trochanter

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

Guidewire Entry


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


Insert guidepin

  • Insert guidepin down to lesser trochanter and check biplanar images


Use entry reamer

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

Reaming and Nail Placement


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)


Build nail

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


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,


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)


Remove long balltip guidewire


Proximal Interlocking Screws


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


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


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


Distal Locking Screws


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


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


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


Take hip through a range of motion to assess for fracture

  • static or dynamic fluoroscopic evaluation is needed

Wound Closure


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


Close deep fascia

  • close fascia lata and IT band with 0-vicryl


Close superficial fascia and skin

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



  • soft incision dressings over hip, proximal and distal femur

Postoperative Patient Care


Perioperative Inpatient Management


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


Discharges patient appropriately

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

Complex Patient Care


Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy


Develops unique, complex post-operative management plans


Discusses prognosis and end of life care with patient and family


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