Updated: 10/4/2016

[Blocked from Release] Retrograde Femoral Intramedullary Nail

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Pearls & Pitfalls
 
Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I
  • Preparation
    • check ipsilateral femoral neck, thigh compartments, knee stability, limb length, rotation, and alignment
  • Positioning
    • radiolucent table and C-arm from contralateral side
  • Approach
    • anterior approach to intercondylar notch
      • through anterior knee (transtendinous or peritendinous)
  • Guidewire Insertion
    • start point in center of intercondylar notch just superior to Blumensaat’s line
  • Fracture Reduction
    • pull traction at 30° angle over triangle for reduction
  • Reaming
    • ream 1.5mm above size of final nail
  • Nail Insertion
    • insert nail over guidewire
  • Interlocking Screws
    • targeting guide to place distal interlocking screws first
    • check femoral neck, get perfect circles of proximal interlocking screws and insert
  • Postoperative 
    • weight-bearing as tolerated
    • immediate range of motion exercises to hip and knee
    • DVT prophylaxis
Planning & Preparation
  • Extremity Exam
    • before case need to check:
      • ipsilateral femoral neck
      • thigh compartments (anterior, posterior, adductor)
    • need AP and lateral radiographs of entire femur, hip, knee
    • CT of femoral neck
      • 2-6% incidence of ipsilateral femoral neck fracture, often basicervical, vertical, and nondisplaced
    • location of fracture site will indicate amount of deforming forces
    • document distal neurovascular status
  • Associated Injuries & Comorbidities
    • if potential delay in definitive fixation with intramedullary nail, place distal femoral or proximal tibia traction pin with ~25lb inline traction to reduce amount of shortening
      • no tibial traction pin if ipsilateral knee injury suspected
    • definitive stabilization within 24 hours is associated with decreased pulmonary complications, thromboembolic events, and length of hospital stay

Equipment & Positioning
  • Equipment 
    • retrograde intramedullary nailing system
    • c-arm fluoroscopy
    • radiolucent flat-top table
  • Position
    • patient supine with feet at the end of the bed
    • small bump under ipsilateral thigh
    • if traction pin in place, can remove prior to prep and drape
      • alternatively can leave in place to use for traction during case
    • prep and drape entire leg up to iliac crest
  • OR Setup and C-arm
    • radiolucent OR table
    • c-arm from contralateral side
      • perpendicular to bed
    • take initial AP and lateral of hip to examine femoral neck

Approaches
  • Anterior Knee 
    • plan out anterior approach to intercondylar notch through anterior knee
    • transtendinous or parapatellar
      • no difference in anterior knee pain
Surgical Technique
  • Approach
    • place knee in ~30° flexion over radiolucent triangle
      • knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius
    • mark out inferior pole of patella and borders of patella tendon
    • transtendinous approach:
      • make 2cm incision from inferior pole of patella distal through tendon
      • tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon
      • insert self-retainers and suction out synovial fluid
      • once in joint, remove small amount of fat pad to minimize guidepin deflection
    • parapatellar approach:
      • 2 cm incision along medial third of patellar tendon
      • cut through subcutaneous tissue and retract tendon/paratenon laterally
      • insert self retainer
  • Guidewire Insertion
    • guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line
    • insert guidepin to distal metaphysis
      • check C-arm image to ensure pin is in center of medullary canal
    • use entry reamer with soft tissue protector
    • remove starting pin and reamer, and place balltip guidewire in canal with T-handle
      • place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site
  • Fracture Reduction
    • reduce fracture by pulling traction
      • can use small blue towel bump to add flexion to distal segment
      • if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius
      • need to pull traction at 30° angle over triangle
    • once fracture reduced, manually push guidewire past fracture site and up to lesser trochanter, check on biplanar imaging
      • insert guidewire past lesser trochanter by 3-4cm
    • use radiolucent ruler to measure appropriate nail length
  • Reaming
    • use ruler on contralateral side to measure intact femur if segmental comminution exists
    • start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer
      • 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 reamer head from becoming incarcerated)
    • if eccentric reaming/wire position is seen, can place blocking screws
  • Nail Insertion
    • attach jig to nail on backtable and check that targeting guide lines up with holes in nail
    • insert nail over guidewire, cover holes closest to nail handle with hand to make sure blood doesn't pressurize out of nail during insertion
      • insert nail with jig lateral to thigh
    • hold nail by handle, not the targeting guide, mallet or manually advance to fracture site
    • 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
      • lateral radiograph of the knee is the appropriate view to assess nail insertion depth
    • remove guidewire before placing interlocking screws
  • Interlocking Screws
    • use targeting guide to place most distal interlock first
    • mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone
    • drill bicortically through the nail
    • leave drill bit in until screw arrives to hold nail/bone position and then place screw
    • repeat process above for placement of other interlocking screws if indicated
    • use attachment to remove nail jig, then take out triangle to lay leg flat
    • check femoral neck again on C-arm
    • obtain perfect circles of proximal interlocking screw holes
      • ensure no rotation of the distal femur is done while getting theseviews (move the C-arm, not the leg)
      • magnification of the fluoroscopic view can be used if desired
      • start with most proximal interlocking hole (screw will be longer than the more distal screw)
    • incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter
    • drill bit placed over center of hole, parallel to C-arm beam
    • to measure, can use a second drill bit or depth gauge
      • alternatively use a 34 or 36mm screw
    • remove drill quickly and insert screw when available
      • use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues
    • repeat above process for 2nd proximal interlocking screw
  • Confirm Nail Position and Extremity Check
    • raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur
    • take hip through a range of motion to assess for fracture
      • fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure
    • check limb lengths and rotation
    • perform a knee examination under anesthesia
Closure
  • Irrigation & Hemostasis
    • place knee under triangle and strongly flush out reamings with saline bulb irrigation
    • irrigate until backflow is clear
    • cauterize peripheral bleeding vessels
  • Fascia Closure
    • transtendinous
      • close patellar tendon and paratenon layers with 0-vicryl
      • subcutaneous and skin closure
    • parapatellar
      • close peripatellar arthrotomy, subcutaneous and skin closure
  • Dressing
    • soft incision dressings over knee, distal, and proximal femur
Postoperative Care
  • Immediate Postoperative Instructions
    • weight-bearing as tolerated
    • foley catheter out when ambulating
    • DVT prophylaxis
    • immediate range of motion exercises to hip and knee
  • 2-3 Weeks
    • wound check
    • staples/sutures removed
    • continue physical therapy and range of motion exercises
    • repeat radiographs of femur
Complications
  • Document Complications
    • post-operative knee pain
    • heterotopic ossification 
    • delayed union, nonunion
    • femoral nerve or artery injury (insertion of proximal interlocking screws)
      • increased risk if screws placed inferior to lesser trochanter
    • malrotation of femur
    • infection
    • hardware failure
    • missed femoral neck fracture
    • iatrogenic fracture (under-reaming, femoral neck fracture)
    • iatrogenic damage to cruciate ligaments
 

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