Preoperative Patient Care A 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 B 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 C 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 Operative Techniques E 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 F 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) G 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 H 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 I 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) J 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 K 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 L 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 N 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 Postoperative Patient Care O 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 R Complex Evaluation and Management 1 Develops unique, complex post-operative management plans
A 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 B 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 C 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
E 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 F 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) G 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 H 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 I 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) J 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 K 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 L 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 N 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
O 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 R Complex Evaluation and Management 1 Develops unique, complex post-operative management plans
All Videos (2) Podcasts (0) Login to View Community Videos Login to View Community Videos Proximal Femoral Nail Kemal Gokkus Approaches - Intertrochanteric Fracture ORIF with Cephalomedullary Nail 6/10/2022 334 views 5.0 (1) Login to View Community Videos Login to View Community Videos Room Preparation Fracture Table Setup and Positioning nicholas frane Approaches - Intertrochanteric Fracture ORIF with Cephalomedullary Nail A 8/11/2019 824 views 5.0 (14)