Retrograde Femoral Intramedullary Nail
- Prep and Drape, Surgical Timeout
Exposure and Nail Placement
- Enter Formal Canal with Guide
- Use Opening Reamer
- Pass Guidewire Across Fracture
- Measure for Length of Nail
- Reaming Femoral Canal
Targeting of Nail
- Check Guidewire Under Fluoro
Femoral Nail Locking Screws
- Distal Locking Screw Placement
- Proximal Locking Screws
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Okay. Blue marker. So really want you want to do is just think, this midline and this for your bolt. That should be kind of good since it’s right on the midline. With the tibby you want to be up under here more, here it’s almost you want to go lower. Incision. You can use the whole thing up to the top here. You do? Ok I thought that -- No, no I just changed my mind. Just be bold, cut right through that there’s nothing bad here. Through that tendon, through that tendon. Yeah there we go. That’s it. Don’t go down, you don’t need to go down. Right? Because you’re going straight that way. Your tibia is going straight down that way, in this one you’re going that way.
That was really nice. You’re in the knee. You can feel the top of the notch. Now the other thing to realize is that this is mid-shaft femur fracture, they typically go apex - posterior, okay? So you’re going to aim a little like this, more down. So you want to be right at the top of that notch, in the center, aiming a little bit down. If you put it in the notch when you ream, you’ll ream the ACL. So don’t put it there. So this is the notch, I want you to be on the top of the notch. Look at your hand, I want your hand way up. Drop your hand a little bit. There you go. Good, good. Put it in. Don’t push that in, just push that in. Good. That looks pretty good.
Alright now let’s go to our lateral. We’re maybe a millimeter too high. Yeah, so I like to keep that other pin in place because that’s your guide. X-ray. Alright now you’ve got to take out the top one. Now I want you to redirect that one. X-ray. Nice. Good. X-ray. Making your incision in the right spot, so being careful and making it right in the center, then you’re going to end up right where you want to be. So it just helps you. That looks good. Good. So save that.
So now we’re going to use the opening reamer and that’s going to create a hole in the end of the femur now to get access. Do you have a schnidt? Yeah, good now take it out. Save that, come proximal. Alright we’re going to trade. Okay, X-ray. Little more. Save that. Alright let’s go to a lateral. Can you get your hand under there to lift? X-ray. Good, come up to an A-P. Yeah, alright.
So a lateral at the knee please? You really can’t tell the depth of the nail, except at the lateral, so I think it’s important that you always check this. So that measures 300 exactly. So if we did 300 it would look like this. X-ray. That’s really not enough room, so let’s do a 280. So 280 by 9, I think. So first reamer is an 8-5. Now this reamer may be too big. She’s got a very small canal. X-ray. Alright that’s fine. Alright hold on. Let’s switch for one second. Can I get some towels, please? Like 3 or 4 towels? Put this under the apex of the fracture there. Good, and now I’m going to pull like this. X-ray. Yeah so we’re going to use a 9. Now just don’t lose that guidewire. So next will be 9-5 and then 10 and then that’s our last reamer. So you’ve just got to know your nail systems, and when the interlock screw sizes change. You know, you’ve got to keep that in mind. A lot of times they go up and if you have a small interlock screw, that’s going to fatigue and fail sooner.
Now for this particular -- for the femoral nail 9s go to 5, yeah. And to be honest, for this fracture pattern it doesn’t really matter. This is a length stable thing, the interlock screws aren’t going to do anything. Good. First, and this is one we’ll be able to impact after we lock it distally and compress and then lock it proximally. It matters what side we’re doing and we’re doing a right so the way I always think of it is that the bow has got to go that way and so it has to go this way. But keep in mind the bow. Here we’re doing a retrograde the bow of the femur matches. If you go this way you kind of reverse the bow, you don’t want to do that. It’ll break the femur that way. So just slide that right on. Try not to touch the metal too much. And then, oh one thing here. I’m going to change this.
So I like to put this right on the end here. So there are two places, and this one is kind of co-linear so when you’re hitting it, you’re hitting it straight down, you’re not hitting it side -- caddywompus type thing. And there’s no twisting or anything with this one. It goes straight in. Straight in, right? Because you’re co-linear with the axis of the femur so you just pound that in. Yep. Good. X-ray.
Let’s come to a lateral please. So that’s your perfect lateral, okay? So save that and that’s really what’s going to show you -- X-ray there. Good. So that’s what’s really showing you that you’re countersunk and I really like this thing to be at least 5 millimeters or more underneath the condyle surface because that thing is prominent and really hurts with patella flexion. Alright, so come up to an A-P. Do you have a blue magic marker? Kind of connect those dots, okay?
Just cut right through. Cut. Good. So the iliotibial band is right here so you just gotta -- yep. Pop through there. Good. X-ray there. Nice. And now this drill should be calibrated. 4-2 for a 5-0 locker. Go through the nail. Good. Now stop a second. X-ray there. Watch your hand. That’s measuring 70, so probably a 65 because this is a little bit off the bone. Actually, really? Oh, 62. Yep go ahead. So that’s about down. X-ray there. You have got to be a little bit careful because this can drive into the bone. That’s a pretty good bite. So that’s about it there. Go a little bit more. Good. So that’s one way that if you just power through, it’ll go right through that lateral cortex. You’ve got that internal rotation that shows you you’re long on the medial side because the distal femur is shaped like a trapezoid so you’re going to see through here. From the A-P you can’t see it but then you eventually rotate and you can. Alright, same thing, second burst same as the first.
X-ray. 52. Is there an instance where you want to lock proximally first? You could probably think of a situation but most of the time not and that’s because to compress you can hit it from this side. Yeah exactly and if you’re back-slapping the nail you’re going to get closer to the knee joint so it’s safer to hit it this way. Come up more proximal. So that looks pretty well reduced so lets go to a lateral and see how it looks right there. So that looks pretty good, nice. So come up to an A-P. X-ray there. Save that. X-ray. A little more. Good. X-ray. Try that. X-ray. X-ray. A-P. Can I get the acorn please. The drill, shorter drill.
Okay and now with the handle out, you can extend the knee. So now this can go away. X-ray again. Alright I can’t do better than that for you. Save that. It’s perfect. Yep. If you make every step go perfectly, then the whole thing goes nice and smoothly. So, perfect X-ray where that circle is really nice and centered in your frame. Incision right over it so you’re not fighting the skin to get your drill bit in the right spot. Drill bit really perfect. Now the other thing is I think a lot of people make a mistake in making their holes too small. I’d make it twice that big. Hold your knife. It’s hard to get much better than that with a femoral shaft fracture because there is a little plastic deformation so it doesn’t key in quite perfectly. A little more proximal.
Nope so that’s too far towards the far side. This is ever so slightly towards you. That’s what I mean by being perfect, like a lot of people do that, it’s eclipsing it. You don’t want to eclipse it you want it right on the center. Tiny bit, tiny bit. There you go, that’s perfect. That’s the nail. So just pop this off. X-ray there. Just adjust it a little bit. Just tap it. X-ray. There you go. X-ray.
So for a lot of femur fractures, rotation is an issue, but for this particular one you can see it interdigitates really nicely so I’m not too worried. And just clinically, one of the advantages of being supine and doing a retrograde nail is you get to see both legs and you can see that they’re fairly symmetric. Now obviously she’s got a fracture here and a fracture in that region so it kind of makes it a little more difficult but things look pretty good. Absolutely.
30s. Like 36. 34? 36. Is it measuring exactly 36? Exactly? 36. So if you look at these screws, they have a long tap area so you want them to stick out. Yeah that’s not going to get much bite. This is a special kind of screwdriver, it grabs onto the screw so you don’t lose it. And then you just have to undo that, you unscrew that and it pops off. Yeah. Just be gentle with it, like its possible to lose that screw and then it really sucks. Just like that. Yeah these are hard. The first few you do by yourself are kind of scary too. But you know the vessels and everything are pretty medial actually, pretty medial. So now if you think you’re down, what I want to do is check a lateral because it’s pretty easy to lose this thing. Let’s come to a lateral, please. X-ray there. That looks pretty good, but you’ve got to go a little further. Yeah I’m going to put it down. Screwdriver. Mallet. X-ray there. That’s a little on the long side. Do you have the blue one? So you were right.
X-ray. You see some of that bleeding, it’s probably because we’re getting into the fracture hematoma because we’re pretty close. Okay. So do the same thing. I think just take off 2. I think 34 like you said. I mean you definitely want that thing to stick out, and that’s not going to bother her there. X-ray there. Yep, I like that. Good. Save that for us? Come up a little more proximal. That’s nice. Save that. Now come down to the knee please? And then come down to a full lateral. Good. So maybe a little bit north from there. Save that.
So now you can see we’re countersunk, your starting point is really nice, and we’ve got a nice alignment. Alright let’s come up to an A-P. And her leg, you know, was really floppy before, and now it’s behaving like a femur. I don’t think she needs traction, the proximal fracture isn’t really displaced. So no traction? No traction, no. Let’s come up proximal. I’ll take a picture of the hip and I’ll see if I pull on it if it helps the acetabulum and if it does, we will. Save that. Little bit more proximal. X-ray there. Come up a little bit more proximal, let’s get that out of the way. It didn’t really change the acetabulum so, x-ray there. X-ray.
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