PPT Proximal Femoral Nail, Principles and Techniques

Proximal femoral nail
orthopedic

1. Proximal Femoral Nail Muhammad Riyadli Orthopedic & Traumatology Department RSO Prof. Dr. R. Soeharso Hospital

2. Objective Indication Preparation Instrument Surgical technique

3. Proximal Femoral Nail Nail Blade Distal screw 170, 200, 240 mm 320 - 440 mm

4. Proximal Femoral Nail Indication Indication 170, 200, 240 mm 320 - 440 mm Low and extend subtrochanteric fractures Combination fractures Pathological fractures

5. Proximal Femoral Nail Contraindication Contrandication 170, 200, 240 mm 320 - 440 mm Isolated or combined femoral neck fractures Low subtrochanteric fractures Femoral shaft fractures Isolated or combined femoral neck fractures Preparation

6. Preparation Adequate X-Rays

7. Preparation Adequate X-Rays Analyzing the fracture pattern (CT)

8. Preparation Adequate X-Rays Analyzing the fracture pattern (CT) Templating CCD Angle Nail Length Nail Diameter Blade Length

9. Preparation Adequate X-Rays Analyzing the fracture pattern (CT) Templating Check the implants

10. Preparation Adequate X-Rays Analyzing the fracture pattern (CT) Templating Check the implants Optimizing the general status & comorbidities of the patient

11. Preparation Adequate X-Rays Analyzing the fracture pattern (CT) Templating Check the implants Optimizing the general status & comorbidities of the patient Neurovascular status of the limb Instrument

12. Instrument

13. Instrument Surgical Technique

14. Surgical Technique Patient Positioning

15. Surgical Technique Perform closed reduction Traction in the direction of long axis of the leg to distract the fragmen & regain length Internal rotation of the femoral shaft

16. Surgical Technique Perform closed reduction Percutaneus reduction technique Flexion deformity Varus deformity Valgus deformity

17. Surgical Technique Perform closed reduction Percutaneus reduction technique Flexion deformity Varus deformity Valgus deformity If doesn’t work OPEN REDUCTION

18. Surgical Technique Assessment of reduction quality in AP & lateral view No gap/increase density Continous medial/lateral cortical line No varus angulation Anteversion approximately 15 Continous anterior/posterior cortical line

19. Surgical Technique Confirm length and diameter of implant

20. Surgical Technique Approach to the entry point

21. Surgical Technique Guide wire insertion

22. Surgical Technique Opening the femur medullary cavity

23. Surgical Technique Reaming the medullary canal After opening femoral canal, insert ball tip guide wire 2,5 Start the reaming from 9 mm reamer head until 0,5 – 1,5 mm larger than chosen nail diameter

24. Surgical Technique Insertion of the nail Use C-arm control to insert the nail Insert nail manually/using light hammer blow Check for the anteversion and depth of nail insertion (projection blade parallel to center of head and neck femur)

25. Surgical Technique Blade insertion Assembly aiming arm Preparation of the wire insertion

26. Surgical Technique Blade insertion

27. Surgical Technique Blade insertion Measure blade length Opening lateral cortex Drill hole for blade (optional)

28. Surgical Technique Blade insertion Blade insertion Lock the blade to achieve fracture compression

29. Surgical Technique Distal Locking

30. Surgical Technique Insert end cap (if needed)

31. Surgical Technique Aftercare Partial weight bearing with walking aid Reassessed at 6 weeks Full ROM of the hip Tips, Trick, Pitfall

32. Negative medial cortex support (NMCS) Positive medial cortex support (PMCS)

33. Which one is the best ? - + N

34. Tips, Trick, Pitfall Which one is the best ? - + N

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36. Summary Preoperative planning Reduction first Entry point Proper blade length and position Positive medial cortex support (overcorrection) for better fixation