23 Antegrade Femoral Nailing
Summary
Intramedullary devices for bone fixation have been described since the 16th century, but modern femoral intramedullary nailing began to gain popularity after the work of Kuntscher during World War II. 1 Over the years, numerous technological advancements have allowed antegrade femoral nailing to be used for the treatment of various femur fracture patterns. 1 The most recent intramedullary devices can be used to treat intertrochanteric, subtrochanteric, and femoral shaft fractures. Once the decision is made to proceed with antegrade femoral nailing for fracture treatment, the implant type, patient positioning, and reduction technique must all be considered. This chapter will discuss these topics, in addition to a general technique for antegrade intramedullary nailing.
23.1 Implant Selection
Piriformis entry nails start within the piriformis fossa, which allows colinear trajectory with the femoral canal (▶Fig. 23.1). The trajectory reduces the risk of fracture comminution and varus malalignment. 3
However, it is more difficult to obtain this entry point, especially in an obese patient. Also, starting too anterior increases hoop stresses on the femoral shaft with the risk of iatrogenic fracture.
Trochanteric entry nails start at the tip of the greater trochanter, just lateral to the axis of the medullary canal (▶Fig. 23.2). There is a lateral bend at the proximal aspect of the nail, which allows the nail to sit straight in the medullary canal with this more lateral starting point.
Technically easier to access starting point, especially in obese patients
Associated with less operative and less fluoroscopy time compared to piriformis entry nails, with similar outcomes 4
Cephalomedullary devices provide fixation into the femoral neck (▶Fig. 23.3). They can be used in intertrochanteric and subtrochanteric femur fractures, and may be indicated in patients with poor bone quality.
23.2 Patient Positioning
Patient positioning is mainly based on surgeon preference with each position having positive and negative attributes.
Supine on a radiolucent table, with a bump under affected hip to elevate the pelvis 10–15 degrees. This will aid with establishing your starting point. A foam wedge under the ipsilateral leg can help with obtaining lateral radiographs. The drape should be low on the buttock to allow flexion of the hip intraoperatively.
Supine positioning allows an easier visualization of anatomy, can be used with or without traction, allows free mobility of the limb to aid in fracture reduction, and checks alignment and rotation. It is also good for patients with chest and spine injuries, who may not tolerate lateral positioning. However, it requires a skilled, scrubbed assistant to aid in traction and limb manipulation.
Supine on a fracture table with a well-padded perineal post and the contra-lateral leg in the lithotomy or a scissored position to facility imaging. Establish reduction on fluoroscopy prior to draping to ensure the feasibility of using the fracture table.
The fracture table eliminates the need for a skilled, scrubbed assistant to manipulate the leg, but requires a skilled un-scrubbed assistant to adjust the table. It can also be difficult to position if there is severe arthritis in the contra-lateral hip, which prevents the lithotomy position.
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