Simultaneous reconstruction nailing of both fractures is attractive for its elegance and efficiency (Fig. 11.2). Theoretically, the surgeon can simultaneously stabilize both injuries with a single device while avoiding trauma to the knee, and some authors have described good results with this technique [6, 11, 38–40]. However, others have reported an increased incidence of problems with femoral neck reduction and healing as compared to the aforementioned two-implant technique [14, 19, 28, 35, 41]. Some surgeons feel that an antegrade reconstruction nail is best reserved for a minimally or non-displaced femoral neck fracture, particularly one identified intraoperatively [35, 42].

The patient may be positioned either on a radiolucent flat-top table or an orthopedic fracture table. If a radiolucent flat-top table is selected, a small trochanteric bump can facilitate access. Prep and drape techniques for contralateral comparison are the same as mentioned above.

Again, an initial attempt at closed reduction can be performed. This can either be done by utilizing the fracture table or by employing a Schanz pin(s) with or without an external fixator bar. If anatomic reduction cannot be obtained closed, an open approach is undertaken to facilitate reduction under direct vision. Once an appropriate reduction has been obtained, it can be stabilized with Kirschner wires strategically placed outside the path of the nail. These wires can even be supplemented with a cannulated screw.

Once the femoral neck has been reduced and provisionally stabilized, attention is turned to the femoral shaft. In the setting of an open femur fracture with a relatively simple pattern, provisional unicortical locked plate fixation of the shaft can be performed at the time of debridement. This can greatly simplify passage of the guidewire and nail with minimal biologic cost if the site has already been exposed for debridement. In the setting of a closed fracture, the usual closed or minimally invasive reduction techniques can be employed.

A trochanteric start reconstruction nail is typically selected for this application, optimizing screw trajectory into the head/neck segment. A starting point is established using conventional techniques and the medullary canal opened. The guidewire must be placed across the femoral shaft fracture site without disrupting the provisional fixation of the neck. Again, the femur should be over-reamed by 2 mm, so the nail can be inserted as gently as possible. As with any cephalomedullary device, the version of the nail must match the version of the femoral neck so that the reconstruction screws can be placed centrally into the femoral head. Partially threaded screws should be used to allow for ongoing compression at the femoral neck [39, 40]. Routine distal interlocking can then be performed.

Less commonly employed alternatives to the aforementioned strategies have also been described. One of these is independent screw fixation of the femoral neck after antegrade femoral nailing of the femoral shaft (Fig. 11.3). This technique is most relevant when a femoral neck fracture is identified after medullary nailing has been completed. Under these circumstances, provided the fracture is not displaced or an appropriate reduction can be obtained, cannulated screws can be deployed around the nail to stabilize the femoral neck. This can be challenging as the nail can compromise precise screw placement, and the surgeon must remain sensitive to the importance of screw position in femoral neck fracture fixation [41, 42]. If appropriate reduction and stabilization of the femoral neck cannot be achieved with the nail in place, it should be removed and an alternative strategy employed. Finally, plate fixation of the femoral shaft can be performed after surgical treatment of the femoral neck. Plate fixation avoids the forceful insertion of a nail into the femoral canal below a femoral neck fracture and obviates the need for reaming which is a known source of systemic inflammation and potential pulmonary compromise [43, 44]. It may also be more attractive in very distal fractures where intramedullary nailing may be more technically difficult or biomechanically less appealing. That being said, reamed, locked intramedullary nailing is the treatment of choice for the vast majority of femoral shaft fractures, with plate fixation serving a limited role given its more invasive nature and inferior biomechanics.

Independent screw fixation of the femoral neck with separate antegrade femoral nailing is most frequently performed when a femoral neck fracture has been identified with the nail already in situ. Under these circumstances, whatever position, prep and drape has been selected for the femoral nailing can also be utilized for the femoral neck fixation. The most important step remains obtaining an anatomic reduction using conventional closed or open reduction techniques. The challenge comes in placing screws that avoid the nail and are appropriately positioned to stabilize the femoral neck fracture femoral neck. If appropriate reduction cannot be achieved or if the nail prevents appropriate femoral neck fracture fixation, all implants should be removed and an alternative strategy employed.

Plate fixation of the femoral shaft following femoral neck fixation can be performed supine on a conventional radiolucent table or a fracture table. Although many surgeons prefer the lateral position when performing plate fixation of isolated femoral shaft fractures, this position is suboptimal for femoral neck fracture reduction and fixation. Depending on the clinical circumstances and femoral shaft fracture pattern, the plate can be deployed in bridge, neutralization, or compression mode. Although there are reports of utilizing a single device such as a compression screw with a long side plate in these circumstances, we believe that separate implants optimally placed for either femoral neck or femoral shaft fracture fixation are preferred.