Lateral Entry Trochanteric Intramedullary Nailing of Femur
Michael Glotzbecker, MD
Diaphyseal femoral fracture
Subtrochanteric and distal metadiaphyseal fractures may be amenable
Any fracture pattern
Ages 11 until skeletal maturity
Younger patients preferably manage with flexible nailing or submuscular plating
Lateral Entry trochanteric nail set
Nail sizes range from 7 to 12 mm in diameter
Trochanteric entry nails available for larger adolescents
Radiolucent fracture table or radiolucent flat table
Supine on the radiolucent fracture table with legs scissored.
Bump underneath ipsilateral buttocks to prevent patient external rotation
Leg/body in adduction to allow easier access to the lateral hip with hip positioned as lateral as possible on the table
Contralateral leg lower to aid in radiographic lateral imaging
Ipsilateral arm across chest over pillow to clear operative side
Avoid malrotation by placing the hip and the knee cap to the ceiling. Look longitudinally from the foot and the limb position of the anterior hip and anterior knee should match and make sense. Significant internal or external rotation of the foot and the distal fracture should be a cause of concern and reevaluation.
Complete fluoroscopic AP and lateral views at the hip, fracture, and knee to assure ability to visualize femur completely and obtain provisional reduction (Figure 21-36A and B).
Lateral on the radiolucent fracture table
Helpful for larger patients
Historically helpful for piriformis nailing. Lateral entry nails make starting point simple for supine nailing
Supine on the radiolucent table
Bump underneath ipsilateral buttocks and flank with prep extending to the level of lilac crest
Longitudinal traction maintained by assistant
Technically more difficult to maintain traction/rotation
Surgical exposure is minimal and may be done through a 3 cm incision.
Incision marked out under fluoro, taking care to center incision just proximal and posterior as the direction of reaming and nail placement will be from cephalad to the caudally directed entry point
Skin incision, followed by fascial longitudinal split and muscle split in line with gluteal fibers down to just lateral to trochanteric tip.
Reduction and Fixation Techniques
Placement of threaded guide wire under fluoro starting at the lateral aspect of the tip of the greater troch just above the midpoint of the trochanteric apophysis. The direction on the AP should be headed from the starting point headed distal to the inferior edge of the less trochanter.
On the lateral fluoroscopic view, the threaded guide need to head directly down the shaft, taking care not to be too anterior given this will make the nail passage difficult due to anterior bow in nail (Figures 21-37A, B and 21-38A, B).
After confirmed adequate position of threaded tip guide pin the use the cannulated opening reamer which needs to open the proximal femur and should be passed to the level of the lesser trochanter on fluoroscopy (Figure 21-39).
Placement of the ball-tipped guide wire may be done keeping the ball tip directed lateral to “bounce” down medial cortex at the level of lesser troch; the ball tip should be then passed to the fracture and checked on fluoroscopy.