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Learn the Femoral neck fracture : proximal femoral nail ( Synthes long TFNA ) for Intertrochanteric fracture surgical proficiency with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certifiable CME of the Femoral neck fracture : proximal femoral nail down ( Synthes long TFNA ) for Intertrochanteric fracture surgical procedure .
Intertrochanteric hip fractures are more normally treated with a Dynamic Hip Screw ( DHS ) in the UK. however, there is good reason to consider a nail in certain situations, in particular if there is any lateral wall or greater trochanter compromise. This is because the DHS is designed to allow the fracture to crumble and in the absence of a lateral pass wall to buttress this collapse, the femoral diaphysis can medialise and the hip abductors lose their mechanical advantage. If recognised, this situation can be prevented by augmenting the DHS with a Trochanteric Stabilisation Plate ( TSP ). however this much irritates the lateral pass soft tissues and can cause a trochanteric bursitis.

The National Institute for Health and Care Excellence ( NICE ), an advisory body in the UK, states that adults with trochanteric fractures above and including the lesser trochanter should be treated with extramedullary implants. evidence to support their side is that like clinical outcomes can be achieved with both types of device and there is some evidence for a higher re-operation rate due to periprosthetic fracture with a smash, which is besides a more expensive plant than a DHS. Looking outside of the UK, then these fracture patterns are routinely treated with intramedullary devices .
Intramedullary implants have been reported to be associated with a higher 30 day deathrate when compared with sliding hep screws and Whitehouse et aluminum. suggest that for every 112 femoral nails there will be 1 excess death. however, they do not know whether the implant / proficiency is causative or whether there were significant differences between the cohorts, as this was not a randomised controlled trial. It is therefore significant to ensure that these devices are used selectively .
The TFNA is available as either a short breeze through ( duration 170mm, 200mm, 235mm ) or a long pinpoint ( length 300-480mm ) and can be used with either a screw or coiling blade. The proximal end of the nail down is 15.66mm and distally the nails are available in 9mm, 10mm, 11mm, 12mm and 14mm diameters. It has a radius of curvature ( ROC ) of 1.0 metres which is different to its ’ harbinger the PFNA which had a ROC of 1.5 metres. internally there is a pre-assembled locking mechanism to control the sword rotation and either lock it statically or dynamically. The blade angles are available in 125 degrees, 130 degrees and 135 degrees and all nails have an anatomic 10 degrees of anteversion. The nails are made from titanium and accept 5mm locking bolts distally. In comparison with a rival nail such as the Stryker Gamma3 nail which has a ROC of 1.5 metres, the TFNA is more probably to have an anatomic suit with the normal anterior bow of the femur and reduces the risk of front tooth impingement of the nail in the distal femur which can potentially perforate or cause distal femoral fractures .
implant failure is a rare event but Synthes has recognised that when these nails do fail, they normally tend to fail at the prison guard / blade trap. This can mean that subsequent origin is difficult. To overcome this there is a thread internally in the nail ( below the blade hole ) where an instrument can be attached and the nail removed more easily .
The TFNA can be augmented with broken viscosity bone cement that can be injected through the cannulate screw or coiling blade into the femoral head for patients with severe osteoporosis. To do this, the interpolation treat is removed and the 3.2mm usher wire is removed from the screw or blade. The cement is then injected through the cannulation where the wire previously was and exits through perforations in the tap of the screw / blade. Bone cementum ( polymethylmethacrylate – PMMA ) is however contraindicated in the follow circumstances :

  • If there is a risk it will leak into the joint e.g. perforated the head with a guide wire
  • Intracapsular fractures
  • Patients with severe cardiac / pulmonary insufficiency
  • Patients with known allergy to any of the cement components e.g. antibiotics

Whitehouse MR, Berstock JR, Kelly MB, Gregson CL, Judge A, Sayers A, Chesser TJ. Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the discussion of trochanteric hip fractures. A prospective national register report. Bone Joint J. 2019 Jan ; 101-B ( 1 ) : 83-91 .
Readers will besides find the postdate OrthOracle operative techniques of interest :

Stryker Omega Dynamic Hip Screw for extra-capsular neck of femur fracture
Femoral intramedullary nail : Synthes Expert Lateral Femoral Nail ( LFN ) for impending diseased fracture .
Femoral ( proximal ) intramedullary breeze through : Synthes Expert Lateral Femoral Nail ( LFN )
arrested development of a diaphyseal femoral fracture with a Depuy-Synthes Expert retrograde/antegrade femoral nail ( RAFN )
Infected femoral nail removal and debridement with Synthes Reamer Irrigator Aspirator ( RIA )
Author: Mr Ross Fawdington FRCS ( Tr & Orth )

Institution: The Queen Elizabeth Hospital, Birmingham, UK .
Clinicians should seek clarification on whether any implant demonstrated is licensed for habit in their own country .
In the USA contact : fda.gov
In the UK contact : gov.uk
In the EU reach : ema.europa.eu

beginning : https://nailcenter.us
Category : Nail Technique

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