- set about
- place knee in ~30° flexion over radiolucent triangle
- knee flexion also prevents distal fragment from being pulled into more flexion by gastrocnemius
- mark out inferior pole of patella and borders of patella tendon
- transtendinous approach:
- make 2cm incision from inferior pole of patella distal through tendon
- tenotomy to develop paratenon layer, sharply dissect or cauterize through paratenon then patellar tendon
- insert self-retainers and suction out synovial fluid
- once in joint, remove small amount of fat pad to minimize guidepin deflection
- parapatellar approach:
- 2 cm incision along medial third of patellar tendon
- cut through subcutaneous tissue and retract tendon/paratenon laterally
- insert self retainer
- place knee in ~30° flexion over radiolucent triangle
- Guidewire interpolation
- guidepin start point is in center of intercondylar notch, just superior to Blumensaat’s line
- insert guidepin to distal metaphysis
- check C-arm image to ensure pin is in center of medullary canal
- use entry reamer with soft tissue protector
- remove starting pin and reamer, and place balltip guidewire in canal with T-handle
- place gentle bend at tip of balltip wire, manually push in to distal aspect of fracture site
- fracture reduction
- reduce fracture by pulling traction
- can use small blue towel bump to add flexion to distal segment
- if pulling straight inline traction on foot you will cause more flexion deformity of the distal segment due to pull of the gastrocnemius
- need to pull traction at 30° angle over triangle
- once fracture reduced, manually push guidewire past fracture site and up to lesser trochanter, check on biplanar imaging
- insert guidewire past lesser trochanter by 3-4cm
- insert guidewire past lesser trochanter by 3-4cm
- use radiolucent ruler to measure appropriate nail length
- reduce fracture by pulling traction
- Reaming
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- use ruler on contralateral side to measure intact femur if segmental comminution exists
- start with 9mm reamer, then ream up 0.5-1.0mm with consecutive reamer
- ream 1.5mm above size of final nail (i.e. size 12.5mm reamer head for size 11mm nail)
- don’t stop reamer in canal (avoids reamer head from becoming incarcerated)
- if eccentric reaming/wire position is seen, can place blocking screws
- Nail interpolation
- attach jig to nail on backtable and check that targeting guide lines up with holes in nail
- insert nail over guidewire, cover holes closest to nail handle with hand to make sure blood doesn’t pressurize out of nail during insertion
- insert nail with jig lateral to thigh
- hold nail by handle, not the targeting guide, mallet or manually advance to fracture site
- manually advance nail past the fracture site to avoid iatrogenic comminution or development of new fracture lines possible with use of the mallet
- insert nail completely and seat fully
- lateral radiograph of the knee is the appropriate view to assess nail insertion depth
- lateral radiograph of the knee is the appropriate view to assess nail insertion depth
- remove guidewire before placing interlocking screws
- Interlocking Screws
- use targeting guide to place most distal interlock first
- mark skin with sleeve, incise through skin, spread down to bone with hemostat, and place trochar on bone
- drill bicortically through the nail
- leave drill bit in until screw arrives to hold nail/bone position and then place screw
- repeat process above for placement of other interlocking screws if indicated
- use attachment to remove nail jig, then take out triangle to lay leg flat
- check femoral neck again on C-arm
- obtain perfect circles of proximal interlocking screw holes
- ensure no rotation of the distal femur is done while getting theseviews (move the C-arm, not the leg)
- magnification of the fluoroscopic view can be used if desired
- start with most proximal interlocking hole (screw will be longer than the more distal screw)
- incise through skin, careful blunt spreading down to bone, especially if distal to lesser trochanter
- drill bit placed over center of hole, parallel to C-arm beam
- to measure, can use a second drill bit or depth gauge
- alternatively use a 34 or 36mm screw
- remove drill quickly and insert screw when available
- use locking screwdriver or place silk suture around screw head so it doesn’t get lost in soft tissues
- repeat above process for 2nd proximal interlocking screw
- Confirm Nail Position and Extremity Check
- raise leg up off of bed, 90° bend in knee, then take final AP and lateral radiograph of proximal, middle, and distal aspects of femur
- take hip through a range of motion to assess for fracture
- fluoroscopic evaluation is key, whether static or dynamic at the end of the procedure
- check limb lengths and rotation
- perform a knee examination under anesthesia
