We use a square proficiency for interpolation of proximal interlocking sleep together obsession during retrograde intramedullary nail of the femur utilizing a common 3 milliliter syringe as a radiolucent easy weave defender. Following insertion of the plant and distal interlock interpolation, the distal Luer-Lok tip off of a 3 milliliter syringe is cut off to create a hollow tube. Once the correct location of the proximal lock in holes is confirmed fluoroscopically, the syringe is inserted through the incision into the easy tissue over the long drill sleeve and trochar. The inner drill guide and trochar is then removed, leaving only the syringe. Through this syringe, the proximal lock hole is drilled and measured, and the screw is inserted. The syringe establishes a safe nerve pathway for passage of orchestration, mitigating wrong to the surrounding soft tissues, and allowing for unobstructed fluoroscopic visual image throughout interpolation of the locking sleep together. This proficiency is safe, cheap and reproducible ; utilize common equipment available in most surgical settings. Keywords:
Femur fracture, Intramedullary nailing, Locking screws, Technique
Intramedullary ( IM ) nail down has become the favored method of treating femoral shaft fractures. 1 It is associated with high union rates and gloomy complication rates. 2 multiple factors must be taken into account when performing this apparently straightforward procedure, including fault characteristics, associated musculoskeletal and/or intuitive injuries, local soft-tissue injury, and the technical familiarity of the surgeon with each nailing method. 1 Patient body physique, peculiarly, big easy tissue profiles in the proximal thigh can make free-handed interpolation of proximal interlocking screws challenging in retrograde femoral breeze through. As the population continues to expand, both in phone number and thigh circumference, surgeons may more frequently confrontation technical challenges related to patients ’ body physique. The prevalence of adult fleshiness in the United States in 2016, as defined by Body Mass Index ( BMI ) greater than 30 was 39.6 %. 3 This represents a 9.1 % increase from good 15 years anterior and encompasses over 98 million Americans over 18 years of historic period. Instrumentation and technical invention should evolve to consider this consequence. We describe a novel and cheap technique to help establish and maintain a safe depart site and trajectory for drilling the proximal interlock holes during femoral regress complete. A clear and preserve path for interpolation of the proximal interlock cheat is created using standard equipment and a coarse 3 two hundred syringe .
The criterion proficiency for retral femoral intramedullary collar is performed up until proximal interlock screw obsession. Most intramedullary femoral nails on the market have anterior-posterior arsenic well as medial-lateral lock options, which are typically utilized with a freehand proficiency. Our proficiency was performed with the Stryker ( Kalamazoo, MI ) T2 Femoral Nailing System. 4 The critical tone with any free-hand lock technique, proximal or distal, requires the visual image of a absolutely round locking hole, or oblong lock trap with the habit of C-Arm. The C-Arm is lightly manipulated to ensure the glow is in plane with the implant. The roentgenogram balance beam is arranged to obtain a ‘ arrant circle ’ with the lock hole. Care is taken to ensure the intramedullary device and limb remain in acceptable anatomic rotation. On the back table, a sterile 3 two hundred syringe is opened. The diver removed and discarded. The tiptoe of the syringe was then cut, leaving a clear, empty, radiolucent tube ( ) .
- mistreat 2
Open in a separate window “ Perfect-circle ” technique 5 was performed in the common fashion, first base with radiographic approximation of the incision using the handle of a Schnidt Tonsil Forceps and a 15-blade. once localized, the skin is incised and the deeper tissues are bluffly dissected using a “ nick and spread ” proficiency .
- step 3
Blunt dissection was carried toss off to the front tooth lens cortex of the femur with a straight Schnidt Tonsil Forceps. The periosteum is roughened slenderly to facilitate bore constancy .
- step 4
The excavate 3 milliliter syringe is then inserted as a sheath over the long drill sleeve and long trocar. This is then introduced through the incision to the front tooth lens cortex of the femur, taking worry to ensure that the 3 milliliter syringe is inserted a deeply as possible to the incision. The alloy guide is removed leaving the 3 milliliter syringe .
- step 5
The center-tipped 4.2 × 230mm bore is inserted through the 3 two hundred syringe down to cortical bone, and the placement of the exercise fix for either the inactive or moral force Anterior-Posterior proximal locking hole of the complete is determined in the usual fashion. Upon roentgenogram verification, the drill is placed perpendicular to the smash and double intensifier receiver. A hole is drilled through the anterior and back tooth lens cortex. confirmation with xray may be obtained ensuring the drill passes through the hole in the complete in the A/P, M/L or both planes ( a–b ).
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Open in a separate window The drill is withdrawn, maintaining the 3 two hundred syringe in the soft tissues, docked to the front tooth femoral cerebral cortex with downward pressure to avoid slippage and loss of trajectory. A depth gauge is inserted through the syringe to determine the appropriate length of the lock prison guard .
- step 7
An appropriately sized proximal interlocking screw of pre-measured duration loaded on the screwdriver is then introduced through the 3 milliliter syringe down to the exercise hole and inserted. once radiographic confirmation that the screw is seated down to cortical bone, the screwdriver and 3 two hundred syringe are removed from the incision ( c–d ) .
- measure 8
Steps 2-7 may be repeated for interpolation of a second proximal interlock fuck, if so indicated .
3. Case Example 1
A 33-year-old female, BMI 34, presented after expulsion off a motorbike with multiple skeletal injuries which included a comminuted midshaft femur fault ( a ). patient was taken to the operate on board on hospital day one for a retral intramedullary nail down for stabilization of the right femur ( bacillus ). The trace proficiency was use to optimize placement of both of the proximal mesh screws. At annual follow-up the patient had returned to work and activities without limitation. There were no issues with weave heal or pain at the lock web site .Open in a separate window
Though a relatively aboveboard procedure in most orthopedic traumatologists ’ hands, retrograde intramedullary smash of femoral shaft fractures is not without its perils and pitfalls. Often performed as the final footfall in fixation of these fractures, following reduction, complete interpolation, and distal lock, proximal interlock presents a alone fit of challenges and electric potential complications, which can be exacerbated by the patient ’ s body physique. difficulty establishing and maintaining drill trajectory and inability to localize the drill hole have been well described in the use of lock intramedullary devices. 6 diachronic techniques included the manipulation of an extra nail to course up the holes 7 for the interlocks, though this is not cost-efficient nor practical with the practice of mod, single-packed sterilized nails. other techniques have been described to assist in accurate drill placement through the pinpoint in antegrade femoral nails, 8, 9 but there has been small focus on accurate and effective placement of the screw itself, likely due to the proportional relief of placement of interlocks in the distal femur proportional to the proximal femur. Loss of the locking screw in the easy tissues, temp or differently, is not reported in the literature but is a potential complication. The risk of drill slippage is reduced in modern with the toothed drill guide. however, once this guide is removed there is no extra device provided for maintaining the corridor for interpolation of the screw itself. These experiences can be frustrating and time consuming, particularly in the academic set. These issues are exaggerated further in patients with BMI > 30. Beyond technical frustrations, complications such as wrong to the nearby neurovascular structures are besides possible. Riina et aluminum. performed a cadaverous study examining the neurovascular structures at risk during proximal interlock of retrograde femoral nails and found that the first division of the femoral steel crossed the femur on average approximately 4cm distal to the piriformis fossa. 10 This anatomy may be far distorted in patients with attendant acetabular fractures, due to the supplanting of the voiced tissues caused by the vector sum hematoma. 11 frankincense, it is imperative mood that the delicate weave be approached with caution. The function of any tool that provides adequate tissue protection and avoids extensive dissection, multiple passes of the drill or depth gauge, or loss of the cheat into the second joint would be useful. By establishing a radiolucent path, from incision to anterior cortex of the femur, the drill trajectory can be maintained following drill, during measurement with a astuteness gauge, and ultimate interpolation of the interlock screw. Advantages of this technique include its simplicity, low-cost and reproducibility. furthermore, as a radiolucent soft tissue projector, radiogram can be taken unobstructed throughout the entire serve of proximal interlocking obsession. Technique-specific challenges inactive remain including drill or syringe slippage, accurate boring depth, off-axis bore, and screw loss or leach. While many of these challenges overlap with standard interlocking techniques, we have found that overall these are less patronize with our technique. While the syringe measures only 7cm in distance, we have had success in brawny and corpulent patients. Considering the pliability of the soft tissue envelope, the syringe can be docked against the anterior femoral cerebral cortex with modest down pressure. however, this proficiency may be challenging in the hard corpulent and we are unable to recommend a circumferential size cut-off. This proficiency may be applicable to other procedures where a radiolucent soft-tissue defender may be advantageous. Based off of a current review of the literature, no exchangeable techniques have been reported .
Compliance with ethical standards
This analyze has no sources of financing to report.
All procedures performed in studies involving human participants were in accord with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki resolution and its late amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. No institutional review board was necessary .
Informed consent was not applicable for this surgical technique report .
Declaration of competing interest
declare that they have no conflict of concern .