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trochanteric femoral nail intraoperative imaging

Once the patient is properly prepped and draped, the operation begins.  The following sequence of images was captured on the intra-operative C-arm which takes real time x-rays of the operation during the course of fracture fixation.

hip fracture  lateral intertrochanteric fracture  trochanteric starting point  guide pin fracture surgery  pin across fracture site  lateral view guide pin  intramedullary reamer  intramedullary reaming  intramedullary implant  implant inserted to depth  tip to apex  guide pin center of head  broach lateral cortex  helical blade  distal interlocking screw  anatomic fixation  anatomic reduction  fracture fixation

Here is the text of the operation note, which describes the steps in detail…..

  • PREOPERATIVE DIAGNOSIS:  Intertrochanteric femur fracture, right side.
  • POSTOPERATIVE DIAGNOSIS:  Intertrochanteric femur fracture, right side.
  • PROCEDURE PERFORMED:  Intramedullary nail fixation of an intertrochanteric right-sided femur fracture.
  • IMPLANTS USED:  Synthes 170 mm long by 10 mm in diameter trochanteric femoral nail with a 100 degree helical blade and a single 38 mm distal interlocking screw.
  • ANESTHESIA:  GENERAL
  • ESTIMATED BLOOD LOSS:  50 mL.
  • OPERATIVE TIME: less than 60 minutes
  • STATUS AT END OF CASE:  Post-anesthesia care unit in satisfactory condition.
  • INTRAOPERATIVE IMAGING: Intraoperative fluoroscopy was used throughout the procedure.

REASON FOR OPERATION: The patient is a pleasant 80-year-old female with right hip pain due to a fracture of the hip with preoperative radiographic evidence of an intertrochanteric right-sided femur fracture.  For details of my admission history and physical, medical evaluation, and consent process, please see the notes dictated by myself.  Prior to the operation, I did have the opportunity to see the patient in the preoperative holding area.  The correct surgical site was marked by writing “yes” on the anterior aspect of the right hip.  I answered all of the patient’s and her daughter’s questions and verified consent.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent, the patient was brought back to the operating room.  After satisfactory induction of general anesthesia in her hospital bed by the anesthesiologist, and placement of laryngeal mask airway, the patient was smoothly transitioned to the fracture table.  Care was taken to pad all bony prominences and 1 gram of Ancef was administered preoperatively for antibiotic prophylaxis.  The right lower extremity was prepped and draped in the standard fashion on the fracture table.

Initially, cast padding was placed over the right foot and it was placed in the traction boot.  A perineal post was used to provide countertraction in the perineal area.  Distraction on the limb by traction on the foot and internal rotation of the foot resulted in satisfactory reduction of the intertrochanteric femur fracture.  Intraoperative fluoroscopy was used to confirm that the fracture was appropriately reduced in both the AP and the true lateral planes before proceeding with prepping the skin and establishing the surigcal drape.

Once the fracture reduction was verified, the right lower extremity was prepped with a chlorhexidine polymer prep and a shower curtain operative barrier was established on the lateral side of the patient’s hip.  Intraoperative fluoroscopy was used to image the hip in the AP view.  The blunt tip of the guide pin was used to palpate the tip of the greater trochanter.  A 3 cm (1 and 1/2 inch) incision located over the tip of the greater trochanter was made and carried down through subcutaneous tissues using Bovie electrocautery for hemostasis.

The fascia of the gluteus maximus was divided in line with the longitudinal axis of the fibers and the tip of the greater trochanter was palpated through this incision.  A guide pin was started in the tip of the trochanter, advanced across the fracture site and into the distal aspect of the femur.  The position of the guide pin was visualized on both AP and true lateral radiographs of the hip.

The guide pin was then overdrilled with a 17 mm one-step canal opening reamer.   The appropriately sized implant, measuring 10 mm in diameter, 170 mm in length was then inserted over the wire and tapped down to the appropriate depth.  Using the lateral outrigger, a guide pin was introduced from the lateral cortex of the femur through the center of the intramedullary nail and into the center of the femoral head, as seen on true AP and true lateral views.  The lateral cortex was broached and a 100 mm helical blade was then inserted over the guide pin and tapped to the appropriate depth.  This guide pin twists as it is inserted and it is designed to preserve as much bone as possible.

The proximal derotational screw was engaged with a flexible screw driver.  A distal interlocking screw was inserted after drilling a pilot hole for the screw through both sides of the femur using the outrigger targeting device which aligns the drill bit with the hole in the center of the implant.  The screw measured 38 mm in length and deployed correctly.  True AP to true lateral views taken every 10 degrees and saved as part of the digital PACS archive.  These images were used to verify that there was no danger of interarticular penetration of the instrumentation.

An anatomic reduction of the fracture fragments was achieved and the fracture was appropriately stabilized.  The wounds were then copiously irrigated and closed in layers; 0 Vicryl was used to close the fascia, 2-0 Vicryl used to close the subcutaneous tissues.  Staples were used for final closure.  At the end of the case, sponge, needle and instrument counts were all correct.  Sterile dressings were applied.

The patient was removed from traction, gently transferred back to the hospital bed and taken to the post-anesthesia care unit in satisfactory condition.

Postoperative plan is to mobilize the patient, weight-bearing as tolerated.  On first day after the operation, we will have physical therapist see the patient and allow her to put as weight on the operative leg.  We expect a 3-4 day hospital stay and then discharge to home or nursing facility, depending upon her needs after the operation.

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  1. Monterey Spine and Joint | Dr Gollogly | Dr Meckel | Dr Lin | Hip fracture diagnosis, surgery, rehabiltation, and recovery explained » www.ihipfracture.com says:

    [...] Next sequence of images….intraoperative images [...]

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