Antegrade Approach To Femur - Sign IM Nail and Interlocking Screw System Technique Manual

Antegrade Approach to FEMUR

Position of patient
Supine or lateral. Lateral is best for open reductions. Technique for lateral position will be described.
Patient must be stabilized in the lateral position to prevent shifting during surgery.
Reduction
If open reduction is indicated, perform this prior to skin incision for nail insertion. Incision should be
as short as possible. Identify the proximal fragment by abducting the leg. Incise the skin and fascia
over the end of this fragment. Dissect through muscle with your finger to identify the fracture site.
You can then extend the incision as needed. Free up each of the main fragments by removing soft
tissue attachments. Save the callus for bone graft. Ream each fragment from the fracture site. Do not
penetrate the metaphysis at either end of the bone. Save the bone from the flutes of the reamer for
bone graft. Secure the reduction with clamps and proceed to preparation for nail insertion.
Variations in reductions
If the fracture is comminuted over a long segment, free up only the 2 main fragments and do not
devascularize the fragments in the middle of the fracture. Pass the nail from the proximal fragment
into the distal fragment without disturbing the fragments within the fracture site.
If the fracture occurred within the past week, closed reduction may be attempted. If the reamers do
not pass immediately into the distal fragment, plan a mini open reduction and guide the reamers and
the nail into the distal fragment with a clamp or bone hook.
Skin incision
Extend from the superior greater trochanter posteriorly in the direction of the gluteus maximus fibers.
Dissect down to the greater trochanter in the region between the posterior and middle one third
junction. Dissect through muscle fibers with finger or periosteal elevator.
Bone entrance
Entrance should be placed in a junction between the
Fig. 1
posterior and middle one third of the greater trochanter,
figure 1. We do not recommend placing the entrance
through the piriformis fossa. Hoop stresses are
generated when the bend passes through the piriformis
fossa. If you doubt this, place a nail into a sawbones
and note the hoop stresses. Use a curved awl to make
the entrance. If possible visualize the fracture site to
determine the direction of the awl. Sink the awl to the
hilt by rotation.
Reaming
Start with the smaller reamers and increase reamer sizes until chatter is heard. Be sure you can feel
the reamer rotating through a 360º arc to know the reamer is in the canal. Once chatter is felt for
4-6cm, over ream the proximal 6cm to allow room for the bend of the nail. Be aware of the reduction
during reaming. Nail diameter is 2mm smaller than the reamer which caused chatter.
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