Closed Cephalomedullary Nailing of a Diaphyseal Femur Fracture on a Fracture Table

CHAPTER 1

I'm Mike Weaver. I'm one of the orthopaedic trauma surgeons here at the Brigham and Women's Hospital. Today, this case is a 76-year-old woman. She has a history of osteoporosis, and she's been on bisphosphonates for a long time - over 5 years. And so, she has an atypical femoral fracture, which occurred just ambulating. It's kind of got the classic features. It's fairly transverse to slightly oblique, and you can see on the AP, there's a slight beak to the fracture, which is a common finding. The thing that makes it slightly unusual is it's a little bit more distal than most of the atypical femoral fractures that we see. Most of them are in the subtrochanteric region or mid-shaft. This is getting into the junction between the middle and distal third, so it's a little bit unusual like that. She's had a previous knee that's been well-functioning. So today the plan is to fix this with intramedullary fixation. That’s a standard treatment for this. You could treat this with a retrograde - retrograde nail. However, in someone with osteoporosis, I like to, you know, treat this like a pathologic fracture, so I use a cephalomedullary device. Today, we’re using the DePuy Synthes Trochanteric Fixation Nail, but any cephalomedullary nail would work fine for this. For this kind of case, I use a fracture table. I can get my reduction. It makes things a little bit easier. For cases where I need to do an open reduction - so that's more often the proximal fractures - I'm gonna use a frac - I’m gonna use a radiolucent table and do it in the lateral position cuz I find that working in an open environment works a little bit easier there. But here the fracture table should bring us out to length, and a low energy fracture should come together nicely.

CHAPTER 2

So setting up the fracture table’s a critical part of this case. Number one - for patient safety. You know, if the patient falls off the table - it's a very narrow bed - that can be a disaster, and then secondly, the fracture table's really your tool to make this case easy. So there are a few things that are important. Number one is the peroneal post - that's the first thing that goes on - as soon as the patient’s on the table - and that's the last thing to come off cuz that’s really gonna be the security blanket to make sure they stay on. There are two ways of positioning the well leg. You can have it hung down like this, which is the way I prefer - the legs padded with a - with a lot of foam then - and then secured to the - the post here. The other way is to use a well leg holder. Either one’s okay, but with a well leg holder, you have to be very careful. There are incidences of compartment syndrome, peroneal palsy, and even a - a fem - femoral fracture if you stress the position of the leg. The foot needs to be securely attached to the - the boot, and I like to overwrap this with some kind of elastic bandage like Coban to really make sure you have a good purchase of it. Particularly, in a case like this for a femur fracture, you’re gonna be pulling really hard, and if the foot becomes loose during the case, that can be a big problem. And then finally, you want the bed as high as it can possibly be so it's comfortable to put the nail in, and you want the foot and the leg to be low so the trajectory of the nail is in line with the bed and the femur. If you have the hip flexed, you're gonna run into the table with the nail when you're trying to put it in. So those are kind of the key things. I like to start with the knee in a fairly neutral position, and then you can always adjust. If you find you’re really internally or externally rotating the knee, you’re probably doing something wrong and malaligning the fracture.

CHAPTER 3

Alright, first thing I like to do is take a marker, and I'll mark out the axis of the femur. And that's so, when you're putting in your rod, you're thinking of the axis of the femur. You're not coming out the front or out the back. The one thing I think we probably need to do is adduct a little bit. Cheryl, would you mind adducting the legs for us? Not gonna make it too big. We’ll make it like that, please. Just be careful - we don’t want to scythe the skin. You know, you’re standing above the patient, so you - it’s - you’re kind of cutting down there a little bit. You just want to be like straight across. Like that, and then - good.

CHAPTER 4

And then I - you know, it's all radiographic. There's no way to feel, and some of that has any real amount of soft tissue - the troc - so I just do it all radiographically. Remember, you got to drop that hand so you’re in line with this. X-ray. X-ray. Good, so you're right there. Now the important thing with the starting point is even though it’s trochanteric or lateral entry, you really want to be on the most medially aspect of the troc. So I would say that’s even a slightly bit too lateral, but you’re - you’re pretty close. So just small movement - movement there. X-ray. The other thing that's reassuring is you’re right on the tip there, so that's a sign that you're probably okay on the anteroposterior plane. You know, if you're too anterior or too posterior, the tip of the wire will actually be - up here sunken into the bone. X-ray. Good. So I like that better. I think that’s a really nice set, but we just gotta get the angle right. X-ray. One more time I think. X-ray. Good, X-ray there. Now, oh - it slid. X-ray. You know, I think - I think we might be off the troc. X-ray. I think you’re too anterior. X-ray. That's better. X-ray. X-ray there. Good. So that - I’d call that ideal. And then what we’ll do is we’re gonna bite it with the mallet. X-ray. So just give it a couple taps - not to drive it in but more just so it doesn’t slide. Good. X-ray there. Good.

X-ray. Alright, drive it in another 2 inches. You’re not gonna adjust it now. There's no way you can do it, so just put it in. Good. X-ray, please. Come to a lateral. Shot there. So I like our starting point. We're just aiming a little bit too posterior, so let's come back up to the AP. So this is when we're gonna back it up but not all the way out of the bone - leave it in just a little bit, and then we can correct it at both points. So we know that we have to drop our hand a little bit more and bring it again. And this is why I want that foot down as low as you can cuz see you’re fighting the table already - particularly in someone that's a little bit bigger, it's tough. Remember, you’re gonna use your - use your eye - use your x-ray. X-ray please. To make sure it’s still in the bone. X-ray. Then back it up a little bit more. X-ray. X-ray. There you go. So now - now - stop. Now you can adjust it. So now you’re gonna drop and then in - and then the - the move - do you - do you have a lady finger for me or a one by one? Push here. And then this - this is gonna bend the wire a little bit. Alright, go ahead. X-ray. Yeah, that’s not gonna be changed. You can try it. You want to take a shot or do you want to just back out. Do it. Go to a lateral. Shot, please. Back up to an AP. So one of the things I - I try to do is separate the different movements. So I got the sense that you were trying to back it up and change it at the same time, so the first thing I’m gonna do is I'm just going to back it up. X-ray. So I'm not trying to change his direction at all. X-ray. X-ray. So I'm still in the bone, but I'm in it. Now I can change it. X-ray. That's not going to change it much there. And then X-ray. X-ray. She is definitely bigger than she looks. X-ray. X-ray. X ray. X-ray there. X-ray. Will you take the mallet? I’m gonna try a different trick here. X-ray. X-ray. Here, go ahead. It's like not working - you know, like - seems like a brutal big delay. X-ray. Keep going. X-ray. Keep going. X-ray. I don’t like this one. I don’t either. X-ray. Real struggle. You have a different wire? X-ray. X-ray. X-ray. Mallet. X-ray. X-ray. What is this? X-ray. X-ray. It’s gonna be way over here. X-ray. X-ray. Tap, tap, tap. X-ray. X-ray. Go ahead. Tap, tap. Really get it down there. Really get it down. Good. X-ray. Let me see that. X-ray. X-ray. Will you come south to center up the femur please? Alright, good. Save that, and come to a lateral. So by tapping it, it hits that cortex and then drives it off - you know, particularly in someone with a fair amount of soft tissue, that’s kind of in your way. That way, it will kind of correct the angle in the top of the shaft.

And then we’ll leave the soft tissue protected for sure. I try not to - to rotate that too much cuz it can saw, and then just give that a few blows. Remember, that’s your angle, so just give that a few blows with you hand. It’s like this - hard-as-you-can kind of blows. There you go. Good. Shot. Good, so now you’re down. And now the key is I’ve got to push you this way - you know, to medialize that reamer, okay? High speed, light touch. X-ray. You don't need a picture. You can just start. This you want to go - you want high speed, but go in slow. X-ray. Good. So I really like that starting point. X-ray. Keep going. X-ray. X-ray. There it is. It’s perfect. All the way in and then out. Just pull it right out. Just pull it out.

And this is the same thing, right? If you just put it in straight like this or you missed the hole, but if you - you can - if you bend it back like this, it changes where the tip is, so you can use that trick here to - to find that hole inside. Cuz again, it’s gonna be really hard in someone like this to feel the entry point with your finger cuz it’s so deep. X-ray. Good. Come down to the fracture please, which is a distal third. X-ray there. X-ray. Can you come further south to the fracture, please? Good. X-ray there. So go ahead and drive it across. X-ray. You feel like you're in bone? No, it feels like it’s soft. No, I don’t think so, right? So - so leave it, right? Cuz do you know? No, you don't. No, so how do you check? You do a lateral. Yeah, so come to a lateral, please. Shot. So it’s out the front, and so that gives us a lot of information, right? So a lot of times it sags the other way, so we know that we got to back this out. So if you just reach around and pull that back a little bit - just until it's in the fragment. X-ray there. Push it down a little bit. X-ray. Good. So now I'm here. X-ray. X-ray. Very stiff today. X-ray there. X-ray. Shot. Shot. Shot. Okay. Mallet. X-ray. Go ahead and advance that. That feels like bone. Get all the way down. X-ray. Good. X-ray there. And you can tell it’s maintaining the reduction. So even that little wire will hold the reduction roughly if you’re okay. Come up to an AP. And that looks nice there. You can really see the cortices. It’s all the little nooks and crannies lining up well. Shot there. Good. So that’s probably the ideal height. You know, you want it right at the top of the patella, which is probably about there. You know, and right down by - here it’s a distal third fracture, so we want to be as distal as we can, safely. Can you come up to the hip, please?

Good, so you’re right where you want to be. So there’s a three forty-five - three sixty or three forty. So three forty? Yep, I agree with that. Eleven by three forty. We’ll start with a - we’ll start with a 12 reamer. So I just pass the 12 reamer. You know, I use 11-mm nail for standard intertroc or femoral shaft in an elderly person. If you get a lot of chatter or resistance, then I stop and ream up. But most people are fairly capacious, and it just slides right down. She measured about a 12 in her workup. We don't need to worry about holding the reduction cuz it was reduced on both views without doing anything. You know, if it wasn't, then I’d try to hold it reduced as you ream, but... Can I have the obturator please? And it’s okay to stop if you're not advancing it. So like - stop. And here you want to push to really get to the end point there. Good. You won’t need that anymore. And this is one where you're - you're right to be careful. You know, if you pull that guidewire above the fracture - you know, this one wasn't too hard to get the reduction, and then here you just don’t want to hurt the soft tissues.

So here, you want this nail to go in like this cuz that's the curve to enter the troc, and then as you insert it and you’re hammering it in, you want to bring the sample down. X-ray. So we got to get it in first. There you go. So now as it goes in, just rotate it in. It’s kind of like a corkscrew there. Good. Nice. And then tap, tap. X-ray there. Let's come down to the fracture site and see how things are there. You know, in general when I’m nailing a diaphyseal fracture - any fracture - I want to watch the nail cross the fracture site cuz that's where you can get into trouble if there’s something really funny. So here it crossed the fracture site without too much hitting, so that's a good sign. Good. X-ray there. A little bit more. Good. X-ray. A little bit more. Now this this is kind of an interesting thing to notice, right? Our guidewire was lateral in the shaft, right? But now, you can see it’s even bending and the nail is more central, okay? Do you know w - why is that happening? Cuz the nail will contact the isthmus whereas the wire wouldn’t? Yeah, so the isthmus is - is forcing, the - the guidewire is flexible. So you know, the isthmus has got to be absolutely right there. Alright, so come up to the hip. So what I’ll do here is I’ll say alright, we’ve got two or three centimeters before we get to the top of the prosthesis. And so here - you know, it looks like we're good - you know, cuz now I just have a rough idea like, oh I'm safe. You know, if it looked like it was a centimeter away and I was looking here, I'd be like maybe we need to check a lateral or something, but I think we’re in good shape. Here the arrow has always been too high. A little more. And obviously, if it feels really hard and there’s lot of resistance, I always check the knee - something’s maybe going on. X-ray. Good. So let’s come down to the knee one last time. I'd say that's probably just a shade high. Yep. And now let's go to a lateral just to make sure everything's not funny. You're good. Nice. So the reduction looks good. You can see - you know, and it's oblique - but we're not hugging that anterior cortex. We’re not hitting that flange of the prosthesis, and that's the one I would worry about if it was a mismatch between the shape of the femur and the nail. A lot of these nails are too straight. If it came out the front and you start hitting on that prosthesis hard, you could loosen it. That's probably about the anteversion we want. Good. Come up to the hip please.

CHAPTER 5

Good - if you just hold that. That’s pretty good I think. Good. Yeah. Make it, remember, a little bigger than that. It's gonna be a fairly decent-sized hole to get this through. Good. I wouldn't worry too much about that. There's no real way of planning that hole. Shot. So I don't worry about getting that thing right down on bone yet, but with any of these systems, that has to be perfectly on bone before you put your blade in. Alright, so shot there. So I like that. That looks nice. So let's go to a lateral, and that's how we're going to aim for the head. So here you can see, we're aiming a little too anteverted, so if I go like this - X-ray. Can you raise the machine for me a little bit? So if you look at that - raise - raise it a tiny bit more. This is a really cool thing. See the neck on both sides? Yeah, you can see the neck is on both sides. X-ray. And you’ve got head, aiming arm, and nail all in a line. So when you put your guidewire in here, it's gonna go - it's gonna keep going, and then radiographically, it's gonna be right at the tip there. So by holding it like this, you can aim for the center of the head, but you have to have this lateral view, which isn't really a lateral of the femur, it’s a lateral the femoral head and neck cuz it's - you know, takes the anteversion into account. Shot there. X-ray there. X-ray there. So I like that - maybe ever so slightly posterior. So to use this trick, you have to be pretty confident about your AP depth, but I think we're pretty good there. Just drive it in that whole depth before you take a picture cuz we know it's gonna be about 80. Yep, shot. Keep going a little further. X-ray. A little more. X-ray. So there you go. It comes right out at the tip there. X-ray. And that' right where we want it. Yeah. Maybe a few millimeters anterior but really close to the tip. So that's good. Now we’re really close to the apex, excuse me. Come up to an AP. And then we're right where we want to be there. First, I would drive that wire in a tiny bit more. So I like the wire to touch the subchondral bone - not that you're going to put your final implant there, but so you can measure off it. X-ray.

X-ray. Perfect. This is - this is pretty tight, right? Cuz you’ve got the iliotibial band there. So what I want you to do is take your opening reamer, and we're not gonna do the final reaming into the head now - but punch a hole through that iliotibial band. X-ray. A little more. And now try turning that. X-ray. X-ray. I'm gonna run it just a little bit more. X-ray. Almost. X-ray. Just making sure that wire stays where it belongs.

Now we're gonna measure it and set our screwdriver - or drill. Measures 98 to subchondral bone - not quite, so put it at 90-ish. Yeah, I agree with a 90 on this. You know with a cephalomedullary implant - particularly a helical blade - you probably want your tip apex to be slightly longer than for a DHS, but still - you know, less than 25.

X-ray. You know, here I'm not worried about slide or cut out - you know, cuz it's a femoral shaft fracture. X-ray. Good, that looks nice. X-ray. The important thing to recognize is that the blade is actually gonna be a little bit deeper than the - the draw. This’ll help us fine tune our reduction now too cuz now we really have control of the proximal fragment. So you have control of the proximal fragment once you have your blade in with this handle, and then you can kind of, you know, rotate the distal piece to really make sure it's keyed in.

You know, I really like that starting point. You know, you - you come lateral, and for an intertroch it'll malreduce it, right? So if you’re starting point’s lateral for an intertroch, it will malreduce the fracture - it'll kick in into varus - but for a femoral shaft fracture, it’ll break the femur because, if you start too lateral, your nail engages - it tries to kick over, and you're trying to put a - you know, it just won't go. You know, if you make a small mistake early, it magnifies by the end, so... X-ray. Looks good. X-ray. Almost there. X-ray. Probably just a few more blows. X-ray. Let's see if I can get it down just a little bit more. X-ray. Good. And I'm not really getting it down for the tip apex distance. I was happy before. It's more just so it's not prominent on the lateral side.

It doesn’t seem like it's down there. Mallet. Shot. You can give it a couple whacks. X-ray. X-ray. Can we adduct the leg a little bit more, Cheryl? Okay. X-ray there. Give that a few taps so - see if we can engage it. Just gentle. There it goes. That’s gonna be squeaky tight.

Good. So before we actually take off the handle, I do want to check a lateral, and that's cuz the handle is your access to get the thing out. So if there's a problem, you want to know before - before you take off the handle attached to the nail. X-ray there. That's great. So if anything, we're ever so slightly below the apex - but if I'm gonna err one way, I'd rather err that way. And then come to a lateral. X-ray there. X-ray there. Good, save that. And that's nice - maybe a few degrees anterior of the apex there, but - but right where we want to be. Alright, so let’s come down to the fracture. If you hold this, I can try twisting. X-ray. X-ray. That looks pretty good. You can see that stress fracture now, nicely, cuz it’s anatomic on the medial side, but you know, you can just see where the beak is there. Let's come to a lateral. Shot there. That - that looks really nice. So we got a nice reduction, and our implant is right where you want it. Let’s whack south. You can see we've got the leg adducted. Good. Shot there. Good, so save that. So I really like our nail position. You know, we couldn't have been 20 longer. X-ray there. A little bit further. Good. X-ray there. Good, so I really like that. That's a nice reduction.

CHAPTER 6

One thing I notice is a lot of people make that incision too small. Like, it doesn't have to be giant, but you know, give yourself a little bit of room to work. X-ray. X-ray. X-ray. X-ray. So it's perfectly centered. You want the tip right in the center of the hole. That's nice. X-ray. Bullseye. Can I get a mallet please?

Need an X-ray there, please? So you gotta think you got to be in that same angle as this, so if you look here, you're probably missing the nail behind it. See if you look back here, this is the - this is it here. Shot. X-ray. Nope, nope, you’re good. So we’re putting in a forty-six? Let’s see where it’s measuring to up there. Yeah, put in a forty-six there.

So now when you think you're down, what we’re gonna do is jump, right? To see if we’re really down. Yeah, so then you just want to hop off and then back on, and that way you'll know. You know, is your head right on or is it... It feels like it’s a couple of millimeters off. That little trick gives you a little security to know you're there though, you know what I mean? In the be - in the end, I’d much rather have to drive it in a few more millimeters on the AP than strip them out. Yeah, it feels like it’s down there. Oh, it’s down, yeah. You’re good. Good. Shot. Alright, I think we’re done. Can you come off mag, please? Actually, you know what? Let’s do a - go back on mag. We’ll do - we’ll do two screws. You know, it’s a pretty distal fracture.

X-ray, please. Nice! Bullseye. So the lesson there is osteoporotic bone is not gonna have a good feel. And so like I said, I'd much rather leave it proud and then come up to an AP and say, "Oh we’re a centimeter off. I've got to drive it in," than strip it. X-ray. X-ray. The important thing is it doesn't really matter if this is a little bit - if the purchase isn't great cuz it’s really just for axial stability and even then - or rotational stability - the pullout strength doesn't matter cuz - I mean, we have an anatomic reduction, so it’s a length stable - you know, load sharing situation. There you go. Good. Is it - like - even there, like I felt - yeah. Well that's cuz it's tricky. The first time like literally. Yeah, X-ray. Good. Can you pull back towards you just about an inch?

X-ray there. Save that. Come up the leg just a little bit. Shot there. Push in please. Shot there. Save that. Now you'll need to come at the angle view to get the head please. Shot there. Make that straight up and down. So again, I like our starting point. You know, if i was gonna be real critical, it would be a tiny bit low in the head - but you know, pretty close, and I'd rather it be low than high. And you know, it's not prominent on the troc, so that's nice. Alright, let’s come to a lateral. X-ray. X-ray. Save that. So that’s nice, we’re centered in the neck - maybe a tiny bit anterior in the head. Good. Shot there. Make that straight across. Save that. And then just come proximal about 6 inches. We’ll take one of the fracture, and then we’re done. Good. Shot there. Nice. Save that.

CHAPTER 7

In this case, we were very lucky with our reduction. You know, just with a little bit of traction and then manual manipulation in the femur, we were able to get the guidewire down. Because this was a diaphyseal fracture, the nail did the reduction for us, right? So if you have a diaphyseal fracture, it’s a hollow tube. When you ream that up and put a nail there, it's gonna make it straight. For fractures that are in the metaphysis of a bone, that’s different. You need to make sure the reduction's perfect as you’re reaming it as you put your nail down. So this was a little bit different in that respect. And because the fracture had some little inner - intricacies to it, it was able to line up nicely, so that - that worked well. And then finally, perfect circles in interlocking - that’s something that a lot of people struggle with. You just have to take your time and again make sure everything's right. You got to have a - a perfect circle X-ray centered in the C-arm V. If it’s off to one side, that parallel axis's gonna make it a little bit harder, and then, you know, just make sure you measure and put your screws in carefully.