Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal by Elliott J. Kim, Samuel.

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Presentation transcript:

Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal by Elliott J. Kim, Samuel N. Crosby, Gregory A. Mencio, Neil E. Green, Steven A. Lovejoy, Jonathan G. Schoenecker, and Jeffrey E. Martus JBJS Essent Surg Tech Volume 4(4):e19 October 8, 2014 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs. 1-A and 1-B Anteroposterior radiographs. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Fig. 1-C Lateral radiograph. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs. 2-A and 2-B While the limb is held stationary, a perfect lateral image is made of the knee. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs. 2-C and 2-D A perfect lateral image is made of the hip. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Fluoroscopic anteroposterior image of the preliminary reduction with use of a fracture table. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The fluoroscopy unit is positioned contralateral to the fractured femur. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The ipsilateral arm is positioned over the chest, and the contralateral arm is positioned and secured on an arm board. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Preparing and draping is performed to provide access to the proximal trochanteric region, thigh, and knee. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The trochanteric region and the intended incision are outlined. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Blunt dissection to the level of the trochanter. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The anteroposterior image demonstrates that the guide pin is lateralized to avoid violating the piriformis fossa and is offset 10° to 15° from the femoral shaft axis. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The lateral image demonstrates that the pin is in line with the femoral shaft. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Adequate lateral position of the guide pin is verified by assessing the diameter of the entry reamer compared with the piriformis fossa. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The entry reamer is driven to the level of the lesser trochanter. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs.12-A and 12-B Before and after placing the bend. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Fig. 12-C The bent guidewire. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

A variety of reduction instruments are demonstrated: reduction F-tool (Fig. 13-A), intramedullary reducer (Fig. 13-B), Schanz pin with T-handle chuck (Fig. 13-C), and ball spike (Fig. 13-D). Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Fig. 14-A The fracture is reduced, and the guidewire is passed into the distal fragment. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs. 14-B and 14-C The wire is then centered in the distal metaphysis 1.0 to 1.5 cm proximal to the physis. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The guidewire is measured to determine nail length. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Reaming is performed utilizing a soft-tissue guide to protect the peritrochanteric soft tissue. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Sequential reaming proceeds until adequate chatter is achieved in the isthmus. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Entry of the reamer. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Maximum advancement of the reamer. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The proximal interlocking guide is checked to verify that the drill passes easily through the nail. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The anterior bow of the nail is rotated apex medial to facilitate early passage of the nail in the proximal part of the femur. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

The guidewire may be removed once the nail has advanced a sufficient distance into the distal fragment. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Placement of the proximal interlocking screw. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs. 23-A and 23-B While the limb is held stationary, a perfect lateral image is made of the knee. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Figs 23-C and 23-D A perfect lateral image is made of the hip. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Sterile dressings are placed. Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.

Elliott J. Kim et al. JBJS Essent Surg Tech 2014;4:e19 ©2014 by The Journal of Bone and Joint Surgery, Inc.