1. Trochanteric Nail Insertion for the Treatment of Femoral Shaft Fractures Journal of Orthopedic Trauma vol.19,8,Sep.2005 DR.ABDULRAHMAN ALGARNI

2. Introduction 1940,Kuntscher : tip of greater trochanter. Late1940,Bohler: ridge of greater trochanter. Winquist : lateral to GT.

3. Varus malalignment. Eccentric reaming of medial cortex of proximal fragment. Comminution at fracture site or both. Advocated piriformis fossa (difficult;supine;obese).

4. Objective Using a nail especially designed for insertion through G.T (TAN) could eliminate complications seen with straight nails.

5. Materials and Methods Design and sitting : prospective; 3 trauma centers; 1 of 4 fellows. Jan. 1,1999 and Dec. 31,2000. 61 patients (14 – 97 yrs ) average (43.6). 50 closed ; 11 open 5(1), 2(3A), 2(3B). 11 obese (113 – 159 kg) ; 3 > 181 kg.

6. Intervention : supine ; TAN(cannulated,interlocking,Tit.). 13mm ; 7 cm ; 4 valgus bend. Tip of GT,nail rotated 90 ;avoid iatrogenic complications. 52 reamed, 9 unreamed.All locked proximally and all but 4 distally.

7. Results Main outcome measures : union, alignment,complications and hip function. 4 Pts died ;46 of 57 Pts (81%) for F\U at a Min. of 12 months.

8. Union Clinical and radiographic, all but 1 at 13 weeks, 1dynamisation at12 wks and united at 22 wks. PT : once start WB.

9. Alignment Angulation(>10% in any plane or rotation>10) :none;1 Pt shortening of 2cm.

10. Complications No iatrogenic fractures or infections. Heterotopic ossification :5 hips. Pain : mild (6),moderate (2).

11. Hip Function 24 Pts :Harris Hip Score 77 (45 – 96). Hip ROM :similar to normal side. Visual & video taped gait analysis : 3 Trend. Gait.

12. Discussion -Kuntscher :lateral;tip of GT; infection,AVN of femoral head and neck fractures. -Bohler : top of GT. -AO : lateral to avoid damage to retinacular vessels and hip joint. -Straight nails through GT : comminution; varus esp. proximal fractures.

13. -Winquist :lateral ;switch to piriformis fossa -Johanson : >6mm anterior to PF; increase risk of complications ; position evolved to supine. -Mc fee and Waddle : morbidly obese ;difficult in supine using PF;increased risk of complications;accept more lateral starting point.

14. -Ostrum :trochantric starting point; supine; satisfactory results in obese Pts. -In this study;esp. nail and tip of GT. -Marks et al : 21% risk of HO using PF; 15% in this study. -Gait and abductor weakness : comparable to PF starting point.

15. Conclusion Antegrade femoral nailing in supine position using specially designed nail inserted through tip of greater trochanter provides high union rate and low rate of complications including comminution and angulation.

16. Thank you