The Art of Intramedullary Nailing for Femoral Fracture

This book offers precise points in intramedullary nailing for the treatment of the femoral fracture. The author's aim is to explain how to find a correct entry point, especially in the case of subtrochanteric fracture with excessive external rotation of the proximal fragment, method of reduction in a severely comminuted fracture which is challenging in the restoration of rotational alignment as well as angulation, and mode of interlocking. This book is based on the author’s personal experiences of 30 years in trauma, who dedicates himself to developing intramedullary nailing for femoral shaft fracture. It also covers cephalomedullary nailing for reverse obliquity trochanteric fracture because the incidence of hip fractures increases due to prolonged life expectancy. This book will be an ideal resource with many fluoroscopic and radiographic pictures to descript the real situations that the surgeons encounter in the operating room and techniques to solve those problems. Preface 5 Contents 7 About the Author 10 Abbreviations 11 1: Brief History of Evolution of Femoral Nail 12 1.1 First-Generation Nail: Open Section Rod Type Nail 12 1.2 Second-Generation Nail: Interlocking Nail 12 1.3 Third-Generation Nail: Reconstruction Nail 13 1.4 Fourth-Generation Nail 13 References 13 2: Fracture Healing Mechanism after IM Nailing 14 2.1 Formation of Hematoma 14 2.2 Intramembranous Ossification and Endochondral Ossification (Stage of Soft Callus: Unstable) 15 2.3 Intramembranous Ossification and Endochondral Ossification (Stage of Hard Callus: Stable) 17 2.4 Remodeling 21 References 21 3: Indication and Contraindication of Femoral Nailing 23 3.1 Indication 23 Femoral Shaft Fracture with Various Degrees of Comminution 23 Segmental Fracture of the Femur 23 Delayed Union or Nonunion of Femoral Shaft Fracture 23 Pathologic Fracture 23 Reconstruction of Segmental Defect 23 Lengthening of Femur 30 3.2 Contraindication 32 References 35 4: Antegrade Femoral Nailing for Femoral Shaft Fracture 37 4.1 Position of the Patient 37 4.2 Entry Point (for the Straight Femoral Nail) 39 4.3 Reduction Technique 45 4.4 Reaming of the Medullary Canal 55 4.5 Insertion of the Femoral Nail 59 4.6 Mode of Interlocking 61 4.7 Summary 66 References 68 5: Retrograde Nailing 70 5.1 Surgical Procedures 70 Patient Positioning 70 Surgical Approach for Entry Portal 71 Fracture Reduction 72 Reaming and Nail Insertion 73 Optional Blocking Screw Fixation and Nail Reinsertion 73 Interlocking and Wound Closure 75 Postoperative Care 75 5.2 Use of Retrograde Nailing in Clinical Situations 75 Femoral Shaft Fractures Associated with Ipsilateral Fractures Including Femoral Neck, Acetabulum, Pelvic Ring, or Tibia Shaft (Figs. 5.4 and 5.5) 76 Infra-Isthmic Fractures of Femoral Shaft 77 Intra-Articular Fractures of Distal Femur 79 Periprosthetic Fractures of Distal Femur Following Total Knee Arthroplasty 79 References 82 6: Ipsilateral Femoral Neck Fracture 83 References 94 7: Bone Defect Due to Open Fracture and/or Infection After Osteosynthesis 96 7.1 Ordinary Interlocked IM Nailing if the Defect Size is not Significant 96 7.2 IM Nailing after Shortening of the Major Fragments (for Later Lengthening) 99 7.3 IM Nailing with Bone Defect Filled with Bone Cement (Masquelet Technique) 109 7.4 Internal Bone Transport Using a Monorail Type External Fixation System 112 7.5 Combination of the External Fixator and Plate Osteosynthesis 114 References 116 8: Atypical Femoral Fracture (AFF) 118 8.1 Association with Bisphosphonate (BP) 119 8.2 Definition of AFF by the American Society of Bone and Mineral Research (ASBMR) Task Force Team 120 Major Features 120 Minor Features 120 8.3 Location of AFF 120 8.4 Early Detection of Incomplete AFF 122 8.5 Treatment of Preclinical Cortical Lesions 125 8.6 Risk Factors for Progression to Complete Fracture 126 8.7 Surgical Treatment for Impending AFF (Prophylactic Nailing) 127 8.8 Surgical Treatment (IM Nailing) for Complete AFF 132 IM Nailing for Complete Subtrochanteric AFF 132 IM Nailing for Complete AFF 134 8.9 Other Miscellaneous Causes of AFF or AFF-Like Fractures 136 References 140 9: Subtrochanteric Fracture: Malalignment and Nonunion After IM Nailing 142 9.1 Tips for Correction of the External Rotation, Abduction, and Varus Deformity of the Proximal Fragment During IM Nailing 142 9.2 Exchange Nailing for Malaligned Subtrochanteric Fracture After IM Nailing 144 9.3 Osteosynthesis with a Fixed Angled Plate for Malaligned Subtrochanteric Fracture After IM Nailing 147 9.4 Removal of a Broken Nail in Nonunion of the Subtrochanteric Fracture 149 9.5 Nonunion of the Subtrochanteric Fracture After IM Nailing with the Appropriate Alignment 151 References 153 10: Isthmic or Non-isthmic Femoral Nonunion After IM Nailing 154 10.1 Supra-Isthmal Nonunion 155 10.2 Isthmal Nonunion 156 10.3 Infra-Isthmal Nonunion 159 References 162 11: Intramedullary Nailing in the Deformed Medullary Canal 163 11.1 Autosomal Dominant Type II (AD II) Osteopetrosis 163 11.2 Obstruction of the Medullary Canal Due to Osteoblastic Bone Metastasis 165 11.3 Deformity of the Medullary Canal Due to Malunion of the Femoral Shaft 166 11.4 Hypophosphatemic Rickets 168 11.5 Osteogenesis Imperfecta 169 References 170 12: Limb Lengthening Using Intramedullary Lengthening Nail 171 12.1 Osteotomy (Lengthening) Site: Previous Fracture (Figs. 12.1 and 12.2) Vs. Intact (Figs. 12.3, 12.4, 12.5, 12.6 and 12.7) 172 12.2 Osteotomy (Lengthening) Site: Diaphysis (Figs. 12.8, 12.9 and 12.10) or Metaphysis (Figs. 12.11 and 12.12) 176 12.3 Summary 180 Osteotomy (Lengthening) Site: Apex of the Deformity or Intact Site 180 Antegrade or Retrograde Nail 180 Rate and Rhythm of Lengthening 180 References 180 13: Various Problems Encountered During the Removal of the IM Nail 182 13.1 Failure of Attempted Removal of the Cephalomedullary Nail or Tibial Nail and its Solutions 182 13.2 Fracture of Femur or Tibia during Removal of a Nail 187 13.3 Femoral Neck Fracture after Removal of Cephalomedullary Nail 188 References 189