Gamma nail for intertrochanteric femoral fracture скачать в хорошем качестве

Gamma nail for intertrochanteric femoral fracture

General information Medical experts: Lasse Rämö (orthopedic surgeon), Rami Madanat (orthopedic surgeon), Jenni Liikanen (orthopedic resident) Name of Procedure: Cephalomedullary nailing of an intertrochanteric fracture of the proximal femur using the Gamma3 trochanteric nail.  Goal of Operation Reduction and stable fixation of an intertrochanteric fracture of the proximal femur with immediate restoration of full weight-bearing. Problem Intertrochanteric fracture of the proximal femur Diagnosis Pertrochanteric fracture (ICD-10: S72.1)  Short Pathophysiological Description Intertrochanteric femoral fractures are usually caused by a same-level fall and are common in elderly people with osteoporosis.  Potential pitfalls Incorrect incision site  The incorrect incision site will make it difficult to achieve correct placement of the guide wire into the trochanteric tip and parallel with the femoral diaphysis. You can use fluoroscopy and a guide wire placed on top of the skin to determine the correct site of incision.  Inadequate knowledge of anatomy and inadequate planning The anatomy of the femoral neck and the neck-shaft angle vary between patients. The varus/valgus angle and the ante/retroversion of the femoral neck are also unique to the individual. This is why planning of the operation and choosing the correct implant is important. Preoperative planning is done using the hip AP X-ray of the intact contralateral side. Inadequate understanding of biomechanics The aim is to achieve a biomechanically stable fixation. For stability, it is vital to achieve good (anatomic) reduction and correct positioning of the nail and the femoral lag screw. Incorrect placement of the nail or the femoral lag screw carries the risk of fracture dislocation and cut-out of the screw through the femoral head articular surface. The location of the nail and the femoral lag screw is determined by the guide wire placement, which must be done with care. The sum of the distances between the tip of the femoral lag screw and the midpoint of the articular surface as measured from the AP and lateral projections must be less than 25 mm (TAD= tip-apex distance) in order to minimize the risk of the lag screw cutting out and fixation failure. Intraoperative orientation challenges Pay special attention to the lateral projection since it may be deceiving when taking intraoperative fluoroscopic images. In uncertain cases, an instrument can be placed in the image area to confirm correct orientation (anterior vs. posterior), especially when adjusting the rotation of the nail while positioning the femoral neck guide wire. Careless tissue handling The deep femoral artery can be injured during guide wire placement or drilling the distal locking screw. Fluoroscopy will help you avoid placing the guide wire too medially and thus endangering the medial structures. Drilling through the medial femoral cortex in placement of the distal locking screw must be done carefully not to drill with too much force and injuring the deep femoral artery. 0:00 Preparation and fracture reduction 02:15 Planning the incision site 03:42 Skin incision and opening of the fascia 04:40 Nail insertion site 08:29 Guide wire insertion 09:52 Reaming of the proximal femur 11:52 Nail insertion 13:41 Determining the correct nail position 17:37 Femoral neck guide wire 22:19 Femoral neck lag screw placement 28:09 Inserting the set srew into the nail 29:44 Placing the distal locking srew 32:25 Final images and wound closure