a. Lateral Incision Over Trochanter

b. Provisional Wire Fixation

1. Exposure and Reduction

a. Insert Guidewire for Drill

b. Drill Through Proximal Cortex

c. Ream Medullary Canal

d. Insert Nail

e. Attach Aiming Arm

f. Insert Lateral Guidewire for Drill

g. Drill Through Lateral Cortex

h. Insert Spiral Blade

i. Insert Locking Mechanism

j. Adjust as Needed

2. Proximal Fixation

a. Align Drill with Distal Nail

b. Drill Through Cortex

c. Insert 1st Distal Screw

d. Repeat for 2nd Screw

3. Distal Fixation

4. Post-op Remarks

Subtrochanteric femoral fractures commonly present in two different populations under very different circumstances. The elderly are commonly affected by low-energy events, such as a simple fall to the floor, while younger populations are more likely to be involved in high-energy events such as motor vehicle accidents. The majority of elderly injuries can be attributed to fragility fractures due to loss of bone density, but it is important to note an atypical fracture pattern that is present in those who have been taking bisphosphonates. This video demonstrates an intramedullary fixation of a reverse oblique trochanteric femoral fracture in the lateral position. There is a classic deformity seen in subtrochanteric fractures due to strong muscular attachments in the region. In this video, we show that while the lateral position may be more difficult for obtaining x-rays, it provides natural external forces that make reduction and fixation easier.

<h4>CHAPTER 1</h4>

<p>Get right through the iliotibial band - just get through there.
Cut.
Good, so you see that band? Yeah.
That’s a little piece there. Proximal.
Yeah, so you got to go just a little bit more proximal.
Do you have a Weity? Good. Yes, sir.
Actually, do you have a Gelpi?
Thank you.
All right, so the iliotibial band is open,
and there’s vastus lateralis, right?
Now do you have your Schnidt?
So you’re right on that piece of bone, so what I want you to
do now is just take this and get behind this -
you know, spread it open
so you’re kind of behind vastus lateralis, okay?
Back there, yep. Yep. You want back here?
You know what? Good.
Good. All right. We’re a little bit cross...
Let me see. All right, so I think you're...
That's right where our fragment is.
Yep, you're right on it, so that's perfect. Okay.
And there’s the distal piece, there.
All right, so now get your wire -
get your wire passer. X-ray there.
X-ray.
Usually, it’s internal rotation. X-ray.
So that’ll be good I think.</p>

<p>So the way this works... So now this is above, yep.
You just kind of put that together. Put that together and
then flip it apart? Okay, so you’re just gonna -
put it and go on, and that way.
X-ray.
So you’re only around... Only around that.
Well no, you got to get around the other way.
So you’re doing this - you just got to...
I'm just hitting some soft
tissue again. Yeah.
X-ray.
Good, so now we’re around there. So now, take this one...
And get over the top. And you’re just gonna loop it that way.
X-ray.
Good, that’ll do it.
Okay, so now...
Now pop that.
Good.
And now take off that. Leave this one.
Yeah, take this one out? Take that one out.
Now with the wires, I always kind of do this. I kind of treat it
like a screw, and so I go clockwise. Okay.
So that way I can always go back to it and tighten it if I want.
So give that a pretty good pull up.
X-ray.
Good, as you tightening give a good pull. Come south just a little bit.
X-ray.
X-ray. We may have to adjust a little bit, but I think that’s
a pretty good start.
We need to have a better reduction when we’re done,
but this is a pretty good start.
Oftentimes, the nail will kind of finish it for you.</p>

<h4>CHAPTER 2</h4>

<p>All right, guidewire. Wire.
No, that looks fine. X-ray.
That's fine.
There you go, yep. Drive that in, please.
Good. X-ray. Good, now try tapping that in with a mallet
just a little bit. That’s
when I use the mallet - it’s once it’s down.
To bounce off the cortex?
Yep, exactly.
X-ray.
Yeah, and now you can tell you’re down
because it’s staying inside the canal. Yep, good. X-ray there.
Good, and you already saw the other views, so you know that's good.</p>

<p>Good.
Dropping your hand aims lateral.
Okay? And that’s the last place you want to be
with this, okay?
You shouldn’t be cramped for space with this.
Yeah, I got it. Good.
Go ahead.
You got to be real careful about going lateral,
all right? Because if it goes - that’s the
soft bone. It’s gonna want to go lateral, and then it’ll tip you
into varus because your blade will push you over -
or sorry, your nail will push you over.
X-ray.
That’s good. Keep going.
Good.
Are you all the way in? Hub it. Hub it.
Hub it.
And out. Good.</p>

<p>Is that down the be - down the pipe? It’s good.
Come down to the knee, please.
X-ray there.
You always measure before you ream.
There you go.
X-ray.
What does that measure? If it measures exactly 360,
and this is your x-ray on the right, what do you want?
8.5?
X-ray.
All right.
Good. 12, please.
That’s it. You’re good.
12 in it? Yep, 12’s it. 12 and then the nail.
Cuz there’s no chatter - it’s a wide capacious canal -
no need to ream up,
but I always like to pass that 12, the final reamer,
just to make absolutely sure.
Now if you hit a lot of chatter here,
I’d say, “Oh, let’s back up
and starting reaming it out,”
but you’re not gonna hit any chatter
All right, we’re ready for the nail.
You can see as the reamer and the guidewire
have gone down, it
helps with your reduction.</p>

<p>It just kind of goes in like a corkscrew.
And just remember
we’re lateral, so this is going to start in the front
and then corkscrew it in that way. There you go. Yep.
Good.
X-ray.
Mallet.
X-ray.
All right, why don’t you come down to the knee.
Just make sure that’s okay.
Good. X-ray there.
Yep, that’s perfect. Good, come back up to the top.
A little less like that, probably.
Good, X-ray there.
That looks pretty good there.
X-ray.
All right.</p>

<p>Just keep careful of those wires, okay?
What’s that?
Be careful of those wires.
So if you go like this? Right.
see, it just keeps pulling that back. If you go the other way,
then it tightens up. Yep. After it locks?</p>

<p>X-ray there. That’s good.
X-ray.
Stop there.
X-ray.
So next time, I want you to be really careful.
That’s most likely in the hip joint.
You - next time, before you drive it beyond halfway, you
really need to check your lateral. Come up to a lateral.
X-ray there.
All right so, that’s right in the joint. All right, so back that out.
X-ray.
X-ray.
X-ray.
Okay.
X-ray.
Keep driving it forward.
X-ray.
X-ray there.
X-ray there.
Drive it forward just a tiny bit more.
Good. X-ray.
Good. Let’s swing around to an AP.
So that looks pretty good.
So you can go ahead and drive that a little bit more.
X-ray.
X-ray.
So you want to go a little bit more than that.
So it doesn't back out when you drill. X-ray.
Okay.
Save that. Can you just swing up to an AP?
X-ray there.
X-ray there.
Can I have the wire driver?
So that’s just a tiny, tiny bit posterior.
X-ray.
X-ray.
X-ray. That looks pretty centered to me.
All right, swing around to an AP.
X-ray there.
See if you can tighten that wire just a little bit more.
I get the sense that it’s - that we keep losing our reduction
ever so slightly. I think we’ll probably take that wire
out at the end. You know, oftentimes, I’ll leave it if it's
a really nice reduction.
You know, in this case, we couldn’t capture that piece, so I don’t think it’s
worth keeping it, but it's helping us -
helping us hold it. Are you pulling?
I’m pulling. Good. X-ray.
X-ray.
Okay, all right. So let’s go do the blade.
So before you measure, you’ve got to get this thing
down, okay? See how it’s not on the bone yet?
It’s off the bone there.
Because the blade is stopped by this cannula,
so if you’re not on the
bone, the blade is going to stick out the side of the femur,
and it's just really prominent and can bother people.
Good. X-ray there.
So even that’s not down. Do you have a Tommy Bar?
I think it might be hitting on the... Yeah, I agree.
It’s hitting on the wire a little bit.
Can you suck?
Do you have a chubby, please?
Bone tamp and a mallet.
So often,
you can just kind of tap that wire around in a circle.
Even when it’s tight, it’ll move that way.
X-ray.
Now that’s down.
X-ray.
I think that's pretty good.
X-ray.
X-ray.
X-ray.
Yeah, that looks good. Okay.
Yep.
I’ll take the wire driver first, please? Yeah, sure.
Now if you measure to 90 and put in a 90 there,
you’re not going to be able to keep that guidewire in
because it’s just gonna come right out. So I always -
that’s why I put it in before,
but then we changed it - but I’d like to put it
it in further so it's got fresh bite in the head.
So you drive it in just a touch?
Normally, I have it touch the subchondral bone
cuz then you’re actually measuring your
tip-apex distance, right? And the tip-apex distance is
probably the second most important thing.
X-ray. As far as keeping it from losing its reduction.
X-ray.
So now, you know, you can double check, but -
yeah, so I think 90 is fine.
That measures 97 or something
like that, so tip-apex distance would be about 15.
So what do you want?
90. 9-0.</p>

<p>X-ray.
You’ve got to check X-rays to make sure you
don’t drive the pin into the head.
X-ray.
X-ray. Okay. Don’t trust your stop.
X-ray.
We still got one.
X-ray.
So yeah, a little bit more.
X-ray.
That's down.
Okay.</p>

<p>So it's important to know that this blade is longer than the drill.
You can’t hold that. It’s rifled. If you hold this, it won’t go in.
Yep. You have to hold it here.
Cuz it’s rifled, so it’s grabbing in the barrel.
There you go.
X-ray.
X-ray.
X-ray.
Go down. Let me see.
Good. Flexible?</p>

<p>All right.
All right.
Wire driver.
Yep.
Thank you.
All right. X-ray there.
X-ray.
X-ray.
Back out for a second.
Do you have a wire cutter for me?
So at some point, we lost our reduction there.
It was like really good until our blade went in.
I got to take this wire out.
X-ray.
X-ray.
X-ray.</p>

<p>I’m gonna go take this out. I need the flexible screwdriver.
Sorry. Can you get me the extractor handle for the blade?
Yep.
I don’t know where I went wrong there.
We had a really nice reduction with the wire. It was great.
And then when we put the blade in, it didn't...
Somehow, it displaced.
And then that is going to connect to the shaft.
Like that. X-ray.
Okay.
X-ray there. Now we’ve got that posterior piece as part of it.
X-ray. Come south for me a little bit.
Give it a really good pull and slight internal rotation there. X-ray there.
Okay, can you pull hard? Like real hard.
X-ray.
All right.
Time to make the magic happen. Here we go.
X-ray.
This is gonna be a Herculean pull, okay?
X-ray.
And then internal - or external maybe? Pull away.
X-ray.
There we go. It’s starting to go in.
X-ray.
Now internal.
X-ray.
X-ray.
Watch out for a second.
I just want to see what happens when I pull.
X-ray.
X-ray.
X-ray.
X-ray.
X-ray.
Just hold that there.
I think that piece is rotated still. Can I see the nail, please?
X-ray.
X-ray.
Mallet.
X-ray.
So sometimes when you get it close, the -
the nail will help kind of fill the canal.
So now we have that reduction a lot better.
It’s not perfect yet, but we’re much
better. I think we’re even better than when we were at the
beginning cuz -
unless there’s a free piece, but now that other piece is -
X-ray.
All right, so that’s good there. All right, Gelpi.
Now I’m back to happy. Like, I think that’s an acceptable
reduction. It’d be nice if we could key that in just a little bit more.
Do you have the 1x1?
X-ray.
Now release - release it.
Good. X-ray.
Just a little bit more. X-ray.
You can see that - that wire -
if it was a tiny bit more distal, would probably be helping
us a little bit better.
I definitely don’t want to put a third wire - you know,
I think we’ve got plenty.
Okay. Guide.
And guidewire stuff. I’ll take the wire freehand.
Mallet, please.
Yep. X-ray there.
X-ray. Wire driver.
X-ray.
X-ray.
That looks pretty centered.
X-ray.
All right, let’s come up to an AP. Yep. X-ray there. Power.
X-ray.
I think that’s the same hole.
That didn’t feel like a lot of - anything.
Looks like we’re gonna stick with a 90.
Do have - I’m gonna use the
one I said I wouldn’t use now.
Same thing.
X-ray.
X-ray.
X-ray.
Blade.
So this turns, and then once it locks in,
you just push it. If you hold here, it stops it from turning, so
it can’t go in.
X-ray.
X-ray.
X-ray.
Lock that down for me.
Glad we changed it though.
Anytime you see it like kind of fall apart,
it’s like, “Eeehhh.” Yeah, it came all the way apart.
But, you know, the - the tip-apex distance is
what’s written about as being the
most important thing, but I think that’s
secondary to reduction. You have a good
reduction, you’re not gonna fail. Yep.
X-ray.
Okay. And acorn.</p>

<h4>CHAPTER 3</h4>

<p>Let’s come up to an AP now, please.
And then tilt a little bit more.
X-ray there.
Knife please.
Yes. Coming up. Knife blade.
X-ray.
How far do you want to spread it? I don't know.
I’m gonna spread with the drill.
X-ray.</p>

<p>X-ray.
Bullseye.
Depth gauge.</p>

<p>50.
X-ray.
X-ray.
If we had reviewed on his lateral,
would you still have opened?
For this one, probably.
X-ray.
It would have been harder.
It would’ve been harder to get a good reduction.</p>

<p>I think we would - I think -
supine, you mean? Yes.
X-ray.
I think we would’ve -
we wouldn’t have ended up quite as good.
Watch your hand.
Thank you.
X-ray.
X-ray.
X-ray.
X-ray.
X-ray.
X-ray.
So that’s the ideal, like when it falls right through.
46.
46.
X-ray.
X-ray.
Do you want one to close off? Yeah, definitely.
Yes, please.
Can you square up for me - nice and straight?
X-ray. Save that.
Come up proximal.
Drop your machine as far as it’ll go. Table up, please.
You got it.
X-ray there.
X-ray there. You can see that piece is folded around the back.
That's what I was trying to undo. X-ray.
Save that.
Come up proximal just a little bit more.
X-ray there.
Save that.
Swing around to an AP, please.
X-ray.
Save that.
Come down to the knee, please.
X-ray.
Save that.
These screws are adding -
aiming slightly posterior to anterior,
which is kind of what you want
cuz that means your version is about right.
That’s another check for
version, right? Thank you.</p>

<h4>CHAPTER 4</h4>

<p>So that was challenging,
but things came out nicely in the end.
So, we performed an intramedullary fixation
of a reverse obliquity in the lateral position.
This positioning is useful
because it allows the soft tissue to fall away and
makes a direct reduction a little bit easier
than if you're on a fracture table.
And also, it neutralizes the deforming forces of
the proximal femur when you’re in
that lateral position. But the X-rays
are a little bit more challenging, and it’s something
you have to get used to, but it works out pretty well.
I think, when you need them,
cerclage wires around the proximal femur are pretty useful,
but you’ve got to make sure you’ve got a good reduction.
If you leave a large
fracture gap, you can have trouble with healing.
And you want to be careful not
to make too many passes
cuz that can lead to the stripping of the bone
fragments, which can lead to a non-union.</p>


Watch this full-length, narrated surgical video of a closed cephalomedullary nail fixation for a reverse oblique subtrochanteric fracture performed in the lateral position by Dr. Michael Weaver at Brigham and Women's Hospital.

Brigham and Women's Hospital