Surgical Technique: Static Intramedullary Nailing of the Femur and Tibia Without Intraoperative Fluoroscopy

Abstract

Background

On a recent mission directed at definitive care for victims of the Haitian earthquake, the orthopaedic team developed a technique for freehand distal locking of femoral and tibial nails without intraoperative fluoroscopy or proximally mounted targeting jigs.

Description of Technique

After performing open antegrade or retrograde nailing by standard techniques, the freehand lock must be obtained before doing standard outrigger locking. This allows the surgeon to control the nail and deliver the locking hole in the nail to a unicortical drill hole in the femur. Before nail insertion, the distance of the desired locking hole is measured from the outrigger in a standard way such that it can be reproduced after the nail is inserted. Through a unicortical drill hole, the nail is palpated with the tip of a Kirschner wire and systematic maneuvers allow the Kirschner wire to palpate and fall into the locking hole. The Kirschner wire is tapped across the second cortex before drilling. The screw is inserted, and the ball-tipped insertion guidewire is placed back into the nail to palpate the crossing screw confirming position.

Patients and Methods

We treated 16 patients with 18 long bone fractures using the described technique. We assessed patients clinically and radiographically immediately postoperatively.

Results

A total of 19 blind freehand interlocks were attempted, and 17 were successful as assessed by direct intraoperative observations and by postoperative radiographs.

Conclusions

We describe a simple technique for performing static locked intramedullary nailing of the femur and tibia without fluoroscopy. This technique was successful in most cases and is intended for use with any nailing system only when fluoroscopy or specialized systems for nailing without fluoroscopy are not available.

Appendix: Description of Standard Antegrade and Retrograde Femoral Nail Technique Used in Conjunction With The Freehand Locking Technique Described Technique

Antegrade Femoral Nailing

For antegrade nailing, the patient is placed in the free lateral position, and a small incision is made at the level of the fracture. Direct dissection into the fracture affords control of the proximal fragment, and a ball-tipped guidewire is inserted retrograde into the proximal fragment (with the ball tip oriented distally). The guidewire is advanced proximally until resistance is felt in the proximal femoral cancellous bone. A mallet then is used to drive the guidewire through the proximal femur. This routinely will drive the guidewire out of the proximal femur through the piriformis fossa, optimizing the starting point for an antegrade femoral nail. Once the wire is through the fossa, it is advanced until it can be palpated subcutaneously. A scalpel is used to cut down on the wire creating a tract for instrumentation.

The fracture subsequently is reduced under observation for simple patterns and the guidewire is passed into the distal fragment. Alternatively, in comminuted fractures, the guidewire can be passed from the proximal to the distal fragment under direct observation. The guidewire is advanced by hand until resistance in felt in the distal femoral cancellous bone. The guidewire is seated firmly by tapping it with a mallet in the distal femur. A second guidewire of identical length then is used to determine the distal position of the intramedullary guidewire and to confirm estimated nail length. Subsequently, the canal is opened proximally and the femur prepared with standard techniques depending on available instrumentation. The nail length is confirmed by holding the nail next to the limb while palpating the tip of the greater trochanter and the superior pole of the patella.

Retrograde Femoral Nailing

A skin incision is made from the middle of the patella to 1 cm above the tibial tubercle. A medial parapatellar tendon arthrotomy is made from the inferior pole of the patella to the tibial tubercle. A starting guidewire is placed under direct palpation of the notch. It is slightly medial and posterior to the center. The opening wire is advanced and the distal femur opened with either an awl or end-cutting reamer depending on instrument availability. The ball-tipped guidewire then is advanced to the level of the fracture. The fracture is opened through a lateral approach and the guidewire is identified in the distal fragment. The fracture is reduced and the guidewire is passed into the proximal fragment under direct observation. The wire is advanced until resistance is felt and tapped into the proximal femoral cancellous bone. A second wire of identical length is used to determine the approximate proximal position of the guidewire and grossly confirm selected nail length.

Reduction of Fracture

Direct observation and inspection of the fracture ends are the best indicators of length, alignment, and rotation. This does not necessitate an anatomic reduction, but simply means that the clues of the fracture configuration assist the surgeon in positioning the distal fragment. This holds true for simple and for comminuted fracture patterns.

Rotation can be controlled until the nail has been locked proximally and distally. All clues must be used including preoperative evaluation of the contralateral arc of hip rotation, and preoperative palpation of the contralateral greater trochanter compared with the patella. It is with all of these steps that the surgeon will approximate rotation. Rotation can be confirmed by taking the operative leg through an arc of rotation after the nail is locked proximally and distally. If the free limb is draped, then this can be done while sterile allowing for alterations if required.

A clamp can be used through the surgical wound at the fracture site to maintain reduction while preparing the canal and passing the nail in fracture patterns that are amenable.