Surgical process analysis identifies lack of connectivity between sequential fluoroscopic 2D alignment as a critical impediment in femoral intramedullary nailing

  • Hamid Ebrahimi
  • Albert Yee
  • Cari WhyneEmail author
Original Article



Identifying key steps and barriers within complex and simple surgical procedures can be accomplished in a structured and rigorous manner using surgical process modeling. For lower extremity long bone fracture stabilization, the current standard of care is closed intramedullary (IM) nailing, which, despite its widespread use, is associated with challenges that greatly impact operative time and lead to the frustration of medical staff. The aim of this study was to identify challenging surgical steps in IM nailing and understand their underlying causation.


Eight semi-structured interviews with staff orthopedic surgeons and eight detailed surgical observations were conducted to understand the surgical steps, challenges and adapted techniques used in IM nailing. Hierarchical decomposition was then utilized to structure the IM nailing surgical procedure into phases, steps and activities.


In the developed IM nailing surgical process model, the most challenging steps were identified as fracture reduction (75 %) and entry point selection (25 %), both of which were associated with high levels of frustration in the observed surgeries. Both of these steps utilize 2D fluoroscopic imaging to guide 3D alignment. Challenges arise when the alignment in one plane is lost while adjusting the alignment in the perpendicular plane. This leads to unpredictable repetition of activities which can be time-consuming and frustrating.


Identifying the causation of surgical challenges in IM nailing through surgical process modeling forms a knowledge base that can be used to guide future improvements to techniques and surgical instrumentation.


Intramedullary nailing Entry point selection Reduction Surgical process modeling Hierarchical decomposition Sequential fluoroscopic 2D alignment 


Compliance with Ethical Standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The informed consent to participate in this study is attached as a supplementary material.


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Copyright information

© CARS 2015

Authors and Affiliations

  1. 1.Holland Musculoskeletal ProgramSunnybrook Research InstituteTorontoCanada
  2. 2.Institute of Biomaterials and Biomedical EngineeringUniversity of TorontoTorontoCanada
  3. 3.Division of Orthopaedic Surgery, Department of SurgeryUniversity of TorontoTorontoCanada

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