Surgical Technique for Femur Nail - ARZZT
Surgical Technique for Femur Nail - ARZZT
Surgical Technique for Femur Nail - ARZZT
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Surgical</strong> <strong>Technique</strong> <strong>for</strong><br />
<strong>Femur</strong> <strong>Nail</strong><br />
Ins Hilden<br />
www.arzzt.com
<strong>ARZZT</strong> <strong>Technique</strong>s<br />
<strong>Surgical</strong> <strong>Technique</strong> <strong>for</strong><br />
<strong>Femur</strong> <strong>Nail</strong><br />
Intramedullary locked nail to screw<br />
<strong>for</strong> femur fractures<br />
Introduction<br />
Implant design<br />
Preoperative planning<br />
Patient position<br />
<strong>Surgical</strong> approach<br />
<strong>Nail</strong> placement in the instrumental set<br />
<strong>Nail</strong> insertion<br />
Distal and proximal locking<br />
Postsurgical care<br />
This guide is made to expose the recommended<br />
techniques and applications <strong>for</strong> femur <strong>ARZZT</strong><br />
intramedullary nail by orthopedics trauma surgeons in<br />
the treatment of fractures.<br />
The recommendations on its use does not seek to<br />
interfere whit the surgeon´s experience and each patient<br />
own needs, following basic rules <strong>for</strong> fractures treatment<br />
by means of internal splint biomechanical principle<br />
intramedullary fixation.<br />
www.arzzt.com 1
<strong>ARZZT</strong> <strong>Technique</strong>s<br />
<strong>Surgical</strong> <strong>Technique</strong> <strong>for</strong> <strong>Femur</strong> <strong>Nail</strong><br />
Introduction<br />
One of this implant favorite utilization features is the distal locking security, since<br />
inside the technique use, practical and simple, a constant symmetry is maintained<br />
between instrumental set and implant, saving surgical time and reducing the use<br />
of images intensifier.<br />
These innovations result in the surgical procedure success, diminishing<br />
considerably locking time <strong>for</strong> patient´s benefit since ischemia short time reduces<br />
deep veined thrombosis risk, of infection by the minimum approaches that are<br />
carried out, patient´s fast recovery to incorporate in short time to rehabilitation and<br />
his work and life routine.<br />
Having more advantage since in necessary case of dynamiting the system, it counts<br />
with a proximal orifice so that upon withdrawing one of the proximal screws the<br />
other one works as dynamic locking, this in cases of consolidation or<br />
pseudoarthrosis delay.<br />
This dynamic system controls de<strong>for</strong>mities in rotation and flexion but allows axial<br />
load transfer through almost the complete bone; it is use in axially stable fractures<br />
and some pseudoarthrosis. The static system controls the rotation, flexion and axial<br />
load and makes the implant a greater load-bearing mechanism reducing fatigue<br />
resistance risk, it is particularly useful in comminuted fractures and not isthmian.<br />
Implant design<br />
<strong>ARZZT</strong> intramedullary femur nail comes presented as solid and cannulated nail,<br />
steel or titanium with two holes <strong>for</strong> fixed distal locking and two <strong>for</strong> proximal locking,<br />
one of them fixed and the other dynamic, where conical head screws are placed <strong>for</strong><br />
cortical bone greater subjection.<br />
<strong>ARZZT</strong> intramedullary femur nail sizes are 9 mm diameter with 320 mm to 420<br />
mm length; 10 mm diameter with 360 mm to 420 mm length, 11 mm diameter<br />
with 340 mm to 420 mm length and 12 mm diameter with 340 mm to 420 mm<br />
length. Each measure with a 20 mm difference.<br />
<strong>Nail</strong> metal alloys that guarantee its resistance is manufactured in STEEL 316 LS and<br />
TITANIUM 6AI4V, each to be use as the Orthopedics surgeon considers better.<br />
<strong>ARZZT</strong> femur nail has been designed to be use in diaphysial fractures, of simple,<br />
complex or comminuted lines, up to 5 cm proximal to distal femur metaphyseal.<br />
2
Preoperative planning<br />
<strong>Nail</strong> diameter and length can be established by means of the healthy extremity X-ray,<br />
keeping in mind a 10 to 15% magnification. Some surgeons use an image intensifier<br />
superimposing the nail to the affected extremity to establish its length and to obtain a sure<br />
distance without affecting the knee and hip articulation. Another method is to measure<br />
from the greater femoral trochanter tip to the knee joint line, subtracting 8 cm.<br />
When operating very narrow bones the smallest diameter nail is suggested as chosen by<br />
the surgeon; and depending fractures comminution and stability is recommended a bigger<br />
diameter nail to obtain better fixing and stability.<br />
Patient position<br />
Patient must be in lateral decubitus or supine position, depending surgeon´s convenience<br />
and if he uses a table <strong>for</strong> fracture reduction or not, the reduction can be per<strong>for</strong>m by means<br />
of direct vision or close using a radioscopic control. The extremity that will be operating must<br />
be in a 90 degrees knee flexion and 90 degrees hip flexion.<br />
Patient Position<br />
Transversal<br />
cross-section<br />
<strong>Surgical</strong><br />
approach<br />
3
Direct vision surgical approach:<br />
Make an incision in the lateral side middle line with post lateral approach depending<br />
fracture height, dissect by planes following the intramuscular septum up to the femur,<br />
retracting soft tissues in anterior direction to minimize quadriceps damage, after exposing<br />
the fracture, pull and pull out the distal fragment, rhyme the fragment one millimeter<br />
greater than the nail chosen by the Orthopedic Surgeon, make the same procedure in the<br />
proximal fragment.<br />
Insert the guide through the shaft to proximal, cross the trochanter until it is subcutaneous,<br />
flex the hip and make an incision where the guide pressure appears, remove the tip, in<br />
blunt <strong>for</strong>m dissect until obtaining enough space <strong>for</strong> the nail insertion, per<strong>for</strong>m fracture<br />
reduction and insert the guide and the intramedullary nail, remove the guide and proceed<br />
to distal locking and subsequently to proximal locking, per<strong>for</strong>m this in case you are using a<br />
cannulated nail. When using a solid nail, guide is only removed to guide and direct nail<br />
insertion in the proximal side.<br />
Close vision surgical approach:<br />
Patient is place with fracture reduction and fluoroscopy control in the fracture table, per<strong>for</strong>m<br />
a oblique incision from greater trochanter proximal extreme to proximal and medial<br />
direction about 8 cm long, dissect by planes in blunt <strong>for</strong>m through gluteus maximums fascia<br />
following fibers direction, in depth piri<strong>for</strong>mis or digital fossa, insert trochanter (Awl), all<br />
under image intensifier view.<br />
Incision Trochanter base (Awl) Patient Position<br />
Insert a guide up to femur distal side, insert<br />
intramedullary reamer progressively by<br />
hand <strong>for</strong>m or mechanical drill up to<br />
inserting the reamer one millimeter<br />
greater than the diameter chosen by the<br />
Orthopedic Surgeon.<br />
Check reduction and measure nail length<br />
requirement, insert the nail until it is<br />
completely inserted up to trochanter edge,<br />
remove guide and proceed to place the<br />
guide to locate the different holes, drill and<br />
screw placement.<br />
4
1<br />
2<br />
3<br />
<strong>Nail</strong> placement in the instrumental set<br />
The nail must be installed and calibrated prior to use inside the femur to corroborate bolts free<br />
passage and exact symmetry.<br />
1.- Place the nail in the insertion handle coinciding<br />
with notches fixing it with the clamp screw.<br />
2.- Hold the nail on the insertion handle with the<br />
fixing screw and tighten the nail, assisting whit a<br />
Allen wrench <strong>for</strong> leverage, entering it through the<br />
locking nut holes.<br />
3.- Place the guide according to nail length coinciding the grip handle arrows with the guide arrows.<br />
5
4<br />
5<br />
6<br />
4.- Secure the guide pressing with a Allen wrench the locking nut<br />
5.- Place the second guide depending which leg is being operated, right or left,<br />
following the arrow in the guide.<br />
6.- Tighten two number 2 screws always matching arrow with arrow according<br />
correct nail length.<br />
6
7<br />
8<br />
9<br />
7.- Place the distal target device tightening it with a number 3 screw.<br />
8.- Place the distal target device tightening it with a number 3 screw.<br />
9.- Place the distal target device tightening it with a number 3 screw.<br />
7
10<br />
11<br />
10.- Place the sleeve and distal drill sleeve and verified a 3.6 mm drill bit goes through the holes<br />
without trouble.<br />
11.- Insert the sleeve and drill sleeve in the proximal holes and verified likewise the drill bit goes<br />
through the proximal holes without trouble.<br />
8
<strong>Nail</strong> insertion<br />
Verifying the system is properly calibrated; proceed to insert the nail in the femur. Remove the<br />
guides when it is completely inserted in the piri<strong>for</strong>mis or digital fossa, previous placement the<br />
impacting handle and with soft hits insert the nail, everything with an image intensifier vision,<br />
then place the guides.<br />
Distal and proximal locking<br />
Place distal guide, place guide sleeve and per<strong>for</strong>m a skin incision in the thigh anterior side, it is in<br />
blunt <strong>for</strong>m dissected, insert the drill sleeve up to the femur anterior cortical with trocar help, insert<br />
the 5.2 mm drill bit up to the nail, insert the locking rod and lock the locking block according to the<br />
diameter the Orthopedic Surgeon chose.<br />
Place the drill guide sleeve in the thigh lateral<br />
side and mark where incisions will be per<strong>for</strong>m,<br />
incisions must be small only to allow the drill<br />
sleeve to go through, dissect by planes, until<br />
locating femur lateral cortical insert the sleeve<br />
with trocar help, place the drill sleeve and drill<br />
up to the second cortical with a 3.6 mm drill bit,<br />
start with the greatest distal hole, verified by<br />
means of inserting the drill sleeve if it is in the<br />
nail hole. Remove the drill bit and the guide,<br />
insert in the depth gauge, having the screw<br />
length, insert the T handle drill up to drilling the<br />
second cortical, remove and place with the right<br />
screwdriver a 4 mm screw, verified it is in the<br />
nail and goes through the second cortical 5 mm<br />
screw, repeat <strong>for</strong> distal proximal hole.<br />
The second guide can or cannot be remove.<br />
Proceed to per<strong>for</strong>m the same operation,<br />
previous reduction and bolt right size according<br />
where they were place is verified. Remove the<br />
system and place an occlusion screw in nail<br />
proximal side, suture by planes or with nylon<br />
the skin, according to Orthopedic Surgeon<br />
preference, the gauzes and elastic bandages<br />
are place, remove fracture table.<br />
9
15<br />
15.- se retira el sistema y se coloca el tornillo de oclusión en la parte proximal del clavo, se<br />
sutura por planos o solo con nylon la piel, de acuerdo a las preferencias del Cirujano<br />
Ortopedista, se colocan apósitos y vendaje elástico, se retira de la mesa de fractura.<br />
Postsurgical care<br />
Must be place a elastic bandage from foot up to tight<br />
nearest origin, inguinal region, keeping the extremity<br />
elevated, the patient can per<strong>for</strong>m free tolerance<br />
flexion/extension, each orthopedic surgeon may choose<br />
how analgesics and antibiotics are prescribed.<br />
Walking and support will be decided by each surgeon, but<br />
walking may be started with partial support in two weeks if<br />
it is approved by radiological control.<br />
Radiological controls must be taken every four weeks,<br />
stitches are removed in two or three weeks, healing must<br />
be per<strong>for</strong>med on free demand as each orthopedic<br />
surgeon prescribes.<br />
Depending on the fracture consolidation evolution, nail<br />
dynamization may be per<strong>for</strong>m by removing one of<br />
proximal screws, remove the round hole screw, it is when a<br />
consolidation or nonunion retard.<br />
© Arzzt. This in<strong>for</strong>mation is protected by Copyright. Don´t distribute without the autorization of <strong>ARZZT</strong><br />
10