Surgical Technique for Femur Nail - ARZZT

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