PREOPERATIVE DIAGNOSIS: Left reverse oblique intertrochanteric hip fracture, displaced.
POSTOPERATIVE DIAGNOSIS: Left reverse oblique intertrochanteric hip fracture, displaced.
PROCEDURE: Closed reduction and trochanteric nailing, left intertrochanteric hip fracture.
PROCEDURE IN DETAIL: After obtaining informed consent, was given a gram of Kefzol and brought to the operating room whereupon a smooth induction of general anesthesia was performed by Dr. The patient was positioned in the supine fashion on the fracture table with the left lower extremity placed in boot traction over a perineal post. The right lower extremity was placed in the well-leg holder in the standard position. A closed reduction maneuver was carried out consisting of longitudinal traction with gentle internal and external rotation. Approximately neutral rotation of the foot yielded best reduction of the fracture on AP and lateral views. It should be noted that the proximal fragment of the fracture was flexed significantly and this could not be reduced entirely in a closed fashion.
Following this the left lower extremity was prepped and draped in the standard sterile fashion. Using intraoperative fluoroscopy as a guide, a percutaneous incision was made proximal to the greater trochanter and a guidepin from the Synthes TFN set was introduced into the proximal femur via the greater trochanter. The guidepin entry site was slightly posterior in an attempt to reduce the flexion deformity of the fracture. Once the guidepin was passed across the fracture and into the distal femoral canal, the starting hole was enlarged with a subcutaneous dissection down to the level of the greater trochanter using a snap-and-spreading technique. The guide for the 17-mm opening reamer was then placed over the guidewire to the greater trochanter and the opening hole was created. Using the reamers, beginning at a size 10, the femoral canal was sequentially reamed up to a size 12.5. No cortical chatter was encountered. No further reaming was performed, as the largest nail size was 12 mm.
The radiopaque ruler was then placed over the anterior thigh and nail length was measured from the tip of the greater trochanter to the knee. A 400-mm nail length was estimated, and to avoid excessive length of the nail, a 380 x 12-mm left trochanteric nail was selected. This was passed over a guidewire, and, ultimately, it was found unfortunately to be too long. Therefore it was removed and a 360 x 12-mm nail was passed. With the 360 x 12-mm nail in place, the guide for the 130-degree spiral helical blade was then attached. The guidewire was removed once the nail was in place.
A skin incision over the lateral thigh was created, and then the vastus lateralis and tensor fasciae latae were dissected gently with a snap-and-spreading technique down to the level of the lateral femur. It should be noted that even with posterior entry point of the nail; the flexion deformity of the fracture was not fully corrected. It was judged to be acceptable, however, and a large open incision for complete reduction of the fracture was elected against. It was felt that the extra operative time and blood loss as well as the strength of the implant justified this approach.
Using intraoperative fluoroscopy as a guide and AP and lateral views, a guidepin was then advanced through the lateral and femoral cortex up through the hole in the nail, and into the center of the femoral head on AP and lateral views. Once this was done, a lateral cortical reamer was used to open the lateral cortex and depth was measured to 100 mm. Using the reamer provided with the Synthes TFN set, the helical blade reamer was passed to a depth of 100 mm, and then a 100-mm helical blade was passed through the nail. With the helical blade fully seated, it was locked in place using the proximal locking mechanism and a 0-mm end cap was then applied. The guidewire and guide for the placement of the helical blade were removed and attention was turned to distal screw fixation.
Using the perfect circle?s technique, the dynamic and static screw holes were filled with 4.9-mm titanium locking bolts of length of 48 and 42-mm. Once this was done final position of the fracture and hardware was checked in AP and lateral views, proximally and distally, and found to be acceptable.
The wounds were copiously irrigated with normal saline and closed in layers. The proximal wounds were closed at the level of the fascia with interrupted #1 Vicryl suture in a simple fashion. The proximal wounds and distal screw insertion wounds were closed using interrupted 3-0 Monocryl suture in a simple buried fashion. Staples were placed at the level of the skin. Sterile soft dressings were applied. The patient was taken out of traction and awoken from general anesthesia. She was placed on a hospital bed and transferred to the ICU for recovery.
ESTIMATED BLOOD LOSS: 250 mL.
URINE OUTPUT: 150 mL.
IV FLUIDS: 900 mL.
COMPLICATIONS: There were no intraoperative complications.
POSTOPERATIVE PLAN: Postoperatively the patient will be allowed partial weightbearing on her left lower extremity. She will have foot pumps and aspirin for DVT prophylaxis. She will have antibiotics and a Foley catheter for 24 to 48 hours. Pain control will be with a combination of p.o. and IV medication. I told the patient preoperatively that it is likely that she will require a stay at skilled nursing facility during her recovery.