SURGICAL TECHNIQUE PRE-OPERATIVE PREPARATIONS Pre-operative X-ray will help to determine the diameter of the nail to be used. Using X-ray of uninjured femur may also help in determining diameter and length to be used. Nail length should be flushed with the tip of the greater trichinae and the proximal locking hole will come at the level of the neck of femur or in the cal car. POSITION OF THE PATIENT In the Supine position the lower leg hangs down with the knee flexed in 90 degree the free hanging of the lower leg will correct the rotational positional alignment, if the pelvis is exactly positioned (fig 2). The uninjured leg is slightly abducted to lateral. The injured leg is abducted to median. Table can be broken to allow 90 degree flexion at knee and allow the leg to hang. After the nailing the leg can be straightening table plate. PAINT AND DRAPE THE SIGTH AS USUAL. GUIDE THE GUIDE-WIRE IN THE PROXIMAL FRAGMENT. Ask the assistant to maneuver the fracture site to allow guide-wire to pass in the distal fragment. The nail should be fixed to the assembly and Pre-operative check should be carried out. Insert the nail over the guide wire.(vide instructions for the assembly of instruments & procedure) PROXIMAL LOCKING It is advisable to lock the distal hole of the two proximal holes first. Pass the protection sleeve through the hole of the jig and retain it till the screw is passed (fig 6) Insert the trochee (pointer) into the protection sleeve and dimple the cortex. (fig7) Remove the pointer and pass drill sleeve (3.2mm for Femur nails) through the protection sleeve pass the drill bit of corresponding sizes. Pass the
depth gauge and measure the length of the screw to be used. Pass the tap sleeve (4.5mm for Femur nails) Pass the Tap. After Tapping pass the screw with the help of the screw driver. Using thin tip suction the hole in the nail can be visualized. Looking can then be done accordingly. Some users advocate use of annulated drill bits to be used over the above guide wires. This may be associated with occasional failures in distal locking. DISTAL LOCKING FOR C-ARM Adjust the length of the Distal Aiming Device according to the size of the nail implanted. Fix the Distal device on the jig. Pass the special radiolucent (white top) sleeve through the rod confirm the distal holes with the help of C-arm. After confirmation of the holes, pass the drill far cortex with 3.2mm drill bit and pass the screw (fig 9). DISTAL LOCKING WITHOUT C-ARM Adjust the length of Distal Aiming Device according to the size of the nail implanted. Fix the Distal device on the jig. Confirm the setting on Distal aiming device to match the length of the nail. Pass the drill sleeve through the rod and pass the K wire through distal most hole of the device. Engage the K wires in the anterior cortex. Take X-ray and confirm the position of the K wire. Invariably the K wire position and the distal hole with match in alignment or there may be a distance of 1 to 2 mm between the k wires and the distal holes position. Keeping this relation in mind, drill the cortex with appropriate drill bits (fig10)
Pass the Bolt (H2) through the Nail Holder (H1) and fix it with the Nail, as shown in (fig1) Nail Holders slots should match with Nail grooves. Pass the jig (H3) on to the Nail Holder, as shown in (fig 2).The jig should be passed as per the desired locking direction i.e. Lateral to Medial or Anterior to Posterior, depending upon the fracture site. Tighten the handle (H4), as shown in (fig2)
For AP locking, fix the AP jig (H5) with Bolt on H3, as shown in (fig 3) PROXIMAL LOCKING IN AP DIRECTION 1. Pass the protection sleeve (H7) through AP jig. 2. Pass the pointer (H8) through protection sleeve (H7) and Dimple the cotex. 3. Remove the pointer and pass the Drill Sleeve (H9) through protection sleeve(h7) 4. Pass the 2.5mm Drill Bit through drill sleeve (H9) and drill it. 5. The Drill Bit and Drill Sleeve should be removed. 6. Pass the Tap Sleeve (H10) through protection sleeve (H7) 7. Pass the 3.5mm tap through tap sleeve (H10) and tap it. 8. Remove the tap and pass the depth gauge to mea sure the screw length. 9. Pass the 3.5mm self tapping screw and tighten it with screw driver. 10. The same procedure should be followed for the other hole. (Protection sleeve should not be removed from the s-jig the locking is done.)
PROXIMAL LOCKING IN LM DIRECTION. 1. Pass the protection sleeve (H7) through AP jig. 2. Pass the pointer (H8) through protection sleeve (H7) and dimple the cotex. 3. Remove the pointer and pass the drill sleeve (H9) through protection sleeve (H7). 4. Pass the 2.5mm Drill Bit through drill sleeve (H9) and drill it. 5. The Drill Bit and Drill Sleeve should be removed. 6. Pass the Tap Sleeve (H10) through protection sleeve (H7) 7. Pass the 3.5mm tap through tap sleeve (H10) and tap it. 8. Remove the tap and pass the depth gauge to mea sure the screw length. 9. Pass the 3.5mm self tapping screw and tighten it with screw driver. 10. The same procedure should be followed for the other hole (Protection sleeve should not be removed from the s-jig the locking is done.) DISTAL LOCKING IN LM DIRECTION The size of the nail is indicated on the jig. Follow the procedure same as that of proximal locking by passing the protection sleeve from the hole indicated for the respective length of the nail inserted. i.e. If nail of 22cm is inserted, the protection sleeve should be passed from the hole marked with 22. Refer fig 6
CENTRAL LOCKING IN LM DIRECTION A hole is provided in LM jig as well as in the nail for the central locking, if desired. The procedure is the same as that of proximal locking in LM direction. Pass drill sleeve (H9) through protection sleeve (H7). Drill the bone, with help of drill bit. Measure the length of the screw to be passed with the help of the depth gauge. Pass the screw. Confirmation is made by introducing a guide rod through the proximal end of the soil. Some procedure should be done for second hole of Humerus nail. LOCKING OF LATERO-MEDIAL HOLES (L/M) After locking A/P holes remove the A/P jig (H5).Loosen the handle (H4) and rotate the Humerus jig (H3) on L/M side. Tight the handle (H4) again. Put L/M jig (H6) on Humerus jig (H3) and tight it with Aluminum nut. Pass Protection sleeve (H7) in L/M jig (H6) Pass drill sleeve (H9) through protection sleeve (H7) Drill the bone with help of drill bit. Measure the length of screw to be passed with the help of the depth gauge. Pass the screw confirmation is made by introducing a guide rod through the proximal end of the nail. Same procedure should be done for second hole, middle hole & distal hole of Humerus nail.