Fracture Femur- Antegrade Rodding

The ideal treatment for a fractured femur is a statically locked, antegrade reamed nail of the appropriate diameter, which allows the patient immediate weight bearing after surgery. The starting point has to be ideal. You do not want to go too anteriorly because you will create iatrogenic fracture of the proximal femur. You do not want to go too posteriorly because this will create anterior perforation of the distal femur. The piriformis starting point is the gold standard. We can use a trochanteric entry especially in obese patients, but you then have to use a trochanteric nail. The ideal location for the trochanteric nail is medial to the tip of the trochanter. If you have a straight nail designed for a piriformis entry and you go through the greater trochanter, then you will get varus. The piriformis entry is collinear with the long axis of the femoral shaft. The greater trochanter entry site is lateral to the femur shaft axis, and this will create malalignment as you advance the rod. The two axis becomes collinear leading to a varus deformity. Try to avoid varus. After you make the entry hole, then you will put the guide wire. It is probably better to bend the guide wire tip. Make sure that you ream over a beaded guide wire and the guide wire must have a curve or a bend to help you in advancing to the distal fragment. Once you put the guide wire, you must see the knee in the lateral view and make sure the guide wire is not anteriorly. After you measure the guide wire, insert the guide wire, insert the guide wire a little bit distally so that it will hold in the bone and so that it does not come up with the reaming. Reaming probably increases the union rates and probably decreases the time to union. Make sure that you do not ream when there is an area of comminution (just push the reamer through the area of comminution). You may want to avoid reaming in somebody with bilateral fracture femurs. Reaming may increase the pulmonary complication rate, especially in bilateral femur fractures (can use unreamed nailing). Some may use retrograde nailing. You measure the proper length and then put the appropriate length rod. Always look at the handle of the insertion of the rod. Make sure that the c-arm in a lateral position is parallel to the insertion of the handle of the rod, then you will get the screw holes perfect. Once you get the holes perfect, then you will ask for magnification. Try to get perfect circles. If you have widening or overlap of the interlocking holes in the proximal/distal direction, then the leg needs adduction or abduction which will improve it. If the overlap is in the anterior/posterior plane, then it is a rotation problem, either internal or external. Make sure the rotation of the extremity is OK. There is a high incidence of malrotation after IM nailing of the femur. Try to get the difference between the two femurs to be within 10 degrees of each other, and the maximum is 15 degrees. Once the perfect circle is seen, then a drill or a handle with a k-wire is pointed at the circle and advanced parallel to the fluoroscopy beam. After that, you will put the proximal and distal screws. Make sure that you remove the guide wire before you put the screws. You can check the proximal screw is in its proper location by inserting a wire through the rod and see if it will stop at the screw or not. If it stops at the screw, then the screw is inserted properly, and then you do not need to get a lateral view to see it. Make sure you get internal rotation view after insertion of the screws in the distal femur to avoid having long screws.