Intertrochanteric neck of femur fracture treated with a proximal femoral nail (Synthes long TFNA)

An Antero-Posterior (AP) radiograph of the right hip demonstrating an inter-trochanteric fracture with involvement of the lesser trochanter.

A Lateral (Lat) radiograph of the right hip demonstrating a neck of femur fracture with involvement of the greater trochanter (note it is posteriorly displaced).

A full length femur radiograph was requested due to a history of previous malignancy and to rule out any obvious metastases.
This is common orthopaedic practice however, O’Flaherty et al. reported that in 114 cases that had a full length femur radiograph, there was no demonstrable pathology.
From my perspective, as long as it doesn’t delay surgery, then I believe it could help with the decision making between a short vs long femoral nail if a distal lytic lesion is detected.
To truly identify if there is a neoplasm within the femur, then an MRI scan would be the investigation of choice. In the context of metastases timely surgery and early mobilisation is often more urgent than waiting for an investigation. If there is any concern, then use a long nail that bypasses the defect distal to the fracture.
In the context of a renal primary its metastatic deposits can be very vascular and require embolisation first.
O’Flaherty MT, Thompson NW, Ellis PK, Barr RJ. Full-length radiographs of the femur in patients with a femoral neck fracture and co-existent malignancy – are they of benefit? Ulster Med J 2008; 77(3): 181-184.

The patient is positioned on the traction table and the fracture is reduced under image intensifier (II) guidance.When positioning a patient for a femoral nail, it is really important to have the shoulders and torso closer to the opposite side of the operating table.
This means that with a little bit of hip adduction, the patient posture is shaped a little bit like a banana. The reason that this is important, is so that you have the correct trajectory with the femoral canal.
If you draw the anatomic axis of the femur and imagine that it extends superiorly towards the top of the operating table, there should be nothing obstructing it e.g. table supports, patient’s abdomen, suction or diathermy.

The fracture is initially reduced under II guidance in the AP view.To achieve the reduction, the traction is initially applied manually to take up any slack in the system. Then if further traction is required, this can be applied by winding the traction handle in a clock-wise direction.
I recommend applying the traction first before applying any internal rotation. If you apply internal rotation, then the fracture fragments can ‘lock’ together and it introduces valgus as the traction is applied.

The fracture reduction is checked on the lateral II view.To orientate yourself, the ischium is posterior to the acetabulum (marked A).
My top tip is to ask the radiographer to rotate the image so that the traction post is vertical and matches its’ normal orientation (C). This will help you determine whether the femoral neck is anteverted or retroverted.
When it comes to inserting your guide wire, you will then know whether you need to raise your hand and direct the wire inferiorly / posteriorly (retroverted neck) or lower your hand and direct the wire superiorly / anteriorly (anteverted neck).
Note in this case the femoral neck fracture has been reduced and the femoral neck is retroverted (in relation to the traction post). Also note that the Greater Trochanter is a separate fragment to the diaphysis (marked B)

The leg is prepped with alcoholic chlorhexidine.
The prep is applied from the iliac crest to below the knee. I like to use both a dark pink stained solution of prep followed by a lighter stained solution. I use the contrast in the colours of the solutions to allow me to see that the whole surgical field has been painted with two coats of antiseptic. Also the lighter pink solution washes off the darker solution colouring.
The most important step when prepping any surgical field, is to give the prep sufficient time to evaporate. This is so that it has:
Sterilised the field
Not pooled and created a fire risk
Allows the surgical drapes to ‘stick / adhere’ better to the patient and not be dislodged when the C-arm rotates to take the images.

For a long femoral nail, the nail length is measured with the radiographic ruler and the image intensifier.The ruler is first placed over the tip of the greater trochanter and an II image is obtained. I use either clips or Kocher forceps to hold the ruler and keep my hands out of the II field.

An AP II image of the hip / proximal femur is obtained first with the ruler overlying it.It should be noted where the oblique holes on the ruler would position the helical blade in the femoral head. If necessary, a different angle nail could be used (ranging from 125 degrees to 135 degrees). It is possible to pass a 3.2mm wire through the ruler to simulate the path of the helical blade into the head but I find I can usually envisage it.
Once you are happy that the tip of the ruler overlies the tip of the trochanter, then I would recommend that you mark the skin with a marker pen to record this position.

The C-arm is moved down toward the knee and an AP image of the distal femur / knee is obtained showing the radiographic ruler.The tip of the nail should be at or just proximal to the physeal scar. To ensure an accurate measurement, the fracture must be reduced and the ruler should be aligned with the femur. If the ruler slips or moves during any adjustment, then the skin mark made in the previous step can be used to correctly re-position the proximal end of the ruler without needing to take any further x-rays or go back a step.
Once satisfied that the correct length has been identified, I ask for these diameter nails to be brought into theatre e.g. 10mm x 360mm, 11mm x 360mm
It is possible to measure the canal diameter, by overlaying the radiographic ruler at the level of the isthmus. However, due to the magnification effect from the II and the distance of the ruler from the patient’s bone, I find these estimates to be unreliable. I therefore use the sound and feel of the reamer against the isthmus to help guide what diameter nail to insert.

To identify where to place the entry skin incision, the anterior and posterior aspect of the greater trochanter are palpated.Using a pinch technique between the thumb and index finger is more reliable and helps to ‘fix’ the skin to the bone. If you palpate the anterior aspect and then move to palpate the posterior aspect, the skin moves with you. If you were to draw on the skin and mark it, it would be in the wrong place as the skin has moved.

The proximal extent of the nail entry incision is identified with the C-arm.A radio-opaque instrument is held gently against the skin and the C-arm is moved both proximally and laterally to give a supero-lateral AP view of the hip. Here the tip of the instrument can be viewed in relation to the greater trochanter and the anatomical axis of the femur.

An oblique entry incision is made in the skin, at the tip of the greater trochanter.I prefer to make an oblique incision, as this allows two degrees of freedom, should the incision not be correctly placed. Typically the incision is too anterior which fails to account for the anterior bow of the femur. When the nail is inserted, the skin can be badly distorted and damaged during nail insertion. This can predispose to wound breakdown or infection.
The obliquity runs anterior-distal to posterior-proximal, this is so that if the fixation ever needs to be revised, it can easily be converted into a curved hip incision. A standard horizontal incision which a lot of surgeon’s use, I feel doesn’t facilitate any future approaches should they be required.

The hip abductors are split in line with their muscle fibres.Although the incision is oblique, once through the subcutaneous fat and down to the abductors, the greater trochanter can be palpated and the scissors can be used to bluntly split the abductors.

The surgeon’s finger is used to sweep any muscle or tissue out of the way and palpate the greater trochanter.The surgeon should also note whether the aperture created within the abductors is sufficient to accommodate the tissue protector. If not, it needs to be increased.

The entry 3.2mm guide wire is inserted under II guidance.I prefer to use a guide wire versus other instruments such as the Shepherd’s crook trochar for creating the entry hole. I find that if the trochar has initially been placed in the wrong position, it is often very difficult to create a new entry hole without falling back into the previous location.
Also perhaps paradoxically I find inserting the 3.2mm guide wire using the power tool is actually more controlled than using a handheld instrument such as a T-handle. With the handheld instrument, in hard bone it is very easy to ‘slip’ and overshoot. Whereas with the power tool, the amount of force required to advance the wire is much more controlled.

The ideal entry point for the 3.2mm guide wire is 5 degrees lateral to the anatomical axis on the AP view.
The tip of the wire should look like it is on the very top of the mountain i.e. not just below it. This means that the entry point should be correctly aligned with the middle of the femur on the lateral view.

Once you are satisfied the wire position is correct, it is advanced to the level of the lesser trochanter and aiming for the middle of the femoral canal. Any impingement on the medial aspect of the femoral neck should be avoided, so that it doesn’t perforate medially or mis-direct the opening reamer.

A lateral II view is obtained to ascertain the wire entry point and also the wire trajectory towards the medullary cavity.
Here it can be seen that the entry point is incorrect – it is too posterior and doesn’t align with the middle of the femoral neck. Also the trajectory is wrong and is aimed too posteriorly toward the posterior cortex of the femur.

Needing to adjust the guide wire for the opening reamer is a common step in the operation and should not be viewed as a mistake. It is important that this step is not rushed as it greatly influences the rest of the operation.
To help reposition the wire, the manufacturer includes a multi-hole drill sleeve on the set. It is an inner sleeve that slots into the reamer protection tube. The holes marked 6 and 4 respectively will allow 6mm and 4mm of translation from the central hole. If you want to move the wire by 10mm (6 + 4 = 10mm), then the original wire can be placed through either the 6 or 4 hole and then the new wire can be placed through the corresponding 4 or 6 hole.
If translation is only required in the lateral plane, then the handle is held parallel with the floor. If you want to translate on both the AP and lateral view, then it can be rotated (internally to increase medial translation or externally to increase lateral translation). As this is a vector movement, the amount of lateral translation will decrease slightly.

The reamer protection tube is inserted with the inner sleeve over the original wire to allow a second wire to be repositioned.In this case, I had inserted the reamer protection tube and multi-hole drill sleeve over the original wire using hole 6 and then inserted the new second wire through hole 4. This gave 10mm of anterior translation.

The entry position is satisfactory on the AP view, so no rotation of the reamer protection tube handle is required and it is held parallel with the floor.

The lateral II view demonstrates that the original wire has been removed and the new second wire has the correct entry point in the greater trochanter and the wire trajectory is correctly aligned with the femoral canal diaphysis.

The inner sleeve is removed from the reamer protection tube.This allows the reamer protection tube to freely rotate and also if not held, it can fall on the floor, so this is to be avoided.

The proximal femur is opened with the cannulated 16mm flexible drill bit.The drill bit is passed over the 3.2mm guide wire and through the reamer protection tube. The reamer protection tube must be against the bone, as the drill bit should be advanced until the drill stop hits the protection tube.
Although the drill bit is flexible, it is being passed over a fairly rigid 3.2mm guide, so it is important to direct the flexible drill bit accordingly and avoid notching or perforating the proximal femur.
In highly comminuted proximal femurs or those with advanced osteoporosis, it is possible to insert the flexible drill using reverse. This allows a slightly gentler advancement of the drill bit without binding on any fragments and causing them to further fragment or displace.

The ball nosed guide wire is inserted using the T-handle, flexible shaft and angled reduction head.This helps to control the wire direction and position within the femur. It is also useful in displaced diaphyseal fractures, as it can help with the reduction and passage of the wire.
I like to orientate the T-handle with the angled reduction head, so that I know which direction it is pointing and then I can work out which way to rotate it, to redirect it.

The reamer protection tube can accommodate a reamer head size up to 16 mm. If the skin is taught and pressing up against the flexible reamer shaft, then I will use it as I don’t want to cause a friction burn on the skin. However, in this case the skin incision was satisfactorily placed and I always ensure that the reamer head is only spinning when safely within the bone, so chose not to use it.

Due to the shape of the proximal femur and isthmus, the ball nosed guide wire will routinely want to pass to the medial aspect of the distal femur.
In diaphyseal or distal third fractures I will use advanced techniques such as blocking wires or screws (Poller technique) to help direct the ball nosed wire to the desired position.

In the lateral view (this is actually an oblique view of the distal femur, as it saves having to change the orientation of the C-arm), the ball nosed guide wire commonly rests up against the anterior aspect of the distal femur. Again in diaphyseal or distal third cases, I will take the necessary steps to redirect this. In patients with neck of femur fractures and associated osteoporosis, it is only necessary to ream the isthmus, as the distal third is usually capacious and the nail will find its’ correct path (which is determined by the proximal femur entry point, the femoral isthmus and the shape of the nail).

The femoral canal is reamed using the Synream system.Once the reamer has been passed down to the end of the ball nosed wire, an II image can be used to confirm this. My recommendation is that you make a mental note of how much of the flexible reaming shaft is still visible outside the patient. You then know exactly how far to advance the reamer without needing to take additional II images each time you increase the reamer head size and pass it down the femur.

When extracting the reamer, it is imperative that the head is stopped from spinning prior to exiting the proximal femur. The proximal femur already has a 16mm diameter hole in it, so it isn’t necessary to ream this bit. Also it can cause damage to the soft tissues and skin.
The ball nosed guide wire should be held with an instrument to prevent it from coming out of the femur while the reamer is extracted, using either a clip, Kocher or wire holding forceps. Alternatively the rod pusher can be passed through the cannulated power tool but I often find that due to the length of the wire, you would be outside the sterile field or laminar airflow hood.

Once sufficient ‘chatter’ or resistance is felt as the reamer passes through the isthmus, I take an II image to help determine the correct nail diameter.The femoral canal should be reamed to 1.5mm greater diameter than the desired femoral nail. At this point, I routinely pass the final reamer up and down the canal a couple of times to ensure that any residual bone swarf is safely removed and won’t impede the nail insertion.

The femoral nail is connected to the insertion handle.The nail has been designed to allow it to be correctly orientated with the insertion handle (note the two notches at the top of the nail). Also the handle has a push fit connection with the nail which prevents it from malaligning with the jig and makes it easier to correctly insert the connecting bolt without cross threading it.

On this view, you can see that at the top of the nail, there is only a single notch that matches with the insertion handle.

The connecting screw ‘snaps’ on to the 8mm spherical head hexagonal screwdriver and reduces the risk of accidentally dropping it.

The aiming arm is connected to the insertion handle and then the guide sleeve with the buttress / compression nut is inserted through the aiming arm and attached to it.The guide sleeve has a flat side which should be orientated correctly with the aiming arm. The hole through the aiming arm is ‘D’ shaped and the flat surfaces correspond with one another. The buttress / compression nut clicks into the aiming arm when it has been correctly orientated and advanced sufficiently.

The drill sleeve is inserted into the guide sleeve and the nail / jig alignment is checked by passing a 3.2mm guide wire through the nail.The wire should pass centrally through the nail hole and not touch the nail at all.
If using a short nail, then the static / dynamic locking bolt hole alignment should also be checked using the:
11.0mm/8.0mm protection sleeve
8.0mm/4.2mm drill sleeve (marked green)
4.2mm calibrated drill bit (marked green)

The aiming arm is removed from the insertion handle and the nail is inserted into the patient.

The driving cap with thread (A) is screwed into the insertion handle and with gentle hammer blows, the nail is advanced into the femoral canal.It is important to use controlled force and not become impatient and advanced the nail too quickly. Often if the nail is not advancing, then there is something that needs to be identified and addressed. Hitting the driving cap harder is not the answer and can result in an iatrogenic fracture or perforation of the femur.
Finally please remember that the nail is curved like a banana so ‘wiggling’ it to try and get it to advance should be avoided as it damages the internal medullary mantle and may displace the fracture reduction.

Once the nail is past the isthmus, and only in proximal femoral fractures, I pull back the ball nosed guide wire. The nails’ path is dictated by the entry hole in the proximal femur and the isthmus and its’ shape. If you don’t pull the wire back, it can sometimes bend or impede the nail from advancing (remember that it was sitting medial and anterior).

An AP II view of the hip is used to determine the correct depth of the nail insertion.The guide wire will pass parallel and centrally through the lag screw / blade hole and follow this trajectory into the femoral head. The guide wire should be positioned centrally on both the AP and Lateral views.
It is better to advance the nail slowly with gentle controlled hammer blows to achieve the correct positioning. If you advance it too far, then you have to perform an additional step and connect the hammer guide to the driving cap and then back slap it with the combined hammer.
Finally check the top of the nail to ensure that it isn’t too prominent in relation to the greater trochanter. If necessary it can be advanced slightly further so that the nail isn’t prominent and the screw / blade will be in the lower half of the femoral head.

The aiming arm and guide sleeve with the buttress / compression nut are connected and advanced up to the skin surface. A small incision is made in the skin and I use a pair of curved scissors to puncture and split the fascia lata and create a path down to the lateral cortex of the femur.Importantly the neck version needs to be taken into account so that the incision is positioned correctly. If it isn’t then the soft tissues can distort the jig when the assembly is rotated to achieve the desired head position for the guide wire on the lateral II image. This therefore can cause the guide wire / blade to miss the nail.
I use curved scissors as when these are passed superiorly over the aiming arm, the curve maintains a horizontal path towards the femur and the jig doesn’t have to be moved out of the way (for the purposes of this photo, we have moved the jig to demonstrate this). Also the scissors should be directed proximally in the direction of the guide sleeve.

The buttress / compression nut is used to advance the guide sleeve down to the bone.On the nut there are markings which demonstrate which way to turn the nut so that the guide sleeve advances.
The drill sleeve and trochar should also be inserted to allow the soft tissues to be safely displaced as the guide sleeve advances.

The guide sleeve is advanced until it just makes contact with the lateral cortex of the proximal femur.An II image will confirm satisfactory positioning.
As the sleeve comes into contact with the lateral cortex, you will see the trochar and drill sleeve pushed backwards out of the protection sleeve by a few millimetres.

The trochar is removed and a 3.2mm threaded guide wire is inserted into the drill sleeve using the wire driver.It is important to have accounted for the femoral neck version when siting the skin incision, as it won’t allow too much movement and can bend the jig preventing the wire from passing correctly through the nail.

The 3.2mm guide wire is passed half way up the neck before checking the position with an AP II image.The wire should be passing centrally (or slightly inferiorly) in the femoral neck.

The 3.2mm guide wire position is checked on a lateral II image.Here it can be seen that if the same trajectory was continued, the wire would be too anterior within the femoral head.
To adjust this, you must bring the wire back all the way to the lateral cortex, make a jig adjustment and then advance it again.
My top tip is to advance the wire on reverse, this is because of the thread on the wire tip. This normally causes the wire to advance quickly and often it takes the path of least resistance and falls back into the previously drilled channel. By using reverse, the thread is de-functioned and the wire acts more like a K-wire and is easier to re-direct.

Here the wire can be seen to be more centrally positioned within the femoral head.

Once satisfied with the wire position on both the AP and lateral II image, it is important to obtain an AP image. This is so that when you measure the wire, you know the distance from the tip of the wire to the edge of the femoral head and also you know how close the guide sleeve is to the edge of the lateral cortex. These positions will influence what length of screw / blade you select.
The manufactures surgical technique recommends that the blade tip is 10mm from the edge of the femoral head. This should not be confused with tip-apex distance which is used in a Dynamic Hip Screw. The blade works differently and having an increased distance lowers your risk of cut-out and cut-through.
Cut-out is superior migration through the femoral head and cut-through is medial perforation of the femoral head.

The guide wire for the blade implant is measured using the direct measuring device.This passes over the guide wire and sits down on to the guide sleeve. The measurement is read off the measuring device but may need to be adjusted depending on the position of the 3.2mm guide wire in the femoral head and also the relationship of the guide sleeve to the proximal femur.

The drill sleeve is removed from the guide sleeve and the drill bit for lateral cortex opening is advanced until it stops.If the patient has good quality bone, then the stepped reamer for the TFNA helical blade and screw can be used to remove some more bone. In general for most osteoporotic insufficiency fractures this will not be required.

The helical blade is connected to the TFNA helical blade impactor using the connecting screw.The blade and the impactor both have an oblique slope that should match one another (see photo). These should be pushed together and then the connecting screw is inserted and tightened.

The blade is inserted into the guide sleeve and importantly the markings on the impactor have to be correctly aligned with the markings on the hilt of the guide sleeve.There is a red mark on the guide sleeve hilt (marked A) and there is a corresponding red mark on the shaft of the impactor (marked B). These must be aligned.

The blade is advanced with gentle hammer blows on the impactor.The impactor should be advanced initially by hand until it stops. There are some ball bearings on the side of the impactor shaft that engage with grooves on the inner aspect of the guide sleeve. These cause the blade to automatically rotate as the blade advances.

The impactor will reach a positive stop when it comes into contact with the guide sleeve.It is important to get to this position, as this correctly orientates the oblique bevel at the base of the blade with the lateral cortex. Also the blade has a groove on it, which is then captured by the internal nail locking mechanism. If it isn’t correctly orientated, the blade / femoral head could rotate in relation to the femoral nail.

An II image is taken to confirm a satisfactory position of the blade within the femoral neck.Things to look for:
Tip of the blade (not too close to the edge of the femoral head)
Base of the blade (should be at the level of the lateral cortex)
Blade should pass congruently through the nail
The fracture should not be distracted (if it is, the compression nut can be turned to close the gap however the blade / screw must be locked to prevent rotation).

A lateral II image confirms a satisfactory placement with no over-distraction of the fracture.

The 5.0mm flexible hexagonal screwdriver is used to engage the internal nail locking mechanism with the blade and prevent blade rotation.This is introduced proximally and needs an assertive push to get it to engage properly with the mechanism within the nail. It takes about 20 rotations to fully engage the locking mechanism with the blade. If you want to statically lock the blade, then you can swap the flexible screwdriver and use the torque driver. However, to allow the blade to collapse dynamically then once it has stopped rotating clockwise, you turn the screwdriver 180 degrees counter-clockwise. This maintains the blades rotation but allows it slide dynamically.
In osteoporotic patients with hip fractures, I would lock the blade dynamically. The risk with locking the blade statically, is that the implant is stronger than the native bone and can fail by cut-out or cut-through.

Occasionally if you have been turning the flexible screwdriver for some time and it hasn’t stopped turning, it may be that you haven’t engaged the screwdriver correctly into the locking mechanism. This is usually caused by the shoulder of the screwdriver catching on the insertion handle preventing it from advancing fully. The II image demonstrates this problem (marked A).

After adjustment of the flexible screwdriver it has advanced and is now correctly aligned with the nail and fully submerged into it.

Once the blade is secure, the next step is to perform the distal locking.The C-arm is moved into position and I like to stick an adhesive edged sterile drape to the bottom of the leg and cover the C-arm with it.

One of the key steps during the patient / table setup is to ensure that the gas strut from the contralateral leg boot/support doesn’t prevent the C-arm from getting into the correct position to obtain a satisfactory image of the distal locking bolt holes.
This often means putting the mounting bracket at the top of the runner. Commonly most surgeons and theatre staff place it at the bottom of the runner.

The C-arm is lined up to obtain perfectly round circles of the distal locking bolt holes.If you have an ellipse which is narrow side-to-side, then horizontal plane adjustment is required. This means the angle that the C-arm is in relation to the leg needs to be adjusted.
If you have an ellipse which is narrow top-to-bottom, then vertical plane adjustment is required. This means that the C-arm needs to rotate around the leg.
Horizontal movement of the machine base or vertical movement of the C-arm will only adjust the position of the hole on the image.
To magnify the image, then move the C-arm emitter closer to the leg. Also there is button on most machines for image magnification, just remember that when magnified the movements need to less.

The skin incision for the distal locking bolts is made by using the C-arm to accurately position the blade over the hole.I find it essential to have the image correctly orientated, so that when I move my hand up / down or left / right, it matches the image.
I only incise the skin and deep dermis. I prefer to use a pair of McIndoe scissors to bluntly perforate the ilio-tibial band and clear a path to the bone. I’ve seen it a few times where a geniculate artery has been inadvertently injured and the incision has to be extended to obtain haemostasis.

The short 4.2mm drill bit is placed on the bone lateral cortex and the II image is used to make fine adjustments so that it concentrically overlies the locking bolt hole.Initially the drill is placed at an angle so that the power tool is not obstructing the C-arm image. Once satisfied that it is in the correct position, the power tool is lowered until it aligns with an imaginary x-ray beam. Alternatively you can aim for the centre of the C-arm detector. At this point when you are ready to drill, push the drill bit into the bone so that the spike on the tip makes a notch and then doesn’t skid off when you start drilling.

Once through the first cortex, you will either fall into the nail hole and be able to drill the far cortex or you may hit the nail. If you hit the nail, don’t panic! Just stop drilling, otherwise you may damage the implant or the drill bit.
Uncouple the drill bit from the power tool and take an x-ray.
You need to determine what is happening. Is the drill going posterior or anterior to the nail or is it correctly aligned with nail but is slightly too proximal or distal in relation to the locking bolt hole?
If the drill bit tip is more than 50% overlying the locking bolt hole, then this can be salvaged. If you hold the drill bit with a Kocher forceps, you can angle it towards the hole under II guidance. Once it is aligned, with very gently taps from the hammer, it can be advanced into and through the nail locking bolt hole. Once in the correct position, the power tool can be re-connected and the far cortex drilled. This step needs great care, as it is very easy to snap the drill bit if being too optimistic. If you have any doubt, then it is better to re-start the step.

An II image is used to confirm that the drill bit goes through the nail locking bolt hole and isn’t lying either anteriorly or posteriorly to the nail. If the drill bit is passing through the hole at a slight angle, then a Kocher forcep can be used to manipulate it, so that this image can be achieved i.e. the drill bit isn’t seen either anteriorly or posteriorly in relation to the nail.

The distal locking bolt length is measured using the depth gauge.It often takes a couple of attempts to measure and re-measure the depth. Sometimes the body of the depth gauge gets caught on the ilio-tibial band and therefore the measurement is incorrect. When measuring, it’s better to add a couple of millimetres and be safely through the far cortex. However, the closer you get to the knee and the metaphyseal flare, the screws become more subcutaneous and are less well tolerated by the patients.

The distal locking bolt is inserted with the T25 stardrive screwdriver.It is important to hold the locking bolt and the screwdriver and gently feel for the hole in the lateral cortex. Once you have located this, then the screwdriver should be aligned in the same trajectory that the hole was drilled. A gentle but constant pressure prevents the locking bolt from slipping off the screwdriver.
If there is significant soft tissue and you are worried about losing the locking bolt, then a suture lasso can be created with an absorbable suture. Keeping this under constant tension will prevent the locking bolt from slipping off the screwdriver.

An II image confirms that the distal locking bolt has been correctly sited through the distal locking bolt hole.

The process is repeated for the second distal locking bolt.
Although the nail is now rotationally stable, I do not feel that one distal locking bolt is sufficient, as the majority of the patient’s body weight will be on this one locking bolt. If it fails and breaks, then the fracture is no longer stable and the reduction will be lost.

The second distal locking bolt is placed at the superior aspect of the oblique hole, so that it is the static position.This means that it is load sharing with the other locking bolt. If it is further down the hole, then it will only load share in rotation (or until the first locking bolt fails).

Sometimes the locking bolts need to be advanced a bit further. It is better to be gentle with their insertion, versus embedding the locking bolt into the lateral cortex or worse still down to the implant.

The insertion handle and connecting bolt are removed using the ball hexagonal screwdriver once all distal locking has been completed.An end cap could be inserted at this stage. There are two methods; either through the insertion handle (once the connecting bolt has been removed), or over a guide wire.
Personally I only use end caps if the nail is significantly submerged within the bone and future removal may be challenging.

The wounds are irrigated with saline to remove any haematoma.
Any remaining haematoma may create a nutrient rich environment to develop a post-operative wound infection.

Final x-rays are taken AP lateral of the whole implant.This image demonstrates a satisfactory fracture reduction and implant position within the femoral head.

A lateral image of the hip shows that the fracture is reduced well and the implant position is satisfactory.

This image has been taken to demonstrate the anterior bow of the implant in relation to the femur’s normal curvature. It would not be possible to start the entry point any further posterior as the flare on the nail is already touching the posterior cortex, so it’s important when inserting the initial guide wire to ensure that you have the optimum position.

The wounds are closed with absorbable sutures.
Self-adhesive dressings are applied to cover the wounds.