Treatment with Locking Intramedullary Nailing for Intertrochanteric Fracture of the Femur Utilizing a New Awl with a Distal Positioner

Summary

Here, we present a protocol for accessing the guidewire of intramedullary femoral nailing in obese patients using an in-house designed awl. Using the new awl with a distal positioner for the guidewire insertion and opening the bone can increase efficiency in inserting the guidewire and reduce the difficulty of surgery.

Abstract

Interlocked intramedullary nailing is now established as the preferred method of managing femoral intertrochanteric fractures. Choosing the ideal entry point and inserting the guidewire accurately are key steps of the procedure. Several factors make the procedure more challenging, such as the supine position, obese patients, and the tip of the trochanter not aligning co-linear with the anatomic axis of the femoral medullary canal in the frontal plane. Our team has developed a new awl with a distal positioner that assists the guidewire insertion and entry portal of femurs. This comparative study analyzed 40 intertrochanteric fracture cases treated with locking intramedullary nailing, which were randomized to receive either the new awl incorporating a distal positioner (n = 20) or the conventional guide apparatus (n = 20). Operation time, blood loss, the success rate of the one-time insertion, radiation times, and bone healing time were recorded. The patients (21 males and 19 females) were treated with Gamma 3 and proximal femur nail antirotation (PFNA) with the help of the new awl with a distal positioner or conventional guide apparatus. There were no transoperative complications in the two groups. The surgical time in the new guide apparatus group was significantly shorter compared to the control group. The new awl group achieved a 100% success rate for one-time needle insertion, surpassing the control group's rate of 66.7%. The fluoroscopy time required for the new awl group was obviously shorter compared to that of the control group. However, no significant differences were observed in terms of intraoperative blood loss or bone healing time between the two groups. The newly designed guide awl with a distal positioner could reduce the difficulty in opening the femur for inserting the interlocked intramedullary nail. This tool is especially suitable for obese patients.

Introduction

Epidemiologic studies of hip fractures reported that the number of hip fractures has probably increased significantly in recent years¹. Intertrochanteric fracture of the femur as a common hip fracture represents about 31%-35% of all hip fractures². Interlocked intramedullary nailing is now established as the preferred method of managing femoral intertrochanteric fractures, offering superior biomechanical stability compared to extramedullary fixation systems. The proximal femoral nail anti-rotation (PFNA) from Depuy Synthes and Gamma 3 Nail System from Stryker are both commonly used for the treatment of intertrochanteric ....

Protocol

The clinical application of this new apparatus has been approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology. The newly designed guide apparatus is shown in Figure 1. The guide apparatus consists of several parts, including an excellent grip handle, a cannulated curved awl that can insert a 3 mm guidewire, a hammering point, and the distal positioner. The guidewire passing through the awl will deviate 15°-20° to the lateral of the trunk, increasing the operating space.

1. Preparation

1. Patient position: ....

Results

Cohort demographics
Between June 2020 and February 2023, 40 patients (21 males and 19 females) with a mean age of 52 years (range 20-63) were admitted to Tongji Hospital with intertrochanteric femur fractures. The patients were treated with locking intramedullary nailing with the help of a newly designed guide apparatus or conventional guide apparatus. Based on the guide apparatus used during the operation, the patients were divided into two groups: the control group (n = 20) and the new guide appara.......

Discussion

The intertrochanteric of the femur is an important pillar for weight bearing through the skeletal system. The area is prone to fractures due to high-level trauma in the young and trivial trauma in the elderly. The principle in the management of intertrochanteric fractures is a good reduction and strong internal fixation. The options contain extramedullary and intramedullary fixation^6,7. For stable intertrochanteric fractures, both fixation devices benefited the p.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Awl with a distal positioner	In house	N/A	The awl is to guide wire insertion and open the femoral bone.
Gamma3 system	Stryker	603611	The Gamma3 System is intended to achieve functionally stable osteosyntheses and stabilization of bones and bone fragments
Hip joint surgical instrument set	Shanghai Jinzhong Surgical Instruments Co., Ltd.	P24020	The hip joint surgical instrument set is to facilitate surgical procedures involving locked intramedullary nailing for the treatment of intertrochanteric femoral fractures.
Image intensifier (G-arm)	Swemac imaging	04-7100020A	The image intensifier (G-arm) is to obtain both anterior-posterior and lateral projections.
Iodine povidone	Wuhan Operation Fine Chemical Co.,Ltd	WYH001	Iodine povidone is to disinfect the surgical field.
PFNA	DePuy Synthes	04.045.870S	PFNA permits an intramedullary approach for the fixation of fractures of the femur.