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髖關(guān)節(jié)置換-Theseimagesdemonstrateadistalfemoralshaftfractureoccurringfromblunttrauma.髖關(guān)節(jié)置換-Beforeperformingantegradefemoralnailing,ahigh-qualityAPradiographofthehipisnecessarytoruleoutoccultfemoralneckfracture.髖關(guān)節(jié)置換-ManypatientswithfemoralshaftinjurieshaveCTscansperformedtoruleoutintraabdominalinjury.TheCTscancutsthroughthefemoralneckshouldalsobereviewedtoruleoutfracture.髖關(guān)節(jié)置換-Lateraldecubituspositionispreferredforantegradefemoralnailinginthepatientwithnormalpulmonarystatusandnospineorpelvicinjury.Theaffectedlegisflexed,exposingthepiriformisfossawithoutstericinterferencefromthepatient’storso.髖關(guān)節(jié)置換-Thedownsidelegiswellsupportedandpaddedtoavoidneuropraxia.Thesurgeonispointingtothestartingpointforthepiriformisentrypoint.髖關(guān)節(jié)置換-Viewoftheareathatispreppedoutforperformingthenailing.髖關(guān)節(jié)置換-PIRIFORMISFOSSAThepiriformisfossaentryportalisdirectlyinlinewiththecanaloftheshaft.However,itisslightlyposteriortothefemoralneck.Itiscurvilinearandangledposteriorly.髖關(guān)節(jié)置換-Becausethepiriformisentryportalisonaslopedsurface,astraightawlmustbeintroducedfirstatanangletothefemoralshaftdirectlyanteriorly…12髖關(guān)節(jié)置換-…andthenasit’sintroduced,thehandisraiseduptogoinlinewiththefemoralshaft.髖關(guān)節(jié)置換-1cmTheskinincision,whichcanbeapproximately1to1-1/2cminlength,shouldbemadeatadistanceawayfromthepiriformisfossatoallowfordirectentryintothefossa.Thiscanbebestestimatedbylooking髖關(guān)節(jié)置換-1cmattheAPradiographtodeterminehowproximaltheincisionneedstobewithrespecttothetrochanter.Theheavierthepatient,themoreproximalinthebuttockstheincisionneedstobeinordertobeinlinewiththefemoralshaft.髖關(guān)節(jié)置換-ThefasciaoftheTensorfasciaLatamuscleisdivided,exposingsomeofthemusculature.髖關(guān)節(jié)置換-Theperfectlateralradiographofthehipdemonstratesthenecktobecolinearwiththeshaftandslightlyanteriortoit.Thepiriformisfossaiseasiervisualized.髖關(guān)節(jié)置換-Thestraightawlisintroducedthroughtheincision,thengentlyplacedagainstthepiriformisfossadirectedanteriorly.髖關(guān)節(jié)置換-Theawlisintroducedintothefemoralcanal;asitentersthebone,theawlisadjustedtobeinlinewiththefemoralshaftbymovingthehandandawlanteriorly.髖關(guān)節(jié)置換-Theawlisintroducedintothefemoralcanal;asitentersthebone,theawlisadjustedtobeinlinewiththefemoralshaftbymovingthehandandawlanteriorly.髖關(guān)節(jié)置換-Oncetheawlhasbeenintroducedgently,itistappeddownpastthecalcartoallowforeasypassageoftheguidewire.髖關(guān)節(jié)置換-Oncetheawlhasbeenintroducedgently,itistappeddownpastthecalcartoallowforeasypassageoftheguidewire.髖關(guān)節(jié)置換-Theguidewireshouldhaveagentledistalbendtoalloweasypassageacrossthefracturesite.Theguidewireisintroduceddownthefemoralshaft..髖關(guān)節(jié)置換-Asofttissueprotectorcanbeusedtominimizemuscleinjuryproximally.髖關(guān)節(jié)置換-Theguidewireisadvanceddownthecanal.Notethecolinearityoftheentrypointwiththecenteroftheshaft.髖關(guān)節(jié)置換-Theguidewireisintroducedtothelevelofthefracture.髖關(guān)節(jié)置換-ThefractureisreducedandtheguidewireispassedacrossanddistallyuntilitisjustshyoftheepiphysealscarinthecenterofthefemurontheAPradiograph.Thisisparticularlyimportantfordistalfractures.髖關(guān)節(jié)置換-Oncetheguidewireisfullyintroduced,lengthmaybemeasuredinmanyways.Whilesomesystemshavejigstomeasurelength,afoolproofsystemistomeasurearesidualofaguidewireofthesamelength.髖關(guān)節(jié)置換-Theaboveimagedemonstratesasecondguidewireofthesamelengthintroducedtothelevelofthetrochanter.髖關(guān)節(jié)置換-AKocherclampisplacedontheguidewiresothattheresidualcanbedirectlymeasured.髖關(guān)節(jié)置換-Measuringtheresidualfromthisguidewirewillgiveanexactmeasurementofthelongestnailthatispossibleforthispatient.Aftermeasurementisobtained,thefemoralcanalisreamed.髖關(guān)節(jié)置換-Thereamerintroducedthroughthestabincisionandthesoft-tissueprotectorusedtoprotectthemusculature.髖關(guān)節(jié)置換-Afterreamingiscomplete,theappropriatesizenailischosen.Beforethenailisinserted,aswithanynailingprocedure,theproximaljigneedstobecheckedforappropriatealignmentofthelockingmechanism.髖關(guān)節(jié)置換-Anexchangetubeisplacedovertheball-tipguidewire,whichisthenremoved.Astraightguidewireisthenplacedthroughtheexchangetube,whichisthenremoved,allowingforplacementofthenailoverthestraightguidewire.髖關(guān)節(jié)置換-Thenailisgentlytappeddownthecanal.Anysignificantresistancewarrantsbiplanarradiographicconfirmationofappropriatepositionofboththeguidewireandthenail,aswellasareasofthefemoralneckforpossiblefracture.髖關(guān)節(jié)置換-Afterthenailisappropriatelyseated,withthejigatthelevelofthegreatertrochanter,theproximaljigisusedtolockthenail.Distallockingisgenerallyperformedusingafreehandtechniqueviaperfectcircles.髖關(guān)節(jié)置換-髖關(guān)節(jié)置換-髖關(guān)節(jié)置換-髖關(guān)節(jié)置換-TheaboveimagedemonstratestheC-arminapositiontoviewaperfectcircle.髖關(guān)節(jié)置換-Thisimageshowsthe

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