Carbon Fiber Implant for Fixation of a Pathologic Subtrochanteric Fracture

CHAPTER 1

My name is Santiago Lozano. I'm an orthopedic oncologist at the Massachusetts General Hospital in Boston, Massachusetts. Thank you for taking the time to review the next video for the surgical technique using carbon fiber implants for fixation of a pathologic subtrochanteric fracture. The following video will describe the surgical technique for the trochanteric entry femoral nail made of carbon fiber as mentioned. The case is a female patient, 63-year-old, that presented with a pathologic fracture of the right subtrochanteric area of the femur. The patient was simply standing when she sustained the fracture, and during the workup, a CT scan of the chest demonstrated a large tumor that was consistent with the primary tumor of the patient. It was decided to take the patient for fixation of this fracture with an intramedullary nail trochanteric entry made of carbon fiber in addition to an open biopsy to typify her metastatic adenocarcinoma. This procedure is going to be performed in the lateral position with the assistance of a bean bag and a flat Jackson table. All the bone prominences of the patient will be protected, and the subaxiliary role will be used to protect and prevent the occurrence of neuropraxia. The left common peroneal nerve will be also offloaded with the assistance of supportive forms. An initial approach to perform the biopsy will be performed. This will be a straight lateral approach to the proximal femur through a subvastus approach. Samples will be taken with a curette, and samples will be sent for frozen and permanent pathology. Once a diagnosis of a metastatic adenocarcinoma is confirmed histopathologically, we will proceed with a second incision in order to access the proximal femur and insert in a progressive manner the carbon femoral nail rod. The steps for the surgery are the same of a traditional metallic rod. The starting point is identified in the AP and lateral views with the assistance of fluoroscopy. Once that wire is advanced and excellent position is confirming those two views, an opening reamer is used to access the proximal femur. It is my preference for subtrochanteric fractures to use the finger tool for the reduction. In most of these cases, I use a coaxial linear clamp for reduction. But because of the patient's poor bone quality, I will use either Schanz pins or K-wires to control the proximal and distal piece. The use of bone hooks or other clamps sometimes is limited because of the poor quality of the bone. Once we have the fracture reduced, we'll proceed to do sequential reaming after advancing a ball-tip guidewire. This sequential reaming will be one and a half size above the diameter of the desired nail. Before the reaming, we'll measure the length of the nail being sure that we have the fracture out to length. The carbon fiber implant has a narrow light inside because of biomechanical purposes. This lumen doesn't allow the passage of a ball-tip guidewire. Therefore, it's important to remember that one of the steps of this surgical technique is to exchange the ball-tip guidewire that's been used for the reaming to prevent the loosening of the sequential reamers, but then change to a smooth wire to be able to insert the nail and remove the wire with no difficulty. In this surgical technique, we will see how this step is performed using an exchange tube. Once the fracture is reduced and the carbon fiber rod is in place, we'll proceed to use the aiming arm and through the same incision, we'll use the triple trocar to access the proximal femur and insert the guidewire for the femoral neck trajectory for the femoral neck screw. We'll use a triple reamer after measuring the length of the screw. Ultimately, we'll advance the screw in the femoral neck after confirming excellent position in the AP and lateral views under fluoroscopy of the guidewire as well as of the screw. And then we will set up the screw with setting a screw that is inserted proximally on the femoral nail. At the end, confirming a good AP and lateral of the hip and a good AP and lateral of the knee, we'll proceed to block the distal portion of the nail using the perfect circle technique, which has a modification in the carbon fiber rod. In this type of implant, instead of a circle, what it is visualized is four dots in the AP view that get aligned to become two dots on the lateral view. Placing the drill in between those two dots will access the hole where the screws will go for blocking. Once the nail is blocked, we'll take shots with fluoroscopy to confirm excellent position of the components. We'll irrigate copiously the surgical field. My preference is to use peroxide solution in order to mitigate the amount of tumoral cells after the open biopsy and the reaming. And we'll close by layers using interrupted number 1-0 and 2-0 monofilament sutures in combination with monofilament sutures for the skin and acrylic dressing for the skin in combination with gauze and Tegaderm dressing. After the surgery, the patient will be made weightbearing as tolerated. The patient will be using a walker for comfort. The patient will be receiving DVT prophylaxis for a period of a month, and the staging status will be completed. This patient is still has pending a CT of the abdomen and pelvis that has not been obtained because of issues with pain control. We expect to take this postoperatively. In addition, the patient will receive preoperative antibiotics for 24 hours, and we'll expect the patient to be ready to receive radiation to the femur postoperatively a week to 10 days from surgery and start chemotherapy approximately two weeks after surgery.

CHAPTER 2

A little bit more anterior. Have the skin - I've just come, anterior to it. Incision. Do you want me to take the whole thing or just a little bit for the biopsy? I will open thing - surgery, can put the, the clamp, et cetera. And hopefully we're at the right spot. And then we'll take the Weitlaner pretty fast. We'll start with Weities. Perfect. Can I have a Jeff, please? Yep. Too posterior. The anatomy gets all distorted. Do you have a Cobb, please? And a cerebellar. Can I have... Tensor fasciae latae or vastus lateralis? I think it's gotta be fasciae latae, right? Yeah. I think so. Do you have a cobra, please? This guy. So I basically, tensor fasciae latae, you put your finger behind, then you feel the subtroch area and then you feel the vastus lateralis. And this is the fat. Incarcerated piece that you were mentioning. Yeah. It just - a little piece went right through the lateralis. Do you have a Cobb please? Could I get a Cobb? Cobb is up, I believe. Yeah, I have it. Nevermind. Harder. Do you have the suction? Do you have the hips, please? This will see it better just like that. So it's the proximal fragment damaged. Do you have the rongeur and a curette, please? Oh yeah, that was on my mind. Those for specimen. Do you have a pickup just here? Perfect. Here, hold that one, one second. Suction. I see one little piece of tumor I think. Yeah, you have two down there. Do you have the curette, please? I do. Do you like - the mushy thing? Yeah, so you can see like some, there's kind of some vasculature, something like this, but this stuff that looks like brains - it's little tumor. Because this isn't a medullary cavity. You can get it there. This stuff here. That guy. Is that some? That looks like, maybe something. Suction, again. Switch out, that is my tumor. Don't suck it out, let's get that. Okay, let's handle that for frozen and then we'll get some for permanent too, in another... Hm, not too bad. So all that stuff is tumor inside. Yeah. Do you have another cobra, please? Two if you can make it two. Or a harmonic I can take next, so you can come out with this one. Oh man. I think we can do it with a rongeur. That's the other part of the bone. Can come out with this one, hold that one. I'm just going to release more of the septum. Do you have the cup again, please? I'll take the suction. Can we get some peroxide irrigation, please? Just one second, it's at the bottom. Well it is a subtrochanteric fracture, so that's where it's supposed to be. Do you have - that's okay. Do you have... Let's see if this is flex... If it's here, so maybe make it here.

CHAPTER 3

Just wanna be like... Do you have another cerabellar, please? Or a gelpi, if you don't have a... Yeah. Yep. Can I have actually a deep knife, please? You need a knife? Yeah, like a deep one. A deep one, yeah. Yeah it just reacts with all the blood that's in the... That's cool to know. That's cool to know. Yeah, I'm sorry. Okay, that's our starting point there. Paula, can we get Schanz pins, please? This is just way too flexed. It's 90 degrees. It's more like 90. We can do some more irrigation while we wait for the Schanz pins. There is nothing to read so, we just have to like line it up as straight. Can't wait. All the way posterior. That's why I went, that's why I made the incision a little bit posterior. And that's why I put my finger to get the hook and then you get like a subvastus. Because otherwise you just go through a muscle and it is just like, all this bleeding and a mess and gets in there. And so, is there any cuff on the septum, or? I don't think so. I kind of like, I think I left everything. What I have here is just tensor fasciae latae, and you can put your finger right there, look you can feel the septum there. That'll be great. Can we get them on power, please?

CHAPTER 4

Let me just move you a little bit. Can you come with the x-ray, please? Do you want it to be on this side, Dr. Lozano? No, you're good, you can do it there. Can bring this guy up. Lemme give you the Cobbie back. And can you swing? Yep, to an AP. Yes, please. Do you have the pin, please? X-ray there. Can I go more proximal, please? All the way up to the hip. So I can go a little more, even more. X-ray there. Some, on the... And this is flexed. X-ray there. X-ray. Do you have the handle, please? Can you go more north, please? Let's get this guy. Do you want to come up to find your starting point? Do you have another one of those pins? So I'm going to shoot posteriorly with this one. X-ray there. Looks pretty good. X-ray. Do you have another T-handle, please? Let me pass this guy back. X-ray there. You know, I just want to get it first, like a good AP of the proximal fragment. X-ray there. More internal rotation. Yeah. X-ray. That looks better, and, we want a little bit of valgus. X-ray. X-ray again. I think that's an acceptable AP. I like it. If anything, I think we're seeing a little bit of lesser, a little bit more than I would. So more external rotation? More internal rotation. But you're saying we're seeing a lot of... He was saying a lot of lesser. Yeah, because we're seeing too much lesser, looks very... Okay. X-ray. But with internal rotation, that will be more. X-ray. That x-ray looks better because you can actually can see the - then internally rotate a little more. X-ray. Yeah. That's it. Okay. Get it George, so you have the starting wire, please. So I'm internally rotating and abducting, so you can find easier the thing.

CHAPTER 5

Have to come more lateral. Yeah. With the wire. Yeah, let me just see where I am. So go more medially. Shot there. Okay. A little bit more medial. What's that, yeah. Shot there. Perfect. I like that. Okay, so you can advance it. You have the power, please? And then if anything, it looks like you're aiming to anterior. I will try to go more posterior for the lateral. Okay. I don't know what happened there. Shot there. Come up. You're either too posterior, or... That bone, is that soft? Yeah, oh my God. Okay. Okay. I don't like it though. Do you wanna come... Shot there. Shot there. Come more lateral. Because you're moving anterior to raise your hand, if you want to come lateral. I want to come a little medial. Shot there. That's what I meant. So you have to raise your hand, so you're in more medial. There we go. Right, I see. Shot there. Okay. Come to a lateral, please. Get the... Have to raise the machine. Split, please. You have to pull it in, then you have to try to connect the two. Yep. Then see over a little more, then pull back towards you a little bit. Tilt like 10 degrees that way. X-ray there. X-ray there, and you need to go more north. Do a little anterior. Have to come more posterior on the - have another 3-2? thank you. Okay, shot there. I like that. X-ray. Have to be more. X-ray there. Okay. Can you come to the AP, please? Then swing by. X-ray there. Can you go north, please. So it's a little bit externally rotated again. So advance the posterior one more, then take the other one out. Okay, x-ray there. Little bit more. Shot. Good, okay, get the other one out. Opening reamer.

CHAPTER 6

So this is a... Okay, shot there. So this is the opening reamer, pushing more. Shot there. And shot. Go for it. Shot. Okay. Shot. All right, pushing the wire. Yeah, that's fine, but I think you open enough that... That it's good? Yeah, because we're going, hitting - the reason why is because I have my, my guy here. There you go. Okay, do you have the...? Let's get the finger tool first.

CHAPTER 7

You're not going- yeah you have to miss, yep. Yeah. Okay, now we have to get ready for the traction. X-ray there. X-ray. Find the thing, or? Yeah, I feel the hole. Okay. X-ray there. If anything, I have to like... X-ray there. X-ray, x-ray. Pathology. Okay, great. Yes, please. Shot there. Okay, he can hear you. Okay, so we received the right proximal femur for biopsy. It shows metastatic carcinoma. Great, thank you! Thank you. You're welcome. Are you in, or? Yeah, it feels like it's in, but I don't like that. Shot there. Okay. The things are in. Try to pass the wire. If - I mean I think I have you pretty well reduced on this. X-ray there. Actually, x-ray. Turn it the other way, like 90 degrees. Shot there. Okay, now making it worse. X-ray there. I think it's like the piece is still, it's flexed. Okay, so you know you're out. X-ray. You can get the - just the wire. See if you can pass it through - to valgus. Shot there. Shot. Hole is right there. Let me just switch with you, one second. This is flexed again a lot. So let's... Can you give me some traction, please? X-ray there. X-ray there. That's way too much. Can you hold this guy like this? One there, somebody has to keep the traction. So you're externally rotated a lot again, can you internally rotate? Because it's very... Internally rotate. X-ray there. X-ray. You x-rayed my leg. Okay that's better. X-ray. Okay, can you give more traction, please? X-ray. Let's screw it a little bit, I have control of it. X-ray there. So you can make it unicortical, like just keep backing out this. Okay, x-ray. X-ray there. A little bit more. X-ray. X-ray. X-ray. X-ray. X-ray. More posterior. X-ray. X-ray. X-ray. Hold on one second. So come on this. X-ray. You wanna put a bump under here? No. X-ray. X-ray there. So let me just have you here and then I will... Yeah. You can advance it when... Have some irrigation? So you see, it's not doing anything. Do you have a cobb, please? Have the suction? Can you put the light on there? Let's put the bump under there, put it the other way. Yeah, turn it. You have to bring this to the front a little bit. So try to advance more the thing, because you're the one that is controlling the varus/valgus, so you have to drop your hand a little bit so it comes out of the... Shot there. Okay. Okay. Shot there. Then it - keep advancing. Try... Shot there. Shot there. Great forearm. Why don't you try to - can you advance more or no? You can feel that you're, let me just... I can. Shot there. Give me one second. We're actually in. Do you have some irrigation, please? Can you see me? Do you have a Schnidt, please? A Schnidt? Yep. Can you come out with the C-arm, please? Watch out that... Completely out? Yeah, completely out. Have to raise the machine. So we're coming anterior. Going anterior to it. The distal. Can you come with the x-ray, please? Hopefully you're hitting this. Mhm. I think you are. Yeah. Pull back. It's fine. Pull back towards you, let's try that. Can you come more distal, please? You're good, can you come to AP, please? Pull some traction. X-ray there. Okay. So... Can you pull it out a little bit more? Because I'm just stuck. I'm going through it, just unicortical. It's just stuck. X-ray. X-ray there. That's it. That's it.

CHAPTER 8

Okay so, do you have the ball-tip guidewire, please? X-ray there. Okay. X-ray there. It's in. Maybe I'm blocking you. X-ray. Oh it's... Okay. So you have to do - so turn it. Turn this thing. Yeah, there we go. X-ray there. Okay, come down to the knee, please. X-ray there. Beautiful, can you come and take a lateral of the knee, please? Can we bring the table up a little bit, please? X-ray there. That's fine. Okay, can you go to an AP of the hip? X-ray there? Yep. X-ray there. X-ray. Do you have one of the wires like that we use for the starting point? Can you load it to put it again with power? I think lengthwise we're doing good. Well you don't take the finger tool out then. X-ray there. Okay, x-ray there.

CHAPTER 9

Okay, do you have the ruler thing? Do you have that guy? X-ray there. Pull back a little bit. Shot there. Let's see if I can really go very anterior. X-ray there. X-ray. This guy. Okay, so it's this line right here, right? So... Yeah. It's over a 360, so... So you can get a 360. Pretty long. So 360. 360. By 11, bend this.

CHAPTER 10

X-ray there. I like it there. In terms of... Rotation. Rotation. And then it makes sense below. And then, we just want it a little bit like this so we're not in valgus. X-ray. And then these things, can you give me some traction here. Without my glove, thank you. For me, it's... X-ray there. That looks worse. X-ray. Well, let's do the reaming and then we can, so you have the 8-5 reamer, please? X-ray there. That's better. And then I have to pull this out a little bit. X-ray. That's good, okay. Go for it. Shot there. Could I use the lap? Can you come a little distal with the C-arm? X-ray. That's good. Okay. Can we get a 9-5, please? 9-5, absolutely. That's why I was transferring in. I was really worried her bone was gonna fall apart. 9-5. I'm still worried about it. Don't jinx me. Don't worry. Good, so far so good though. Good for... She was laughing at my jokes. 10-5 next, please. 10-5, yep. 10-5, there you go. 10-5. You want to help Paula with the... You want 11? 11-5? 11-5, please. Yeah, and then we're gonna get, this is gonna be an 11 probably. What size is this one? 11 and a half? 11 and a half. I think it's gonna be, probably an 11 nail. Yeah, that's what we have. X-ray there. Good. Are you good with that, or do you want another one? We'll get a 12 and then 12 and a half please. Okay. I have to push more that thing in there. There we go. So you get the next, to get that stuff ready. That's for the exchange tube and the smooth wire. So the nail is 11, we'll do 12 and a half. The inner diameter of the nail, if you put it over a ball-tip guidewire, the ball-tip doesn't fit through the nail. So you have to use an exchange tube to make it to put a smooth wire. The ball-tip thing is more so the flexible reamer but there are some reamers that if you use the similar cannulated ones, those come incorporated, you could do them over the smooth wire. Right, you don't need... You don't have to use the ball-tip. Okay.

CHAPTER 11

So this is. So that goes, just slide it, yep. All the way in. You just have to be past there? Yep, push in, over the wire. Just like that. Could take that one out. Put this - move. You need to take some. Am I hitting, I think I might be. Okay, x-ray there. Yeah, it should be fine. Okay. Just take that one out. This seems longer than this. Can you come down to the knee, please? Okay, x-ray there. We love it.

CHAPTER 12

Okay, get your nail. Can you keep some of the traction, please? This is not doing anything. Did you have the irrigation, please? Yes. Just hold on one second, so I can keep it ready as well. Can we have this to the pathology? Okay, advance it. Not all the way in but just - x-ray there. So you're past. I'm right the fracture site. Past the fracture site. I'm past? Yep, stay at the - so back it out a little bit. Give me some traction. Okay. X-ray there. Okay. Okay, now let's see, advance it more. X-ray. Okay, that looks good. That internal rotation looks good, keep going. So you have to come a little bit more like this so it advances more. And then you kind of start to turn. X-ray there. I like it. Keep going. Okay. X-ray there. Good, keep going. Do you have the wire driver, please? Yep. Wire back. Let's see, x-ray there. Good, keep going. Does the rotation look okay proximally? It looks a little external, doesn't it? Compared to the... You can get... X-ray. That's it. That's better. Looks fine to me. Yeah, well we'll advance it also, we can secure the proximal fragment and then we can work around with the distal one. Okay. Shot there. Good. I think that's it. I think that, couple of taps but that's it, okay. Do you have the trocar, please? I just wanna make sure we're good by the knee. One second. Hold on one second, x-ray there. Okay, take the traction off, yep. X-ray there. That's reduced. So can you tap it a little bit more? Just a couple more taps. Because what I will do is like I will lift it up like this. Hold on one second. Okay, x-ray. Very tiny. Tiny bit more. Shot. X-ray. That's it. I think that's - can we come down to the knee, please? So we need to get a little bit more of external rotation - x-ray. X-ray. Okay, can you go up to the hip again? Can you hold that in traction, in that position? X-ray there. And come more distal, please. That's pretty good. Do you have the trocar, please?

CHAPTER 13

So it's on the 1-30, that's the one where it comes. Oh, nice. Okay. Yeah. Yep. So you can take this guy out. Want to come on this side, or? X-ray there. Do you have the... I can hold... The driver. I feel a traction and Brandon can do it. This is the one that goes in here. That's the long one, yeah. Oh but we can - can we make sure on this one. X-ray. Ooh. Ooh. Ooh. X-ray. It's locked in the... It's okay. X-ray. Okay, can you come to a lateral, please? Do a little anteverted. It's pretty good I think. If anything we have to go a little bit posterior. You have the wire driver? Just a little bit. Yeah it's not bad. On the - as premium mode. X-ray there. X-ray. Too much. X-ray. That's pretty - that's pretty good. X-ray. Kind of like in the center. Huh? I don't think it's the best lateral of the neck. Can you tilt 10 degrees that way? I want to start more posterior. X-ray there. X-ray. X-ray there. X-ray. X-ray. X-ray. X-ray. Problem is like if we ream on this one, I'm going to get the the anterior cortex. X-ray. X-ray. Is that the same hole? X-ray. X-ray. X-ray. X-ray. And that's the... Can you see back towards you a little bit? Actually stay there, yep. X-ray there. I think that works. I still have anterior neck there. Yeah. That's fine. Can we come back to the AP, please? X-ray there. You can kind of make new one. Okay.

CHAPTER 14

Do you have the ruler please, for the... It's a pretty damn good reduction. Yeah, I'll say so. It got better. That's good traction. So, we'll do 85, please. Actually, actually we are going a little in... I'm pretty sure. Hold on one second. X-ray there. It's wearing the - 80 that's, yeah, 85 is fine. 85.

CHAPTER 15

All right, so I'm told that once this is set, it's not supposed to move? Yeah. And I can't get it to not move, so I dunno if you can tighten that tighter. It goes the opposite way of what you'd think. Okay, that's good. That did it, 85 in there? Yep. So so you measured... You measured 85. You measured exactly 85. 85, and I'm going to an 85. Might have to turn it back to drill. Yeah, I have it on drill. Yep. X-ray there. X-ray. Why is it so short? Doesn't make any sense. Can we take the measuring tool back? I feel like the - and then the... Yeah. It's measuring... That's the 90. Lin, do we have the - this wire, the long one is the appropriate for measuring, this is just doesn't, I just did 85 on this and it looks... Yeah, it looks great. No, look at - that's the, we measured 85 off of that wire that's in there. And that's how far it went. Let me see, x-ray there. X-ray. Hmm. I'll probably have to change it. Are you supposed to... Do we have one that is femoral neck? Just looks... Really short. Like, longer than the previous, like... Oh okay, that's maybe what it was. That's why. Okay, so it's actually... It's little over 90. 95, so let's do 90. Can you change it to 90? Let's see. It still doesn't seem like it's gonna be enough. But it's not going to be enough. Why you don't do 95? Yeah, so I'm still moving this even though it's supposedly locked. Okay, x-ray there. X-ray. Even is measuring short. You did 95, right? Or 90? But it's usually between 90 and 100. X-ray there. X-ray. That's great. That sounds good. So it is going to be 105. 105? Oh it's measuring from the top of the thing. The second trocar. If it measures from this. No, but that's not how it goes. Yeah. It goes like this. X-ray there. And that's measuring 100. X-ray there. But now it's off. So it still is off. Okay, we'll try the 105. So as bad as the bone is, it's always, don't get any surprises of... X-ray. It's a really good reduction, we're looking. Well I think it's not moving or, you think it's moving? We're internally rotated here... Oh yeah, no I'm just saying that makes sense, we're internally rotated. This looks internally rotated. Yeah. We're happy. We're happy. X-ray. Measuring 90. Unless you're doing a rotation plasty, then that's all intentional. X-ray. Oh. Oh. So this is measuring 100. X-ray. 90. So it was really, hold on one second. X-ray. That's measuring... 85, right? 85, that's the first one that I gave you. We have it open on the table. Okay. So do you want me to load it? Yeah, load that one in instead. We did something wrong, cannot know what. X-ray there. That like, just come like this. X-ray there. That's a good view of the... So that is the 85. 85, okay. X-ray there, please. X-ray. X-ray. X-ray there. It looks short because... No, it doesn't look short. It's like... No. because the interface, no but the interface of the screw. Yeah. With the other one, like you see it should be outside the, inside the bone with the screwdriver. You see how the screw is going all the... Oh I see, yeah, I see what you're saying. Yeah. Yeah, you're all the way in the bone. What is the other one that we have? A 105. Can I get that one, please? This is good bread and butter, pathologic trauma. Yeah because that's subtroch. X-ray. That's the key for this case. Yeah, the Schanz pins. Then the finger tool. Schanz pins and the finger tool. Where is the dot? The first one was 85. It's going to be 95. It is a 95. Okay, I don't know what it was with the measuring thing but, do you have a 95? The third is the charm, is the expression? Yep. Is there anything like that in Spanish? Hm? That's like the third time's the charm? No, it doesn't translate. The only thing that translates in Spanish is, "This sucks." X-ray there. Alright, we're taking bets. Oh this has to be it. X-ray. It's going to look beautiful. X-ray. Like that? Ooh. That's it. That's as far as it can possibly go. That's perfect, yep. Otherwise…

CHAPTER 16

Do you have the setting screwdriver, please? So it's like your screwdriver with this tiny little screw that is coming. And it's just this one hole right here? Yep. Okay. All the way in. That's a tiny little screw, yeah. There is no helical blade. No squeak or anything, right? Nope, X-ray there. Just super tight. As hard as you can. See. That's it. Okay. Your eye balls were coming out, so I think we're good.

CHAPTER 17

Let's see. X-ray there. That's not a good AP. X-ray. That's a better... Take it again. X-ray. That looks like a good AP, agree? You like that better? I like it. Okay so hold it there, make sure that we didn't move. Good, can you come down to the knee? X-ray. That's a good AP of the knee. I like it, okay.

CHAPTER 18

Can you come to the lateral of the knee, please? And put the machine as high as you can and go proximal, x-ray there. Can you open the C, please? X-ray there. X-ray. X-ray. X-ray. So lock it for the C and then open the tilt a little bit. X-ray again. Can you open the C again and lock the tilt? Can you lock it there? Do you have the 10 blade, please?

X-ray. X-ray. Small posterior. X-ray. Schnidt, please. Shooting in between those holes and this? Yes. Have the drill, please?

X-ray. Going anterior, x-ray. X-ray. It looks pretty good. So now this is the... I'm going from your side. I'm looking at this but in this side, how am I looking? This side is fine, yeah it is, yeah. Okay. You have to tell me because I can't look at you. Okay. How am I looking from your other. Still all right there. Okay. It's through. X-ray there. Perfect. 10 blade again, please. X-ray. X-ray. Can I have the Schnidt? This is the easy part of this case. X-Ray. X-ray. X-ray. A little posterior. X-ray. That looks pretty good. Parallel to that, where I'm looking. So I'm going to use the other pin to guide myself. I'm looking good there? Yeah, that looks really good. Can you come to the AP of the knee, please? Can we bring the table up. please? Yes. How is she doing, Kelly? You can come now, the nail is blocked because of the drills. Depth gauge.

Okay, do you have a 40, please? 40.

40. I'll take it, okay. X-ray there. Can I pass off those two lag screws? Yeah, for sure. Do we have necklaces for... I have to bring them downstairs and have them set back up first, and then yes. Since I'm giving all these fluids, can we get them also like a nail, just so they have the two things. Feels proud. There we go. X-ray. Okay. Have the power again, please? Yeah.

The nail looks - well, we got it a little shorter, right? Just... Oh I'm sorry, I thought you were... No. You think the nail looks short, or? Well, it's shorter than what we did. I mean it's finishing maybe like half. I'm just being as premium mode. X-ray. Kind of like five, four millimeters of perfection. I think that's a very good guesstimate. X-ray there. This one is measuring 42. Like 40 as well. Oh wow. Well, I guess... I guess we don't... We have the..? If you're in the posterior part. Yeah, I guess. But it's going to look short. Do you have the 42.5? We'll just do it a little bit more proud.

X-ray. X-ray. Okay. X-ray. Great bite, okay.

CHAPTER 19

So now let's see. X-ray there. X-ray again. Save that, that's a good AP of the knee. Can you go up to the hip? X-Ray. Take the arm so we can actually, I mean it's going to be like a five degrees of external rotation but she's not going to be internally rotated. It was an 85 screw. X-ray there. Okay, save that. That looks great. Okay, can you come over and get a lateral of the hip? Yep, and then if you could give us the tilt the other way. X-ray there. A little bit... Save that. It's like a tiny bit flexed, like... Not like it was. Yeah. Okay, save that. Let's do the AP first. I haven't moved. X-ray. Okay, save that. Now let me - x-ray there. X-ray again. Sorry. X-ray. Too much. X-ray. X-ray. Okay, save those. Then come to an AP of the knee. Save that. X-ray again. Save that. Okay, can you go up just to the hip out of curiosity to see how... Yeah, because that's like a perfect AP. That's a perfect AP. Yeah. There. This - so she's externally rotated there. That's a perfect fit. Has a little flex. So, we'll see what her, if anything, she'll be a little bit more internally rotated than the other leg but, can come out and... Paula, can we get a pulse lavage, please?

CHAPTER 20

Yep, wash that out completely. To be sure that nothing else is having bleeding. Yeah. No. Let's do, 2-0 and a Monocryl. I can try to put it here. Oh yeah. Well she wants to have all her care in Newton-Wellesley. So I guess what we'll get is like a CT of the abdomen and pelvis, which she doesn't have, she just has the chest. That's correct, right? She just has the chest. She just has the chest. So I'll do abdomen and pelvis. Could I have a 2-0?

CHAPTER 21

There's a clean one. Thank you. We'll get you another one in a minute. So kind. Do you have another one? Have a Yankauer and a Schnidt, please? And then could I grab a Weitlaner and a one? Do you have a number one PDS, please? I'm gonna close this, Brandon. See that pock hole that the fracture made? Three Bovie tips. And the scratch to go with it. Have another, another number one, yep, please. And I'll take a Richardson too. A what? A Richardson or a lady finger. So, I'm going to... I think it's interesting because he has an anterior predominant lesion, but obviously... Yes. So it's a little bit more fussy with femoral implants. Then I'll take an 0. A sponge and suction. Do you want a wrap? I think we're okay, Dr. Lozano had one, sorry. Give you this. Have a 0 for Brandon, please. Just a subtroch. Hold that. The finger tool. That's the key. And so that works when you have a knot inside, so you have to leave tails for both and then you just pull them when you put Dermabond. Want to come here so you can actually see and, and you can get a wet and dry and... No we'll do a deep layer of zeros there too. I was going with 2-0 Do you want another? Yeah, let's do the 2 and see if it works.

CHAPTER 22

As you notice in the video, the patient was positioned in the lateral decubitus. This surgery can be performed also in a fracture table in the supine decubitius, but it's my preference to attend the lateral position, given that there is more freedom to flex the leg and match the reduction between the distal fragment and the proximal fragment. In this case, you saw how the proximal fragment was flexed almost 90 degrees with incarceration of the proximal fragment in the anterior fascia of the musculature of the thigh. You notice how I use Schanz pins to manipulate the pieces and correct the deformity of the proximal piece, which is characteristically in external rotation and abduction and flexion of the proximal fragment. The distal fragment usually is in adduction and with shortening. You could observe as well how we use the finger tool to reduce the fracture after doing the standard steps to access the proximal femur in order to advance the ball-tip guidewire. You saw how we used the finger tool to advance the ball-tip guidewire to an excellent position in the AP and lateral views with x-rays. You could also see how we measured the length of the nail with the leg in traction to avoid discrepancy. The rotation and reduction was assessed with the help of fluoroscopy obtaining the most anatomic AP view of the hip as well as of the knee. This is very important because in these type of pathologic fractures, there is no fracture line that may facilitate the width and anatomic reduction of the fracture. You also observe how we use the perfect circular dot technique to insert the two blocking screws. In this case, you saw how we position the C-arm to match the position of the leg as we didn't want to mobilize the leg to change the obtained reduction. You also saw how I used two drills and left one in place to help me as a guide to insert the trajectory for the second screw. The remaining of the steps, as you could see, are pretty standard to one, an intramedullary nail fixation of the subtrochanteric area is. In this technique, we use the trochanteric entry nail, but you can also use a piriformis nail. It is my preference to use a carbon fiber nail because of its radiolucency and the planiation of postoperative radiation after surgery, as well as the evaluation of subsequent CT scans and MRIs that are obtained for oncologic purposes. In addition, the radiolucency allows to evaluate and visualize intraoperative fractures. The modulus of elasticity is also closer to the one of bone. The mechanical properties and bending forces are also superior when compared to the metallic implants of this nature. I hope you find this surgical technique video useful and the information contained on it valuable. Thank you for reviewing it.