Femoral shaft fractures associated with a narrow medullary canal and cortical alterations require precise planning of the entry portal, strict rotational control, and proper nail positioning to avoid mechanical complications.

This training demonstrates the complete execution of osteosynthesis with a retrograde intramedullary nail, presented in full 4K video from the surgeon’s perspective, with emphasis on medullary canal alignment, progressive reaming strategy, rotational correction based on the lateral cortex, and distal and proximal locking guided by fluoroscopy.

TRAINING FOCUS

• Indication of retrograde intramedullary nail in femoral shaft fracture
• Planning of the entry portal through the patellar tendon
• Patient positioning and operating table setup
• Guidewire insertion with fluoroscopic control
• Fracture reduction and femoral rotational control
• Progressive reaming of the medullary canal
• Intramedullary nail insertion and proper positioning
• Distal and proximal locking guided by fluoroscopy

DETAILED CONTENT

• Entry Portal Planning: Definition of the access point through the patellar tendon aligned with the previously marked femoral axis, allowing precise guidewire trajectory within the medullary canal.
• Operative Positioning and Table Setup: Patient positioning in the supine position with controlled knee flexion and use of a split table to facilitate image intensifier access.
• Guidewire Insertion and Intramedullary Alignment: Technique for guidewire insertion with confirmation in anteroposterior and lateral views to ensure parallelism with the medullary canal.
• Fracture Reduction and Rotational Control: Strategies for rotational correction using references from the femoral lateral cortex, allowing reconstruction closer to anatomical alignment.
• Progressive Reaming of the Medullary Canal: Technical sequence of reaming aimed at accommodating larger diameter implants and improving intramedullary fixation stability.
• Safe Nail Positioning: Criteria for proper positioning of the nail above the lesser trochanter, avoiding stress concentration zones and risk of subtrochanteric fracture.
• Distal Locking Technique: Precise alignment of the skin access with the nail holes and fluoroscopy-guided drilling for safe insertion of distal screws.
• Proximal Locking and Rotational Stability: Insertion of proximal screws under radiographic control for definitive stabilization of the osteosynthesis.
• Final Implant Assessment: Verification of alignment, fracture reduction, and absence of implant prominence.
• Layered Closure: Anatomical reconstruction of surgical planes with suturing of the paratenon, subcutaneous tissue, and skin.

INCLUDED MATERIAL

Detailed PDF: Didactic document that objectively presents the principles of retrograde intramedullary osteosynthesis of the femur, including entry portal planning, patient positioning, guidewire insertion technique, progressive reaming of the medullary canal, criteria for nail positioning above the lesser trochanter, and the technical sequence of distal and proximal locking under fluoroscopy.

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