What is the step-by-step procedure for treating an intertrochanteric fracture using a Trochanteric Fixation Nail (TFN)?

From the Guidelines

The treatment of an intertrochanteric fracture using a Trochanteric Fixation Nail (TFN) involves a systematic surgical approach, with the strongest evidence supporting the use of cephalomedullary nail fixation for unstable intertrochanteric fractures, as seen in the 2022 study by the American Academy of Orthopaedic Surgeons 1. The procedure begins with the patient positioned supine on a fracture table, but preoperative traction should not be used for hip fracture patients, as recommended by the American Academy of Orthopaedic Surgeons with strong strength of evidence and strong strength recommendation 1. After sterile preparation and draping, a 5 cm incision is made proximal to the greater trochanter. The entry point is established at the tip of the greater trochanter using a guide pin under fluoroscopic guidance. The proximal femur is then reamed to accommodate the nail. The TFN is inserted over a guide wire down the intramedullary canal. Once positioned correctly, a lag screw is placed through the nail into the femoral head, ensuring it is centrally located in both anteroposterior and lateral views. The lag screw should be within 5-10 mm of the subchondral bone for optimal fixation. A set screw is then inserted to prevent rotation of the lag screw. Distal locking screws are placed through the nail to prevent rotation and provide additional stability. Fluoroscopic images are taken to confirm proper implant position and fracture reduction. The wound is irrigated and closed in layers. Postoperatively, patients typically begin weight-bearing as tolerated with assistive devices, progressing based on fracture healing. This procedure is effective because the intramedullary device provides biomechanical advantages over plate fixation, allowing for load sharing and minimizing soft tissue disruption while providing stable fixation for early mobilization, as supported by the 2022 study by the American Academy of Orthopaedic Surgeons 1. Some key points to consider during the procedure include:

• The use of spinal anesthesia, as seen in the case study 1
• The importance of achieving stable fixation, particularly in unstable intertrochanteric fractures 1
• The need for postoperative monitoring, including vitamin D, calcium, and parathyroid hormone levels, as well as an outpatient dual energy X-ray absorptiometry (DEXA) scan 1

From the Research

Procedure Overview

The procedure for treating an intertrochanteric fracture using a Trochanteric Fixation Nail (TFN) involves several steps:

• Preoperative planning: This includes evaluating the patient's overall health, assessing the fracture type and location, and selecting the appropriate TFN device 2, 3.
• Surgical approach: The surgeon makes an incision in the skin and dissects the tissue to expose the fracture site. The TFN device is then inserted through the greater trochanter and into the femoral canal 4, 5.
• Reduction and fixation: The fracture is reduced, and the TFN device is secured in place using a helical blade or other fixation mechanism. The quality of calcar reduction is crucial to prevent mechanical complications 2, 3.
• Postoperative care: The patient is monitored for complications, such as excessive lateral migration of the helical blade, blade migration in the head, or femoral shaft fracture at the tip of the nail 2, 3.

Key Considerations

• Fracture classification: The AO/OTA classification system is used to classify intertrochanteric fractures, which helps guide treatment decisions 2, 3.
• Implant selection: The choice of TFN device depends on the fracture type, patient anatomy, and surgeon preference 4, 5.
• Surgical technique: The surgical approach, reduction, and fixation techniques can affect the outcome of the procedure. A retrospective study found that the quality of calcar reduction was significantly predictive of mechanical complications 2.

Potential Complications

• Mechanical complications: These include excessive lateral migration of the helical blade, blade migration in the head, or femoral shaft fracture at the tip of the nail 2, 3.
• Loss of reduction: This can occur during the healing process, even with optimal implant placement and surgical technique 4.
• Implant-related complications: These can include infection, nerve damage, or other adverse reactions to the implant 6, 5.

Clinical Outcomes

• Functional outcomes: Studies have reported satisfactory functional outcomes, with mean Harris Hip Scores ranging from 80 to 86 points 3, 6.
• Complication rates: The overall complication rate for TFN procedures has been reported to be around 12% to 20% 2, 5.
• Union rates: High union rates have been reported, with all patients achieving union in some studies 4, 5.