Nice presentation. The key is the position of the patient. Most of the obese patients, if not positioned properly it becomes extremely difficult to medicalise the entry point.
It’s very helpful Vedio .. it made me understand wedge effect of nail perfectly sir 😊.. I have done this mistake several times without knowing why it fracture went in to varus at the end of passing nail which was well reduced till then .. thank u
Thanks. As we prefer a closed reduction in these cases, whenever the proximal fragment is flexed, we place a Hohmann lever through the entry incision to press the fragment in its normal position. The technique is elaborated on in this clip: ua-cam.com/video/e9-shsp83DA/v-deo.html
Although now we dont do DHS except NOF fractures in young patients, I feel DHS is undervalued...atleast it avoids wedge effect leading to varus reduction and failure ...Should be used when lateral wall is intact!
Yes, DHS is a simple device. All orthopods should be familiar with it. We mostly keep it for young patients and those with simple trochanteric fractures.
Yes, keeping the entry directly in the piriformis fossa would be a concern. The main step is to keep the entry point medial to the greater trochanter tip, not directly over the piriformis fossa. We tend to ream more on the lateral side, as our manipulation starts laterally. So, basically, we need a space between the piriformis fossa and GT. Not sure how long-term clinicoradiological outcomes would be affected, but almost all patients land up in fracture union without any neck-related complications. But for lateral entry, we definitely invite complications like malunion, non-union, screw/blade displacement and early reduction loss.
The wide portion has been a concern previously as well. Newer nails (like TFNA) have addressed this issue to some extent. In elderly/osteoporotic patients, we just use the flexible proximal reamer to just open the mouth of the entry point. The remaining track is either created with a cannulated awl or sometimes left when the bone is of too weak.
Subtroch and some IT fractures have an inherent tendency to go into varus. The nail will take the space created during proximal reaming. So if a wrong track is created, then the fracture will go into varus. Entry point medial to GT will save from varus deformation. The direction of proximal reaming is also important; it should be towards the canal, not the medial cortex. I will soon add a video on entry points in subtroch fractures that will help understand things better.
Ассалому алейкум доктор менинг сон суягим хам ёрилган эди 3 та винт билан аператсия қилишди хозир 110 кун бўлди юряпман оғриқ йўқ ишласам бўладими жавоб учун олдиндан раҳмат узбееистандан сизга салом
Hech qanday og'riq yo'qligi yaxshi. Odatda, suyak holatini sharhlash uchun rentgenogramma amalga oshiriladi. Siz buni amalga oshirishingiz mumkin. Aks holda, 3-6 oy odatda davolanish uchun etarli bo'lgan vaqt hisoblanadi. Eng yaxshi tilaklar.
Thank you for the comment. Three things can be used as indicators of varus besides the actual neck-shaft angle. Here, when the blade is in the inferior part of the neck, it should end in the inferior quadrant of the femoral head also if normal valgus alignment needs to be restored. Second, the tip of the trochanter lies roughly at the level central zone of the femoral head when seen from the front; here, it is lying at the superior zone of the femoral head. Third, if you have medial cortical contact but opening proximally, that also means that the proximal fragment is rotated in varus. And most importantly, we need to see the preoperative valgus on the opposite side as well. Here is the link of post op radiograph which shows that the affected side is fixed in varus. ibb.co/Jy28Tvs
Sir in the link given The screw tip is matching with GT , screw remains central . Except for proximal opening , it looks as good reduction. When compared to opposite hip it looks varus . Is it because of inter observer difference
@@chaitanyaksk90 There can definitely be interobserver differences, but the proximal opening and medial contact should definitely indicate some varus even if subtle. The case is actually my operated case only, and I have been measuring the radiograph parameters in all such cases to improve subsequent surgeries. The nail when entering through the fracture hinders healing due to distraction. I have attached the markers that indicate that some varus malalignment is definitely there. Hope that helps. Thank you. ibb.co/jy3tGFh
@@chaitanyaksk90 Yes, Mild only. But that potentially risks further collapse due to soft bone in osteoporotic patients. In healthy bone, it might not affect much.
Yes, agree with you on this concern. But we should get a medial entry to GT, not exactly in the piriformis fossa. Maybe going medial would at least ensure fracture healing rather than a failure. Personal experience: no avn with medial entry even at more than one year follow up, but yes would need large evidence to comment. Thanks
Hi. The current presentation was specifically focused on the wedge effect we see in the AP view. The axial view of the first case in which the wedge effect occurred can be found here: photos.app.goo.gl/wLc8XJShjj71RJsT9 and for the second case in which the entry point was made medially, the axial image can be found here: photos.app.goo.gl/5mSujMgQnyEGeirx6
@@dr.hunaidhaider5701 Thanks for your feedback. Making an entry lateral to the GT tip will carry the risk of negative reduction, and a medial entry will prevent that. I have explained all this in detail in another video ua-cam.com/video/e9-shsp83DA/v-deo.html
Nice presentation. The key is the position of the patient. Most of the obese patients, if not positioned properly it becomes extremely difficult to medicalise the entry point.
It’s very helpful Vedio .. it made me understand wedge effect of nail perfectly sir 😊.. I have done this mistake several times without knowing why it fracture went in to varus at the end of passing nail which was well reduced till then .. thank u
This ll help many surgeons 👍👍
Great keep doing good work
excellent discussion..common problem...but meticulous and thoughtful solution.....❤
Thanks for your feedback!! 😇
Great…we followed same trick in our last case
Very nice.. helpful and informative
Great teaching Sir ❤
I see a lever placed on neck .
1- Was it displaced anterior ?
2- a separate incision for this lever ?
Thanks. As we prefer a closed reduction in these cases, whenever the proximal fragment is flexed, we place a Hohmann lever through the entry incision to press the fragment in its normal position. The technique is elaborated on in this clip: ua-cam.com/video/e9-shsp83DA/v-deo.html
Although now we dont do DHS except NOF fractures in young patients, I feel DHS is undervalued...atleast it avoids wedge effect leading to varus reduction and failure ...Should be used when lateral wall is intact!
Yes, DHS is a simple device. All orthopods should be familiar with it. We mostly keep it for young patients and those with simple trochanteric fractures.
Thanks for the presentation. Won't the wide proximal portion of the nail disturb the neck when the entry point is medial or through piriformis fossa
Yes, keeping the entry directly in the piriformis fossa would be a concern. The main step is to keep the entry point medial to the greater trochanter tip, not directly over the piriformis fossa. We tend to ream more on the lateral side, as our manipulation starts laterally. So, basically, we need a space between the piriformis fossa and GT. Not sure how long-term clinicoradiological outcomes would be affected, but almost all patients land up in fracture union without any neck-related complications. But for lateral entry, we definitely invite complications like malunion, non-union, screw/blade displacement and early reduction loss.
The wide portion has been a concern previously as well. Newer nails (like TFNA) have addressed this issue to some extent. In elderly/osteoporotic patients, we just use the flexible proximal reamer to just open the mouth of the entry point. The remaining track is either created with a cannulated awl or sometimes left when the bone is of too weak.
Thank you.
Thanks for this video
ONLINE EDUCATION IS FUTURE EDUCATION
What about trochanteric entry nails?. there also we have to make piriformis entry to prevent wedge effect?
Subtroch and some IT fractures have an inherent tendency to go into varus. The nail will take the space created during proximal reaming. So if a wrong track is created, then the fracture will go into varus. Entry point medial to GT will save from varus deformation. The direction of proximal reaming is also important; it should be towards the canal, not the medial cortex. I will soon add a video on entry points in subtroch fractures that will help understand things better.
Entry point through GT can be taken in a stable/simple diaphyseal fracture.
Khuub valo. B sivshankarer video dekho
Ассалому алейкум доктор менинг сон суягим хам ёрилган эди 3 та винт билан аператсия қилишди хозир 110 кун бўлди юряпман оғриқ йўқ ишласам бўладими жавоб учун олдиндан раҳмат узбееистандан сизга салом
Hech qanday og'riq yo'qligi yaxshi. Odatda, suyak holatini sharhlash uchun rentgenogramma amalga oshiriladi. Siz buni amalga oshirishingiz mumkin. Aks holda, 3-6 oy odatda davolanish uchun etarli bo'lgan vaqt hisoblanadi. Eng yaxshi tilaklar.
Sir,can u share any 3 months or 6 months follow up x ray with same type of fracture.
Sure, will update with follow up of some cases soon. Will add link here.
3:49 can you show how the image is in varus position (image in C arm) i coulnt appreciate it. Thank you
Thank you for the comment. Three things can be used as indicators of varus besides the actual neck-shaft angle. Here, when the blade is in the inferior part of the neck, it should end in the inferior quadrant of the femoral head also if normal valgus alignment needs to be restored. Second, the tip of the trochanter lies roughly at the level central zone of the femoral head when seen from the front; here, it is lying at the superior zone of the femoral head. Third, if you have medial cortical contact but opening proximally, that also means that the proximal fragment is rotated in varus. And most importantly, we need to see the preoperative valgus on the opposite side as well. Here is the link of post op radiograph which shows that the affected side is fixed in varus.
ibb.co/Jy28Tvs
Sir in the link given
The screw tip is matching with GT , screw remains central .
Except for proximal opening , it looks as good reduction.
When compared to opposite hip it looks varus .
Is it because of inter observer difference
@@chaitanyaksk90 There can definitely be interobserver differences, but the proximal opening and medial contact should definitely indicate some varus even if subtle. The case is actually my operated case only, and I have been measuring the radiograph parameters in all such cases to improve subsequent surgeries. The nail when entering through the fracture hinders healing due to distraction. I have attached the markers that indicate that some varus malalignment is definitely there. Hope that helps. Thank you.
ibb.co/jy3tGFh
@@Justorthothings there are signs of varus. My doubt is , is that gross varus ? For me it looks like mild varsu
@@chaitanyaksk90 Yes, Mild only. But that potentially risks further collapse due to soft bone in osteoporotic patients. In healthy bone, it might not affect much.
That entry is almost in piriformis and carries risk of avn
Yes, agree with you on this concern. But we should get a medial entry to GT, not exactly in the piriformis fossa. Maybe going medial would at least ensure fracture healing rather than a failure. Personal experience: no avn with medial entry even at more than one year follow up, but yes would need large evidence to comment. Thanks
Hi
Where is axial view?
Hi. The current presentation was specifically focused on the wedge effect we see in the AP view. The axial view of the first case in which the wedge effect occurred can be found here: photos.app.goo.gl/wLc8XJShjj71RJsT9
and for the second case in which the entry point was made medially, the axial image can be found here: photos.app.goo.gl/5mSujMgQnyEGeirx6
Thanks@@Justorthothings
Will making a medial entry not lead to a negative reduction, since the nails and their bends are built for a more lateral entry?
@@dr.hunaidhaider5701 Thanks for your feedback. Making an entry lateral to the GT tip will carry the risk of negative reduction, and a medial entry will prevent that. I have explained all this in detail in another video ua-cam.com/video/e9-shsp83DA/v-deo.html