intertan technique guide
The InterTan technique represents an innovative approach to addressing proximal femur fractures. It utilizes a specially designed intramedullary nail shaped for these specific fractures. This system offers a unique combination of rotational stability and compression, aiming for enhanced fracture fixation and improved patient outcomes compared to some earlier methods.
Indications for InterTan Nail
The InterTan nail is primarily indicated for the treatment of specific types of femur fractures, particularly those occurring in the proximal region. These include stable and unstable intertrochanteric fractures, a common injury, especially among the elderly population. The nail’s design, incorporating integrated compression screws, provides rotational stability. This is crucial in preventing malrotation of the fracture fragments during healing.
Its trapezoidal shape allows for a press-fit within the metaphyseal region, offering enhanced fixation in this area. The InterTan nail is also suitable for certain types of subtrochanteric fractures, offering a stable construct for fracture healing. It may be considered in cases with comminution, where multiple fracture fragments are present, as the nail provides comprehensive support.
Furthermore, the InterTan system can be used in fracture nonunions or malunions, aiming to correct deformity and promote healing. The decision to use the InterTan nail depends on the fracture pattern, bone quality, patient’s age, and other relevant factors. Proper preoperative planning and implant selection are essential to ensure optimal outcomes. The InterTan nail is not typically recommended for simple femoral shaft fractures.
Surgical Technique: A Step-by-Step Guide
The InterTan nail surgical technique involves precise steps. These ensure proper fracture reduction and stable fixation. Key steps include patient positioning, implant selection, entry point acquisition, intramedullary reaming, fracture reduction, nail insertion, locking, and lag screw placement, all meticulously performed for optimal results.
Patient Positioning and Anesthesia
Optimal patient positioning is crucial for the InterTan nail procedure. The patient is typically placed supine on a fracture table. This allows for traction and rotation to aid in fracture reduction. Proper padding and support are essential to prevent pressure sores and nerve injuries during the procedure. Fluoroscopy should be readily available to visualize the femur throughout the surgery.
Anesthesia considerations are also paramount. General anesthesia is commonly employed, providing muscle relaxation and a controlled surgical environment. Regional anesthesia, such as spinal or epidural anesthesia, may be considered in select cases based on patient factors and anesthesiologist preference. Careful monitoring of the patient’s vital signs is essential throughout the procedure. The anesthesia team should be aware of the potential for blood loss and be prepared to manage any complications that may arise. Preoperative assessment and planning are critical to ensure patient safety and optimize the anesthetic approach for InterTan nail insertion. Communication between the surgical and anesthesia teams is vital for a successful outcome. The choice of anesthesia should be tailored to the individual patient’s needs and medical history, always prioritizing their well-being.
Implant Selection and Preoperative Planning
Careful implant selection and meticulous preoperative planning are paramount for a successful InterTan nail procedure. The TRIGEN INTERTAN Nail Preoperative Template Set can be used to assist. This allows for accurate determination of nail size, screw length, and femoral neck angle. The template magnification level is set at 117, so measurements are estimates.
Preoperative planning involves a thorough review of patient imaging, including X-rays and CT scans, to assess fracture pattern, bone quality, and anatomical variations. It is important to assess any bowing. Appropriate implant size is selected. Consideration should be given to the patient’s bone density and the degree of comminution. Planning should address potential challenges and develop contingency plans; Anticipating potential difficulties ensures the surgical team is well-prepared. Accurate preoperative planning minimizes operative time and improves the likelihood of optimal fracture fixation and alignment. Ultimately, these steps contribute significantly to a more predictable and successful surgical outcome for the patient undergoing InterTan nail fixation.
Entry Point Acquisition and Intramedullary Reaming
Precise entry point acquisition is crucial for proper InterTan nail placement. After anesthesia and positioning, the proximal femur is exposed. The entry point, typically located at the tip of the greater trochanter or slightly medial, is identified using fluoroscopy. A dedicated awl or trocar is used to create the initial opening in the bone. This step must be performed carefully to avoid iatrogenic fractures or damage to surrounding soft tissues.
Intramedullary reaming prepares the femoral canal to accommodate the InterTan nail. Reaming is performed sequentially, using flexible reamers of increasing diameter, until the desired canal size is achieved. This process removes bone debris and creates a smooth pathway for nail insertion. Proper reaming technique is essential to prevent femoral shaft fractures. Fluoroscopic guidance ensures accurate reaming and avoids cortical perforation. Thorough irrigation is used to remove bone chips. This facilitates subsequent nail insertion and promotes optimal contact between the nail and the surrounding bone, leading to enhanced stability.
Fracture Reduction
Achieving anatomical or near-anatomical fracture reduction is paramount for successful InterTan nail fixation. Prior to nail insertion, the fracture fragments must be carefully aligned to restore the natural anatomy of the proximal femur. This often involves a combination of traction, rotation, and direct manipulation. Fluoroscopy is essential throughout this process to visualize the fracture fragments and assess the quality of the reduction.
Various techniques can be employed to aid in fracture reduction, including the use of traction tables, percutaneous reduction clamps, or specialized fracture reduction instruments. The goal is to achieve a stable and congruent reduction that will facilitate optimal load sharing and bone healing. In some cases, temporary fixation with K-wires or cerclage wires may be necessary to maintain the reduction while the InterTan nail is inserted. The quality of fracture reduction directly impacts the overall stability of the construct and the long-term functional outcome for the patient.
Nail Insertion and Proximal/Distal Locking
With the fracture reduced, the pre-selected InterTan nail is carefully inserted into the prepared intramedullary canal. This step requires meticulous technique to avoid further injury to the bone or soft tissues. The nail is advanced until the proximal end is properly positioned within the greater trochanter. Fluoroscopic guidance is crucial to ensure accurate placement and alignment of the nail within the femur.
Once the nail is fully seated, proximal locking screws are inserted through pre-drilled holes in the nail to secure it to the proximal femur. These screws provide rotational stability and prevent migration of the nail. Distal locking screws are then inserted in a similar fashion to further stabilize the construct and prevent telescoping of the fracture fragments. The precise number and configuration of distal locking screws depend on the fracture pattern and bone quality.
Lag Screw Insertion
Following nail insertion and proximal/distal locking, the next critical step is lag screw insertion. The InterTan system utilizes two integrated compression screws designed to generate push/pull forces for optimal fracture compression. A superior lag screw, often larger, is inserted first, followed by an inferior compression screw. The inferior screw prevents rotation of the superior screw, enhancing stability.
These screws are crucial for achieving and maintaining fracture compression, promoting healing and preventing non-union. The worm gear mechanism converts rotation to active compression, holding compression after instrument removal and eliminating the Z-effect. The precise placement and angulation of the lag screws are guided by fluoroscopy to ensure optimal purchase in the femoral head and neck.
Postoperative Care and Rehabilitation
Postoperative care and rehabilitation following InterTan nail fixation are crucial for optimal recovery. Initial management focuses on pain control through appropriate analgesics. Wound care is essential to prevent infection, with regular monitoring of the surgical site. Early mobilization is encouraged, starting with range-of-motion exercises to prevent stiffness and promote circulation. Weight-bearing protocols are determined by fracture stability and surgeon preference, often beginning with protected weight-bearing.
Physical therapy plays a vital role in restoring strength, balance, and function. The rehabilitation program progresses gradually, with increasing weight-bearing as tolerated. Patients are educated on proper use of assistive devices, such as crutches or walkers. Regular follow-up appointments with the surgeon are necessary to monitor fracture healing and assess progress. Adherence to the prescribed rehabilitation program is essential for a successful outcome and return to pre-injury activity levels.
Potential Complications and Management
While the InterTan technique offers advantages, potential complications can arise. These may include infection, which is managed with antibiotics and potentially surgical debridement. Fracture nonunion or delayed union can occur, requiring further intervention such as bone grafting. Hardware failure, including screw breakage, is a possibility, potentially necessitating revision surgery. Femoral shaft fractures, although less common with InterTan compared to some other methods, can still occur and require appropriate fixation.
Other potential complications include malrotation, leg length discrepancy, and nerve or vascular injury. Thromboembolic events, such as deep vein thrombosis or pulmonary embolism, are also risks and may require prophylactic anticoagulation. Careful surgical technique, meticulous postoperative care, and close monitoring are essential to minimize the risk of complications. Prompt recognition and management of any complications that do arise are crucial for optimizing patient outcomes and preventing long-term morbidity.
Comparison with Other Fixation Methods
The InterTan nail stands as one option amidst various fixation methods for proximal femur fractures. Sliding hip screws, a traditional approach, offer simplicity but may lack rotational stability compared to InterTan. Proximal femoral nails, including PFN-A, present alternatives, with some studies suggesting that InterTan demonstrates a reduced risk of femoral shaft fractures in comparison. The Gamma3 nail is another intramedullary device; however, InterTan has been shown to potentially yield fewer complications, particularly femoral shaft fractures.
Dynamic hip screw (DHS) systems are also used, but they might not be suitable for unstable fracture patterns where rotational control is paramount. The choice between these methods hinges on fracture complexity, patient factors, and surgeon preference. InterTan’s dual screw system aims to enhance stability and compression at the fracture site, potentially leading to improved outcomes in specific fracture types compared to some of the aforementioned methods.