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1、髋关节置换第一页，本课件共有40页These images demonstrate a distal femoral shaft fracture occurring from blunt trauma.第二页，本课件共有40页Before performing antegrade femoral nailing,a high-qualityAP radiograph of the hip is necessary to rule out occultfemoral neck fracture.第三页，本课件共有40页Many patients with femoral shaft injur
2、ies have CT scans performedto rule out intraabdominal injury.The CT scan cuts through thefemoral neck should also be reviewed to rule out fracture.第四页，本课件共有40页Lateral decubitus position is preferred for antegrade femoralnailing in the patient with normal pulmonary status and nospine or pelvic injury
3、.The affected leg is flexed,exposing the piriformis fossa without steric interference from the patients torso.第五页，本课件共有40页The downside leg is well supported and padded to avoid neuropraxia.The surgeon is pointing to the starting point for the piriformis entry point.第六页，本课件共有40页View of the area that
4、is prepped out for performing the nailing.第七页，本课件共有40页PIRIFORMISFOSSAThe piriformis fossa entry portal is directly in line with the canalof the shaft.However,it is slightly posterior to the femoral neck.It is curvilinear and angled posteriorly.第八页，本课件共有40页Because the piriformis entry portal is on a
5、sloped surface,astraight awl must be introduced first at an angle to the femoralshaft directly anteriorly12第九页，本课件共有40页and then as its introduced,the hand is raised up togo in line with the femoral shaft.第十页，本课件共有40页1cmThe skin incision,which can be approximately 1 to 1-1/2cm in length,should be mad
6、e at a distance away from the piriformis fossa to allow for direct entry into the fossa.This can be best estimated by looking第十一页，本课件共有40页1cmat the AP radiograph to determine how proximal the incisionneeds to be with respect to the trochanter.The heavier thepatient,the more proximal in the buttocks
7、the incision needs tobe in order to be in line with the femoral shaft.第十二页，本课件共有40页The fascia of the Tensor fascia Lata muscle is divided,exposing some of the musculature.第十三页，本课件共有40页The perfect lateral radiograph of the hip demonstrates theneck to be colinear with the shaft and slightly anterior t
8、o it.The piriformis fossa is easier visualized.第十四页，本课件共有40页The straight awl is introduced through the incision,thengently placed against the piriformis fossa directed anteriorly.第十五页，本课件共有40页The awl is introduced into the femoral canal;as it entersthe bone,the awl is adjusted to be in line with the
9、 femoralshaft by moving the hand and awl anteriorly.第十六页，本课件共有40页The awl is introduced into the femoral canal;as it entersthe bone,the awl is adjusted to be in line with the femoralshaft by moving the hand and awl anteriorly.第十七页，本课件共有40页Once the awl has been introduced gently,it is tappeddown past
10、the calcar to allow for easy passage of theguidewire.第十八页，本课件共有40页Once the awl has been introduced gently,it is tappeddown past the calcar to allow for easy passage of theguidewire.第十九页，本课件共有40页The guidewire should have a gentle distal bend to allow easy passage across the fracture site.The guidewir
11、e is introduced down the femoral shaft.第二十页，本课件共有40页A soft tissue protector can be used to minimize muscle injury proximally.第二十一页，本课件共有40页The guidewire is advanced down the canal.Note the colinearity of the entry point with the center of the shaft.第二十二页，本课件共有40页The guidewire is introduced to the le
12、vel of the fracture.第二十三页，本课件共有40页The fracture is reduced and the guidewire is passed across and distally until it is just shy of the epiphyseal scar in the center of the femur on the AP radiograph.This is particularly important for distal fractures.第二十四页，本课件共有40页Once the guidewire is fully introduc
13、ed,length may bemeasured in many ways.While some systems havejigs to measure length,a foolproof system is to measure a residual of a guidewire of the same length.第二十五页，本课件共有40页The above image demonstrates a second guidewire of thesame length introduced to the level of the trochanter.第二十六页，本课件共有40页A
14、Kocher clamp is placed on the guidewire so that the residual can be directly measured.第二十七页，本课件共有40页Measuring the residual from this guidewire will give an exact measurement of the longest nail that is possible for this patient.After measurement is obtained,the femoral canal is reamed.第二十八页，本课件共有40页
15、The reamer introduced through the stab incision and the soft-tissue protector used to protect the musculature.第二十九页，本课件共有40页After reaming is complete,the appropriate size nail is chosen.Before the nail is inserted,as with any nailing procedure,theproximal jig needs to be checked for appropriate alig
16、nment ofthe locking mechanism.第三十页，本课件共有40页An exchange tube is placed over the ball-tip guidewire,which is then removed.A straight guidewire is then placed through the exchange tube,which is then removed,allowing for placement of the nail over the straight guidewire.第三十一页，本课件共有40页The nail is gently
17、tapped down the canal.Any significantresistance warrants biplanar radiographic confirmation ofappropriate position of both the guidewire and the nail,aswell as areas of the femoral neck for possible fracture.第三十二页，本课件共有40页After the nail is appropriately seated,with the jig at thelevel of the greater
18、 trochanter,the proximal jig is used tolock the nail.Distal locking is generally performed using a freehand technique via perfect circles.第三十三页，本课件共有40页第三十四页，本课件共有40页第三十五页，本课件共有40页第三十六页，本课件共有40页The above image demonstrates the C-arm in a position to view a perfect circle.第三十七页，本课件共有40页This image shows the distal end of the nail with thescrews in place,the blackout radiograph.第三十八页，本课件共有40页AP and lateral radiographs of the nail in place.第三十九页，本课件共有40页Portable AP x-ray of the hip,which should be taken in the operating room to rule out iatrogenic femoral neck fracture.第四十页，本课件共有40页