Femoral Intramedullary Nailing - Engtin Nge Insertion Point tha ber i thlan theih ang?

Inhmelhriattirna

Femoral fracture enkawlna lama hmasawnna hi kum 1940 chho vela Kuntscher-a’n closed intramedullary nailing technique a rawn luh tirh atang khan a lo awm tawh a ni. Femoral fracture-a intramedullary nails (IMNs) hman hi kum sawmhnih kalta chhung khan enkawlna standard a lo ni ta a, tuna hmasawnna a awm mek bawk intramedullary nailing leh surgical technique lama hmasawnna avang hian femur-a intramedullary nailing hmanna pawh nasa takin a pung thei a ni.

Femoral stem fracture-a conservative treatment hi damlo tlemte chauh, anesthesia leh surgery-a dodalna langsar tak neiah chauh hman a ni a, enkawlna bulpui ber chu surgical fixation a la ni reng a ni. Heng ruh tliak te hi surgical treatment chungchangah hian duhthlan tur engemaw zat a awm a, chung zingah chuan intramedullary nailing, plate screw fixation, leh external fixation te pawh a tel. Surgical option dang nena khaikhin chuan intramedullary nailing hi complication rate hniam ber leh fracture healing rate sang ber modality a ni a, clinical practice-ah pawh hman a ni nasa hle.

Proximal femur anatomy, femoral head-a thisen supply leh hip muscles anatomy hriatthiamna tha tak chuan femoral fracture-a intramedullary nailing hlawhtlinna rate nasa takin a tisang thei a ni. Chumi danglamna chu, entry point thlan dan hi thil tam takah a innghat a, chung zingah chuan intramedullary nail design, fracture site, fracture comminution, leh patient factors (eg, polytrauma, naupai, leh thau lutuk) te pawh a tel. Entry site thlan chu eng pawh ni se, intramedullary nail insertion laiin reduction tling tak neih theih nan entry point dik tak hmuh hi a pawimawh hle a, chutih rualin complication awm theihna a tlem phah bawk.

Femoral Anatomy a ni

1.Femoral head-a thisen supply

Femoral head hian artery lian 3 atanga vascular supply a dawng thin. Lateral rotator femoral artery (branch 3-4 nei), round ligament supply tu obturator artery leh medial rotator femoral artery (Fig. 1), chunglam hawia chho thei vessel pawh a chhuah a, chu chuan lateral rotator femoral artery nen anastomose a, greater trochanteric region a supply bawk.

2.Hip Muscles te Anatomy

Femur-a intramedullary nailing kan tih hian rotor chhehvela ruh awmte hriatthiamna tha tak neih a pawimawh a, chu chuan a tul lo taka hliam a tuar lo thei a ni. Gluteus medius muscle hi ilium atanga lo chhuak niin greater trochanter lateral aspect-ah a tawp a, gluteus minimus muscle pawh hi ilium atanga lo chhuakin hip joint posterior aspect kaltlangin greater trochanter posterior aspect-ah a tawp a ni (Figures 2 & 3). Heng muscle pahnih hian thigh adductors leh hip internal rotators angin hna an thawk a ni. Chuvangin, paracentric femoral intramedullary nail dah laiin heng ruhte hi a chhiat chuan adductor chak lohna leh Trendelenburg gait a thlen ang a, hei hian damlo dam lehna leh a chhuah danah nghawng tha lo tak a nei a ni.

Fig. 2. Hip joint chhehvela taksa peng hrang hrangte anatomy

Figure 3. proximal femoral muscle inzawmna hmun

A rilru a buai em em a, a rilru a hah em em bawk a. Parallel Femoral Intramedullary Nail

Tun hnaia zirchianna engemaw zatah chuan paracrine femoral nail luh theihna tur hmun tha ber chu an zirchiang tawh a ni. Nail entry point option-ah hian greater trochanter leh pyriform fossa te a tel a, anmahni hian anmahni indication leh a kaihhnawih complication hrang hrang an nei vek a ni (Table 1).

Table 1.Paracrine leh retrograde femoral nailing avanga bul tanna tur leh hlauhawm awm thei te
variant a ni	parallel intramedullary nail a awm bawk		retrograde intramedullary nail a awm bawk
	rotor hmanga siam a ni	pyriform fossa (a taksa peng hrang hrangte) .
lallukhum thlawhna a ni	Vertex of the greater trochanter leh medial-a medullary cavity lam hawia awm	inzawmna trochanter lian zawk leh femoral neck	median a awm a, chu chu intercondylar fossa (anatomy) a ni.
sagittal plane (math.) tih a ni.	Greater trochanter lairil leh femur-a marrow cavity lairil inkar line	pyriform fossa (a taksa peng hrang hrangte) .	PCL chu femoral starting point hmalam 1.2 cm a ni a, medullary cavity lam hawiin a awm.
exposure te pawh a awm	Hip abductor group-in an chawlhna hmuna hliam an tuar	thisen kalna a chhiat Femoral head leh hip external rotator muscle-a	Handling dik lo chuan PCL a thlen thei
PCL: hnunglam cruciate ligament a ni

1.Rotor needle luhna hmun lian tak

Trochanter lian zawk chu femoral neck lateral aspect-a awm, pawn lam ber trapezoidal bony protuberance anga sawi a ni a, a chunglam hian lateral gluteus medius leh anterior gluteus minimus muscle-te nena inzawmna a pe a ni (Figure 2 leh 3). Hei hi ruh chhinchhiahna tenau tak ni mah se, femoral IMN tih huna bul tanna dik tak localizing hi femoral stem fracture hmachhawn hunah result lungawithlak emaw, tha lo emaw hmuhna inthlauhna a ni thei.

Tuna literature-a femoral entry point sawifiahna kan enfiah chuan femoral rotor IMN entry point atana anatomical landmark chiang taka tarlan a awm loh thu kan hmu a.Bharti et al. a sawi a, greater trochanter apical apex atanga entry point chu orthostatic position-a medullary cavity lam hawia medial a nih thu leh, greater trochanter center chu femoral medullary cavity center nena inmil lateral position-a awm anga sawi a ni (Fig. 4), lateral hip view-a greater trochanter entry point sawifiahna dang chu anterior inkar hmalam inkar rotor-ah a ni rotor hmun thuma ṭhena hmun khat leh hnunglam hmun thuma ṭhena hmun hnih.Georgiadis et al. chuan needle luhna hmun chu rotor apical superior margin hnunglam ber a nih thu a sawi.

FIGURE 4. Intraoperative orthostatic leh hip lateral view-ah chuan greater trochanter-a femoral paramedian intramedullary nailing luhna tur entry point tha ber a ni. '*' hian intramedullary nail luhna hmun a kawk a ni.

Tun hnaia literature-a zirchianna hrang hrangah chuan greater trochanter apex hi optimal line of force hmuhna atana bul tanna tha ber a ni tih a tarlang a, inversion deformity avanga alignment tha lo chu a point of entry chu greater trochanter lam 2 mm aia lateral lateral-a sawn a nih hian a thleng fo thin tih a tarlang bawk. He zirchianna hian posterior entry point tam zawk chuan distal forward displacement a thlen thung a, chutih laiin intermediate entry point chuan distal fracture block chu posterior-ah a displace thei tih a sawi uar hle bawk. Chumi danglamna chu, zirchianna dang pakhatah chuan intertrochanteric femur fractures-ah chuan pinning point chu anterior side-a lateral-a awm a nih chuan medial leh posterior side-a inhnaih zawk pinning point aiin intramedullary nail impingement a tam zawk tih a tarlang.

Greater trochanteric apex pinning point hi damlo thau lutuk tan hman a ni tlangpui a, he procedure hi technically demanding a tlem zawk a, operative time a tlem zawk a, pyriform fossa pinning point aiin complication risk a tlem zawk bawk.

COMPLICATIONS: Trochanteric approach point lian zawk nei femoral intramedullary nailing-a intraoperative leh postoperative complications te chu publication engemaw zatah sawiho a ni tawh. Chung zinga pakhat, nailing technique nena inzawm tlangpui chu medically induced fractures a ni. Intertrochanteric femoral fracture-ah chuan greater trochanter lateral leh anterior-a awm entry point chuan medial side hnaih zawk entry point aiin medial fracture a thlen tam zawk.

Complication dang kaihhnawih chu soft-tissue hliam vang a ni a, a bik takin medial rotator femoral artery branch leh adductor muscles te a ni a, mahse heng hliam te hi pyriform fossa entry nail nena khaikhin chuan a tam lo hle. Tin, entry point angin greater trochanter apex nei femoral head-a ischemic necrosis awm zat pawh a hniam hle nia ngaih a ni a, zirchiannaah chuan 0.3% velin a tlahniam tih an sawi bawk.

Intraoperative time leh fluoroscopic exposure ngaihtuah chuan trochanteric entry point lian zawk tan chuan mean operative time chu minute 90.7 a ni a, pear-shaped fossa entry point group tan chuan minute 112.7 a ni a, fluoroscopic time erawh chu greater trochanteric entry point group tan second 5.88 a ni a, pear-shaped group tan chuan second 10.08 a ni thung fossa entry point group, pear ang maia fossa entry point nen khaikhin chuan.

Intramedullary nail entry point chungchanga thutlukna siamnaah pawh damlo prognosis hi thil pawimawh tak a ni a, a chhan chu operational recovery hmasa (chair-seat test leh timed elevation test hmanga teh angin) chu operational recovery hmasa ber (chair-seat test leh timed elevation test hmanga teh angin) chu trochanteric entry point lian zawkah chuan trochanteric entry point lian zawkah chuan pyriform fossa entry point nail nen khaikhin chuan a tha zawk tih a chiang hle a, mahse he danglamna hi thla 12 hnuah chuan a langsar lo hle. Trochanteric access point lian zawk hi a awmna hmun avang hian soft tissue stripping tlem zawk nen inzawm mahse, abductor muscle group-ah hliam a la thlen thei tho a, hei hi Ergiş et al. An hmuhchhuah dan chuan trochanteric entry peg lian zawk nei damlote chu hrisel control te nena khaikhin chuan dynamic balance leh hip abductor strength a tlahniam a ni. Tin, an zirchiannaah hian non-operated side nena khaikhin chuan hip abductors, flexors leh internal/external rotators te chakna a tlahniam nasa hle tih an sawi bawk.

2. Pearly fossa luhna hmun

Pyriformis muscle fossa hi anatomical landmark pawimawh tak a ni a, paracentesis femoral intramedullary nail luhna hmun pakhat anga hriat a ni.An autopsy cadaveric study-ah Lakhwani et al. pyriformis muscle fossa chu 'pear' ang chi a ni lo va, pyriformis muscle attachment pawh a ni lo tih an hmuchhuak. Muscle hi greater trochanter tip-a hmun tlemteah a inzawm a, pyriform fossa erawh chu greater trochanter medial side-a depression a ni a, extensor carpi radialis brevis muscle attachment a ni thung. Hemi ziaktute hian pyriform muscle leh pyriform fossa hi entity hrang hrang pahnih an nih thu an sawi chhuak a, pyriform fossa an tih chu chiang zawk leh anatomical correctness atan 'rotor' emaw 'occlusal' fossa emaw tia sawi tur a ni. Anni chuan cis-femoral an zir hnuah parafemoral entry point terminology an zir chian hnuah 'pyriform fossa' tih ai chuan 'rotor fossa' tih thumal hmasa ber 'rotor fossa' tih chu literature-ah dah leh turin an rawt a ni. Heng zirchianna pahnih point-te hi ngaihsan hlawh tak ni mah se, sawifiah awlsam zawk nan leh trochanteric entry point lian zawk nena inthlau lo turin, he entry point hi pyriform fossa entry point tiin kan la sawi chhunzawm zel ang.

Tuna literature-a zirchianna engemaw zatah chuan intramedullary femoral nails-a pearly fossa luhna hmun dik tak chu dik takin an sawi a ni.Georgiadis et al. pearly fossa entry point chu femoral neck bul hnaia depression-a extensor carpi radialis brevis muscle inzawmna hmun angin sawi rawh (Fig. 5). Hemi ziaktute hian entry point hmalam lutuk emaw, chhung lam hla lutuk emaw chuan femoral neck fracture a tipung thei tih an sawi bawk a, entry point chu hnunglam a hla lutuk chuan ischemic necrosis a awm theihna a sang hle thei tih an sawi bawk a, hei hi tleirawl damlote zingah a sang zawk a ni.

Figure 5. Intraoperative frontolateral view of the hip a pyriform fossa retrograde femoral intramedullary nail tan entry point tha ber a ni. '*' hian intramedullary nail bul tanna hmun a tarlang a.

Harper leh a thawhpuiten an sawi. kum 1987 khan mihring ruang femur pawl 14 zirchianna an tichhuak a, chutah chuan intramedullary guide pin awmna hmun leh intramedullary nail chhuahna hmun chu distally leh proximally-a retrograde fashion-a femur intercondylar notch atanga retrograde fashion-a luhtir chu an zirchiang a ni. An thutluknaah chuan pyriformis paramedian intramedullary nail luhna hmun chu greater trochanter leh femoral neck inzawmna hmunah a awm a, pyriformis occulta hma lam deuhah a awm a ni.The insertion site was reconfirmed by Gausepohl et al. Cadaveric study dang pakhatah chuan femoral intramedullary nail tan ideal entry point chu pyriformis tendon chunga greater trochanter medial edge-ah an localized a. Chubakah, Labronici leh a thawhpuiten cadaveric study an neihah chuan, pyriformis muscle fossa chu pear ang maia lian luminal region anga sawi a ni a, chu chu coronal plane-a femoral intramedullary cavity central axis nen a inmil a ni.

Pyriform fossa access point hian harsatna bik engemaw zat a nei a, a chhan chu trochanter access point lian zawk nena khaikhin chuan technically a harsa zawk a, a bik takin damlo thau lutuk tan chuan a harsa zawk a ni. Chu bakah, pear-shaped fossa needle entry point luhna hmun tha ber chu hmun zau tak a nih avangin localize a harsa zawk. Entirnan, femoral neck-a hmalam panna hmun tam lutuk chuan circumferential stress nasa lutuk a thlen ang a, hmalam cortical burst theihna a tipung ang, a bik takin a bul tanna hmun chu fossa hmalam 6 mm aia tam a nih chuan. Chu bakah, morphologic contrast hian entry site dik tak a tikhawlo thei a, a bik takin short external rotator chu bulky emaw rotor protruding emaw a nih chuan entry site chu medial lutuk a nih avangin femoral neck fracture a awm thei a ni.

COMPLICATIONS: Femoral intramedullary nailing atana trochanteric entry site lian zawk 38 leh pearly fossa entry site 53 an khaikhin chuan Ricci et al te chuan pearly fossa group hian operation hun 30% a rei zawk a, fluoroscopy hun pawh 73% a rei zawk tih an hmuchhuak. Heng thil hmuhchhuah te hi Bhatti et al. needle entry point 2 te khaikhin a nih chuan.

Soft-tissue hliam chungchangah chuan, trochanteric needle entry point lian zawka interosseous neuromuscular nena khaikhin chuan pyriformis inlet-ah soft-tissue hliam a awm theihna a sang zawk. Dora leh a thawhpuiten an sawi. puitling cadaveric femur 16 chu pyriformis muscle leh rotor entry pin-a soft tissue hliam an neih leh neih loh an zirchiang a. An hmuh dan chuan pyriformis fossa hi geometrially optimal ni mahse, femoral head leh a chhehvel muscle leh tendons-a vascular supply-ah chhiatna nasa zawk a thlen a ni. Heng thil hmuhchhuah te hi Ansari Moin et al. WHO pawhin entry point pahnih a khaikhin bawk. Pyriformis muscle atanga nail internal fixation hian hip abductors leh external rotators te a tichhe zawk tih an hmuchhuak. Tin, medial rotator femoral artery chhiatna chu case zawng zawngah hmuh a ni bawk (Table 2).

Table 2. Needle luhna hmun hrang hranga soft tissue hliam awm dan tlangpui
variant a ni	Pyriform fossa luhna hmun (n=5) .	Rotor feed point lian tak (n=5) .
tissue nem tak
gluteus medius taksa ruh (anatomy) a ni.	5	1
gluteus medius tendon a ni	0	4
tendon hliam a awm
gluteus minimus (anatomy) tih hi a ni.	3	0
pyriformis muscle (ruh chunglam chunglam) .	3	3
obturator internus (anatomy) hmanga thil tih dan (anatomy) .	1	0
latissimus dorsi taksa peng (anatomy) .	3	0
Thisen kalna kawng leh ruhkawr (joint capsule) te
MFCA Branch thuk tak tak te	4	0
MFCA Shallow Branch-ah a awm a	4	0
articular capsule (anatomy-a khup ang chi joint) .	1	0
MFCA: ke ruh (medial circumflex femoral artery) a ni.

Tun hnaiah Bharti leh a thawhpuiten an sawi. an zirchiang a, femoral intramedullary nailing-a complication risk chu greater trochanteric entry point leh pearly fossa entry point-ah an zirchiang a, fracture healing rate ang chi complication risk an hmuchhuak a, a hnuaia mi ang hian an khaikhawm a ni (Table 3).

Table 3. Pyriform fossa luhna hmun leh trochanter lian zawk luhna hmun femoral bone marrow
harsatna (complication) a awm	Piriformis sinus ah hian a zung a awm	Trochanter dahna hmun lian zawk
Infect a ni	6.7	3.3
Malunion a ni	20	13.3
Damna a tlai	20	13.3
Hip motion tihtlem a ni	20	33.3
Khup inthlak danglamna limited	6.7	6.7
Limb sei zawng inang lo	13.3	20
Tail cap hi bone cortex chungah a rawn chhuak a	13.3	20
Operation chhunga femoral neck fracture a awm	10	0
Trochanter fracture lian zawk a awm	0	3.4
Femoral lu lam natna (femoral head necrosis) a awm	6.7	0

Retrograde femoral intramedullary nailing hmanga tihbuai a ni

Retrograde femoral intramedullary nailing atana entry point dik tak hriat chian chuan fracture alignment, a sei zawng, leh rotation tha ber siam thatna kawngah a pui ang a, chutih rualin articular cartilage chhiatna, anterior cruciate ligament (ACL), posterior cruciate ligament (ACL), leh soft tissue injury te a tihtlem phah bawk ang (Table 1). Tun hnaiah hian retrograde femoral intramedullary nailing hi ngaihven a hlawh chho zel a, hei hi paracromial nailing nena inzawm harsatna tihziaawmna tur a ni a, chung zingah chuan hip pain, heterotopic ossification, adductor weakness, leh pudendal nerve palsy te pawh a tel a, hei hi incisional reduction leh locking femoral plating for internal nena khaikhin chuan minimally invasive anga ngaih a ni fixation, a bik takin femoral stem hmun thuma ṭhena hmun khat distal fracture-ah. Chu bakah, tun hnaia evidence atanga a lan dan chuan heng retrograde intramedullary nails te hi a size dik taka siam a nih chuan proximal locking nails hi a ngai lo mai thei bawk.Meccariello et al. leh Bisaccia leh a thawhpuiten an ziak bawk. distal one-third femoral stem fracture enkawlnaah locking leh nonlocking retrograde intramedullary nails hmanga enkawl a ni. Chutiang chuan retrograde femoral nailing hman chu a lar ta hle a, mi tam takin an pawm ta a ni.

Retrograde femoral intramedullary nailing atana entry point tha ber sawifiahna tam tak chu literature-ah hmuh theih a ni. Zirna tam zawk chuan retrograde femoral nail tan entry point tha ber chu posterior cruciate ligament femoral origin hmalam 1.2 a ni tih an hmuchhuak

cm (medullary cavity nena inmil) leh intercondylar fossa lairil (Figure 6) te a ni.

FIGURE 6. Khup intraoperative orthostatic leh lateral views atanga retrograde femoral intramedullary nail tan entry point tha ber a lantir. '*' hian intramedullary nail bul tanna hmun a kawk a ni.

Retrograde femoral intramedullary nailing awm theihna tur absolute indication awm lo mah se, multiple relative indications sawi a ni tawh bawk. Chung zingah chuan polytrauma vei, morbidly obese patient, naupai, bilateral femoral stem fracture, ipsilateral femoral stem leh acetabular/pelvic fracture emaw femoral neck fracture emaw, ipsilateral femoral stem leh tibial fracture te an tel. Heng indication tam zawk hi damlo positioning awlsamna leh hnai taka surgery hliam tam tak venna nen a inzawm a ni.

A lehlamah chuan retrograde femoral intramedullary nailing hman lohna tur absolute contraindications te chu retained implant hmanga retrograde intramedullary channel tihkhawtlai leh distal femur open fractures te a ni. Relative contraindications chu lesser trochanter atanga cm 5 chhunga awm fracture, khup flexion degree 45 aia tlem avanga optimal entry point thlen harsa, khup infection hmaa femoral stem-a darh theihna, khup vel soft-tissue hliam na tak, leh inferior pole of the intra-articular fracture te hi a ni patella leh extreme distal pole te a ni.

Harsatna: Retrograde femoral nailing-a harsatna tam zawk hi hman dik loh vang a ni a, a bik takin entry point dah dik loh vang a ni. Sagittal plane-ah chuan hmalam entry point tam zawk a awm chuan posterior fracture translation a awm ang a, articular surface a tichhia ang a, khup a flex laiin patella-ah nail impingement a awm thei bawk. A lehlamah chuan entry point chu posterior direction-a dah dik loh chuan hei hian posterior cruciate ligament origin-a hliam leh fracture site hmalam panna a thlen thei a ni.

Hutchinson leh a thawhpuiten an ziak a ni. coronal plane entry point dik lo avanga harsatna awmte a sawi. An hmuh dan chuan medial entry point tam lutuk chuan posterolateral deformity a thlen a, posterolateral fracture translation a nei a, lateral lutuk chuan medial deformity leh medial translation a thlen thung.Sanders et al. report chuan medial axis atanga cm 2 aia hlaa medial starting point thlan chuan medial cortical fracture a awm a, chu chu fracture posterior isthmic bending moment vangin malunited a ni a, chu chuan posterolateral reduction tha lo a thlen a ni.

Retrograde femoral follower nailing nena inzawm harsatna dangte chu khup na, khup khauh, heterotopic knee ossification, leh intra-articular knee free body formation te a ni.

Thutawp sawi rawh

Intramedullary nailing technique tin hian a inmil tur indication nei mahse, femoral stem fracture enkawlna atana eng intramedullary nailing technique nge hman tur tih thlan chu surgeon duh danah a innghat tlangpui. Femur-a intramedullary nailing tih hian fixation atana hman tur nail chi hrang hrang entry point dik tak hmuh a ngai a, chu chu hlawhtling taka a chhuah theih nan a ni. Local anatomy leh imaging performance hriatna chuan surgeon chu technically adequate procedure a tih theih nan a pui ang a, chutih rualin associated complications risk a ti tlem bawk ang. Tin, intramedullary nailing procedure-ah chuan reduction enkawl hi malunion leh malunion emaw nonunion of fractures emaw venna atana thil pawimawh tak a ni.