Arch Orthop Trauma Surg (1996) 115:43M4 © Springer-Verlag 1996

K. A. S t e r i o p o u l o s - G. M . K o n t a k i s • P. G. K a t o n i s
I. A. G a l a n a k i s • E . K . D r e t a k i s

Placement of the distal locking screws

of the femoral intramedullary nail without radiation

Received: 4 November 1994

A b s t r a c t A n H-shaped device was invented to facilitate

placement of the distal interlocking screws during closed
femoral nailing. E l e v e n sound cadaveric femurs were ex-
perimentally nailed before the application of the device in
15 patients with a femoral shaft fracture. In all experi-
mental cases the insertion of the distal screws proved to
be easy. In 11 of 15 patients with a femoral fracture, distal
locking was achieved using the H-device. These primary
results should stimulate further clinical application of the
device.

Introduction

Accurate targeting of the distal screws is the most difficult

part of the interlocking femoral nailing procedure. The
Fig. 1 The H device
current procedures are those using targetting devices
m o u n t e d on the image intensifier or n a i l - m o u n t e d de-
vices. The A O radiolucent drill and the free hand tech-
nique are also used [1-4]. These techniques, however, nail outside, parallel and laterally, helps the location and place-
ment of both distal cross-screws (Fig. 1).
have the disadvantage of i n v o l v i n g irradiation. A n H-
shaped device was i n v e n t e d to facilitate distal screw tar-
getting and reduce the a m o u n t of irradiation. Experimental testing

In 11 sound cadaveric femurs experimental GK nailing was per-

formed. After reaming, nails from 12 to 14 mm in diameter were
Materials and methods inserted the reaming was done 1 mm larger in diameter than each
nail. The length varied from 38 to 44 cm. The cross-screws were
The instrument inserted using the H-device.

In the H-device two similar, parallel, intramedullary nails can

be fitted. This device enables insertion of one nail within the
medullary cavity for the fixation of the fracture. The second free
K. A. Steriopoulos (N~)
3 Louka Petraki Street, Heraklion 713 06, Grete, Greece
K. A. Steriopoulos - G. M. Kontakis • P. G. Katonis
1. A. Galanakis • E. K. Dretakis
Department of Orthopaedics-Traumatology,
University Hospital, School of Health Sciences,
University of Crete, Heraklion, Crete, Greece
Clinical application
After obtaining informed consent, the H-device was used during
closed intramedullary nailing in 15 patients with fracture of the
middle third of the femur. Skeletal traction was exerted via a Stein-
mann pin inserted through either the femoral condyles or the tibial
tubercle. A small lateral incision was made to expose part of the
distal femur for the insertion of the cross-screws. Using a guide
sleeve, a 4-ram Steinmann pin was passed through the free (outer)
nail, the lateral cortex, the nail hole and the inner cortex. Conse-
quently, a 5-ram drill bit was used to drill through both cortices
and a 6-mm drill bit to over&ill the near cortex. An image intensi-
fier was used briefly to confirm the correct position of the distal
screws.
44
Results
In all experimental cases the insertion of the distal cross-
screws was possible at the first attempt. However, in 6 of
11 experiments, the nail advancing towards the distal
shaft hit the anterior cortex. In all 6 cases the insertion of
the distal screws was precise. In the remaining 5 cases the
holes of the nails were not absolutely in line, but did not
obstruct distal cross-screw insertion.
In 9 of 15 clinical cases, the insertion of the distal
screws was successful without difficulties. The patients
were thin, and application of the H-device proved to be
easy. In two cases several attempts were needed because
the nails were not initially fitted in the H-device correctly.
In four cases the patients were obese, and the depth of the
site of insertion of the nail in the femur did not allow ap-
plication of the H-device. The distal screws were inserted
using the targetting device on the image intensifier.
Discussion
The methods successfully employed up to now for the in-
sertion of distal nail cross-screws need the use of an image
intensifier with the accompanying danger of radiation [5].
With various procedures, during nail insertion the radiation
from an image intensifier may be regarded as excessive. It
is used once to assess reduction, a second time to confirm
correct penetration of the owl at the trochanteric tip, a third
time to confirm placement of the guide wire within the
medullary canal and possibly a fourth time to confirm sat-
isfactory placement at the lower end.
Distal cross-screw placement appears to be a time-con-
suming procedure. Nails containing an open section over
most of their length frequently undergo torsion on inser-
tion. This changes the relationship between the plane of
the distal transfixion screw tunnels and the top of the nail
and prohibits correct alignment of the proximal mounted
target device when it is reattached. Because these guides
often extend for a distance of more than 40 cm between
their point of proximal attachment and the distal holes, the
problem of malalignment is further aggravated by the ten-
dency of the guide to sag toward the floor when used in
the supine position on the femur or tibia. The H-device is
simple and effective for the targeting of the distal screws
in all experimental samples. The sagging effect by using a
second nail was shown to be insignificant in the six ex-
perimental cases. Reaming by 1 m m more than the diam-
eter of the nail to be used reduces the likelihood of in-
creasing the comminution of the fracture during the inser-
tion of the nail. The resistance to torsion supplied by the
intramedullary nail does not decrease. Although some de-
formation of the nail is expected to occur, this is minimal
with overreaming, and the device was precise. The ideal
device for targetting of the distal locking screws could be
designed if the possible deformation of the nail could be
predicted. Despite this, further investigation to establish
the usefulness of the H-device and to improve it further
may be needed. The effort to place the distal locking
screws without radiation must continue.
Acknowledgement Dr. George Kontakis conceived invented and
designed the H device.
References
1. Grosse A (1981) Manual of osteosynthesis for femoral and tibial
shaft fractures. Howmedica International, Kiel
2. Johnson KD (1992) Femoral shaft fractures. Browner BD et al.
(eds) Skeletal trauma. Saunders, Philadelphia, pp 1525-1641
3. Muller ME, Allgower M, Schneider R, Willeneger H (1991)
Manual of internal fixation, 3rd edn. Springer, Berlin Heidel-
berg New York, pp 291-365
4. Russell T, Taylor J (1986) Interlocking intramedullary nailing in
the femur: current concepts. Cemin Orthop 1:217-231
5. Sanders R, Koval KJ, DiPasquale T et al. (1993) Exposure of the
orthopaedic surgeon to radiation. J Bone Joint Surg [Am] 75:
326-330