Cephalomedullary fixation for femoral neck/intertrochanteric and ipsilateral shaft fractures: surgical tips and pitfalls

Objective: Surgical management options for femoral shaft fracture and ipsilateral proximal femur fracture vary from single-implant to double-implant fixation. Cephalomedullary fixation in such fractures has relative advantages over other techniques especially because of less soft tissue dissection and immediate postoperative weight bearing with accelerated rehabilitation. However, the surgery is technically demanding and there is a paucity of literature describing the surgical techniques for this fixation. The aim of the study was to describe the surgical technique of cephalomedullary fixation for femoral shaft fracture and ipsilateral proximal femur fracture. Methods: Sixteen cases (10 males and 6 females with a mean age of 41.8 years) of ipsilateral proximal femur and shaft fractures were treated by single-stage cephalomedullary fixation at tertiary level trauma center in northern India. The fractures were classified according to AO classification. An intraoperative record of duration of surgery as well as technical challenges unique to each fracture pattern was kept for all the patients. Results: The most common proximal femoral pattern was AO B2.1 observed in 9 of our patients. The AO B2.3 fractures were seen in 4 patients while the AO A1.2 fractures in 3 patients. Four of the AO B2.1 and 2 of the AO B2.3 fractures required open reduction with Watson-Jones approach. The mean operative time was around 78 minutes, which tended to decrease as the surgical experience increased. There was only one case of malreduction, which required revision surgery. Conclusion: Combination of ipsilateral femoral shaft fracture and neck/intertrochanteric fracture is a difficult fracture pattern for trauma surgeons. Cephalomedullary nail is an excellent implant for such fractures but it requires careful insertion to avoid complications. Surgery is technically demanding with a definite learning curve. Nevertheless, a majority of these fractures can be surgically managed by single-implant cephalomedullary fixation by following basic surgical principles that have been summarized in this article.