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I think your concern is very much valid. But, as I told in the video, this case was taken in emergency OT by a resident, who thought that it would be just another neck femur fracture as the patient had given false history to get admission. The old nature of the injury was realized only when the patient was on a fracture table under general anesthesia. Now, in that situation, you don't have any backup implant or consent for a bone graft. Ideally, as I told in the video end, I would have planned for valgus osteotomy with a fibular strut.

Thanks! Yes, a 2 hole longer plate could have been better. But main principle is that the plate length should be 2-3 times the comminuted zone and with scope of at least 3 locking screws with screw density of 50% in diaphyseal segment spanned by the screws. That ensures almost negligible stress on last screw. So when putting the top screw, if it is close to second screw, it will result in stress concentration, but if is it 1-2 hole away, it will not.

Two screw PFN should never be used in unstable trochanteric fractures (screws loosening, collapse and Z effect issues), pfna can be used with blade in suboptimal bone quality but to be avoided in severely osteoporotic bones. Nails that control rotation and some sliding of blade/screw should be preferred.

If isolated medial condyle with split then medial parapatellar approach would do. If medial condyle split with simple lateral condyle, then also medial parapatellar would do. If medial condyle and lateral condyle both split (with additional posterolateral and posteromedial apices) then dual medial+ lateral approach. This has been explained with illustrations and case examples here th-cam.com/video/-hq4E5kYyK8/w-d-xo.htmlsi=AGt-4q31Dd_YZ46z

Really sorry for this issue. If speed is the issue then you can adjust it to 0.75 around in youtube player settings. Otherwise if have any specific query I can address that in comment or will add a small video addressing the same. Thanks

@@Justorthothings Thanks

Hi, thanks for your feedback. Most patients do bear some weight despite advice against doing so. We instruct them to avoid weight bearing till we are sure that there is radiological bridging bone. So, considering the noncompliance to non-weight bearing and to avoid full weight bearing, we ask patients to use a walker and then avoid weight bearing. So, with a walker, we have at least some security that the patient will not bear full weight. Partial weight bearing, I feel, should not be an issue because the forces around the hip without weight-bearing are also high and may equate to the load-bearing forces.

@@Justorthothings thank you very much. Its verys clear now. Btw, should x ray performed every months or every 2 months enough? ANd before you apply weight bearing after 2,5 month. Is it directly weightbearing or start slowly

@@nunurosi8028 We follow every 4-6 weeks until radiological healing and consolidation are evident. After that, 3-6 months. Yes, weight bearing is gradual so that the patient develops some proprioception and muscle balance.

See, in some fractures, you are invariably going to merge the nail entry with the fracture line, even if you don't intend to do so. The main thing is to avoid the wedge effect, even if your entry merges with the fracture line. See this video; you ll get it: th-cam.com/video/t3lexJPKCkY/w-d-xo.html

No, once guidewire has been put, no traction should be increased. See releasing traction at the first time is to align the medial cortex levels and is thus can be controlled, the second time its for relaxing muscle tension which will be perceived as the difficulty in gaining compression. As I have shown in second example, the amount of traction release can be negligible at times when medial cortex spikes are at same level even if fracture is slightly distracted. So, you have the indicators (medial cortex levels and force for compression) for sequential release of traction at two steps and the amount will vary from case to case.

Hi, Sorry, at this stage, I won't be able to make it public due to professional commitments, but maybe later I will.

Could have thought that, but here the patient was less than 20 years old, so saving the hip is worth it!

Thanks! See, as I told in the video, once you have inserted the screw, the excess traction is of no use. You can release the traction gradually so that muscle tension is relaxed. The compression actually pulls the shaft towards the proximal fragment in a direction parallel to the direction of the screw/or blade. If your reduction is positive and medial spikes (calcar ends) are at the same horizontal level, then after placing the screw, the excess release of traction won't be an issue. Problems can occur when there is a wedge effect or when the guide wire is inserted in a distracted position.

Yes, the K wire shall be removed only after some length stable fixation is done. Either you can secure that length with some lag screws when K wire is still in place and when that is not feasible, you can put plate with a screw hole over the K wire, the lock few proximal and distal screws and then remove the k wire.

Thanku sir

Thanks! Yes, a 2 hole longer plate could have been better. But main principle is that the plate length should be 2-3 times the comminuted zone and with scope of at least 3 locking screws with screw density of 50% in diaphyseal segment spanned by the screws. That ensures almost negligible stress on last screw. So when putting the top screw, if it is close to second screw, it will result in stress concentration, but if is it 1-2 hole away, it will not.

Thanks for your feedback! 🙏

Thanks for your feedback!

Thanks for your feedback!

So CT angiography is must for this kinda cases right?

@@parkaviyanr6397 In cases with extensive diaphyseal comminution, definitely yes.

Thanks for you feedback, will add soon.

The release of traction can be helpful when the fracture is distracted and should be done before screw placement. That means the medial fragment's lower spike is higher and does not match the defect on the lateral fragment. The calcar side should be matching before placement of screw. Otherwise, when traction is released with the screw in position and fracture distracted when the screw was placed, it will result in a "negative reduction."

Sure, will do it soon.

Thanks!! When a short medial plate is needed, the Swashbucker or midline approach is sufficient for proximal and distal exposure. But when long plate is needed, you can pass it through MIPO technique. An entry incision is made over medial condyle prominence and an exit incision is made proximally over the diaphysis, just in line with it under C-arm guidance, as we do in proximal locking of DFN, the vastus muscles are split and diaphysis is exposed. After that the plate can be pushed from medial condyle to anterior surface of femoral duaphysis and then rotated anteromedially using a locking sleeve. The technique is quite simple once you become familiar with it. The proximal screws go from anteromedial to posterolateral direction and under direct vision. I will try to record the steps in some surgical case and add a stepwise video soon.

@@Justorthothings thank you for your reply sir . What about the artery while passing in mippo . Can you share a video or image showing relation of plate and artery

@@chaitanyaksk90 Than ks. The plane is very much safe and is submuscular in location as we remain on the anteromedial and anterior surface of the femur when passing a long plate from distal to proximal. Otherwise in most scenarios, the plate is small and the anterior approach to distal femur is sufficient for medial plate as well. I will post the postop CT of a long medial plate case so that the plane of the long plate can be understood. I will also try to record clinical images/video when doing a long medial plate later.

@@Justorthothings sir in the ct image you're going to upload show the relation of artery and plate so that it becomes easy

Thanks!! When a short medial plate is needed, the Swashbucker or midline approach is sufficient for proximal and distal exposure. But when long plate is needed, you can pass it through MIPO technique. An entry incision is made over medial condyle prominence and an exit incision is made proximally over the diaphysis, just in line with it under C-arm guidance, as we do in proximal locking of DFN, the vastus muscles are split and diaphysis is exposed. After that the plate can be pushed from medial condyle to anterior surface of femoral duaphysis and then rotated anteromedially using a locking sleeve. The technique is quite simple once you become familiar with it. I will try to record the steps in some surgical case and add a stepwise video.

Thanks for the feedback. At 1:50, it's the right calcaneum that is seen from above.

Short 25 mm Long 38 mm

🙏Thanks for the feedback.

Thanks 🙂

Thanks for your feedback. Will fix that for sure. ✔️

🙏

Thanks, Rightly asked! Yes it’s intentionally kept in slight valgus. We always confirm the alignment from the contralateral limb to see if valgus or neutral reduction is needed. In several young patients the distal femur is in slight valgus while proximal tibia is in slight varus normally, so that helps as template in guiding the reduction adjustments. The opposite knee is always available for c arm view and that really helps. In bilateral injuries, we just add slight valgus considering that failure of such fixation is mostly in varus and thus slight valgus is more suitable if we are not sure of pre injury alignment.

The part 2 is related to case examples pertaining different injury patterns and their final outcomes. Currently I am in process of collecting and arranging the data for the same . I will post soon. Thanks