Yes, exactly. I probably missed mentioning, yes drain should be placed posterior to the posteriomedial edge of tibia to avoid drain site wound complications

Yes

Yes 👍

Thanks for your feedback. I use medial entry in two broad indications: Trochanteric comminution (can result in wedge effect) and subtrochanteric fractures (to avoid varus alignment).

@Justorthothings thank you

Sure, will add soon

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A simple curved cannulated awl can help. Just insert the threaded guidewire medial to the GT and insert only for a few millimeters. Then pass the awl over the guidewire and with that remove the medail bone with gentle rotation/hammer taps as per bone quiality.

@Justorthothings tq sir

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Thanks for your feedback. DHS can't be used as its sliding force will displace the unstable trochanteric fracture as the lateral wall is deficient. DCS is difficult as you cannot create an overlapping zone with the distal femur locking plate to avoid stress risers at the end of two implants. Nail is a must, considering its biomechanical superiority.

Thanks for your feedback. Yes, as we try medial entry to avoid wedge effect, the medial entry is difficult with extensive trochanteric area comminution. Removing the medial bone is the alternative step in such cases.

When pushing the punch from the medial side, I make a proper round window same as size of punch maximum dimension for lifting depression. When using Steinmann Pin to lift depression, I just a hole with sharp end of Steinmann pin and then turn it to use blunt end for passing through that hole. The hole is small and gets fully covered with perosteum. When punching from lateral, I go through the lateral condylar fracture plane to push depressed fragment.

Nail plate combination will help, you can share images on email: [email protected]

Thanks for your feedback🙏

Thanks for your feedback. Actually no screw is from anterior to posterior(see ap view), either you are exiting posteromedially or posterolatetally. For avoiding the risk of longer screw, we do not drill the far cortex and hit it with woodpecker technique, and then compensate 2mm extra in the screw size.

Please send on [email protected] or whatsapp on 8178605393

Thanks for your feedback 🙏

Thanks for your feedback 🙏

Actually three are sufficient and this is scientifically established. We unknowingly make construct rigid by adding extra screw. A good screw density of 50% in diaphysis and 3 locking screws, good plate length and zero screw near comminuted zone makes all heal biologically.

@Justorthothings got it sir 🙏

Thanks for your feedback. See, what you are saying is correct regarding blade design and its principle. But that may not be correct in all cases. The motion of the spiral part and the outer part is relative to each other, which means both have to close the gap. In that attempt in some osteoporotic hip fractures, the spiral part comes closer to the outer tube owing to weak purchase in bone rather than the outer tube going towards the spiral part. That creates a mismatch in the intended TAD vs. TAD we actually got at the end of screwdriver disengagement. The latter becomes large. The mandatory compression here means the shortening of the gap between the spiral part and the outer tube, not always the fracture compression. Like in the example shown in the video, it's the gap closure without bringing compression at the fracture site.

@ thanks for explaining. But the point is the outer cortex is over-drilled and free sliding of the outer tube is must/ extremely easy. If we say the osteoporosis may allow pull-out of helical blade from head, then every DHS would fail at tightening of lag screw. Still every DHS survive not only insertion but also compression.

@AnwarKhan-xi4rh technically thats because DHS had deep pitch threads and pfn has a blade, the previous one is inserted by rotation and the latter gets hold because of impaction. I dont have any experience with DHS with spiral blade, if thats what you want to convey. Also, I feel osteoporosis is definitely the issue for poor hold of spiral blade, otherwise there wouldn’t have been the need to design cement augmentation for these fractures.

Definitely, medial skin issues quite frequent in proximal tibia. I ll soon add a presentation on that. Thanks

@@nooralam-bc8lv yes, implant positioning would have become challenge in single approach

Thanks for your feedback.I humbly differ with the opinion of designers. I would be happy if some renowned surgeon posts all cases of FNS done with good bolt positioning and show the outcomes till union. IMO the FNS use will fall over coming years unless some real changes in design are made.

Thanks for your feedback!

Yes .. for both columns !!👍

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Thanks for your feedback!!

Thanks 🙏

Often, when the fracture is unstable, it will tend to displace in the direction of deforming force, even after interlocking has been done. So, it's always safe to retain the poller screw.

Yes, whenever in doubt about the void, I am in favor of autologous bone grafts more than bone graft substitutes.

Thanks for the feedback. The above video was added on some specific requests in previous videos on distal femur. If you want additional details I can address that in separate presentation or those might be already addressed in previous videos on distal femur. Thanks.

Thanks! Yes, definitely for large voids, we do use some bone graft substitutes. However, in most other situations, the impacted cancellous bone is sufficient and gets a good screw purchase. Mostly, it's a subjective decision. But we ensure that we have a good network of screws in the subchondral bone so that bone subsidence is minimized.