Cephalomedullary Nail Insertion Procedure

Preoperative Assessment and Planning

Critical preoperative imaging of the entire femur is mandatory to identify any proximal lesions that could lead to implant failure or necessitate alternative fixation strategies, according to the American Academy of Orthopaedic Surgeons 3, 4
A long bone survey or bone scan within 2-3 months is recommended when treating pathologic fractures to detect other disease sites that may affect weight-bearing, as suggested by the National Comprehensive Cancer Network 1, 2
Key preoperative assessments include life expectancy estimation 1, mental and mobility status 2, pain level and metabolic status 2, and skin condition and nutritional status 6

Either spinal or general anesthesia is appropriate with no clear preference, and prophylactic antibiotics must be administered within one hour of skin incision, as recommended by Praxis Medical Insights 6
The patient should be positioned carefully to avoid excessive flexion and internal rotation of the non-operative hip, which can cause pressure damage, particularly in elderly patients with fragile skin 6

External rotation of the intramedullary nail during insertion reduces malreduction risk in bowed femurs, according to Praxis Medical Insights 5
The lag screw or helical blade should be inserted through the tack hole, ensuring it achieves good purchase at the femoral calcar, reaches within 5-10mm of subchondral bone, and avoids placement in the superior femoral head 6

The procedure typically requires a hospital stay of approximately 2 days, and immediate postoperative management includes DVT prophylaxis with fondaparinux or low molecular weight heparin, regular paracetamol for pain control, cautious opioid use, and early mobilization protocols with immediate weight-bearing as tolerated 1, 2, 6
Case series demonstrate excellent outcomes with complete pain relief and resumption of ambulation in a large proportion of patients, though these results may reflect careful patient selection, as reported by the National Comprehensive Cancer Network 1, 2