Introduction: Closed repair of peritrochanteric fractures with cephalomedullary nail fixation with the patient in the lateral decubitus position on a flat table with manual traction may allow improved fracture reduction and fixation in comparison with what is possible in a supine setup.
Step 1 operating room preparation: Perform sterile preparation, have the patient brought to the operating room, induce anesthesia, and place the patient in the lateral decubitus position before sterile draping.
Step 2 fracture reduction: Reduce the fracture using manual traction and slight internal or external rotation; confirm anatomic reduction radiographically.
Step 3 nail insertion: Determine the appropriate nail length, identify the nail entry point, open the femoral canal, insert a ball-tipped guide into the canal, insert the nail, and attach the aiming arm to the nail.
Step 4 insertion of cephalic lag screw: Attach the aiming arm to the insertion handle, pass a guidewire, drill over the guidewire to open the lateral cortex, and insert the cannulated screw with soft hammer blows.
Step 5 insertion of distal interlocking screw: Confirm fracture reduction on anteroposterior and lateral views, drill through the lateral cortex of the femur for the distal interlocking screw, measure the screw length, insert the screw, and remove the aiming arm if one was used.
Step 6 final radiographic imaging: Obtain anteroposterior and lateral views to confirm maintenance of fracture reduction and appropriate placement and length of the nail and cephalic and distal locking screws.
Step 7 wound closure: Irrigate and close the wounds, and apply operative dressings.
Results: Intramedullary device technology has been altered to address the complication of periprosthetic fracture at the distal tip that made earlier intramedullary fixation less appealing compared with extramedullary fixation for stable fracture patterns.