Innovative Surgical Positioning for Percutaneous Femur Nailing in a Geriatric Patient with Fixed Flexion Deformity of Knee

Respected Editor, In this unique case, we encountered a 75-year-old male patient who sustained a hip injury, prompting urgent surgical intervention. With a medical history of controlled diabetes and a significant past knee injury requiring surgical fixation leading to a fixed flexion deformity, he presented us with a complex clinical picture. Routine investigations, including an echocardiogram, revealed no other comorbid illnesses, a positive sign in preparing him for surgery. Preoperatively, the patient’s mobility was acceptable; he could walk, albeit with compromise due to the previous knee deformity [Figure 1]. Understanding the implications of his age and the need for early mobilization, we chose to proceed with a percutaneous femur nailing procedure.[1] Given the patient’s specific conditions, including the potential challenges posed by his previous knee injury, we decided on a novel approach to positioning during surgery. To ensure optimal access and minimize discomfort, we opted for the fracture table, which would facilitate proper alignment of the femur during nailing. The anesthesia plan included an ultrasound-guided femoral and obturator nerve block aimed at providing effective pain relief while maintaining the necessary relaxation for the procedure.Figure 1: Fixed flexion deformity (yellow arrow) with positioning in fracture tableThe choice is to administer a spinal anesthetic, with 2 mL of hyperbaric bupivacaine at the L3-4 level to achieve a level of T11. Despite achieving complete relaxation, the fixed flexion deformity governed the biomechanics of the patient’s lower limb, resulting in persistent difficulties in knee extension. To address this, we innovated a method of staff positioning by having an assistant sitting under the surgical table; this arrangement allowed for manual elevation and stabilization of the leg during the procedure [Figure 2]. This method ensured minimal limb movement, essential for accurate C-arm imaging during the surgery. The surgery was completed in approximately 45 min, with minimal complications attributed to our unconventional positioning technique. Postoperatively, the patient exhibited prompt recovery, successfully ambulating with assistance while accommodating some degree of knee flexion within just 2 days. The hospital stay was extended to 3 days, during which he received thorough physiotherapy. The discharge was smooth, and he returned for suture removal and ongoing rehabilitation, indicating his willingness to engage actively in the recovery process. Different positions in fracture tables or a radiolucent table with differing positions, such as supine and lateral, have been described for such cases with varying advantages and disadvantages. Reports of cases being done without fracture tables are there, which were our other options, but the surgical approach may be difficult.[2,3] Distal femoral pin traction with additional support for the leg was an option. The distal femur was fused and malformed, and any form of distal femur pinning and traction will be surgically difficult and may prove otherwise. This case stands out in the medical literature not only for its distinct surgical challenges but also for the innovative adaptations made to optimize patient care in the context of fixed deformities in older adults.Figure 2: Staff hands under the table (yellow) to hold the legDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.