Patent Publication Number: US-2007123875-A1

Title: Intramedullary nail

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
      Cross-reference is made to the following applications: DEP5499 titled, “MULTIPLE PURPOSE NAIL, NAIL ASSEMBLY AND ASSOCIATED METHOD,” DEP5606 titled “INTRAMEDULLARY NAIL WITH OBLIQUE OPENINGS,” and DEP5607 titled “MULTIPLE PURPOSE NAIL WITH OBLIQUE OPENINGS” filed concurrently herewith which are incorporated herein by reference.  
     TECHNICAL FIELD OF THE INVENTION  
      The present invention relates generally to the field of orthopaedics, and more particularly, to a device for securing a prosthetic component to bone for use with orthopaedic trauma or orthopaedic joint products.  
     BACKGROUND OF THE INVENTION  
      The skeletal system includes many long bones that extend from the human torso. These long bones include the femur, fibula, tibia, humerus, radius and ulna. These long bones particularly are exposed to trauma from accidents, and as such often are fractured during such trauma and may be subject to complex devastating fractures.  
      Automobile accidents, for instance, are a common cause of trauma to long bones. In particular, the femur and tibia frequently fracture when the area around the knee is subjected to a frontal automobile accident.  
      Often the distal end or proximal portions of the long bone, for example the femur and the tibia, are fractured into several components and must be realigned. Mechanical devices, commonly in the forms of pins, plates, screws, nails, wires and external devices are commonly used to attach fractured long bones. The pins, plates, wires, nails and screws are typically made of a durable material compatible to the human body, for example titanium, stainless steel or cobalt chromium.  
      Fractures of the long bone are typically secured into position by at least one of three possible techniques or methods.  
      The first method is the use of intramedullary nails that are positioned in the intramedullary canal of those portions of the fractured bone.  
      A second method of repairing fractured bones is the use of internal bone plates that are positioned under the soft tissue and on the exterior of the bone and that bridge the fractured portion of the bone.  
      Another method of securing fractured bones in position is the use of external fixators. These external fixators have at least two general categories. In one category, the fixator is generally linear, with a first portion of the fixator to connect to a first fracture segment of the bone and a second fracture segment of the fixator to connect to a second fracture segment of the bone. A first series of bone screws or pins are first connected to the fixator and then to the first fracture segment of the bone. Then a second series of screws or pins are connected to the fixator and then to the second fracture segment of the bone, thereby securing the first fracture segment of the bone to the second fracture segment of the bone.  
      A second method of external fixation is through the use of a ring type fixator that uses a series of spaced-apart rings to secure the bone. For example, an upper ring and a lower ring are spaced apart by rods. A plurality of wires is placed through the long bone and connected on each end of the long bone by the ring. The wires are then tensioned much as a spoke in a bicycle are tightened, thereby providing for a rigid structure to support the first fracture segment portion of the bone. Similarly, a plurality of wires are positioned through the second fracture segment of the bone and are secured to and tensioned by the lower ring to provide a rigid fixation of the second fracture segment of the bone bridging the fracture site.  
      There are a variety of devices used to treat femoral fractures. Fractures of the neck, head or intertrochanter of the femur have been successfully treated with a variety of compression screw assemblies which include a compression plate having a barrel member, a lag screw and a compressing screw. The compression plate is secured to the exterior of the femur and the barrel member is inserted into a predrilled hole in the direction of the femoral head.  
      The lag screw which has a threaded end and a smooth portion is inserted through the barrel member so that it extends across the break and into the femoral head. The threaded portion engages the femoral head. The compressing screw connects the lag screw to the plate. By adjusting the tension of the compressing screw the compression (reduction) of the fracture can be adjusted. The smooth portion of the lag screw must be free to slide through the barrel member to permit the adjustment of the compression screw.  
      Subtrochanteric and femoral shaft fractures have been treated with the help of intramedullary rods, which are inserted into the marrow canal of the femur to immobilize the femoral parts involved in fractures. A single angled cross-nail or locking screw is inserted through the femur and into the proximal end of the intramedullary rod. In some varieties, one or two screws may also be inserted through the femoral shaft and through the distal end of the intramedullary rod. These standard intramedullary rods have been successfully employed in treating fractures in lower portions of the femoral shaft.  
      Trochanteric nails for use in preparing femoral neck fractures utilize a screw in the form of, for example, a lag screw. The lag screws have several different problems in use that are generally related to the lag screw not remaining in the proper positions with respect to the intramedullary nail during the operating life of an implant. For example, the lag screw may cut proximally through the femoral neck and head, causing the neck and head to move out of its operating position in cooperation with the acetabulum. Such a movement may render the patient non-ambulatory. Another issue that may occur with lag screws is medial migration of a lag screw through the femoral head and into the pelvic cavity. A further issue with an intramedullary nail lag screw is lateral migration or lateral pullout of the screw from the long bone.  
      Yet another problem with lag screws in trochanteric nail applications is the problem of neck collapse. Early after the implantation of the trochanteric nail, for example, at the first weight-bearing instance of the patient, the head of the femur may move distally due to a phenomenon known as neck collapse. If the lag screw does not capture enough cancellous bone in the femoral neck, the neck and head may move laterally causing the phenomenon known as neck collapse and creating a leg length and other issues for the patient.  
      Medial migration is only one of many problems that occur with a fastener for use with orthopaedic prosthetic components. The design of fasteners in cancellous and/or osteoporotic bone must deal with parameters such as pull-out forces, installation torque requirements, stripping of the bone, migration and others.  
      The proximal femoral fractures, for example, those around the lesser trochanter, greater trochanter, and femoral neck have been successful treated with a variety of compression screw assemblies and intramedullary rods. The intramedullary rods are inserted into the narrow canal of the femur to immobilize the femur parts involved in the fracture. Typically, a single screw is inserted through the femur and the proximal end of the intramedullary rod. Alternatively, a second screw may be inserted through the femur and into the proximal end of the intramedullary rod to prevent rotation of, for example, the neck and head of the femur.  
      One of the earliest intramedullary devices introduced in the United States was the Grosse-Kempf nail manufactured by Howmedica Company of Rotherudge, N.J. The Grosse-Kempf nail includes a threaded hole in the intramedullary rod for receiving an interlocking screw. The fully threaded screw cannot freely slide in order to permit the compression found in typical compression screw assemblies.  
      Another prior art device is in the form of Zickel™ nail (U.S. Pat. No. 3,433,220). The Zickel nail is a solid intramedullary nail having a single proximal tri-flangle cross-nail which is inserted into the direction of the femoral head. The solid cross-section does not permit the nail to be introduced over a guide rod. Thus, the nail is prevented from being used for comminuted and distal fractures of the femur because the closed surgical technique cannot be practiced. In addition, adequate compression cannot be achieved due to the requirement to lock cross-nail.  
      Yet another prior art device is in the form of the Russell-Taylor™ interlocking nail manufactured by Richards Medical Company of Memphis, now Smith, Nephew, and Richards. The Russell-Taylor nail similarly requires a fully threaded locking screw and therefore does not permit sliding of the screw relative to the intramedullary rod.  
      Yet a further prior art device is in the form of the Gamma™ nail is manufactured by Stryker-Howmedica. The Gamma nail provides for sliding compression of the lag screw through the use of a smooth shaft. The Gamma nail stops rotation of the lag screw by means of a set screw through the proximal portion the intramedullary nail.  
      A further prior art device in the form of the Ace Trochanteric™ nail manufactured by DePuy Orthopaedics, Inc. provides for means of stopping rotation of the femoral head in an unstable fracture pattern by the use of a second threaded screw in the femoral head. The lag screw is permitted to rotate freely within the nail.  
      In unstable femur fractures, stability is necessary to facilitate proper healing of the bone. The femur fractures may be a greater trochanteric to lesser trochanteric fracture, or a fracture of, for example, the neck of the femur. In compound fractures, the bone may be fractured at more than one fracture site. Such multiple fractures are instable and the proper healing of such fractures is difficult. Axial and rotational stability of such fractures may also be an issue. The present invention is an attempt to address at least some of the aforementioned issues.  
      The present invention is directed to alleviate at some of the aforementioned concerns with orthopaedic fasteners.  
     SUMMARY OF THE INVENTION  
      An embodiment of the present invention is in the form of an intramedullary nail containing a series of holes that allows for locking screws to be placed in various positions. The nail can be locked using a combination of screws, which allows various locking constructions. The nail of the present invention allows two separate screws to be placed through the nail, each screw in one of two different planes. The ability to use multiple screws in different planes allows better stability to be achieved with the locking screws.  
      The intramedullary nail of the present invention may be in the form of a Trochanteric Entry Nail (“TEN Nail”) design allowing for multiple screw fixation to be achieved in opposing planes for better fracture stabilization. As an alternative to this design, the Trochanteric Entry Nail may be adapted for use with two screws that are located in the same plane and extend into the femoral neck. In unstable femoral fractures, stability is necessary to facilitate the proper healing and the TEN Nail design of the present invention accomplishes the improved stability. In addition to using multiple planes, the screw creates a triangular geometry that aids in better axial and rotational stability.  
      According to the present invention, an intramedullary nail is provided with two transverse holes for reconstruction screws and an angulated crossing hole for a trochanteric screw that goes from the greater trochanter to the lesser trochanter regions of the femur for locking screw placement. The locking screws are placed through the nail in a combination in ways that, if one reconstruction screw and the trochanteric screw are utilized, an (X) shape appears in the medial to lateral plane. When this two-screw construction is observed down the axis of the nail, the screws have an (X) appearance. The opposing nature of the screw in this nail configuration gives the added stability that is desired for this type of fracture repair. The screw configuration can be changed, so that a combination of one or two screws can be used depending on the fixation that is desired based on a particular fracture pattern.  
      According to one embodiment of the present invention, there is provided an intramedullary nail for use in a medullary canal of a long bone. The nail includes a body defining a longitudinal axis and an external periphery of the body for fitting in the medullary canal of the long bone. The body has a first internal wall of the body defining a first opening through the body. The first opening defines a first opening centerline. The body has a second internal wall of the body defining a second opening through the body. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The first opening centerline and the longitudinal axis of the body form an acute angle between the first opening centerline and the longitudinal axis.  
      According to another embodiment of the present invention there is provided an intramedullary nail assembly for use in a medullary canal of a long bone. The nail assembly includes a nail defining a longitudinal axis and an external periphery of the nail for fitting in the medullary canal of the long bone. The nail has a first internal wall of the nail defining a first opening through the nail. The first opening defines a first opening centerline. The nail has a second internal wall of the nail defining a second opening through the nail. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The first opening centerline and the longitudinal axis of the body form an acute angle between the first opening centerline and the longitudinal axis. The nail assembly also includes a first screw slidably fitted to the first opening and a second screw slidably fitted to the second opening.  
      According to yet another embodiment of the present invention there is provided a method for performing trauma surgery on a long bone. The method includes the step of providing an intramedullary nail. The nail defines a longitudinal axis and an external periphery of the nail for fitting in the medullary canal of the long bone. The nail has a first internal wall of the nail defining a first opening through the nail. The first opening defines a first opening centerline. The nail has a second internal wall of the nail defining a second opening through the nail. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The first opening centerline and the longitudinal axis of the body form an acute angle between the first opening centerline and the longitudinal axis.  
      The method also includes the steps of positioning the nail at least partially in the medullary canal and providing a first screw for cooperation with the long bone and for sliding cooperation with the first opening in the nail. The method also includes the steps of inserting the first screw through the cortical wall of the lesser trochanter of the long bone and inserting the first screw through the first opening. The method also includes the steps of inserting said first screw through the cortical wall of the greater trochanter of the long bone and providing a second screw for cooperation with the long bone and for sliding cooperation with the second opening in the nail. The method further includes the steps of inserting the second screw through the cortical wall of the long bone, inserting the second screw through the second opening, and inserting the second screw through the cortical wall of the long bone.  
      According to another embodiment of the present invention there is provided an intramedullary nail for use in a medullary canal of a long bone. The nail includes a body defining a longitudinal axis of the body and an external periphery of the body for fitting in the medullary canal of the long bone. The body has a first internal wall thereof defining a first opening through the body. The first opening defines a first opening centerline.  
      The body has a second internal wall of the body defining a second opening through the body. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The longitudinal axis of the body and the first opening centerline form an acute angle between the longitudinal axis of the body and the first opening centerline. The longitudinal axis of the body and the second opening centerline forming an acute angle between the longitudinal axis of the body and the second opening centerline.  
      According to yet another embodiment of the present invention there is provided a kit for use in repairing a fracture in a long bone. The kit includes a nail adapted for implantation in a medullary canal of the long bone. The nail defines a longitudinal axis and an external periphery of the nail for fitting in the medullary canal of the long bone. The nail has a first internal wall thereof defining a first opening through the nail. The first opening defines a first opening centerline. The nail has a second internal wall of the nail defining a second opening through the nail. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The longitudinal axis of the body and the first opening centerline form an acute angle between the longitudinal axis of the body and the first opening centerline. The longitudinal axis of said body and the second opening centerline form an acute angle between the longitudinal axis of the body and the second opening centerline. The kit also includes a first screw adapted to be slidably fitted with the first opening and a second screw adapted to be slidably fitted with the second opening.  
      According to another embodiment of the present invention there is provided a method for performing trauma surgery on a long bone. The method includes the step of providing an intramedullary nail. The nail defines a longitudinal axis and an external periphery of the nail for fitting in the medullary canal of the long bone. The nail has a first internal wall of the nail defining a first opening through the nail. The first opening defines a first opening centerline.  
      The nail has a second internal wall, which defines a second opening through the nail. This second opening defines a second opening centerline. The first and the second opening centerlines are oblique with respect to each other. At least one of the first opening centerline and the second opening centerline are transverse to the longitudinal axis of the nail. The longitudinal axis of the body and the first opening centerline form an acute angle between the longitudinal axis of the body and the first opening centerline. The longitudinal axis of the body and the second opening centerline forming an acute angle between the longitudinal axis of the body and the second opening centerline.  
      The method also includes the steps of positioning the nail at least partially in the medullary canal and providing a first screw for cooperation with the long bone and for sliding cooperation with the first opening in the nail. The method also includes the steps of inserting the first screw through the cortical wall of the lesser trochanter of the long bone and inserting the first screw through the first opening.  
      The method also includes the steps of inserting the first screw through the cortical wall of the greater trochanter of the long bone and providing a second screw for cooperation with the long bone and for sliding cooperation with the second opening in the nail. The method also includes the steps of inserting the second screw through the cortical wall of the long bone and inserting the second screw through the second opening. The method also includes the step of inserting the second screw through the cortical wall of the long bone.  
      The technical advantages of the present invention include the ability to provide locking screws in various positions in an intramedullary nail. For example, according to one aspect of the present invention, an intramedullary nail for use in a medullary canal of a long bone is provided. The nail includes a body defining a longitudinal axis and an external periphery for fitting in the medullary canal of the long bone. The body defines a plurality of internal walls for defining a plurality of openings through the nail. Thus, the present invention provides for the ability to provide locking screws in various positions in that the locking screw can be placed in each of the openings.  
      The technical advantages of the present invention further include the ability to allow two separate screws to be placed at one time in one or two different planes. For example, and according to another aspect of the present invention, an intramedullary nail for use in the medullary canal of a long bone is provided. The nail includes a body defining a longitudinal axis and an external periphery for fitting in the canal of the long bone. The body has a first internal wall defining a first opening and a second internal wall defining a second opening. The second opening defines a second opening centerline and the first opening defines a first opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. Thus, the present invention provides for the ability to allow two separate screws, one in each of the two openings, to be placed at one time in one or two different planes.  
      The technical advantages of the present invention also include the ability to allow for multiple screw fixations to be achieved in opposing planes for better fracture stabilization. For example, according to yet another aspect of the present invention, an intramedullary nail for use in the canal of a long bone is provided. The nail includes a body defining a longitudinal axis and an exterior periphery. The body has a first internal wall defining a first opening and a first opening centerline. The body also has a second internal wall defining a second opening having a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. Each of the first opening and the second opening are adapted for receiving a screw. Thus the present invention provides for multiple screw fixation to be achieved in opposing planes for better fracture stabilization.  
      The technical advantages of the present invention also include the ability to place two screws in the same plane of the femoral neck. For example, according to yet another aspect of the present invention, an intramedullary nail is provided including a body defining a longitudinal axis and an extended periphery. The body includes a first internal wall defining a first opening and a second internal wall defining a second opening spaced from the first opening. The first opening and the second opening are parallel and spaced apart and are positioned such that the openings may be in alignment with the femoral neck of the patient. The openings may be adapted for receiving spaced apart screws that may be fitted into the neck of the femur. Thus, the present invention provides for two screws in the same plane of the femoral neck.  
      The technical advantages of the present invention also include the ability to place screws in multiple planes to treat unstable femoral fractures. For example, according to yet another aspect of the present invention, an intramedullary nail assembly is provided including a nail defining a longitudinal axis and an external periphery. The nail includes a first opening defining a first opening centerline and a second opening defining a second opening centerline. The first opening centerline and the second opening centerline are oblique. Each of the first opening and the second opening are adapted for receiving screws. Thus, the present invention provides for a nail in which screws may be placed in multiple planes to treat unstable femoral fractures.  
      The technical advantages of the present invention also include the ability to use two screws that may provide for an x-shaped geometry that aids in better axial and rotational stability. For example, according to yet another aspect of the present invention, an intramedullary nail assembly is provided, including a nail having a first opening as well as a spaced-apart second opening. The first opening and the second opening are oblique with respect to each other. The first opening and the second opening define generally an x-shape. Each of the two openings may receive screw. Thus the present invention provides for the use of two screws to provide an x-shaped geometry that aids in better axial and rotational stability.  
      The technical advantages of the present invention also include the ability to permit trochanteric to greater trochanteric as well as femoral neck fixation with the same nail. For example, according to yet another aspect of the present inventory, an intramedullary nail assembly is provided including a nail, that has a first opening along a first axis and a second opening along a second axis. The first and second axes are oblique and the first axis is in alignment with the greater trochanter and the lesser trochanter, while the second centerline is in alignment with the femoral neck of the femur. Each of the first and second openings are adapted for receiving screws. Thus the present invention provides for greater trochanteric to lesser trochanieric bone fixation and femoral neck fixation within the same nail.  
      Other technical advantages of the present invention will be readily apparent to one skilled in the art from the following figures, descriptions and claims. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       FIG. 1  is a partial anterior/posterior view of a intramedullary nail assembly in accordance with an embodiment of the present invention in the form of a left femoral trochanteric nail assembly implanted in a left femur;  
       FIG. 1A  is an end view of the nail assembly of  FIG. 1  showing the angular relationship of the screws;  
       FIG. 1B  is a perspective view generally from the proximal end of the nail of  FIG. 1  showing the screws intersecting the nail;  
       FIG. 2  is an anterior/posterior view of the intramedullary nail of the intramedullary nail assembly of  FIG. 1 ;  
       FIG. 3  is a medial/lateral view of the intramedullary nail of  FIG. 2 ;  
       FIG. 3A  is an enlarged medial/lateral view of the distal tip of the nail of  FIG. 3  showing the chamfer in greater detail;  
       FIG. 3B  is an enlarged anterior/posterior view of the distal tip of the nail of  FIG. 3  showing the chamfer in greater detail;  
       FIG. 4  is an enlarged partial anterior/posterior view partially in cross section of the proximal end of the intramedullary nail assembly of the intramedullary nail of  FIG. 2 ;  
       FIG. 5  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail assembly of  FIG. 1  implanted in a left femur with only the greater trochanter/lesser trochanter screw in use;  
       FIG. 6  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail assembly of  FIG. 1  implanted in a left femur with two fully threaded femoral neck screws in use;  
       FIG. 7  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail assembly of  FIG. 1  implanted in a left femur with two partially threaded femoral neck screws in use;  
       FIG. 8  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 1  implanted in a left femur with a fully threaded femoral neck screws and a partially threaded femoral neck screws in use;  
       FIG. 9  is a plan view of a cortical screw for use in the nail assembly of  FIG. 1 ;  
       FIG. 9A  is a plan view of a first distal cortical screw for use in the nail assembly of  FIG. 1 ;  
       FIG. 9B  is a plan view of a second distal cortical screw for use in the nail assembly of  FIG. 1 ;  
       FIG. 10  is a plan view of a first cancellous screw for use in the nail assembly of  FIG. 1 ;  
       FIG. 10A  is a plan view of a second cancellous screw for use in the assembly of  FIG. 1 ;  
       FIG. 11  is an anterior/posterior view of an intramedullary nail in accordance with an embodiment of the present invention in the form of a right femoral trochanteric nail implanted in a right femur;  
       FIG. 12  is a medial/lateral view of the intramedullary nail of  FIG. 11 ;  
       FIG. 12A  is a partial medial/lateral view of the elongated slot of the intramedullary nail of  FIG. 12 ;  
       FIG. 13  is a partial anterior/posterior view of the intramedullary nail of  FIG. 11 ;  
       FIG. 14  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 11  implanted in a right femur with only a greater trochanter/lesser trochanter screw in use to form a nail assembly according to the present invention;  
       FIG. 15  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 11  implanted in a right femur with a greater trochanter/lesser trochanter screw and a partially threaded femoral neck screw in use to form a nail assembly according to the present invention;  
       FIG. 16  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 11  implanted in a right femur with two partially threaded femoral neck screws in use;  
       FIG. 17  is a partial anterior/posterior view of a intramedullary nail assembly in accordance with another embodiment of the present invention in the form of a left femoral trochanteric nail with two partially threaded femoral neck screws, one being a cannulated lag screw in use to form a nail assembly implanted in a left femur;  
       FIG. 17A  is an end view of the nail assembly of  FIG. 17  showing the angular relationships of the screws;  
       FIG. 18  is an anterior/posterior view of the intramedullary nail of the intramedullary nail assembly of  FIG. 17 ;  
       FIG. 19  is a medial/lateral view of the intramedullary nail of  FIG. 18 ;  
       FIG. 20  is an plan view of a lag screw for use in the nail assembly of  FIG. 17 ;  
       FIG. 21  is a cross sectional view of the lag screw of  FIG. 20  along the line  21 - 21  in the direction of the arrows;  
       FIG. 22  is a partial view of a box type form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 22A  is a partial view of a standard thread form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 22B  is a partial view of a V-shaped thread form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 22C  is a partial view of a square-shaped thread form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 22D  is a partial view of a truncated V-shaped thread form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 22E  is a partial view of a reverse box thread form for an alternate lag screw for use with an alternate embodiment of the intramedullary nail assembly of the present invention;  
       FIG. 23  is an enlarged cross-sectional view of the box shaped thread of the screw of  FIG. 22 ;  
       FIG. 24  is an anterior/posterior view of an intramedullary nail in accordance with an embodiment of the present invention in the form of a right femoral trochanteric nail implanted in a right femur;  
       FIG. 25  is a medial/lateral view of the intramedullary nail of  FIG. 24 ;  
       FIG. 26  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 11  implanted in a right femur with a greater trochanter/lesser trochanter screw and a femoral neck screw in use to form a nail assembly according to another embodiment of the present invention;  
       FIG. 27  is a partial anterior/posterior view of a intramedullary nail assembly in accordance with another embodiment of the present invention in the form of a left femoral trochanteric nail with two partially threaded femoral neck screws, one being a cannulated lag screw in use to form a nail assembly implanted in a left femur with a piriforma fossa entry;  
       FIG. 27A  is an end view of the nail assembly of  FIG. 27  showing the angular relationships of the screws;  
       FIG. 28  is an anterior/posterior view of the intramedullary nail of the intramedullary nail assembly of  FIG. 27 ;  
       FIG. 29  is a medial/lateral view of the intramedullary nail of  FIG. 28 ;  
       FIG. 29A  is an enlarged medial/lateral view of the distal tip of the nail of  FIG. 29  showing the chamfer in greater detail;  
       FIG. 29B  is an enlarged anterior/posterior view of the distal tip of the nail of  FIG. 29  showing the chamfer in greater detail;  
       FIG. 30  is an anterior/posterior view of an intramedullary nail in accordance with an embodiment of the present invention in the form of a right femoral trochanteric nail implanted in a right femur with a piriforma fossa entry;  
       FIG. 31  is a medial/lateral view of the intramedullary nail of  FIG. 30 ;  
       FIG. 32  is an enlarged partial anterior/posterior view of the proximal end of the intramedullary nail of  FIG. 30  implanted in a right femur with a greater trochanter/lesser trochanter screw and a femoral neck screw in use to form a nail assembly according to another embodiment of the present invention;  
       FIG. 33  is a plan view of a kit for use in performing trauma surgery in accordance with yet another embodiment of the present;  
       FIG. 34  is a first portion flow diagram of a method of performing trauma surgery in accordance with another embodiment of the present;  
       FIG. 34A  is a second portion of the flow diagram of  FIG. 34 ;  
       FIG. 35  is a first portion flow diagram of a method of performing trauma surgery in accordance with yet another embodiment of the present; and  
       FIG. 35A  is a second portion of the flow diagram of  FIG. 35 . 
    
    
      Corresponding reference characters indicate corresponding parts throughout the several views. Like reference characters tend to indicate like parts throughout the several views.  
     DETAILED DESCRIPTION OF THE INVENTION  
      Embodiments of the present invention and the advantages thereof are best understood by referring to the following descriptions and drawings, wherein like numerals are used for like and corresponding parts of the drawings.  
      According to the present invention and referring now to  FIG. 1 , a first embodiment of the present invention is shown as intramedullary nail assembly  10 . Intramedullary nail assembly  10  is used in a medullary canal  2  of a long bone  4 . The nail assembly  10  includes a nail  20 . The nail  20  defines a longitudinal axis  22  of the nail  20 . The nail  20  further includes an external periphery  24  of the nail  20 . The external periphery  24  of the nail  20  is adapted for fitting in the medullary canal  2  of the long bone  4 . The long bone  4  may be any long bone in the human anatomy. For example, the long bone  4  may be a femur, a tibia, a humerus, or any other long bone. Preferably, the long bone in which the nail of the present invention is used is a humerus, a femur, or a tibia, where the canal of the bone is large enough to receive a nail of the type of the present invention.  
      The nail  20  defines a first internal wall  26  of the nail  20 . The internal wall  26  defines a first opening  28  through the nail  20 . It should be appreciated that if the nail  20  is solid, the opening  28  passes obliquely through the nail  20 . It should likewise be appreciated that if the nail  20  has a longitudinal opening or is cannulated, the opening  28  passes through both the external walls of the nail.  
      The nail  20  as shown in  FIG. 1 , further includes or defines a second internal wall  30  of the nail  20 . The second internal wall  30  defines a second opening  32  through the wall  30  of the nail  20 . The first opening  28  defines a first opening centerline  34 . The second opening  32  defines a second opening centerline  36 .  
      According to the present invention, the first opening centerline  34  and the second opening centerline  36  are oblique. The first opening centerline  34  and the second opening centerline  36 , as is shown in  FIG. 1 , do not intersect and are not coplanar.  
      The nail assembly  10  of the present invention further includes a first screw  38 . The first screw  38  includes a shank portion  40  that is slidably fitted to the first opening  28 .  
      As shown in  FIG. 1 , the first screw  38  extends from greater trochanter  44  through cortical bone  6  into the first opening  28  into cancellous bone  8  and into cortical bone  6  and then to the lesser trochanter  46 . As shown in  FIG. 1 , head  42  of the first screw  38  rests against the cortical bone  6  of the greater trochanter  44 . The shank portion  40  of the first screw  38  engages cortical bone  6  around the lesser trochanter  46 .  
      As shown in  FIG. 1 , the nail  10  includes a proximal portion  48  and a distal portion  50 . As can be seen in  FIG. 1 , the nail  10  may, if it is straight or linear, enter the long bone or femur  4  through piriforma  52 . If, however as shown in  FIG. 1 , the nail is in the form of a bent or trochanteric nail, the nail  20  is installed or placed in the long bone  4  through the greater trochanter  44 . Since the greater trochanter  44  is not in alignment with the centerline of the canal  2  of the femur  4 , the proximal portion  48  of the nail  20  is bent and forms an angle β between longitudinal centerline  56  of the distal portion  50  of the nail  20  and longitudinal centerline  54  of the proximal portion  48  of the nail  20 .  
      The first opening centerline  34  of the first opening  28  forms an angle θ between the first opening centerline  34  and longitudinal centerline  54  of the proximal portion  48  of the nail  20 . The angle θ is chosen such that the first screw  38  may extend from greater trochanter  44  to lesser trochanter  46 .  
      The nail assembly  10  of the present invention further includes a second screw  58 . The second screw  58  is adapted to be fitted into the second opening  32  of the nail  20 . The second screw  58 , similar to the first screw  38 , includes a shank  60  and a head  62 . The shank  60  extends into the second opening  32 . The shank  60  of the second screw  58  may include cancellous threads  64  for engaging with cancellous bone  8 .  
      The second opening centerline  36  forms an angle α with respect to the longitudinal centerline  54  of the proximal portion  48  of the nail  20 . The angle α is chosen such that the second screw  58  may extend into neck  3  and head  5  of the femur or long bone  4 . The head  62  of the second screw  58  rests upon the exterior wall of the long bone  4  and the shank  60  of the second screw  58  extends through cortical  6 , cancellous bone  8 , the second opening  32 , additional cancellous bone  8 , through the neck  3 , and into the head  5  of the femur or long bone  4 .  
      The nail  20  may be solid or may include a central opening or cannula  66 . Nail  20  may also include a third opening  68  formed in the nail  20 . The third opening  68  may define a third opening longitudinal centerline  70 . The third opening  68  may, shown in  FIG. 1 , be parallel to the second opening  32 . Thus, the second opening centerline  36  and the third opening centerline  70  may be parallel to each other.  
      The proximal portion  48  of the nail  20  may be larger in cross section than the distal portion  50  in that the proximal portion  48  of the nail  20  is adapted for positioning in the larger condylar portion of the femur  4 .  
      As shown in  FIG. 1 , the nail assembly  10  is for use with a left femur. It should be appreciated that the nail  20  may be utilized with a right femur. Nail  20  includes additional bone conforming features that make the nail  20  particularly compatible with a left femur.  
      Referring now to  FIG. 1A , the positioning of the first opening  28 , the second opening  32  and the third opening  68  are shown in greater detail. The first centerline  34  of the first opening  28  defines a first plane  72 . As shown in  FIG. 1A , the first plane  72  is coincident with longitudinal centerline  54  of the proximal portion  48  of the nail  20 . It should be appreciated that the first plane  72  may be positioned elsewhere than the longitudinal centerline of the proximal portion of the nail.  
      As shown in  FIG. 1A , the second centerline  36  of the second opening  32  and the third centerline  70  of the third opening  68  define second plane  74 . The second plane  74  is shown in  FIG. 1A  is coincident with longitudinal centerline  54  of the proximal portion  48  of the nail  20 . The first plane  72  and the second plane  74  define and angle σ formed there between. The angle σ as shown in  FIG. 1A  may be an acute angle. For example, the angle σ may be from about 10 degrees to 45 degrees.  
      Referring again to  FIG. 1 , it should be appreciated that with the first screw  38  positioned in the first opening  28  and the second screw  58  positioned in the second opening  32 , a generally x-shaped configuration is provided by the first screw  38  and the second screw  58 . The x-shaped screw configuration of  FIG. 1  provides for the strength and stability that may be desired when repairing a femoral fracture.  
      Referring now to  FIG. 1B , the nail assembly  10  is shown with the first screw  38  and the second screw  58  intersecting the nail.  
      Referring now to  FIG. 2 , the nail  20  of the present invention is shown with the full distal portion  50  shown. The distal portion  50  of the nail  20  extends into cavity  1  formed in the canal  2  of the femur  4  toward distal condyle  76  of the femur  4 . The nail  20 , depending on its length, may extend into the condyle  76  or may end short of the condyle  76 .  
      The distal portion  50  may, as shown in  FIG. 2 , include a first distal opening  78  and, for example, a second distal opening  80  spaced from, and may as is shown in  FIG. 2 , be parallel to the first distal opening  78 . The first distal opening  78  and the second distal opening  80  may, as shown in  FIG. 2 , be normal or perpendicular to centerline  56  of the distal portion of the nail  20 . First distal screw  82  may be slidably fitted into the first distal opening  78  and a second distal screw  84  may be slidably fitted into the second distal opening  80 . The first distal screw  82  and the second distal screw  84  may, as is shown in  FIG. 2 , be in the form of a cortical screw for engagement with external cortical walls of the cortical bone  6  of the femur  4 .  
      Since proximal hip condyle  86  of the femur  4  may be larger than the shanked portion of the femur  4 , the proximal portion  48  of the nail  20  may have a diameter DP, which is larger than the diameter DD of the distal portion  50  of the nail  20 . The nail  20  may, as is shown in  FIG. 1A , have a generally circular shape. It should be appreciated that the nail may also have other shapes. The nail  20  may be solid or may, as shown in  FIGS. 1 and 2 , be cannulated and be defined by the longitudinal opening or cannula  66 . It should be appreciated that the nail  20  may rather than the cannula include a longitudinal groove to substitute for the cannula  66 .  
      Referring now to  FIG. 3 , the nail  20  of the present invention is shown in the medial/lateral plane. In the medial/lateral plane, the nail  20  has a shape to conform to the bow in the natural femur. For example and as is shown in  FIG. 3 , the nail  20  includes the proximal portion  48  and the distal portion  50 . The distal portion  50  includes an arcuate portion  88  defined by radius R extending from origin  90 . The distal portion  50  also includes an end portion  92  extending from the arcuate portion  88 . The end portion  92  is defined by angle θ θ. The end portion  92  includes the first distal opening  78  and the second distal opening  80 .  
      The nail  10  may, as shown in  FIG. 3  include a relief surface such as a flat surface for example a chamfer  49  for assisting in leading the curved nail  10  into the medullary canal of the long bone, for example the femur. It should be appreciated that the chamfer may have a surface that is not flat, for example arcuate, for example a portion of a sphere or a cylinder.  
      Referring now to  FIG. 3A  the chamfer  49  is shown in the medial/lateral view with chamfer  49  shown on the side of the distal tip opposed to the origin  90  of the curved portion of the nail  10 . The chamfer may be defined by angle θ 2  from the longitudinal periphery of the nail  10 . The chamfer may be further defined by chamfer length CL from the distal end of the nail  10 .  
      Referring now to  FIG. 3B  the chamfer  49  is shown in the anterior/posterior view with chamfer  49  shown at distal tip. It should be appreciated that the tip may be larger or smaller than shown.  
      Referring now to  FIG. 4 , the proximal portion  48  of the nail  20  is shown in greater detail. The proximal portion  48  includes the first opening  28 , which defines first opening centerline  34 . The proximal portion  48  also includes second opening  32  defining second opening centerline  36 . The proximal portion  48  also includes the third opening  68  defining third opening centerline  70 . The nail  20  further defines a counter bore  94  extending from the proximal end of the proximal portion  48 . As shown in  FIG. 4 , the counter bore  94  is generally concentric with the longitudinal opening  66  of the nail. The counter bore  94  defines internal threads  96  for cooperation with a fastener to lock the screws.  
      The nail  20  further includes a transverse slot  98  which may be helpful for guiding the nail  20  during installation.  
      Referring now to  FIG. 5 , second assembly  12  of a nail assembly in accordance with the present invention is shown. The second nail assembly  12  is for use in securing the greater trochanter  44  to the lesser trochanter  46 . The second assembly  12  includes the nail  20  of  FIGS. 1 through 4  and the first screw  38 . The first screw  38  is placed in first opening  28  and the head  42  of the first screw  38  is advanced until it seats against cortical bone  6  of the femur  4 . The shank  40  of the screw  38  extends into the cancellous bone  8 , through the first opening  28  and through additional cancellous bone  8 . The shank  40  also engages cortical bone  6  to secure the screw  38  t o the femur  4 .  
      Referring now to  FIG. 6 , yet another aspect of the present invention is shown as third nail assembly  14 . The third nail assembly  14  is for use to engage the neck  3  and the head  5  of the femur or long bone  4 . The nail assembly  14 , as shown in  FIG. 6 , includes the nail  20  as well as second screw  58 . The second screw  58  is slidably fitted in second opening  32  of the nail  20 . The second screw  58  is placed into the second opening  32  with head  62  of the second screw  58  positioned against cortical bone  6  and shank  60  of the second screw  58  extending through the cortical bone  6  into cancellous bone  8 . The second screw  58  further extends through the opening  32  and into the cancellous bone  8 . The second screw  58  extends through the neck  3  and may extend into the head  5  within the cancellous bone  8 .  
      While the nail assembly  14  may be operable with a solitary screw, for example, second screw  58 , the third assembly  14  may also include an additional screw in the form of third screw  67 . The third screw  67  is utilized in the third assembly  14  to provide fixation of the neck  3  and the head  5 . The third screw  67  is slidably fitted into the third opening  68  of the nail  20 . The third screw  67  includes a head  69  and a shaft or shank  71 . The head  69  of the screw  67  rests against the outer surface of the cortical bone  6  of the femur  4 . The shank  71  extends through cortical bone  6 , cancellous bone  8 , the third opening  67 , and into the cancellous bone  8 . The third screw  67  extends into the cancellous bone  8  of the neck  3  and into the cancellous bone  8  of the head  5 . As shown in  FIG. 6 , the third screw  67  when assembled into the third opening  68  may extend along third centerline  70 , which is parallel and spaced from second opening centerline  36 .  
      While the second screw  58  and the third screw  67  may be fully threaded, as is shown in  FIG. 6 , it should be appreciated that the second screw  58  and the third screw  67  may be partially threaded.  
      For example, and referring now to  FIG. 7 , yet another form of the present invention is shown as fourth nail assembly  16 . The fourth nail assembly  16  is in the form of a nail assembly with screws that are only partially threaded. The use of partially threaded may permit the sliding compression or motion of the head and neck in a downward fashion to facilitate healing.  
      The fourth nail assembly  16  of  FIG. 7  includes the nail  20  of  FIGS. 1 through 5  as well as second partially threaded screw  58 A similar to the screw  58  of  FIG. 6 . The second screw  58 A, as shown in  FIG. 7 , is, however, only partially threaded in shank  60 A of the second screw  58 A.  
      Similarly, the fourth nail assembly  16  includes a third screw  67 A similar to the third screw  67  of  FIG. 6 . The third screw  67 A has a shank  71 A that is, however, only partially threaded.  
      As shown in  FIG. 7 , the second screw  58 A includes a head  62 A, which rests against cortical bone  6  of the femur  4 . The shank  60 A of the second screw  58 A includes a smooth portion  73 A of the shank  60 A, which is positioned between the head  62 A and threads  64 A of the screw  58 A. The smooth portion  73 A of the second screw  58 A extends from the head  62 A, through the cortical bone  6 , through cancellous bone  8 , through the second opening  32  of the nail  20 , through cancellous bone and to the threads  64 A of the shank  60 A.  
      Similarly, the third screw  67 A includes a smooth portion  75 A of the shank  71 A, which extends from head  69 A to threads  77 A of the shank  71 A. The third screw  67 A when installed in the nail  20  is installed such that head  69 A of the third screw  67 A rests against the outer wall of the cortical bone  6  of the femur  4 . The smooth portion  75 A of the shank  71 A extends through cortical bone  6 , through cancellous bone  8 , through the third opening  68 , and into the cancellous bone  8 . The threads  77 A extend from the smooth portion  75 A of the shank  71 A. It should be appreciated that the smooth portion  73 A of the second screw  58 A and the smooth portion  75 A of the third screw  67 A extend through the respective second opening  32  and third opening  68  of the nail  20 , such that sliding compression of the fractured hip joint may be provided.  
      Referring now to  FIG. 8 , yet another form of the present invention is shown in fifth nail assembly  18 . The fifth nail assembly  18 , as shown in  FIG. 8 , includes both a fully threaded screw and a partially threaded screw.  
      Referring now to  FIG. 8 , yet another form of the present invention is shown as fifth nail assembly  18 . The fifth nail assembly  18  utilizes both a partially thread and a fully threaded screw. The fifth assembly  18  as shown in  FIG. 8 , includes the nail  20  as well as second screw  58 A and third screw  67 . The second screw  58 A is fitted into the second opening  32  and the third screw  67  is fitted into third opening  68 .  
      The nail  20  may be made of any suitable durable material and may, for example the made of a plastic, a metal or a carbon fiber composite material. To obtain the strength necessary, the nail  20  is preferably made of a metal. If made of a metal, the nail  20  may be made of a metal that is compatible with the human anatomy and is sterilizable. Such materials include cobalt chromium alloy, a stainless steel alloy, and a titanium alloy.  
      Referring now to  FIG. 9 , the first screw  38 , as is shown in greater detail. The first screw  38  as shown in  FIG. 9 , is in the form of a cortical screw for securing the screw to cortical bone. The first screw  38  includes the head  42  and the shank  40 . The shank  40  includes threads  64  for engagement with bone. The screw  38  as shown in  FIG. 9 , may include a self-tapping feature  79  for tapping or preparing the threads in the bone to receive cortical threads  11  of the screw  38 . It should be appreciated that the self-tapping feature  79  may also include a self-drilling feature similar to and provide the opening in the bone for preparing the bone for receiving the threads  64 .  
      Referring now to  FIG. 9A , the first distal screw  82  is shown in greater detail. The first distal screw  82  includes a head  81  and a threaded shank  83 . The shank  83  may be threaded with cortical screw threads for engagement with cortical bone. The shank  83  may also include a self-tapping feature similar to the self-tapping feature  79  of the screw  38  of  FIG. 9 .  
      Referring now to  FIG. 9B , the second distal screw  84  is shown in greater detail. The second distal screw  84  includes a head  85  as well as a shank  87 . Shank  87  may include cortical threads and may include a self-tapping feature similar to the self-tapping feature  79  of the screw  38  of  FIG. 9 .  
      The cortical screws  38 ,  82  and  84  may be made of any suitable durable material and may, for example, be made of a plastic, a metal or a carbon fiber composite material. To obtain the strength necessary, the screws are preferably made of a metal. If made of a metal, the screws may be made of a metal that is compatible with the human anatomy and is sterilizable. Such materials include cobalt chromium alloy, a stainless steel alloy, and a titanium alloy.  
      Referring now to  FIG. 10 , cancellous screws for use with the intramedullary nail of the present invention are shown. For example as shown in  FIG. 10 , second screw  58  includes head  62  as well as shank  60  extending from the head  62 . The shank  60  includes threads  64  that may be positioned on the entire shank  60  or, alternatively, be provided only on a portion of the shank  60 . The second screw  58  may include a self-drilling and self-tapping feature  89  located on the end of the threads  64  to provide for self-drilling and self-tapping of the thread  64  through cancellous bone.  
      Now referring to  FIG. 10A , the third screw  67  is shown. The third screw  67  may likewise be a cancellous screw and include a head  69  as well as a shank  71 . The shank  71  may include threads  77 , which are positioned on the entire shank  71  of the third screw  67 . The third screw  67  may further include a self-tapping and self-drilling feature  91  similar to the self-tapping and self-drilling feature  89  of the second screw  58 . The third screw  67  may alternately include a shank  71 , which is not fully threaded. For example and as shown in  FIG. 10  in phantom, unthreaded shank portion  75 A may be included in alternate screw  67 A.  
      According to the present invention and referring now to  FIG. 11 , yet another embodiment of the present invention is shown as intramedullary nail assembly  110 . The intramedullary nail assembly  110  as shown in  FIG. 11 , is for use with right femur  4 . The intramedullary nail assembly  110  of  FIG. 11  is a mirror image of the nail assembly  10  of  FIGS. 1 and 2 . The intramedullary nail assembly  110  includes a nail  120  that is a mirror image of the nail  20  of  FIGS. 1 and 2 .  
      The intramedullary nail  120  may have any suitable shape to fit within canal  2  of femur  4 . To fit within the canal  2 , the nail  120  may be longitudinally elongated. For simplicity and to fit into the canal  2 , the nail  120  may have a generally circular cross section. The nail  120  may be linear or straight or may be curved and bent to more closely conform to the shape of the canal  2 . The nail  120  may be solid or, as is shown in  FIG. 11 , be cannulated or include a central opening  166  extending along the length of the nail  120 .  
      The nail  120  as shown in  FIG. 11 , may include a proximal portion  148  as well as a distal portion  150  extending from the proximal portion  148 . The proximal portion  148  defines a proximal portion centerline  154 , while the distal portion  150  defines a distal portion centerline  156 . The proximal portion centerline  154  forms an angle α′ with respect to the distal portion centerline  156 . Such an angular relationship between the proximal portion  148  and the distal portion  150  facilitates the nail  120  to be installed through greater trochanter  44  of the femur  4 .  
      The assembly  110  may include screws, for example first screw  138 , for use with the nail  120 . The screws may be used to connect greater trochanter  44  with the lesser trochanter  46  or alternatively, or in combination, the nail assembly  110  may also include screws (described later) for engagement with neck  3  and head  5  of the femur  4 . The nail  120 , as is shown in  FIG. 11 , may, thus, include a first opening  128  defining a first opening centerline  134 . The first opening  128  is adapted for receiving a screw for connecting the greater trochanter  44  to the lesser trochanter  46 .  
      The nail  120  may further include a second opening  132  defining a second opening centerline  136 . The second opening  132  may be adapted for receiving a screw for engagement with neck  3  and head  5  of the femur  4 . The nail  120  may further include a third opening  168  defining a third opening centerline  170 . The third opening  168  may be adapted for receiving a third screw. The third opening  168 , as shown in  FIG. 11 , may be parallel to the second opening  132 . The screw for the third opening  168  may be positioned in the neck  3 , as well as, in the head  5  of the femur  4 .  
      The nail assembly  110  may further include distal screws for distally securing the nail  120  to the femur  4 . For example and as shown in  FIG. 11 , the nail  120  may include a first distal opening  178  for receiving a first distal screw  182 . The first distal screw  182 , as shown in  FIG. 11 , may be normal or perpendicular to distal portion centerline  156 . The nail  120  may further include a second distal opening  180  spaced from and parallel to the first distal opening  178 . The nail assembly  110  may further include a second distal screw  184  for cooperation in the second distal opening  180  of the nail  120 . The first distal screw  182  and the second distal screw  184  may be in the form of cortical screws that may cooperate with cortical bone  6  of the femur  4 .  
      Referring now to  FIG. 12 , the medial/lateral view of the nail  120  is shown. The proximal portion  148  of the nail  120  includes the first opening  128 , the second opening  132  and the third opening  168 . The proximal portion  148  may be, as is shown in  FIG. 12 , larger in diameter than the distal portion  150 , so that the screw openings may be accommodated in the proximal portion  148 .  
      The distal portion  150  as shown in  FIG. 12 , may have a shape conforming to a right femur. For example and as is shown in  FIG. 12 , the distal portion  120  may be arcuate and may be defined by a radius R′ extending from origin  190 . The arcuate shape of the distal portion  150  corresponds to the arcuate shape of the right femur medullary canal, in which the nail  120  is positioned.  
      As shown in  FIG. 12 , the distal portion  150  of the nail  120  may include a distal portion which may not be arcuate, but may extend at an angle θ′ from the distal portion  150 . The distal part of the distal portion  150  may include the distal openings. For example, the distal portion  150  may include a first distal opening  178 , which may, as is shown in  FIG. 12 , be generally cylindrical in shape as well as a second distal opening  180 .  
      Referring now to  FIG. 12A , the second distal opening  180  may be generally oval. For example and as shown in  FIG. 12 , the second distal opening  180  may be defined by a overall length L′ and a width W′. The second distal opening  120  may further be defined by radii R″, located on both ends of the second distal opening  180 .  
      Referring now to  FIG. 13 , the proximal portion  148  of the nail  120  is shown in greater detail. The nail  120  may include the longitudinal opening  166 , as well as first opening  128  defining first opening centerline  134 . The proximal portion  148  may further define the second opening  132  defining the second opening centerline  136 . The proximal portion  148  may further define the third opening  168  defining third opening centerline  170 .  
      To lock at least one of the screws with respect to the nail  120 , the nail  120  may include a feature for locking the screw to the nail. For example, the nail  120  may include a counter bore  194  onto which internal threads  196  are formed. The internal threads  196  may be adapted for fitting to a fastener used to contact the screw to lock the screw to the nail  120 . The nail  120  may further include a slot  198  to angularly position the nail  120 .  
      Referring now to  FIG. 14 , another embodiment of the present invention is shown as intramedullary nail assembly  112 . The intramedullary nail assembly  112  includes the nail  120  of  FIGS. 11 through 13 . The nail assembly  112  of  FIG. 14  is adapted for connection of the greater trochanter  44  with the lesser trochanter  46 . The nail assembly  112  includes first screw  138  for positioning in the first opening  128 . The first screw  138  may as shown be a cortical screw and is similar to the screw  38  of the nail assembly  10  of  FIGS. 1-9 . The first opening  128  is positioned such that the first opening centerline  134  extends from greater trochanter  44  to lesser trochanter  46 .  
      Referring now to  FIG. 15 , yet another embodiment of the present invention is shown as intramedullary nail assembly  114 . The intramedullary nail assembly  114  is used to connect the lesser and greater trochanter  144  and  146 , respectively, as well as to secure the femoral neck  3  to the femur  4 .  
      The nail assembly  114  as shown in  FIG. 15 , is adapted for use with a right femur. The nail assembly  114  includes the nail  120 . First screw  138 , as well as, second screw  158 . The second screw  158  is similar to second screw  58  of the nail assembly  10  of  FIGS. 1-9 . The second screw  158  is adapted for engagement with the femoral neck  3  and is preferably in the form of a cancellous screw.  
      The first screw  138  is fitted into the first opening  128 , while the second screw  158  is fitted into the second opening  132 . The first screw  138  extends from the greater trochanter  44  to the lesser trochanter  46 . The second screw  158  extends from the outer cortical wall of the long bone or femur  4  through the second opening  132  and into cancellous bone within the neck  3  and head  5  of the femur  4 .  
      As shown in  FIG. 15 , the first screw  138  and the second screw  158 , when installed in the nail  120 , form an (X) shape with the nail  120 . The first screw  138  and second screw  158  may both be installed simultaneously because the first screw opening  128  and the second screw opening  132  are not coplanar, but they are oblique with respect to each other. Therefore, the first opening  128  and the second opening  132  do not intersect with each other. Therefore, the first screw  138  and the second screw  158 , when both are installed into the nail  120 , do not intersect with each other and therefore may both be utilized simultaneously.  
      Referring now to  FIG. 16 , yet another embodiment of the present invention is shown as nail assembly  116 . The nail assembly  116  includes the nail  120  as well as second screw  158  and third screw  167 . The third screw  167  may be similar or even identical to the second screw  158 .  
      The second screw  158  extends through second opening  132  and extends from the outer cortical wall of the femur  4  through the second opening  132  and into the cancellous bone of the neck  3  and head  5 . Similarly, the third screw  167  is fitted in the third opening  168 . The third screw  167  may, for simplicity, be in a position spaced from and parallel to the second screw  158 . The third screw  167  extends from the outer cortical wall of the femur  4 , through the third opening  168  and into the cancellous bone in the neck  3  and head  5  of the femur  4 .  
      As shown in  FIG. 16 , the second screw  158  and the third screw  167  may, as is shown in  FIG. 16 , include a smooth portion for assisting in providing for sliding compression of the femoral neck fracture. For example and as shown in  FIG. 16 , the second screw  158  includes a smooth portion  157  for positioning through the second opening  132 . The smooth portion  157  assists in the sliding compression of the fracture. The second screw  158  further includes a threaded portion  159  having cancellous threads  161 , which are located in the neck  3  and head  5  of the femur  4 . The third screw  167  is similar to the second screw  158  and includes a smooth shank portion  169  slidably fitted in the third opening  168 . The third screw  167  further includes a threaded portion  171  extending outwardly from the threaded portion  169 . The threaded portion  171  includes cancellous threads  173  for cooperation with the cancellous bone in the neck  3  and head  5 .  
      Referring now to  FIG. 17 , yet another embodiment of the present invention is shown as nail assembly  210 . The nail assembly  210  is similar to the nail assembly  16  of  FIG. 7 , except that the nail assembly  210  of  FIG. 17  uses screws, which have a different thread form to minimize medial migration of the thread through the head  5  and femoral neck  3 . For example and as shown in  FIG. 17 , the nail assembly  210  includes nail  220  which is similar to the nail  20  of  FIG. 7 , except that the openings in the nail  220  may be larger to accommodate larger diameter screws. The nail  220  includes a proximal portion  248  as well as a distal portion  250  extending from the proximal portion  248 . The nail  220  may be solid or may, as is shown in  FIG. 17 , be hollow or include a central opening or cannula  266  extending longitudinally through the central portion of the nail  220 .  
      The proximal portion  248  defines a proximal portion centerline  254  and the distal portion  250  defines a distal portion centerline  256 . The proximal portion centerline  254  and the distal portion centerline  256  define an angle α″ therebetween. The angle α″ is established to assist the installation of the nail  220  through greater trochanter  44 .  
      The nail  220  is adapted for use with femoral neck fractures as well as greater trochanter to lesser trochanter fractures. Therefore, and as shown in  FIG. 17 , the nail  220  includes a first opening  228  extending in the direction of first opening centerline  234 . The first opening centerline  234  extends from greater trochanter  44  to lesser trochanter  46 . The nail  220  further includes a second opening  232 , which defines second opening centerline  236 . The second opening centerline  236  is oriented in a direction toward the neck  3  and head  5  of the femur  4 . The second opening  232  may be larger than the opening  32  of the nail  20  to accommodate a larger fastener.  
      The nail  220  further includes a third opening  268  positioned in a direction along third opening centerline  270 . As shown in  FIG. 17 , the third opening centerline  270  is parallel and spaced from the second opening centerline  236 . The third opening  268  may be smaller in size than the second opening  232  to receive a smaller screw. The third opening  268  may be provided to provide for a smaller screw that may serve as anti-rotation screw for the nail assembly  210 .  
      The nail assembly  210  includes a second screw  258  that is slidably fitted in the second opening  232  of the nail  220 . The second screw  258  is different than the second screw  58  of the nail assembly  10 . The second screw  258  is adapted to limit the medial migration of the screw  258 . The second screw  258  includes a head  262  and a shank  260  extending from the head  262 . The shank  260  may include external cancellous screw threads  264  for engaging with the cancellous bone  8  located in the neck  3  and head  5  of femur  4 .  
      The nail assembly  210  may further include a third screw  267 . The third screw  267  extends along centerline  270  of the third opening  268  and is slidably positioned within the third opening  268  of the nail  220 . The third screw  267  may, as is shown in  FIG. 17 , be parallel and spaced from the second screw  258 . The third screw  267  may be smaller in diameter than the second screw  258 . Since the third screw  267  may be utilized as an anti-rotation device, the third screw  267  may be substantially smaller than the second screw  258 . The third screw  267  may include a head  269  and a shank  271 . The shank  271  may include threads  277  for engaging cancellous bone  8  formed in the neck  3  and head  5  of femur  4 .  
      The length of the second screw  258  and the third screw  267  are determined so that the screw head rests against the cortical wall  6  of the femur  4  and the screw shank extends into the head  5  of the femur  4 .  
      Referring now to  FIG. 17A , the first opening  228 , the second opening  232 , and the third opening  268  of the nail  220  are shown in greater detail. First opening centerline  234  intersects centerline  254  of the proximal portion  248  of the nail  220 . The first opening centerline  234  and proximal portion centerline  256  defines first plane  272 . The second opening centerline  236  also intersects centerline  254  of the proximal portion  248 . The third opening centerline  270  also intersects centerline  254  of the proximal portion  248  of the nail  220 . In fact, the second opening centerline  236  and the third opening centerline  270  form second plane  274 . The first plane  272  and the second plane  274 , as shown in  FIG. 17A , form angle σ′ therebetween.  
      Referring now to  FIG. 18 , the nail assembly  210  is shown in the anterior/posterior view. The nail assembly  210  includes the proximal portion  248 , as well as, the distal portion  250 . The proximal portion  248  includes first opening  228 , second opening  232 , and third opening  268 .  
      The distal portion  250  of the nail  220  of the nail assembly  210  includes a first distal opening  278  which may, as shown in  FIG. 18 , be substantially perpendicular or transverse to longitudinal axis  256  of the nail  220 . The distal portion  250  of the nail  220  may further include a second distal opening  280  spaced from and parallel to the first distal opening  278 . The first distal opening  278  and the second distal opening  280  may be utilized in cooperation with fasteners to provide for distal fixation of the nail  220 .  
      For example, and as is shown in  FIG. 18 , the nail assembly  210  further includes a first distal screw  282  that is fitted through the first distal opening  278  of the nail  220 . The nail assembly  210  may further include a second distal screw  284  that is fitted through the second distal opening  280 . The first distal screw  282  and the second distal screw  284  may be in the form of cortical screws and may engage with the external cortical walls  6  of the femur  4 .  
      Referring now to  FIG. 19 , a medial/lateral view of the nail  220  of the nail assembly  210  is shown. The nail  220  includes the proximal portion  248 , as well as, the distal portion  250 . The distal portion  250  may, as is shown in  FIG. 19 , have a shape generally conforming to that of the canal of the long bone. For example, and as is shown in  FIG. 19 , the distal portion  250  may include an arcuate portion  288  and an end portion  292  extending from the arcuate portion  288 . The arcuate portion  288  may be defined by a radius R 2 ′ extending from origin  290 . The end portion  292  of the distal portion  250  may extend from the arcuate portion  288  and may be generally linear.  
      Referring now to  FIGS. 20 and 21 , the screw  258  may further include a removal feature  231  in the form of, for example, internal threads formed in the small counter bore  233  formed in the longitudinal opening  266  adjacent second end  235  of the screws  258 . The screw  258  may further include a large counter bore  237  extending from the second end  235  of the lag screw  258  and concentric with the small counter bore  233  as well as with the longitudinal opening  266 .  
      Referring now to  FIG. 21 , the screw  258  may further include a plurality of threads  264  formed on the shank periphery  241  of shank  260  of the screw  258 . The threads  264  may as shown in  FIG. 21  have a non-uniform cross-section, which is more fully described in U.S. patent Ser. No. 11/168,737 incorporated hereby in its entirety.  
      Referring again to  FIG. 21 , the periphery  241  of the shank  260  of the screw  258  includes a first portion  243  into which the threads  264  are formed. It should be appreciated that the first portion  243  may extend along longitudinal axis  245  of the screw  258  from first end  247  to second end  325  of the screw  258 . It should also be appreciated and as is shown in  FIG. 21 , that the periphery  241  may include a second portion  249 . The second portion  249  of periphery  241  of the shank  260  may define a smooth surface  251 . As is shown in  FIG. 21 , the periphery  241  of the shank  260  may be generally cylindrical and defined by a diameter, for example, DS.  
      The screw  258  as is shown in  FIG. 21 , is generally cylindrical and defined by the diameter DS and an overall length L. The shank  260  of the screw includes the first portion  243  which include threads  264  and the second portion  249  having the smooth surface  251 . The overall length L, of the diameter DS is divided into a thread TL and a smooth or unthreaded length UL. The thread length TL defines the first portion  243  and the smooth length UL defines the second portion  249 . The thread length TL may, for example, be a portion of, for example, 20-40% of the overall length L of the shank  260 . It should be appreciated that the smooth length UL is preferably a sufficient length such that the second portion  249  of the screw  258  may be positioned in the oblique third opening  268  of the intramedullary nail  220  (see  FIG. 17 ) to permit compression of the bone fracture of femur  4 .  
      The threads  264  as is shown in  FIG. 21 , may advance spirally around the periphery  241  of the shank  260  of the screw  258 . The threads  264  may be defined by a pitch P defining a spacing along longitudinal axis  245  between adjacent threads. The threads  264  may advance spirally around the longitudinal axis  245  in either a right or a left hand spiral configuration. The threads may, as is shown in  FIG. 21 , be of a single lead type but may alternatively be double lead configuration or a triple lead configuration.  
      Referring now to  FIG. 23 , the threads  264  may have any suitable shape or thread form. For example and as shown in  FIG. 23 , the threads  264  may have a combination box and tapered configuration. For example and is shown in  FIG. 23 , the threads  264  may have any suitable shape or profile  253 . For example and is shown in  FIG. 23  the profile  253  may include a crest  255  and opposed root  257 . A trailing surface  261  is positioned between the crest  255  and the root  257  adjacent the second end  235  of the screw  258  while leading edge  263  is positioned between the crest  255  and root  257  adjacent the first end  247  of the screw  258 .  
      As shown in  FIG. 23 , the leading edge  263  and the trailing edge  261  may be configured to provide for less force to assemble in the direction of arrow  261  than to disassemble in the direction opposed to arrow  261 . Such ease of assembly and difficulty in disassembly may be accomplished as is shown in  FIG. 23  by providing the trailing edge  261  with a configuration that is normal or perpendicular to the root  257  and the crest  255  while providing the leading edge  263  with chamfered or angled surface or, as is shown in  FIG. 23 , or with a partially angled surface between the crest  255  and the root  257 .  
      Referring to  FIG. 23 , the threads  267  are shown in greater detail. The threads  264  of the screw  258  may, as is shown in  FIG. 23 , include the leading edge  263  such that the leading edge  263  includes normal or perpendicular portion  265  as well as an angled portion  267 . The angled portion  267  provides for reduced force to assemble the screw  258  into the long bone or femur  4 . The normal portion  265  and the angled portion  267  may define an angle αα therebetween. To minimize stress, the crest  255 , the root  257 , trailing edge  261 , and leading edge  263  may include arcuate portions therebetween to minimize the stress.  
      Referring now to  FIG. 22-22E , alternative profile configuration for threads of the screw of the nail of the present invention is shown. According to the present invention and referring now to  FIG. 22 , another form of profile of the screw of the present invention. The screw  258 F of  FIG. 22  includes threads  264 F defining profile  253 F. The profile  253 F includes a spaced apart parallel crest  255 F and root profile  257 F includes a trailing surface  261 F, which is normal to the root  257 F and the crest  255 F. The profile  253 F further includes a leading surface  263 F, which is positioned at angle between root  257 F and crest  255 F.  
      Referring now to  FIG. 22A , profile  253 A is shown which includes arcuate roots and crest. For example and is shown in  FIG. 22A , the profile  253 A of screw  258 A includes an arcuate crest  255 A to which trailing angled surface  261 A extends. Leading edge  263 A extends likewise from the arcuate crest  255 A. The profile  253 A further includes an arcuate root  257 A, which connects with trailing surface  261 A and leading surface  263 A.  
      Referring now to  FIG. 22B , yet another profile for threads for screw of the present invention is shown as screw  258 B includes threads  264 B having a profile  253 B which include generally v-shaped threads  264 B. The profile  253 B includes trailing surface  261 B and leading surface  263 B. Root  257 B and crest  255 A are as shown in  FIG. 22B  are minimal.  
      Referring now to  FIG. 22C , yet another profile of threads for a screw according to the present invention is shown. For example and is shown in  FIG. 22C , the screw  258 C includes threads  264 C having a profile  253 C that is blocked or rectangular. The profile  253 C includes parallel and spaced apart root  257 C and crest  255 C. The profile  253 C includes a trailing surface  261 C, a spaced apart and parallel leading surface  263 C. The trailing surface  261 C and the leading surface  263 C are normal or perpendicular to the root  257 C and the crest  255 C.  
      Referring now to  FIG. 22D , yet another embodiment of a profile of threads for a screw according to the present invention is shown. The profile  253 D of threads  264 D of the screw  258 D has a generally truncated v-shape of that of a standard screw thread. The profile  253 D includes a flat crest  255 D and opposed angled trailing surfaces  261 D and leading surface  263 D. A root  257 D extends from the trailing surface  261 D and the leading surface  263 D.  
      Yet another profile of threads of a screw of the present invention is shown as profile  253 E. Screw  258 E includes threads  264 E having the profile  253 E. The profile  253 E includes a leading surface  263 E that is normal to a crest  255 E and a spaced apart parallel root  257 E. The profile  253 E further includes a trailing surface  261 E that is positioned at an angle between the root  257 E and the crest  255 E.  
      Referring now to  FIGS. 24 and 25 , yet another embodiment of the present invention is shown as nail assembly  310 . The nail assembly  310  is similar to the nail assembly  14  of  FIG. 6 , except that the nail assembly  310  is for use with a right femur rather than a left femur. For example and as shown in  FIG. 24 , the nail assembly  310  includes a nail  320  that is the mirror image of the nail  20  of  FIG. 6 . The nail  320  includes a proximal portion  348  as well as a distal portion  350 . The proximal portion  348  includes a first opening  328  for use in connecting the greater trochanter  44  to the lesser trochanter  46 . The proximal portion  348  also includes a second opening  332  and a third opening  368  for engagement with the neck  3  and head  5  of femur  4 .  
      The distal portion  350  of the nail  320  includes a first distal opening  378 . The first distal opening  378  may be generally perpendicular or normal to longitudinal axis  356  of the distal portion  350  of the nail  320 . The distal portion  350  of the nail  320  may further include a second distal opening  380  spaced from and generally parallel to the first distal opening  378 . The first distal opening is sized to receive first distal screw  382 . Similarly, the second distal opening  380  is sized to receive second distal screw  384 . The first distal screw  382  as well as the second distal screw  384  may, as shown in  FIG. 24 , be in the form of cortical screws, which engage with cortices  6  of the femur  4 .  
      The nail assembly  310  as shown in  FIG. 24 , is for use in securing femoral neck fractures and as such, includes a second screw  358 , which is slidably fitted in second opening  332 . The second screw  358 , as is shown in  FIG. 24 , is a fully threaded screw and extends into the neck  3  and head  5  of femur  4 . The second screw  358  may be in the form of a cancellous screw. The nail assembly  310  further includes a third screw  367 , which is slidably fitted in the third opening  368 . The third screw  367  extends from cortical wall  8  of the femur  4  through the third opening  368  and into the neck  3  and head  5  of femur  4 . The third screw  367  is positioned parallel and spaced from the second screw  358 . The third screw  367  may be in the form of a fully threaded cancellous screw.  
      Referring now to  FIG. 25 , the medial/lateral view of the nail  320  is shown. The nail  320  includes the proximal portion  348  as well as the distal portion  350 . The proximal portion  348  may be generally linear. The distal portion  350  may include an arcuate portion  388  as well as an end portion  392 . The arcuate portion  388  and the end portion  392  are designed to conform with the canal of a right femur. The arcuate portion  388  may be described, for example, by radius R 2 ″ extending from origin  390 . The end portion  392  may extend at, for example, angle θ′″. The end portion  392  may include first distal opening  378 , which, as is shown in  FIG. 25 , may have a generally circular shape. The end portion  392  may further include the second distal opening  380 , which may, as shown in  FIG. 25 , have a generally oval shape.  
      Referring now to  FIG. 26 , yet another embodiment of the present invention is shown as nail assembly  312 . The nail assembly  312  utilizes the nail  320  of  FIGS. 24 and 25 , but utilizes screws in a different fashion. The nail assembly  312  provides for screws with a generally (X) shape and may be used to repair fractures that include both a greater trochanter to lesser trochanter fracture, as well as a femoral neck fracture. The nail assembly  312  includes the nail  320 , as well as, a first screw  338  and second screw  358 . The first screw  338  is slidably fitted in the first opening  328  and extends from greater trochanter  44  to lesser trochanter  46 . The second screw  358  extends through second opening  332  and engages neck  3  and head  5  of femur  4 .  
      Referring now to  FIG. 27 , yet another embodiment of the present invention is shown as nail assembly  410 . The nail assembly  410  as shown in  FIG. 27 , is for use in a left femur and includes the nail  410 , which is suitable for entry into the piriforma fossa  9  of the femur  4 . In that the nail  410  is inserted through piriforma fossa  9  of the femur  4 , the nail in the anterior/posterior view as shown in  FIG. 27 , is generally straight. The nail  410  as shown in  FIG. 27 , includes a proximal portion  448  and a distal portion  450 . The nail  410  may include a central opening or cannula  466  and have a longitudinal centerline  454  that is generally straight or linear in the anterior/posterior view of  FIG. 27 .  
      The nail assembly  410  further includes a second screw  458 , which is slidably fitted in second opening  432  of the nail  420 . The second screw  458 , as shown in  FIG. 27 , is in the form of a partially threaded screw and includes a head  462  and a shank  460 , including a portion having threads  464 . The second screw  458  extends into the cancellous bone  8  of the neck  3  and head  5  of the femur  4 .  
      The nail assembly  410  of  FIG. 27  may further include a third screw  467  slidably fitted into third opening  468  formed in the nail  420 . The second opening  432  defines a second opening centerline  436 . The third opening  468  defines a third opening centerline  470 . The second opening centerline  436  and the third opening centerline  470 , as shown in  FIG. 27 , may be parallel and spaced apart. The nail assembly  420  may further include a third screw as shown in phantom as first screw  438 . The first screw  438  may be fitted into first opening  428  formed in the nail  420 .  
      The third screw  467  may include a head  469  that rests against cortical bone  6  of the femur  4 . The third screw  467  may include a shank  475  including a smooth part as well as including external threads  477 . The external threads  477  of the third screw  467  may be of a cancellous type for fitting and engaging with cancellous bone.  
      Referring now to  FIG. 27A , the openings of the nail  410  are shown in greater detail. The nail  410  includes the first opening  428  extending along first opening centerline  434 . The first opening centerline  434  intersects with longitudinal axis  454  of the nail  420 . The longitudinal axis  454  of the nail  420  and the first opening centerline  434  define a first plane  472 .  
      The nail  410  further includes the second opening  432  defining second opening centerline  436 . The nail  420  further includes the third opening  468 , which defines the third opening centerline  470 . As shown in  FIG. 27A , the second opening centerline  436  and the third opening centerline  470  intersect the centerline  454  of the nail  420 . The second opening centerline  436 , the third opening centerline  470  and the centerline  454  of the nail  420  define second plane  474 . The second plane  474  and the first plane  472  define an angle σ′″ therebetween.  
      Referring now to  FIG. 28 , yet another embodiment of the present invention is shown as nail assembly  412 . The nail assembly  412  is similar to the nail assembly  410  of  FIG. 27 , but utilizes fully threaded screws rather than partially threaded screws. The nail assembly  412  includes the nail  420  of  FIG. 27 . The nail  420  includes first opening  428 , second opening  432 , and third opening  468 . The nail  420  includes the proximal portion  448  and the distal portion  450 . The nail assembly  412  includes a fully threaded second screw  458 A that is slidably fitted in the second opening  432 . The nail assembly  412  further includes a fully threaded third screw  467 A that is slidably fitted in the third opening  468 .  
      The distal portion  450  of the nail  420  includes a first distal opening  478 , which is positioned transversely or perpendicular to the longitudinal axis  454  of the nail  420 . The nail  420  may further include a second distal opening  480  spaced from and generally parallel to the first distal opening  478 . The nail assembly  412  may further include first distal screw  482 , which may be fitted into the first distal opening  478 . The nail assembly  412  may also include second distal screw  484  for fitting to the second distal opening  480 .  
      Referring now to  FIG. 29 , the medial/lateral view of the nail  420  for use with the nail assembly  410  of  FIG. 27 , as well as with the nail assembly  412  of  FIG. 28  is shown. The nail assembly  420  includes the proximal portion  448  as well as the distal portion  450 . The proximal portion  448  includes the first opening  428 , the second opening  432  and the third opening  468 . The distal portion  450  includes an arcuate portion  488  and an end portion  492 . The arcuate portion  488  and the end portion  492  are configured to form into the arcuate intramedullary canal of the left long bone or femur.  
      The arcuate portion  488  is defined by radius R 2 ′″ extending from origin  490 . The end portion  492  is generally linear and extends at an angle θ″″ from the arcuate portion  488 . The end portion  492  includes the first distal opening  478  and the second distal opening  480 . The first distal opening  478  may, as is shown in  FIG. 19 , be generally cylindrical. The second distal opening  480 , as shown in  FIG. 19 , may be oval.  
      The nail  410  may, as shown in  FIG. 29 , include a relief surface such as a flat surface for example a chamfer  449  for assisting in leading the curved nail  410  into the medullary canal of the long bone, for example the femur. It should be appreciated that the chamfer may have a surface that is not flat, for example arcuate, for example a portion of a sphere or a cylinder.  
      Referring now to  FIG. 29A  the chamfer  449  is shown in the medial/lateral view with chamfer  449  shown on the side of the distal tip opposed to the origin  490  of the curved portion of the nail  410 . The chamfer may be defined by angle θ 3  from the longitudinal periphery of the nail  410 . The chamfer may be further defined by chamfer length CL 2  from the distal end of the nail  410 .  
      Referring now to  FIG. 29B  the chamfer  449  is shown in the anterior/posterior view with chamfer  449  shown at distal tip. It should be appreciated that the tip may be larger or smaller than shown.  
      Referring now to  FIGS. 30, 31  and  32 , the intramedullary nail of assembly of the present invention, may be in the form of a piriforma fossa nail for a right femur.  
      For example and as shown in  FIG. 30 , yet another embodiment of the present invention is shown as nail assembly  510 . The nail assembly  510  includes an intramedullary nail  520 . The nail  520  includes a proximal portion  548  and a distal portion  550 . The proximal portion  548  and the distal portion  550  may be linear in the anterior/posterior view of  FIG. 30 . In other words, the proximal portion  548  and the distal portion  550  may be defined by a common longitudinal centerline  554 . The proximal portion  548  includes a first opening  528 , a second opening  532  and a third opening  568 .  
      The distal portion  550  of the nail  520  may include a first distal opening  578 , which is transverse or perpendicular to the longitudinal axis  554  of the nail  520 . The distal portion  550  of the nail  520  may further include a second distal opening  580  spaced from and parallel to the first distal opening  578 .  
      The nail assembly  520  may include the nail  520 , as well as, a second screw  558 , which is slidably fitted into second opening  532 . The second screw  558  may be a cancellous screw and may, as shown in  FIG. 30 , be fully threaded. The second screw  558  may extend into the neck  3  and head  5  of the femur  4 . The nail assembly  510  may further include a third screw  567 , which is slidably fitted into third opening  568 . The third screw  567  may be in the form of a cancellous screw and may be parallel to and spaced from the second screw  558 . The third screw  567  may extend into the neck  3  and head  5  of the femur  4 . The third screw  567  may be used as an anti-rotation device to avoid the rotation of the head  5  with respect to the remainder of the femur  4 .  
      The nail assembly  510  may further include a first distal screw  582  for slidably engagement with the first distal opening  578 . The first distal screw  582  may be in the form of a cortical screw and may extend from first cortex  6  to the opposed cortex of the femur  4 . The nail assembly  510  may further include a second distal screw  582  for slidably fitting into the second distal opening  580  of the nail  520 . The second distal screw  584  may be similar to the first distal screw  582  and may be in the form of a cortical screw.  
      Referring now to  FIG. 31 , the nail  520  for use with the nail assembly  510  of  FIG. 30  is shown in greater detail in a medial/lateral view. The nail  520  preferably has a shape conforming to that of the medullary canal of the right femur into which the nail  520  is to be inserted. The nail  520  may include the proximal portion  548  and the distal portion  550 . The proximal portion  548  may include the first opening  528 , the second opening  532  and the third opening  568 .  
      The distal portion  550  may include an arcuate portion  588  having a generally bowed shape to conform with the medullary canal of the femur. The arcuate portion  588  may be defined by radius R 2 ′″″ extending from origin  590 . The distal portion  550  may further include an end portion  592 , which is generally linear. The end portion  592  may extend at an angle θ′″″ from arcuate portion  588  and include the first distal opening  578  and the second distal opening  580 . The first distal opening  578 , as is shown in  FIG. 25 , may be generally cylindrical. The second distal opening  580  may, as shown in  FIG. 25 , have an oval shape.  
      Referring now to  FIG. 32 , yet another embodiment of the present invention is shown as nail assembly  512 . The nail assembly  512  utilizes the nail  520  of  FIGS. 30 and 31  and is used to repair neck fractures and greater trochanter  44  and lesser trochanter  46  fractures, or to be able to repair a fracture with both neck screw support and greater trochanter to lesser trochanter screw support. The nail assembly  520  includes the nail  520  as well as a first screw  538  and the second screw  558 . The first screw  538  is fitted into first opening  528  of the nail  520  and extends from greater trochanter  44  to lesser trochanter  46 . The first screw  538  may be in the form of a cortical screw and be able to engage the cortical wall  6  on both the greater trochanter and the lesser trochanter  546 . The second screw  558  is fitted into second opening  532  and extends from cortical wall  6  of the femur  4  into neck  3  and head  5  of the femur  4 . The second screw  558  may be in the form of a cancellous screw to engage with cancellous bone  8  located in the neck  3  and head  5 .  
      Referring now to  FIG. 33 , yet another embodiment of the present invention is shown as nail assembly or kit  600 . The kit  600  includes nail  20 . The kit  600  may also include a screw, for example, first screw  38 . The kit  600  may further include a second proximal screw in the form of, for example, partially threaded second proximal screw  658 . The kit  600  may further include third partially threaded screw  667 . It should be appreciated that the kit  600  may include additional screws. For example, the kit  600  may include fully threaded screws for use in the femoral neck. The kit  600  may further include a second fully threaded screw  658 A as well as a third fully threaded screw  667 A. It should be appreciated that the kit  600  may further include distal screws, for example, first distal screw  682  and second distal screw  684 .  
      Referring now to  FIG. 34 , yet another embodiment of the present invention is shown as surgical technique or procedure  700 . The surgical procedure  700  includes a first step  702  of providing an intramedullary nail. The nail includes a longitudinal axis and an external periphery. The external periphery is sized for fitting in the medullary canal of the long bone. The nail has a first internal wall defining a first opening. The first opening defines a first opening centerline. The nail has a second internal wall, which defines a second opening through the nail. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The first opening centerline and the longitudinal axis of the body form an acute angle between them. The method  700  further includes a second step  704  of positioning the nail at least partially in the medullary canal. The method  700  further includes a third step  706  of providing a first screw for cooperation with the long bone and for slidable cooperation with the first opening and the nail. The method  700  further includes a fourth step  708  of inserting the first screw through the cortical wall of the lesser trochanter of the long bone. The method  700  further includes a fifth step  710  of inserting the first screw through the first opening, as well as a sixth step  712  of inserting the first screw through the cortical wall of the greater trochanter of the long bone. The method  700  further includes a seventh step  714  of providing a second screw for cooperation with the long bone and for slidable cooperation with the second opening in the nail. The method  700  further includes an eighth step  716  of inserting the second screw through the cortical wall of the long bone and a ninth step  718  of inserting the second screw through the second opening. The method  700  further includes a tenth step  720  of inserting the second screw through the cortical wall of the long bone.  
      Referring now to  FIG. 35 , yet another embodiment of the present invention is shown as surgical procedure or surgical method  800 . The method  800  includes a fist step  802  of providing an intramedullary nail. The nail defines a longitudinal axis and an external periphery of the nail for fitting in the medullary canal of the long bone. The nail has a first internal wall, which defines a first opening through the nail. The first opening defines a first opening centerline. The nail has a second internal wall, which defines a second opening through the nail. The second opening defines a second opening centerline. The first opening centerline and the second opening centerline are oblique with respect to each other. The first opening centerline and/or the second opening centerline are transverse to the longitudinal axis of the nail. The longitudinal axis of the body and the first opening centerline form an acute angle between each other. The longitudinal axis of the body and the second opening centerline form an acute angel between each other. The method  800  includes a second step  804  of positioning the nail at least partially in the medullary canal. The method  800  includes a third step  806  of providing a first screw for cooperation with the long bone and for slidable cooperation with the first opening in the nail. The method  800  includes a fourth step  808  of inserting the first nail through the cortical wall of the lesser trochanter of the long bone. The method  800  includes a fifth step  810  of inserting the first screw through the first opening and a sixth step  812  of inserting the first screw through the cortical wall of the greater trochanter of the long bone. The method  800  further includes a seventh step  814  of providing a second screw for cooperation with the long bone and for slidable cooperation with the second opening in the nail. The method  800  includes an eighth step  816  of inserting the second screw through the cortical wall of the long bone and a ninth step  818  of inserting the second screw through the second opening. The method  800  includes a tenth step  820  of inserting the second screw through the cortical wall of the long bone.  
      Although the present invention and its advantages have been described in detail, it should be understood that various changes, substitutions, and alterations can be made therein without departing from the spirit and scope of the present invention as defined by the appended claims.