Removal Of Intramedullary Nail Research Articles

Factors which can influence elastic stable intramedullary nailing removal in healed bone cysts in children

Elastic stable intramedullary nailing (ESIN) internal fixation is used clinically to treat pathological fractures of bone cysts in children. However, one of the most important complications was removal difficulty. In this study, we aim to analyse the factors which can influence ESIN removal in healed bone cysts in children. From April 2014 to November 2020, the clinical data of 49 children who underwent elastic stable intramedullary nail removal for pathological fractures of the bone cysts in our hospital were retrospectively analysed. The following data, including age, sex, pathological fracture site, with bone graft, number of ESINs, ESIN indwelling time, and extraosseous length of ESIN were collected, and univariate analysis and logistic regression analysis was performed. The frequency of difficulty in ESIN extraction was 44.90% (22/49). The univariate logistic regression analysis showed that age,ESIN indwelling time,with bone garft and extraosseous length of ESIN may be correlated with the difficulty in removing ESIN (P < 0.05), while sex, pathological fracture site, number of ESIN may not be correlated with the difficulty in removing ESIN (P > 0.05).The multivariate logistic regression analysis showed that the ESIN indwelling time was the independent influencing factor for difficulty in removing ESIN (P < 0.05). The factors influencing the ESIN removal in healed bone cysts in children include over 11.79 years old, the long indwelling time of the ESIN(over 10.5 months),with bone graft and short extraosseous length of ESIN(≤ 0.405 cm). These factors influencing ESIN removal in healed bone cysts in children should be considered.

Nail-extraction device mismatch: an issue in developing countries intramedullary nail removal practice.

Intramedullary nail is the gold standard in the management of long bone diaphyseal fractures of tibia and femur. The jig of these nails has corresponding extraction device whose pitch for nail coupling come in various sizes. This unlike plate and screws may be difficult to predict preoperatively and may pose a problem during removal. Difficulties in removal may arise due to the proliferation of nail brands especially in developing countries. The study aims to identify the incidence of extraction device mismatch among orthopaedic surgeons in Nigeria as well as the indications and complications associated with intramedullary nail removal. A two-page questionnaire was administered to 87 orthopaedic surgeons attending the Annual General Meeting of the Nigerian Medical Association. The attitudes of the participants towards intramedullary nail were assessed. All participants agree to asymptomatic removal. Patients wish was the leading indication for asymptomatic removal among the participants. Sixty-one percent of the surgeons have had the need to remove a nail different from the brand in the hospital their practice. The commonest indication for symptomatic removal was infections. Forty-seven percent of the participant encountered nail extraction-device mismatch. The incidence of extraction device mismatch may portend a public health issue. There may be need for patient who had intra medullary nail insertion to be told their brand. We advocate for standardization of extraction device pitch for intramedullary nail.

Commentary on: High Nonunion and Amputation Rates With Early Intramedullary Nail Removal Versus Retention for Tibial Shaft Fracture-Related Infections.

Orthopaedic Trauma Service Promedical Toledo Hospital, Toledo, Ohio. Corresponding Author: Gregory Minas Georgiadis, MD ProMedica Toledo Hospital Toledo, Ohio UNITED STATES The authors report no conflicts of interest related to this work.

Removal of a Bent Humeral Intramedullary Nail: A Case Report and Review of Removal Techniques.

We present a case of a (65°) bent intramedullary nail (IMN) in a humerus after a pseudoarthrosis in a 65-year-old man. Bent IMNs have been described in femurs and tibias, but are considered rare. Possibly even rarer is the bending of a humeral IMN. This report provides an overview of removal techniques and our approach to this uncommon complication: open sectioning of the bent IMN and 2-piece extraction through the fracture site. Removal of a bent or broken IMN is a rare and challenging surgical problem. A bent humeral IMN requires a different and more careful approach for extraction than bent nails in the lower extremity, given the greater potential for neurovascular disruption.

High Nonunion and Amputations Rates With Either Early Intramedullary Nail Removal or Retention for Tibial Shaft Fracture-Related Infections.

To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement. Retrospective case-control. Four academic, Level 1 trauma centers. Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN. DAIR versus IMN removal pathways. Fracture union. Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing ( P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN ( P < 0.001), McPherson systemic host grade B ( P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst ( P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing ( P = 0.029). Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone-conserving radiation-free intramedullary nail removal technique: A prospective surgical study on 108 patients with healed tibia fractures

Background: While attempting hardware removal, intraoperative challenges and hardware removal strategy vary in each case. Only a few nail removal techniques are reported in the literature. Surgeon’s understanding and resolution of these rather challenging situations improve with experience and exposure. Patients having healed tibia fracture with in-situ intramedullary nail were subjected to intramedullary nail removal. Aims and Objectives: The aim of this study was to assess the performance of novel bone-conserving C-arm-free technique of intramedullary nail removal and describe trends such as surgical timing, complications, hardware removal ratio, intraoperative fluoroscopy requirement, comorbidities, and time since the first surgery in patients undergoing the surgical procedure. Materials and Methods: This was a prospective therapeutic observational study conducted from July 2017 to December 2021. Patients having healed tibia fracture with in-situ intramedullary nail were subjected to hardware removal using a novel bone-conserving radiation-free technique. Results: Among 108 patients, 49.72 (%) were men and 50.28 (%) were women. Patient demographics: age-45 years (mean); range-18–75 years. The overall surgical timing was 117.5±2.1 min (mean/S.D). Hypertension was the most common comorbidity overall with the incidence of 32.40% (35/108 patients); maximum 50% in the age group of 46–60 years (12/24 patients). Nail retrieval was possible in all cases with a 100% hardware removal ratio. The most common complication encountered was DVT/Thrombii (7.40%, 8/108 patients), followed by surgical site infection (5.55%, 6/108 patients) and fractures (2.77, 3/108 patients), with maximum complications in the age group of 61–75 years (63.63%, 7/11 patients). Patients presented 3.8±1.1 years (mean/SD) after the first surgery for nail removal. Conclusion: In complicated situations, an extra bony window over interlocking bolt slots can be used to maneuver the nail, thus facilitating tibial or femoral nail delivery.

A Special Technique to Remove a Jammed Cephalic Screw from an Intramedullary Nail: A Case Report

Background: The complexity of implant removal is a well-known problem in the field of orthopedics. It is encountered mainly during the removal of plates and screws and understood by the phenomenon of seizing or cold-welding, formerly known in mechanics. In this case study, we describe a complex experience during a gamma nail removal in a 21-year-old male patient, explained by the same phenomenon of seizing or cold-welding. The case is rather unusual and rare, with no similar reports in the literature, and required a special technique of extraction. Case Report: A 21-year-old male presented to our clinic with a 5-months history of right groin pain radiating to the anterior thigh. The patient was a victim of a car accident three years ago that resulted in right femoral neck and shaft fractures, which were managed by open reduction and internal fixation by a long gamma nail with distal locking. After proper examination, the team decided to remove the implant. There was difficulty loosening the cephalic screw as it was welded to the nail. For this reason, we opted for a technique that involved making a transverse slit at the level of the anterior part of the nail which is in contact with the cephalic screw. It was followed by a hammer blow at the level of the cephalic screw, allowing it to loosen and thus allowing the screws along the femoral nail to be removed successfully. Conclusion: Our report describes a rare case of a cephalic screw cold-welded/seized into the intramedullary nail, which can be an unexpected and serious complication during intramedullary nail removal. However, our technique described in this case can be an effective way to treat such a complication.

Antibiotic artificial bone implantation and external fixation for the treatment of infection after intramedullary nail fixation: a retrospective study of 33 cases

ObjectiveTo explore the clinical effect of antibiotic artificial bone implantation and external fixation in the treatment of infection after intramedullary nail fixation.MethodsWe retrospectively reviewed the clinical data of patients with infection after intramedullary nail fixation treated from March 2010 to August 2020. There were 27 males and 6 female, aged from 12 to 67 years (average 42.27 years), 18 cases on the left side and 15 cases on the right side. Among them, 20 cases were open fractures with initial injury and 13 cases were closed fractures. All patients were treated with intramedullary nail removal, local debridement, antibiotic artificial bone implantation and external fixation. Because of bone defects, 19 patients underwent secondary autologous cancellous bone grafting after infection control. Postoperative wound healing, related inflammatory indicators, fixation time, and bone healing time were recorded and followed up.ResultsThe 33 patients were followed up with period of 10 ~ 98 months (average 62.7 months). One patients failed to control the infection effectively after treatment, so received antibiotics artificial bone implantation again. Two patients also received antibiotic artificial bone implants again due to the recurrence of the infection. After treatment, infection was controlled and the fracture healed well. One patient received vacuum sealing drainage (VSD) due to persistent postoperative exudation, and five patients were also cured successfully after continuous dressing. Two patients had sinus tract after surgery, and the wound was cured by continuous dressing change. Nineteen patients received autogenous iliac bone grafts for healing due to bone defects ranging from 3 to 6.5 cm (average 4.15 cm) after infection control. The external fixation time of 33 patients ranged from 4 to 16 months (average 7.79 months), the bone healing time ranged from 4 to 13 months (average 6.67 months), and the related inflammatory indexes returned to normal within 2–8 weeks (average 4.48 weeks).ConclusionAntibiotic artificial bone implantation and external fixation is an effective method for the treatment of infection after intramedullary nail fixation.

Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE).

BackgroundIntramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals.Materials and methodsWe performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included.ResultA total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication.Conclusion and clinical significanceThis study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails.How to cite this articleFrost MW, Kold S, Rahbek O, et al. Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE). Strategies Trauma Limb Reconstr 2021;16(2):110–115.

Novel technique of removal of broken intra-medullary nail from femur with secondary DCS plating

&lt;p class="abstract"&gt;Femoral shaft fractures are one of the commonest fractures of the lower limb which are frequently operated with intramedullary nailing which enables immediate post-operative mobilization of the patient. There could be various causes of nail breakage – some of the notable being weight bearing over the non-union of the femur shaft, or a re-trauma over the operated limb causing both the implant and the nail to be broken. There are various methods of removal of the broken implant the commonest being the use of T-reamer technique. However not always can this be used due to varied intra-operative obstacles in different cases as described in this case below. We have a 35 year old male patient who was brought to us 2 hours after an alleged history of slip and fall following which he had sustained right sided subtrochanteric femur fracture with a broken implant – intramedullary interlock nail. The patient is a previously operated case of right sided femur shaft fracture with interlocking nailing done 15 years back. The patient was operated with – broken implant removal on the right side along with a secondary DCS plating with bone grafting for the subtrochanteric femur fracture. Intra operative period was met with a certain number of challenges and difficulties in view of a 15 year old implant for removal which was successfully with removed with DCS plating done. As is obvious with the above case, it would be quite imperative to say that older the implant, more difficult it becomes for its removal. &lt;/p&gt;

Ablation des clous d’allongement intramédullaires PRECICE Stryde cassés

This paper describes two different techniques for removal of broken Precice Stryde intramedullary bone lengthening nails, which, unlike trauma nails, are solid containing mechanical components. Consequently, surgeons face unique challenges when these implants brake within medullary canal. Here, we present our surgical approach for removal of three broken implants. In one patient (46kg), both Ø10mm femoral Stryde implants (max. weight allowance 68kg) broke through the proximal locking screw hole preoperatively on the right side and intraoperatively on the left side (413 and 504 days after index surgery, respectively). The third Ø11.5 femoral nail broke through the area containing the magnet (55kg patient, 325 days after index surgery). Level of evidence: IV.

Removal of broken PRECICE Stryde intramedullary lengthening nails

This paper describes two different techniques for removal of broken Precice Stryde intramedullary bone lengthening nails, which unlike trauma nails are solid containing mechanical components. Consequently, surgeons face unique challenges when these implants brake within medullary canal. Here, we present our surgical approach for removal of three broken implants. In one patient (46kg) both Ø10mm femoral Stryde implants (max. weight allowance 68kg) broke through the proximal locking screw hole preoperatively on the right side and intraoperatively on the left side (413 and 504 days after index surgery respectively). The third Ø11.5 femoral nail broke through the area containing the magnet (55kg patient, 325 days after index surgery). Level of evidenceIV.

Removal of intramedullary tibial nail and placed Ilizarov fixator under spinal anesthesia and combined femoral-sciatic block for analgesia in elderly patient

Removal of intramedullary tibial nail and placed Ilizarov fixator under spinal anesthesia and combined femoral-sciatic block for analgesia in elderly patient

The association between intracompartmental pressure and skeletal muscle recovery after tibial diaphyseal fractures: an ambispective cohort study

BackgroundDue to the special anatomy of the lower leg, tibial diaphyseal fracture causes increased intracompartmental pressure (ICP). Not only is this increased ICP the manifestation of skeletal muscle injury, but it induces further deterioration of the injury. The aim of this study was to assess the association between short-term ICP elevation and long-term skeletal muscle recovery after severe limb trauma.MethodsIn this single-center ambispective cohort study, we retrospectively screened and recruited a cohort of tibial diaphyseal fracture patients with integrated ICP data during the early post-traumatic period, and performed a prospective observational study to evaluate their skeletal muscle recovery through long-term follow-up and MR imaging after the removal of the implants. We analyzed the association between ICP elevation and skeletal muscle recovery using statistical methods.ResultsA total of 46 patients with healed fractures underwent intramedullary nail removal and MR imaging. The absolute values of the Pearson product-moment correlation coefficients between various ICP parameters and the cross-sectional area ratio (CSAR) ranged from 0.588 to 0.793, and the correlation coefficients between the ICP parameters and the average T2-weighted signal intensity ratio (T2SIR) varied from 0.566 to 0.775. Statistically significant associations were observed between the ICP parameters and the MR imaging parameters when simple linear regression analysis was performed. Among the ICP parameters, the accumulated ΔP (ΔP = diastolic blood pressure minus ICP) had the highest determination coefficient and explained 62.1% and 59.1% of the variance in CSAR and T2SIR, respectively.ConclusionsShort-term ICP elevation was associated with long-term skeletal muscle recovery following tibial diaphyseal fracture, especially for ICP data that integrated time factors.Level of evidenceLevel 3.

Outcomes of hip arthroplasty with concomitant hardware removal: influence of the type of implant retrieved and impact of positive intraoperative cultures.

The impact of residual internal fixation devices on subsequent procedures about the hip has not been clearly well defined. The objective of the current study is to evaluate the outcome of hip arthroplasty after hardware retrieval as a one-stage replacement, to analyze possible differences related to the type of removed implant, and to assess the impact of unexpected intraoperative cultures during implant retrieval. We present a retrospective study including all those cases undergoing hip arthroplasty with concomitant hardware removal (cannulated screws, intramedullary nail, or dynamic hip screw) from 2005 to 2018. We evaluated demographics, intraoperative cultures, early infection rate, and other complications. A total of 55 cases were included in the study. The median time between the implant surgery and the hip arthroplasty was 113days. The removed devices included 6 cannulated screws, 34 intramedullary nails, and 15 dynamic hip screws. Up to 74.5% of the failed osteosynthesis belonged to intertrochanteric femoral fractures. Dislocation rate was 9.1% (1.8% requiring revision surgery), 25.5% of the cases needed further new surgeries after the hip arthroplasty, and 49.1% died during the follow-up period. Any-cause revision surgery and mortality rates were significantly increased after intramedullary nail removal. Intraoperative cultures were performed in 46 cases, and in 9 (16.4%), there was bacterial contamination: 6 cases (10.9%) presented one single positive culture and 3 (5.5%) presented ≥ 2 positive cultures for the same microorganism. A total of five cases (9.1%) presented early prosthetic joint infection that required debridement. None of these five cases had presented positive cultures at the implant removal. According to our results, hip arthroplasty with concomitant hardware removal is related to a high 5-year mortality rate, mainly when intramedullary nail is retrieved. Whereas a high risk of early prosthetic joint infection is associated, it seems not to be related to the elevated presence of unexpected positive cultures.

Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases

BackgroundThe incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis.MethodsWe retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed.ResultsA total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively.ConclusionIntramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

A Novel Technique for the Removal of Elastic Intramedullary Nail in Pediatric Long Bones: A Technical Note.

Elastic stable intramedullary nails have been commonly used to treat unstable long bone fractures in children. The nail tip at the insertion site can cause problems. The nail tip should be of optimal length as a prominent nail tip or a short nail tip, or both, may cause different sets of problems. If the nail tip is short, nail removal after fracture union can be difficult and may pose challenges. A short nail tip may lead to difficulty in nail removal, longer duration of surgery, and need for special equipment for extracting the nail. Few techniques have been suggested in the past for removing elastic nail with the short tip, but all these techniques need special instruments. We describe a surgical technique using a metallic suction cannula to aid elastic nail removal. This method utilizes an easily available instrument in the operating room and does not need any special equipment.

Removal of Broken Intramedullary Femoral Nail with Broken Distal Locking Bolt – A Case Report

Non-union after closed femoral interlock nailing is an uncommon complication and occurs when a patient starts early weight-bearing, due to faulty surgical technique or after re-trauma. Removal of broken with broken locking bolt is a difficult and challenging procedure. The present case report deals with a case of the broken intramedullary nail with a broken distal locking bolt. A 30 years male patient was inserted interlocking nail for fracture shaft femur five years back. He presented with pain with instability and inability in weight-bearing after re-trauma. An X-ray revealed a broken nail with a broken distal locking bolt. The far fragment of the broken bolt was engaging bone and nail both and was the main obstacle. His nail with the broken bolt removed and re-nailing did in a single sitting. Steinmannpin (St.pin) was inserted through the distal piece of the nail to push the trapped small screw piece.

Application of Self-Made Connection Device in Intractable Intramedullary Device.

Intramedullary fixation a standard surgical technique for long bone meta/diaphyseal fractures. There were many difficulties in removal of the intractable intramedullary device. The authors reported a new technique to remove the intractable intramedullary nail by using a self-made connecting device. The subject underwent removal of the intramedullary nail using a self-made connecting device, the core components of which were a caudal connecting rod and a sliding hammer in the common intramedullary nail removal device, and the auxiliary device was mainly a clinically commonly used Kirschner wire (K-wire; diameter 1.5-2.5 mm). In technical procedure, the key point was the connection between the k-wire and the intramedullary device, according to the specific conditions of the intramedullary device. From 2012 to 2017, a total of 10 cases of intractable intramedullary devices were taken out using this self-made connection device, including 7 cases of tibial intramedullary nails, 1 case of femoral nail, and 1 case of tibial elastic nail. The technique provided satisfactory results, no infection or re-fracture occurred after the. The self-made connecting device may provide new technique for more surgeons in the face of intractable intramedullary device.

Removal of Elastic Stable Intramedullary Nail

Introduction: Removal of the elastic stable intramedullary nail (ESIN) after the union is routinely performed in the pediatric population. However, ESIN removal can be lengthy and difficult due to the strong bonding between nail and bone. Technique: We preferred keeping the nail tip tangentially flush (&lt;5mm) to the bone to avoid skin irritation. In our technique, after incision and subcutaneous dissection, the nail tip is identified and exposed using a 6-mm osteotome, and a trough is created around it sufficient enough to pass the hollow mill over it. In cases with buried nail tip, a rectangular cortical window may be required. The nail tip is then gently bent at 90° using the hollow mill as the lever taking care not to cause an iatrogenic fracture. The nail tip is held at the bent from sideways with a plier and the nail is removed by rotatory backward motion or reverse impaction using a mallet in cases of strong bonding between nail and bone. Using this technique, ESIN removal was successful in all 28 cases using the previous incision. Of these cases, 10 were forearm (36%), 8 were tibia (28%), 7 were femur (25%) and 3 were humerus (11%). 6 cases (21%) were considered difficult due to increased thickness of the nails, deeper location of the nail tip, and increased bone growth around the tip of nails. Conclusion: Our technique is simple, innovative, and can be easily reproduced by all Orthopaedic Surgeons. The use of this technique is recommended for all ESIN removals. Keywords: Diaphyseal fractures; Elastic stable intramedullary nail; Hardware removal; Paediatric long bone.