Removal Of Nail Research Articles

IS METALLOSIS AN ISSUE IN INTERNAL LENGTHENING?

IntroductionThere is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.Materials & MethodsAll patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent.ResultsWe identified 7 Precice nails in 5 patients still implanted. All patients had consolidated after lengthening and were ready for nail removal. Elevated Titanium blood ion levels were identified at the time of retrieval. Histological abnormalities consistent with metalosis were identified. In all cases the nail was grossly intact and examination of the motor showed no evidence of wear or failure. Follow up ion levels obtained post retrieval showed persistent elevation.ConclusionsOur retrieval audit shows persistent elevation of Titanium ion levels and abnormal histology despite apparent nail integrity. These findings require further evaluation in a larger retrieval series to determine if there is a high incidence of this phenomenon and if ion levels have a clinical effect.

Melanonychia and subungual papule in a middle-aged man

Melanonychia and subungual papule in a middle-aged man

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 novel feasible technique for rapid removal of broken proximal femoral nails: A case series.

Proximal femoral nail (PFN) fixation is a technique widely used to treat various femoral fractures, but femoral re-injury may occur, leading to PFN breakage. Broken nail removal, particularly removal of the distal broken nails, is usually challenging. Herein, we describe a feasible approach to successfully remove broken femoral intramedullary nails in three sites (proximal, middle, and distal section) of the PFN. Three patients required surgery for PFN breakage. We performed a novel technique using minimal exposure and a cerclage wire to remove the PFN fragment, which a distal knot on the wire was applied to hold the PFN fragment, and the removal trajectory was completed through the minimal exposure, a distal femoral bone window, and the marrow cavity. We successfully operated these three patients and removed the PFN fragments rapidly and effectively. In conclusion, this novel technique is rapid, feasible, and cost-effective, and can also be promising in removing intramedullary nail breakages in other long bones.

Technique for removing a “cold-welded” interlocking screw from an intramedullary nail in the femur: A case report

Rationale: Removing a bent or broken intramedullary (IM) nail can be challenging even if the nail is intact. Several methods have been described for removing bent or broken nails. However, few studies have reported the removal of an IM nail when a proximal interlocking screw is cold-welded. We hope to share our successful treatment strategy for future use. Patient concerns: A 33-year-old male was admitted to our clinic for IM nail removal. The patient complained of discomfort in his right thigh when the weather changed. He had fallen down the stairs 3 years prior, causing a closed fracture of the right femur, and was treated with an IM nail. Diagnoses: Radiography showed an IM nail in the right femur. Interventions: Initially, the distal interlocking screw was easily removed using a screwdriver. Attempts to remove the proximal interlocking screw using various methods were futile. Finally, a high-speed cutting burr was used to cut the proximal interlocking screw. Outcomes: The IM nail was successfully removed. Lessons: A cold-welded proximal interlocking screw was encountered during IM nail removal. The applied technique is an effective alternative when a screw is difficult to remove using conventional tools.

Removal Technique of Penetrating Nail in The Head: A Case Report

Objective: To present a unique case involving a 44-year-old man who sustained a penetrating head injury after nailing his head with a hammer. Despite the severity of his injury, the patient underwent successful surgical treatment and experienced a good recovery.Methods: Clinical and imagery review was performed on a cranial puncture trauma caused by a metal nail, which penetrated the cranium, dura mater, right parietal cerebral parenchyma, and right ventricle. The nail was lodging next to midline without damaging the superior sagittal sinus. The patient underwent craniotomy nail removal and debridement with normal saline and metronidazole antibiotics.Results: Craniotomy, careful nail extraction, wound debridement, and duraplasty remain the treatment standard for penetrating nail injury in the head. Patient in this case study did not exhibit any signs of neurologic deficit or infection.Conclusion: Proper diagnosis and treatment are required in patients with penetrating brain trauma, with head x-rays and CT scans help in evaluating vascular depth and damage. Craniotomy and debridement are the main treatments for this type of trauma.

Tibia Fractures in Children: A Single-Centre 11-Year Retrospective Study for Evaluating the Management and Outcomes in an Acute General Orthopaedic Hospital.

Introduction Tibia fractures are children's most typical lower limb fractures affecting their general and mental well-being. This study aims to evaluate the management and outcomes of displaced tibia fractures. Methods A retrospective study was conducted to review children up to 16 years of age with displaced tibia shaft fractures who received treatment in our department from January 2011 to December 2021. Fractures managed in the operating theatre and patients who completed follow-up until fracture healing were included in the study. Treatment procedures were assessed, and outcome was measured by hospital stays, complications and revision procedure incidences. Results The study included 74 patients (75 fractures, including one re-fracture). The patient's ages ranged from 2 to 16 years (median age: 11 years). Seven patients sustained open fractures (Gustilo I, II). Tibia diaphysis was the most common site of involvement. A total of 43 patients were treated by manipulation under anaesthesia and cast. Surgical fixation was directly proportional to increasing age (p<0.05). Overall, 74% of patients were treated by fixation when age was >10 years. Three patients needed conversion of casting to surgical fixation. One patient had re-fracture following a secondary injury after six months of initial tibia shaft fracture treated by casting. Five patients had complications, including delayed union, pin site and surgical site infections. Antibiotics were adequate to manage infections except in one patient who needed debridement. The average hospital stay was three days. The median number of follow-up X-rays was 4. The planned removal of all flexible nails, and the circular frame was done between 2 and 15 months, except for one that had delayed union. All the patients underwent clinical and radiological union at the end of the follow-up. Conclusion The treatment plan was dependent on the individual need of the patient and the fracture pattern. Children older than 10 years were more likely to undergo surgical fixation. The majority of fractures were treated by manipulation and cast in operating theatres. Better logistic support in the emergency department could reduce the burden on the operating theatre.

Management of Eight Hand Drill Nails Induced Penetrating Brain Injury

Abstract Background Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with hand drill while working in a factory is a peculiar accident. Because of its rarity and lack of standard protocol management, the management of PBI is complex. Case Presentation We presented a case of a 26-year-old male with alleged history of insertion of eight nails from a hand drill machine from right side of head while working in a factory accompanied by loss of consciousness and history of vomiting. Computer tomography demonstrated that nails passed through the right parietal bone and reached up to contralateral hemisphere and posterior cranial fossa. Removal of nails and hematoma evacuation was done timely that led the patient to have a good postoperative recovery. Conclusion In this case report, we discussed the successful management of a very rare penetrating head injury with a hand drill machine. The goal of this case report is to demonstrate the general management principles in PBI that can improve the patient outcome.

Extraction force, energy and nail deformation for 1.5 m versus 1.0 m intramedullary femoral nail bow design: A biomechanical investigation

BackgroundThe impact of the nail radius of curvature, as one of the most important design features in modern femoral nails on the ease of nail removal, remains unknown. Therefore, the aim of this study was to investigate force, energy, and nail deformation of different nail designs. MethodsNail insertion and extraction was performed on six pairs of fresh-frozen human cadaveric femora on a material testing machine with two different nail systems – Trochanter femoral nail ADVANCED™ Nailing System with a radius of curvature of 1.0 m and Proximal Femoral Nail Antirotation System with a radius of curvature of 1.5 m. Deformation was measured after insertion (plastic and elastic deformations) and extraction (plastic deformations). FindingsThe peak force during nail removal was significantly lower in the first group (274.5 ± 130.4 N) compared to the second group (695.2 ± 158.8 N, p = 0.001). Plastic deformation was observed in all implants, being significantly larger in the Proximal Femoral Nail Antirotation System (p = 0.027). There was a strong positive correlation between the first peak force during nail removal and nail insertion (r = 0.802, p = 0.002) as well as between extracting energy and insertion energy (r = 0.943, p < 0.001). InterpretationThe results from this study showed that a radius of curvature of 1.0 m is easier to remove from the set of cadaver femora. Furthermore, our findings support the idea of further reducing the nail radius of curvature below 1.0 m in order to more closely match the anatomy of populations with strong-bowed femora.

Plate over nail and bone graft for management of tibial non union after intramedullary fixation

Abstract Non union after intramedullary nail fixation is difficult to treat. Many options are available for its management including nail exchange, bone graft while keeping the nail, nail removal and plating. Each method has its advantages and disadvantages. The aim of this study is to evaluate the results of management of tibial non union after intramedullary fixation using plate augmentation. Between January 2012 and December 2019, thirty four patients with nonunited fracture tibia previously treated with locked intramedullary nails were included in this study. The ages of patients ranged from 20 to 62 years ( an average age: 43 years). All patients were diagnosed to have aseptic nonunion. All patients achived bony union except 2. Bone union was achieved in a time ranged from 3 to 9 months (an average time 5 months). The average limb length discrepancy was 1 cm ( range 0 to 1.5 cm ). The reported complications were superficial wound infection in 2 cases, joint stiffness in 3 patients and nonunion in 2 cases. There were no intraoperative complications. All patients reported no pain at the fracture site during weight bearing at the final follow-up. We concluded that augmentation plate fixation is a good option for treatment of tibial nonunion after intramedullary nail.

Episiotomy-assisted Incarcerated Femoral Nail Removal: Technical Note

Incarceration of intramedullary nails can pose a significant challenge. There are many reported techniques of nail removal, but when these fail, it can be difficult to determine how to proceed. Here, it is shown that a proximal femoral episiotomy can be used with great effect. 64-year-old male developed hip arthritis. The patient had a solid antegrade femoral nail placed 22 years ago that required removal for a hip arthroplasty. A proximal femoral episiotomy-assisted approach was used with good results and patient outcome. There are several well described techniques to assist with incarcerated nail removal that all trauma surgeons should be familiar with. Proximal femoral episiotomy is a useful technique, every surgeon should have in their arsenal.

Results of Antegrade Intramedullary Elastic Wires for Severely Displaced Distal Radial Fractures in Children

Objective: The objective of this study is to present a new method of Antegrade elastic wires, which is a minimally invasive surgical approach to treat displaced fractures in the distal radial metaphyseal and dia-metaphyseal fractures in children. Materials and Methods: We conducted a retrospective analysis of 18 patients who received antegrade elastic wires treatment for distal radial fractures from January 2019 to January 2023. The surgical indications encompassed closed, significantly displaced, and unstable fractures located in the metaphysis or diaphyseo-metaphyseal region of the radius. The fractures were stabilized using two prebent short elastic nails that were introduced from the diaphysis to the metaphysis. In instances when an ulnar fracture was present, a traditional anterograde nailing procedure was also carried out. A long or short arm plaster cast was administered for a duration of 3 weeks. Results: The group consisted of 15 boys and 3 girls, with an average age of 10.8 years (ranging from 7 to 16 years). The right hand was implicated in 12 instances, whereas the left hand was implicated in 6 instances. The mean duration of follow-up was 7.8 months, with a range of 4 to 28 months. Out of the 18 patients, 2 individuals experienced skin irritations, which were resolved after the removal of the radial nails. All patients had complete restoration of their range of motion and experienced successful bone healing without any problems. Conclusions: An antegrade elastic wire fixation is a very efficient, secure, and readily replicable technique for treating unstable fractures of the distal radius, while also preventing harm to the physeal plate. It successfully attains favorable functional and radiological outcomes and allows early mobilization. Keywords: Distal radius, Metaphyseal fracture, dia-metaphyseal fractures, Elastic wires, Antegrade.

Modified trapdoor procedure versus complete nail removal for subungual glomus tumor excision at minimum 2 years follow-up

Modified trapdoor procedure versus complete nail removal for subungual glomus tumor excision at minimum 2 years follow-up

Functional outcome of pediatric femoral shaft fractures treated with TENS nailing: A case series of 25 patients

TENS (Titanium Elastic nailing system has become the standard treatment for pediatric femoral shaft fractures in the age group 6-14 years. The other treatment options are traction plus spica casting and external fixation. In spite of excellent results described in various studies, there still exists disunity in the orthopedic fraternity with regards to its usefulness. The aim of this study is to determine the outcome of pediatric femur fractures treated with TENS nailing. Between September 2020 and November 2022, 25 children within the age group of 3-12 years with femoral shaft fractures were included in the study. Two TENS nails of precalculated size were inserted in a retrograde fashion under fluoroscopic guidance. Patients were followed up at regular intervals to assess clinical and radiological parameters. Final results were evaluated using Flynn’s clinical criteria. Results: There were 14 males and 11 females with an average age of 6.8years. Fracture levels included N=6 subjects (24%) proximal third fractures. N=15 (60%) subjects with Middle third fractures. N=4 (16%) subjects presented with Lower third fractures. Open injuries were present in 6 cases and 19 cases with closed injuries. The mean injury to surgery interval was 2.37 days, mean hospital stay was 7.3 days and mean time to union was 8.16 weeks. Severe complications were severe skin irritation with bursitis requiring early nail removal in one case, delayed union in one case, Results were excellent in 13(52%) patients, satisfactory in 10 (40%) patients and poor in 2(8%) patients. Conclusion: TENS is safe, reliable and an effeciant method of fixation owing to its simplicity, minimal invasiveness, ease of insertion and removal, TENS additionally has better cosmesis, rapid union with short rehabilitation, less psychosocial stress to the patient and family.

Combined dynamized nailing with partial fibulectomy for aseptic diaphyseal tibial nonunion in adults

Abstract Background and aim of the study Mechanical stability of hypertrophic nonunion remains the goal for treatment leading to bony bridging and remodeling. Partial fibulectomy or dynamization was reported with a wide range of clinical and radiological results. This study aims at assessment of combined dynamically locked nailing with partial fibulectomy technique to reach biological and mechanical stability with shorter healing time. Patients and methods This study included seventeen skeletally mature patients with aseptic diaphyseal hypertrophic tibial nonunion after nailing or external fixator. Patients with infected nonunion, atrophic nonunion, skeletally immature, and those with incomplete follow-up were excluded. Included patients were allocated into two groups, and final functional and radiological outcome regards healing time, union, limb alignment and rotation, knee and ankle rage of motions were reported. Results The mean follow-up period was 33.3 ± 6.2months. All nonunions healed successfully within 11.9 ± 1.5weeks (range: 10–16 weeks). One patient had tibial plafond injury that necessitated nail removal. The mean angle of coronal angulation was 1.4 ± 1.4°. The rotational difference between both limbs as per the thigh-foot angle was 2.5 ± 1.7°. The average functional outcome as per the Karlström-Olerud scale score was 30.9 ± 3. A significant difference was evident between the external fixator group and the nailing group in terms of functional grading scale (P=0.03). Conclusion The combined dynamically locked nailing with partial fibulectomy technique is a biology-preserving technique that provides mechanical stability, allows early return to functional activity with complete bone healing and no need for further surgeries.

Mechanical Failures in Magnetic Intramedullary Lengthening Nails.

Magnetic intramedullary lengthening nails (MILNs) have gained popularity in recent years for the treatment of limb-lengthening discrepancies. We sought to catalog mechanical failures and their prevention and management in a large, single-institution series. We specifically assessed the rate of mechanical failures, the types of failures observed, and management strategies. We retrospectively reviewed 377 patients (420 limbs) who underwent limb lengthening with early (P1) or later (P2) MILN iterations with ≥12-month follow-up. Mechanical failure was defined as mechanical breakage of the instrumentation or nail and/or failure of the internal lengthening mechanism. Failure assessment was arranged by lengthening phases and was sorted with a complication classification system. All lengthening and alignment parameters were assessed radiographically. Mechanical failure was observed in 40 nails (9.5%), most of which (63%) were corrected with an additional surgical procedure. The mechanical failure rate was 11.3% in P1 nails and 9% in P2 nails. Two nails failed the intraoperative distraction test, and 1 nail was found to have a broken washer during the insertion phase. Sixteen nails had mechanical failures in the lengthening phase. Some nails (8 of 16) required nail replacement surgery. Thirteen nails failed during the consolidation phase; 7 of these cases were managed by replacement with either a functional MILN or a conventional intramedullary nail. Eight failures happened during the extraction phase and were managed intraoperatively. A 9.5% overall rate of mechanical failure of MILNs was observed in this large series. Resolution was achieved with an additional surgery in most cases. Nail distraction and weight-bearing compliance should be closely monitored during the lengthening and consolidation phases. Nail removal can be difficult and requires a careful study of radiographs for locking-screw bone overgrowth and backup removal equipment. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical diagnosis and treatment of subungual exostosis in children.

To analyze and summarize the clinical characteristics and treatment effects for subungual exostosis in children. Clinical data for children with subungual exostosis treated in our department from January 2008 to September 2022 were evaluated. Forty children with subungual exostosis were evaluated, comprising 31 boys (77.5%) and 9 girls (22.5%) with a median age of 9 years (4-17 years). The median disease course was 6 months (1-48 months). Seven patients (17.5%) had definite trauma history and 5 (12.5%) had infection. The toe or finger nail appearance was abnormal in 36 patients and normal in 4 patients. Twenty-seven patients (67.5%) had pain when wearing shoes and walking, and 25 (62.5%) had toenail tenderness. The lesions were located in the distal phalanxes of the toes in 37 patients (92.5%), with 14 patients affected on the left side and 23 on the right side. Twenty-two patients had lesions in the great toe, 6 in the second toe, 6 in the third toe, and 3 in the fourth toe. The lesions in the other 3 patients (7.5%) were located in the distal phalanxes of the fingers, with 2 patients affected in the second finger and 1 in the third finger. Regarding the relationship between lesion location and nail bed, 4 patients were type I, 21 were type II, and 15 were type III. All 40 patients received surgical treatment, with nail removal in 15. The median maximum lesion diameter was 1.0 cm (0.8-2 cm), median operation time was 25 min (20-45 min), median blood loss was 1 ml (1-2 ml), and median postoperative hospital stay was 2 days (1-4 days). All cases were histopathologically confirmed as subungual exostosis. The median follow-up time was 24 months (3-60 months), with normal appearance of the toe or finger nail. There were no complications in 38 patients (95.0%). Two patients (5.0%) relapsed at 3 months postoperatively and underwent a secondary operation, with no subsequent recurrence during 12 months of follow-up. Subungual exostosis in children is a rare benign disease that often occurs in the toes. Selection of the appropriate incision and nail bed treatment based on the relationship between lesion location and nail bed is helpful for improving the treatment effect.

Evaluation of bone healing process after intramedullary nailing for femoral shaft fracture by quantitative computed tomography-based finite element analysis.

There is no proven method for quantitative evaluation of bone healing progress or decision to remove the nail after intramedullary nailing for femoral shaft fractures. Finite element analysis has become commonly utilized in bone analysis, but it may also be used to evaluate callus. The goal of this study was to use quantitative CT-based finite element analysis to assess the bone healing process and predict bone strength with the nail removed. Quantitative CT-based finite element analysis was conducted on CT images from patients who had intramedullary nailing after a femoral shaft fracture at 6, 12, and 15months postoperatively. The failure risk of the callus was evaluated with maximal load throughout the gait cycle. The tensile failure ratio was calculated using the volume ratio of the callus element with a tensile failure risk ≥100%. A virtual model with the nail removed was built for bone strength study, and the strength was calculated using the displacement-load curve. The tensile failure ratio reduced with time, reaching 11.6%, 2.6%, and 0.5% at 6, 12, and 15months postoperatively, respectively, consistent with bone healing inferred from imaging results. At 15months, the bone strength at nail removal grew to 212, 2670, and 3385N, surpassing the healthy side's 2766N. Quantitative CT-based finite element analysis enables mechanical assessment during the bone healing process and is expected to be applied to the selection of revision surgery. It is also applicable to the nail removal decision.

Use of a rubber fingerstall to dress wounds after a nail surgery

It can be challenging to place an appropriate pressure dressing on surgical wounds after various types of nail surgery. Residual nail bed wounds can bleed extensively following nail removal, and dressing this wound and applying appropriate hemostasis can be difficult. While gauze is frequently used to wrap the injured digits, in this context, the hemostatic effects of this dressing strategy are limited and the gauze may be easily loosened. Coban may represent a promising choice for digit pressure dressings, yet it may not be readily accessible.

Derotational Plate Augmentation with Retention of Intramedullary Interlocking Nail in Resistant Nonunion at Distal Femur Shaft

Background: Non-union in femur shaft after satisfactory treatment with closed intramedullary interlocking nail is not very common. This nonunion is always a challenging condition for surgeon. These nonunion are usually treated by dynamization, close exchange nail with larger diameter, retention of nail and onlay bone graft, removal of nail and fixed with plates and bone graft, removal of nail and application of cast brace and sometimes removal of nail and applications of external fixators. But no treatment is’ gold standard’ the rotational instability is blamed to be one of the most common reason of nonunion. Aim: To control rotational instability, we did plate augmentation with or without bone grafts without removing the nail to treat this nonunion. Methods: Total patients were 16. Proximal and distal interlocking screws were removed, nonunion site was opened, compression at nonunion site was done, and broad DCP was applied as de rotation plate with or without bone grating. We excluded fracture less than one-year duration and fracture with infective nonunion. Results: In 12 patients bone grafting was done where there was less callus or there was suspicion of atrophic non-union. We got union in all patients. 6.25 months were average time of union. 13 months was average time between the primary and secondary surgery. 71 minutes was means surgical time. Complications or implant failure were not noted. 0.9 cm was average residual limb shortening and 115 degrees was average range of motion at knee joint. Conclusion: Nonunion in distal femur shaft fracture with interlocking nail in situ is reliable and effective procedure Keywords: Distal femur, plate, External fixator. Bone grafting