Ava Monroe
Femoral nail removal is a challenging procedure for orthopedic surgeons. Intramedullary nails are used to fix femoral fractures and may require removal for various reasons, including symptomatic hardware, implant breakage, peri-implant fracture, infection, or preparation for arthroplasty surgery. The process involves the use of a conical, threaded extraction device attached to a bar for impaction. The patient is positioned laterally, and the hip is flexed to almost 90 degrees. Proximal and distal locking screws are removed, and a guidewire is used to penetrate the nail core and guide the extraction device. The procedure can be simplified using a drill-guided technique to identify the margins and depth of the nail, minimizing soft tissue and bone damage.
| Characteristics | Values |
|---|---|
| Reasons for femoral nail removal | Prominent or symptomatic hardware, skeletally immature patients, broken hardware, revision fracture surgery for nonunion, malunion, infection, peri-implant failure, persistent pain or irritation |
| Average time for removal of titanium nails | 110 minutes |
| Average time for removal of stainless steel nails | 84 minutes |
| Position of the patient | Straight lateral position using a bean bag or other positioning device on a radiolucent operating table |
| Preparation | Prepare the entire leg, lateral buttock, and torso to the ribs. Drape the leg out to allow full hip and knee motion for positioning. Flex the hip to almost 90° |
| Guidewire placement | Lay a guidewire on the thigh and obtain a fluoroscopic image of the proximal hip. Adjust the wire to coincide with the femoral nail on the lateral view. Draw a line along the wire, extending it onto the buttock. Externally rotate the thigh and mark a line in a similar fashion to determine the anteroposterior nail position. |
| Heterotopic bone removal | Make a larger incision. Bluntly expand the wound with large Mayo scissors. Insert a 3.2 guidewire along the scissors until it touches the nail. Remove the scissors and adjust the guide pin until it advances into the nail. |
| Extraction | Insert the cone-shaped femoral extractor into the wound, over the guide pin. Gently but forcefully screw the extractor into the nail. Reinsert the extractor over the guide pin or wire and tighten it onto the nail. |
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What You'll Learn
Femoral nail removal procedure
Femoral nail removal is considered a challenging procedure for orthopedic surgeons. The process can be time-consuming and difficult, especially in cases of implant breakage or bony overgrowth. The average removal time for titanium nails is 110 minutes, while stainless steel nails take around 84 minutes.
The patient is placed in a straight lateral position using a bean bag or other positioning device on a radiolucent operating table. The entire leg, lateral buttock, and torso to the ribs are prepared. The leg is draped to allow full hip and knee motion for positioning, and the hip is flexed to almost 90 degrees.
The proximal and distal locking screws are removed in a standard fashion. A guidewire is laid on the thigh, and a fluoroscopic image of the proximal hip is obtained. The wire is adjusted to coincide with the femoral nail on the lateral view. A line is drawn along the wire, extending it onto the buttock. The thigh is then externally rotated, and a line is marked to determine the anteroposterior nail position. The intersection of the two lines indicates the site of the incision for placing the extractor.
If there is heterotopic bone, the incision must be made larger. The wound is expanded with large Mayo scissors. Once the nail is reached, the scissors are used to hold the wound open, and a 3.2 guidewire is inserted along the scissors until it touches the nail. The guide pin is adjusted until it advances into the nail. Anteroposterior and lateral images of the hip are obtained to confirm the placement of the guidewire.
The cone-shaped femoral extractor on the extraction bar is inserted into the wound, over the guide pin. The extractor is gently but forcefully screwed into the nail. The extractor is reinserted over the guide pin or wire and tightened onto the nail with force.
Femoral nail removal should generally be restricted to symptomatic patients, as asymptomatic removal is not recommended and may not be cost-effective.
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Reasons for femoral nail removal
Femoral nails are used to fix femoral fractures. However, there are several reasons why a femoral nail may need to be removed after the fracture has healed.
Some sources recommend that all femoral nails be removed after the fracture has healed. However, this is not a universally accepted practice, and others suggest that only nails that are causing symptoms need to be removed. These symptoms can include persistent femoral pain or irritation, which was the most common reason for removal in one study. Other symptoms may include infection, peri-implant failure, or broken hardware.
In some cases, femoral nails may need to be removed due to cultural reasons or patient preference. For example, patients in Asian countries may prefer to have metallic hardware removed for cultural reasons.
In addition to the reasons above, there may be other factors that influence the decision to remove a femoral nail. These can include the patient's age, sex, nail dimensions, complications, occupation, BMI, insurance, and litigation.
It is important to note that the removal of femoral nails can be difficult and time-consuming, especially in the case of titanium nails, which require the removal of more locking screws than stainless steel nails.
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Challenges of femoral nail removal
Femoral nail removal is considered a challenging procedure for orthopedic surgeons. The removal of an intact femoral nail can be difficult and time-consuming. The longer removal times are attributed to the removal of more locking screws. Femoral nails also frequently require the removal of a heterotopic bone cap, which demands a larger incision.
Another challenge is the incision area. The incision area may differ when the nail is placed in a supine position and when extracted with the patient in a lateral decubitus position. The patient must be placed in the straight lateral position using a bean bag or other positioning device on a radiolucent operating table. The hip should be flexed to almost 90 degrees. The proximal and distal locking screws must be removed in the standard fashion.
The removal of percutaneous embedded distal locking screws can also be challenging and may require a bigger incision. A guidewire is inserted along the scissors until it touches the nail, and the guide pin is adjusted until it advances into the nail. The cone-shaped femoral extractor on the extraction bar is then inserted into the wound, over the guide pin. The extractor is gently but forcefully screwed into the nail.
A novel technique to aid the removal of a proximally (antegrade) inserted femoral nail is to apply drilling consecutively to identify the margins and depth of the nail into the intramedullary canal of the femur. This technique minimises soft tissue and bone damage by being more precise with the skin incision and the tip of the nail.
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Techniques for femoral nail removal
Femoral nail removal is considered a challenging procedure for orthopedic surgeons. The removal of intramedullary nails from the femur can be demanding, especially in cases of implant breakage or bony overgrowth at the end-cap. Here are some techniques used for femoral nail removal:
Patient Positioning
It is important to place the patient in the correct position. The patient should be positioned laterally using a bean bag or another positioning device on a radiolucent operating table. The entire leg, lateral buttock, and torso up to the ribs should be prepared. The leg should be draped out to allow full hip and knee motion for positioning. The hip should be flexed to almost 90 degrees.
Removal of Locking Screws
The proximal and distal locking screws should be removed in the standard fashion. This step is important to access the nail and guide the extraction device into place.
Guidewire Placement
A guidewire is used to help identify the position of the nail and guide the extraction process. The guidewire is laid on the thigh, and a fluoroscopic image of the proximal hip is obtained. The wire is then adjusted to coincide with the femoral nail on the lateral view. The wire is then used to determine the anteroposterior nail position by marking a line on the buttock and thigh.
Heterotopic Bone Removal
If there is heterotopic bone or bony overgrowth at the end-cap, the incision must be made larger. Mayo scissors can be used to hold the wound open, and a guidewire is inserted along the scissors until it touches the nail. The guide pin is then adjusted until it advances into the nail.
Extraction Device Placement
The extraction device, such as a conical, threaded extraction tool, is then inserted into the wound over the guide pin. The extractor is screwed into the nail and tightened with force, often requiring the use of wrenches. The extractor is then used to remove the nail.
Drill-Guided Extraction
A novel technique for femoral nail extraction involves using drilling to identify the margins and depth of the nail within the intramedullary canal. This technique aims to minimize soft tissue and bone damage by being more precise with the skin incision and nail tip identification.
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Patient preparation for femoral nail removal
The patient should be placed in a straight lateral position using a bean bag or another positioning device on a radiolucent operating table. The entire leg, lateral buttock, and torso to the ribs should be prepared. The leg should be draped out to allow full hip and knee motion for positioning. The hip should be flexed to almost 90 degrees.
Before the procedure, the patient should be well-informed about the risks and benefits of the surgery, and provide consent. The surgical team should ensure that the patient is comfortable and any anxiety or concerns are addressed.
Good preoperative planning is essential to prevent complications and legal issues. The exact insertion depth of the nail, the use of an end-cap, and the control of the osseous path are important considerations. The use of a dynamometric screwdriver for locking screws in plate fixation procedures is also crucial.
If heterotopic bone removal is required, the incision must be larger. The wound is expanded with large Mayo scissors, and a guidewire is inserted until it touches the nail. The guide pin is adjusted, and anteroposterior and lateral images of the hip are obtained to confirm the placement of the guidewire.
The patient should be positioned supine on the standard operating table for conventional guide-wire placement. Fluoroscopic images are taken to determine the optimal position of the fixation elements and to check for bone overgrowth that may hinder percutaneous removal.
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Frequently asked questions
Femoral nails are intramedullary nails used to fix femoral fractures.
Femoral nails may need to be removed due to persistent pain, irritation, infection, peri-implant fracture, or non-union. Some recommend routine removal after fracture healing, while others suggest removing only those that cause symptoms.
The removal procedure can be time-consuming and challenging, with an average of 110 minutes required for titanium nails and 84 minutes for stainless steel nails.
The patient is positioned laterally on a radiolucent operating table with their leg draped out for full hip and knee motion. The proximal and distal locking screws are removed, and a guidewire is laid on the thigh to obtain a fluoroscopic image. The wire is adjusted to coincide with the femoral nail, and the extractor is inserted over the guidewire and screwed into the nail.
Yes, a novel technique called drill-guided femoral nail extraction has been proposed, which uses consecutive drilling to identify the margins and depth of the nail in the intramedullary canal. This technique aims to simplify the procedure and minimize soft tissue and bone damage.
