Sophia Delgado
Intramedullary nails are implanted to stabilize bone fractures, particularly in the tibia, femur, and humerus. They are inserted through a small incision in the skin and tissue, and they form a self-contained internal splint to stabilize the fracture. Once the bone has healed, the nail must be removed. This is typically considered a minor, low-risk procedure, although there are some challenges and potential complications. Removing an intramedullary nail involves first taking out the bone above the nail, then removing the end cap, and finally taking out the nail itself. The process requires careful execution to avoid damaging surrounding structures such as the meniscus and ligaments.
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What You'll Learn
Removing tibial intramedullary nails through the original suprapatellar incision
The suprapatellar approach is a popular method for tibial intramedullary nail placement due to its advantages over the infrapatellar approach, including being easier to perform for treating proximal shaft and metaphyseal fractures and resulting in less postoperative anterior knee pain. However, removing the implant from the same suprapatellar approach is challenging, and removal is often performed through a new transpatellar tendon approach.
A novel method for removing tibial intramedullary nails through the original suprapatellar incision has been proposed, offering a quick and simple procedure for nail extraction. This technique avoids the complications associated with the classic infrapatellar access method, such as the formation of new scars and potential damage to the patellar ligament and infrapatellar fat pad.
The patient is placed in a supine position, and an anterolateral portal is made to gain a direct view of the joint. A nail extractor is inserted via the suprapatellar wound and passed through the lateral parapatellar space to prevent patellofemoral chondral damage. The arthroscope is then redirected medially to observe the tibial nail insertion point. Once the extraction rod is firmly attached to the nail, the proximal and distal interlocking screws are removed through stub incisions.
To ensure the stability of the nail during the procedure, it is recommended to remove the interlocking screws only after the universal rod is attached. After screw removal, peripheral bone ingrowth is debrided to allow for the insertion of a universal rod. This rod is used to screw the end of the nail, facilitating its accurate removal without damaging surrounding structures such as the meniscus and ligaments.
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Using a slide hammer
A slide hammer is a tool used to remove intramedullary nails. It has an exchangeable attachment tip that can be expanded by a threaded rod with a T-shaped grip. The rod fits into an impact tube that carries an impact anvil. The tip has a hardened and textured engagement surface that fits into the thread of the nail. Different diameter tips are available to suit different nails.
To remove an intramedullary nail using a slide hammer, first remove the tail cap and use the guide arm to grasp the nail. All locking screws must be removed before attempting to remove the main nail. If bone growth is suspected in the nail hole or on the surface of the nail, the nail can be driven a few millimetres inward with a slide hammer before removal.
The slide hammer is also used in hip replacement surgery to pull the femoral head out of the thigh. It is important to note that the removal of asymptomatic or uncomplicated intramedullary nails is controversial. Surgeons should carefully consider the indications for removal, such as persistent or progressive pain after the fracture has healed.
In one case, a patient underwent surgery for intramedullary nail removal. The patient was placed in the supine position and received epidural or spinal anesthesia. After exsanguination, the distal interlocking pins and one proximal pin were removed using the original incision. The last proximal pin was then taken out by attaching a puller to the end of the intramedullary nail, and the nail was removed using a sliding hammer.
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Removing the bone above the nail
First, it is essential to understand the anatomy and the specific type of intramedullary nail that was inserted. This information guides the appropriate approach for removal. In the case of tibial intramedullary nails, the suprapatellar approach is often preferred for nail insertion. However, for nail removal, the traditional method involves using the infrapatellar access to avoid surgical complications.
Before beginning the procedure, ensure that the patient is adequately anesthetized and that the necessary instruments are readily available. The knee should be bent at approximately 30 degrees to provide better access to the intramedullary nail.
Using a hollow drill, carefully remove the bone above the intramedullary nail. This step requires extreme precision to avoid damage to nearby structures. A multi-holed guide pin sleeve can be fine-tuned to guide a 2-mm guide needle into the cavity of the intramedullary nail to a depth of at least 2-3 cm. Intraoperative X-rays can be used to confirm the positioning of the guide needle.
Once the guide needle is in place, a hollow jig is screwed into the end of the intramedullary nail, following the path of the guide needle. This process ensures that the bone on top of the nail is accurately removed without causing harm to the surrounding structures. Fluoroscopy can be used to confirm the positioning of the jig and the removal of the bone above the nail.
After removing the bone, the proximal and distal locking nails can be safely extracted. This step releases the interlocking screws that secure the intramedullary nail in place. Finally, the intramedullary nail can be retracted using an appropriate tool, such as a mallet.
It is important to note that this procedure may vary slightly depending on the specific circumstances and the medical team's expertise. The main challenge lies in accurately removing the bone above the nail while minimizing the risk of damage to surrounding tissues and ligaments.
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Using a hollow drill
The use of a hollow drill is an innovative technique for removing an intramedullary nail, particularly in cases of antegrade femoral intramedullary nail subsidence and heterotopic bone formation. This method minimises damage to the bone and surrounding tissues.
Procedure:
Firstly, the patient is positioned laterally, and an incision is made over the prominence of the greater trochanter, extending distally and proximally. The fasciae latae is carefully incised to expose the femoral diaphysis and the origin of the vastus lateralis.
Above the origin of the vastus lateralis, k-wires are drilled to identify the anterior and posterior margins of the intramedullary nail, forming a triangle (TAP) on the lateral side of the femur. The drilling point where no metal-on-metal effect is produced corresponds to the proximal endpoint of the nail (point T).
Knowing the anterior (point A) and posterior (point P) margins, multiple drillings are performed proximally and perpendicular to the median of the triangle (TAP). This helps determine the depth of the nail in the intramedullary canal.
Once the margins and depth of the nail are identified, a hollow drill can be used to create a hole in the nail, allowing for its removal. This process may be guided by intraoperative imaging to ensure accuracy and minimise bone damage.
Benefits:
This technique offers several advantages over traditional methods. It does not require a traction table or fluoroscopy to identify the nail, reducing the complexity of the procedure. It also minimises soft tissue and bone damage, particularly in the area of the greater trochanter.
Additionally, this method is simple, efficient, and cost-effective, making it a valuable option for orthopaedic surgeons when removing intramedullary nails.
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Removing nails for pain relief
Intramedullary nails are small, rod-like devices implanted into the medullary cavity of a bone to stabilise fractures. They are often used for fractures of the tibia, femur, and humerus. In some cases, the proximity of the nail to certain anatomical structures can cause pain, particularly in the knee.
Several studies have investigated the effects of intramedullary nail removal on pain relief, with most concluding that removal of the nail results in significant pain relief, especially in patients with moderate to severe knee pain. One study found that out of 100 cases of lower limb intramedullary nail removal, 25 tibial nails and 11 femoral nails were removed due to pain. Another study of 71 patients treated with intramedullary nails for tibial fractures found that 33 nails were removed, with 12 of those being removed due to knee pain.
A new method for removing tibial intramedullary nails through the original suprapatellar incision has been proposed, which may help to avoid surgical complications associated with the traditional infrapatellar access method. This method involves first removing the bone above the intramedullary nail with a hollow drill, then removing the end cap and taking out the nail.
Overall, the decision to remove an intramedullary nail should be made based on the patient's complaints of pain and radiographic assessment of fracture union, weighing the potential benefits of pain relief against the risks of surgical complications.
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Frequently asked questions
An intramedullary nail is a long nail that is driven down the middle of the leg to help a broken bone stay straight while healing.
An intramedullary nail may need to be removed if it is causing pain or infection. Anterior knee pain is the main reason for the removal of the nail.
The main risk of fracture is from placing the nail, not removing it. However, the outcome after nail removal is unpredictable, and the procedure may cause anterior knee pain.
The procedure for removing an intramedullary nail involves first removing the bone above the nail with a hollow drill, removing the end cap, and taking out the end of the nail. The nail is then screwed into a target device to remove it.
