Ava Monroe
The routine removal of intramedullary nails has been a topic of debate, with studies exploring the outcomes and justifications for this procedure. Intramedullary nailing is a widely accepted treatment for tibial shaft fractures, but the decision to remove the nail is often a matter of routine or patient preference. Anterior knee pain and young patient age have been considered justifications for tibial nail removal, but there is limited data on the outcomes. Some studies have investigated the incidence and factors influencing hardware removal, particularly in femoral fractures, while others have explored the safety and efficacy of the procedure. With a range of complications and outcomes reported, the justification for routine removal remains a subject of ongoing investigation.
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What You'll Learn
Anterior knee pain and young age as justification for removal
Anterior knee pain and the patient's young age have been considered justifications for the removal of a tibial intramedullary nail. However, there are few reports on the outcomes of nail removal. In a study of 71 patients, 39 patients experienced less pain after nail removal, 14 had unaltered pain, and 18 patients had increased pain. Of the 6 patients who had been treated with fasciotomy, 4 were not satisfied with the outcome of nail removal. The results of nail removal to alleviate pain are poor, and removal should not be undertaken unless there is a convincing indication.
In a study of 100 cases of lower limb intramedullary nail removal, 12 femoral and 25 tibial nails were removed due to pain, and 4 tibial nails were removed due to infection. There were 3 operative complications, 2 abandoned procedures, and 1 tibial fracture. In 9 out of 16 cases, anterior knee pain improved after tibial nail removal. However, 4 patients who were previously asymptomatic developed anterior knee pain following the procedure.
The incidence of iatrogenic damage to the infrapatellar nerve after tibial nailing is high and lasting. This nerve injury appears to be associated with anterior knee pain after the procedure. In a study of 71 patients, 27 (38%) complained of chronic anterior knee pain, and infrapatellar nerve damage was found in 43 patients (60%). Of the 27 patients with knee pain, 21 (78%) had sensory deficits in the distribution area of the infrapatellar nerve, compared to 22 out of 45 patients (49%) without knee pain. At the time of follow-up, a total of 33 nails were removed due to knee pain, and the pain persisted in 7 out of these 12 patients (58%).
While intramedullary nailing is widely accepted as a safe and effective treatment for tibial shaft fractures, there is controversy regarding the indications for nail removal. The decision to remove a tibial nail has often been a matter of routine or the patient's personal choice. Anterior knee pain has been mentioned as a reason for tibial nail removal. However, it has not been proven that the nail itself is the cause of the pain, and knee pain may even arise after nail removal.
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Tibial intramedullary nail removal outcomes
Intramedullary nailing is a widely accepted treatment for tibial shaft fractures. However, there is controversy regarding the indications for nail removal. Anterior knee pain has been mentioned as a justification for the removal of a tibial intramedullary nail. However, it has not been conclusively proven that the nail is the cause of the pain, and knee pain may persist or even arise after the procedure.
A study by Boerger et al. (1999) found that out of 16 patients with anterior knee pain, 9 showed improvement after tibial nail removal, while 4 previously asymptomatic patients developed anterior knee pain following the procedure. Similarly, another study found that out of 12 patients who underwent nail removal due to knee pain, 7 (58%) continued to experience pain.
In a retrospective study of 71 patients who had tibial nails removed, 39 experienced less pain, 14 had unaltered pain, and 18 experienced increased pain. The authors concluded that the results of nail removal to alleviate pain are poor and that removal should only be undertaken with a convincing indication.
Complications associated with tibial intramedullary nail removal are rare but can include tibial fracture and infrapatellar nerve damage. A novel method for removing tibial intramedullary nails through the original suprapatellar incision has been proposed to avoid the complications associated with traditional infrapatellar access. This method involves inserting a guide needle into the cavity of the intramedullary nail and using a hollow jig to screw the end of the nail along the guide needle, allowing for accurate bone removal on top of the nail.
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Incidence of femoral nail removal
The incidence of femoral nail removal is a topic that has been explored in several studies, with a focus on understanding the factors influencing the removal of intramedullary nails (IMN) and the outcomes for patients.
One study, conducted between July 1990 and November 2003, examined adult femoral fractures with IMN placement, totalling 74 IMNs in 68 subjects with midshaft fractures. The overall incidence of IMN removal was 20% (15 out of 74 fractures). This study analysed various demographic factors, including age, sex, body mass index (BMI), occupation, and insurance involvement, but found no significant differences in the incidence of IMN removal across these variables.
Another study, conducted between September 2016 and September 2018, involved 15 patients ranging in age from 29 to 72 years, with 10 males and five females. Nine of the patients had femoral fractures, and the study focused on the removal of interlocked nails using bolts due to the absence of an appropriate extraction system.
The incidence of femoral nail removal has also been explored in relation to the design of the nails themselves. One study investigated the force, energy, and nail deformation of different nail designs, specifically examining the Trochanter femoral nail ADVANCED™ Nailing System and the Proximal Femoral Nail Antirotation System. The results indicated that the first system, with a radius of curvature of 1.0 m, required significantly lower peak force during nail removal compared to the second system with a radius of 1.5 m.
In addition to these studies, there are reports of femoral nail removal rates at specific institutions. For example, one source mentions an overall implant removal rate of 24.3%, with variation depending on patient diagnosis.
While these studies provide insights into the incidence of femoral nail removal, it is important to consider the limitations of the available data. One challenge is the lack of comprehensive information on hardware removal after femoral fracture healing, as mentioned in several studies. Additionally, the studies focus on specific time periods and patient populations, which may not capture the full scope of femoral nail removal incidences.
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Routine removal of asymptomatic patients
The routine removal of intramedullary nails in asymptomatic patients is not recommended. There are limited reports on the outcome after nail removal. However, in a retrospective study of 71 patients, 39 patients experienced less pain after nail removal but were not asymptomatic. 14 patients had unaltered pain, and 18 patients experienced increased pain.
In another study of 100 cases of lower limb intramedullary nail removal, 12 femoral and 25 tibial nails were removed due to pain, and 4 tibial nails were removed due to infection. For 22 tibial nails and 38 femoral nails, there was no recorded indication for removal. There were 3 operative complications, 2 abandoned procedures, and 1 tibial fracture. 9 out of 16 cases of anterior knee pain improved after tibial nail removal, but 4 patients who were previously asymptomatic developed anterior knee pain following the procedure. 40 patients who were initially discharged without crutches returned in pain and had to be given crutches.
Intramedullary nail removal is generally considered a minor, low-risk procedure with little morbidity. However, it can be challenging and may not always receive the desired preoperative planning, operative expertise, and staff support. While the overall incidence of femoral nail removal after midshaft femoral fracture healing is low (20%), the overall complication rate is notable at 19%.
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Removal techniques
The removal of intramedullary nails is generally considered a minor, low-risk procedure with little morbidity. However, it is important to note that there are limited data and few reports on the complications associated with the removal of intramedullary nails.
One study investigated the outcome of 100 cases of lower limb intramedullary nail removal. Of these, 12 femoral and 25 tibial nails were removed due to pain, and 4 tibial nails were removed due to infection. There were 3 operative complications, 2 abandoned procedures, and 1 tibial fracture. The study concluded that all complications were avoidable and that intramedullary nail removal is safe.
Another study evaluated 71 patients with tibial shaft fractures treated with intramedullary nails to determine the long-term incidence of infrapatellar nerve damage and its relation to anterior knee pain. The study found that 39 out of 71 patients experienced less pain after nail removal, but they were not asymptomatic. 14 patients had unaltered pain, and 18 patients experienced increased pain.
When it comes to removal techniques, there are a few different approaches that have been described:
- Suprapatellar Approach: This involves removing a suprapatellar intramedullary nail via a suprapatellar approach, as described by Lu et al. in their retrospective cohort study.
- Medial Paratendinous Approach: Song et al. mentioned this approach in their discussion of anterior knee pain after tibial intramedullary nailing.
- Tension System for Angular Correction: Freitas et al. proposed this technique for bent intramedullary nails, involving an in vitro analysis.
- Removal of Interlocking Intramedullary Nail: Zhang et al. discussed this technique in the context of relieving knee pain after tibial fracture repair.
- Bent Intramedullary Nail Removal: Kose et al. reported on the removal of a bent intramedullary nail in the lower extremity, providing a case report and review of removal techniques.
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Frequently asked questions
An intramedullary nail is a treatment for tibial shaft fractures.
Anterior knee pain and young age have been considered justifications for the removal of an intramedullary nail.
There is a chance that pain may persist or arise after nail removal. There is also a risk of complications, such as screw breakage, nonfatal fat embolism syndrome, and osteomyelitis.
The removal of an intramedullary nail is commonly regarded as a minor, low-risk procedure. However, it can be challenging and requires careful preoperative planning, operative expertise, and staff support.
