Liam Carter
Femoral nails are used to fix fractures in the femur, with intramedullary nailing being a common treatment method for femoral shaft fractures in adults. While the removal of femoral nails can be challenging and time-consuming, it may be necessary for a variety of reasons. Some recommend that all femoral nails be removed after fracture healing, while others suggest removing only those that cause symptoms. The process of removing a femoral nail involves the use of extraction tools and techniques to safely and effectively extract the nail from the bone. In some cases, a minimally invasive approach may be preferred to reduce iatrogenic morbidity and operating time.
| Characteristics | Values |
|---|---|
| When to remove femoral nail | After fracture healing or only when symptoms are present |
| Femoral nail type | Titanium or stainless steel |
| Femoral nail shape | Bent |
| Extraction tools | Third-generation universal femoral nail extraction tool, conical threaded extraction device, slotted mallet, guidewire, fluoroscopy, cone-shaped femoral extractor, hacksaw |
| Challenges | Heterotopic bone, nail intrusion, bony overgrowth at the end-cap, deep intramedullary placement, longitudinal fracture lines |
| Precautions | Good preoperative planning, control of nail insertion depth, use of an end-cap, dynamometric screwdriver for locking screws |
| Patient considerations | Postoperative pain, ability to bear weight, prohibition from high-impact activities, follow-up care |
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What You'll Learn
- Femoral nail removal is safe, rapid and effortless with a third-generation universal femoral nail extraction tool
- Heterotopic bone removal requires a larger incision and the use of a guidewire
- A minimally invasive approach can be used to reduce iatrogenic morbidity
- Removal of titanium nails takes longer than stainless steel nails due to more locking screws
- In situ bending of a femoral nail is a rare complication that requires special attention
Femoral nail removal is safe, rapid and effortless with a third-generation universal femoral nail extraction tool
Femoral nail removal is a common procedure, often performed following the healing of femoral fractures. While some recommend the removal of all nails after fracture healing, others suggest removing only those that cause symptoms.
The procedure can be challenging and time-consuming, especially with titanium nails, which require the removal of more locking screws than stainless steel nails. Heterotopic bone caps also complicate the process, requiring larger incisions and increasing the risk of iatrogenic morbidity.
However, a third-generation universal femoral nail extraction tool offers a safe, rapid, and effortless solution. This conical, threaded extraction device can be attached to a bar and guided into place using a standard 3.2-mm guide pin or guidewire. The patient is positioned laterally on a radiolucent operating table with the leg draped out to allow full hip and knee motion. The hip is flexed to almost 90 degrees, and the proximal and distal locking screws are removed. A guidewire is then laid on the thigh, and fluoroscopic images are taken to adjust the wire to coincide with the femoral nail.
The cone-shaped femoral extractor is inserted into the wound over the guide pin and gently but forcefully screwed into the nail. While the first pass may not fully engage, it removes soft tissue, and subsequent passes, guided by fluoroscopic images, ensure accurate placement and complete extraction. This technique minimizes fluoroscopy exposure and operating time, reducing potential complications and providing a safe and efficient femoral nail removal process.
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Heterotopic bone removal requires a larger incision and the use of a guidewire
Femoral nails are used to fix fractures in the femur. These nails may require removal for a variety of reasons, including when there is bone overgrowth at the end-cap, or when the patient requests it. 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. Heterotopic bone, or bony overgrowth, can also complicate the procedure.
In the case of heterotopic bone removal, a larger incision must be made. Mayo scissors are used to hold the wound open, and a 3.2-mm guidewire is inserted along the scissors until it touches the nail. The guidewire is then adjusted until it advances into the nail. Fluoroscopic images are taken to confirm the placement of the guidewire. The cone-shaped femoral extractor is then inserted into the wound, over the guidewire, and screwed into the nail. The extractor is then reinserted over the guidewire and tightened onto the nail with force.
The use of a guidewire in heterotopic bone removal ensures accurate placement of the extractor and reduces the risk of iatrogenic morbidity associated with an extensive open approach. The guidewire also helps to reduce fluoroscopy exposure and operating time.
In addition to the use of a guidewire, good preoperative planning is essential to prevent complications and legal issues. The depth of nail insertion and the use of an end-cap are important considerations during the index surgery. The use of nails with closed and constant cross-sectional designs can also prevent the problem of difficult removal due to bone overgrowth.
Overall, the removal of femoral nails, especially in the presence of heterotopic bone, requires careful planning and the use of appropriate tools, such as guidewires and conical extractors, to ensure a safe and efficient procedure.
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A minimally invasive approach can be used to reduce iatrogenic morbidity
Femoral nails are used to fix fractures in the femur. While intramedullary nailing is a common treatment for femoral shaft fractures in adults, with low complication rates, there are some cases where the nail may need to be removed. This could be due to a rare complication like in situ bending of the nail, or as a result of patient requests, or because of symptoms caused by the nail.
The removal of femoral nails can be challenging and time-consuming, especially in the case of titanium nails, which require the removal of more locking screws than stainless steel nails. The procedure can also be difficult due to deep intrusion of the nail, heterotopic bone, or osseous overgrowth at the end-cap.
To address these challenges, a minimally invasive approach can be used to reduce iatrogenic morbidity. This technique is based on instrument placements over a navigated guide-wire. The guide-wire is inserted along the scissors or Mayo scissors until it touches the nail, and then images are obtained to confirm its placement. The cone-shaped extractor is then inserted over the guide-wire and screwed into the nail. This method reduces fluoroscopy exposure and operating time, thanks to the first-pass accuracy of the guide-wire placement.
The use of a third-generation universal femoral nail extraction tool has also been found to allow for quick, easy, and predictable removal of femoral nails. This tool is a conical, threaded extraction device that can be attached to a bar for impaction with a slotted mallet. The patient is positioned laterally on a radiolucent operating table, with the leg draped out to allow for full hip and knee motion. The hip is flexed to almost 90 degrees, and the locking screws are removed. A guidewire is then laid on the thigh and adjusted to coincide with the femoral nail on the lateral view. This technique can be used in conjunction with the minimally invasive approach to further enhance the accuracy and efficiency of the procedure.
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Removal of titanium nails takes longer than stainless steel nails due to more locking screws
Femoral nails are used to fix femoral fractures. They may need to be removed for a variety of reasons, including patient requests, symptoms, and hardware issues. The removal procedure can be difficult and time-consuming, especially with titanium nails, which have longer removal times due to the need to remove more locking screws compared to stainless steel nails.
The process of removing femoral nails involves first placing the patient in a straight lateral position using a bean bag or other positioning device on a radiolucent operating table. The leg, lateral buttock, and torso up to the ribs are prepared, and the leg is draped to allow for full hip and knee motion. The hip is flexed to almost 90 degrees. Standard protocol involves removing the proximal and distal locking screws. A guidewire is then 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, and lines are drawn along the wire onto the buttock. The thigh is then externally rotated, and another line is marked to determine the anteroposterior nail position.
If heterotopic bone removal is required, the incision must be made larger. Mayo scissors are used to expand the wound and hold it open, and a 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. A cone-shaped femoral extractor is inserted into the wound over the guide pin and gently but forcefully screwed into the nail. This process may need to be repeated to fully engage the nail and remove interposed soft tissue. The extractor is tightened onto the nail, sometimes requiring the use of wrenches.
The removal of titanium nails, in particular, takes longer due to the presence of more locking screws. Husain et al. noted that the average time for removing titanium nails was 110 minutes, compared to 84 minutes for stainless steel nails. The longer removal time for titanium nails is attributed to the increased number of locking screws that need to be addressed during the procedure.
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In situ bending of a femoral nail is a rare complication that requires special attention
Intramedullary nailing is considered the gold standard technique for treating femoral shaft fractures. While it has low complication rates, in situ bending of a femoral nail can occur in rare cases, usually due to a new trauma. This complication demands special attention as it can be extremely challenging to remove a bent nail, especially when compared to a broken one.
The rarity of this complication means there is no widely accepted algorithm for the removal of a bent femoral nail. However, several techniques have been described in the literature. One method involves treating the bent nail as a straight nail, which has the advantage of soft tissue preservation and not requiring any special equipment. Another technique involves nail cutting, where the nail is usually stuck in the femoral canal, and a longitudinal bone window approach is needed. The bone window technique requires a rectangular bone window and total nail exposure, with the nail being extracted from the proximal part of the window. If the nail cannot be fully resected, it can be twisted to enable easier extraction of the distal part.
In some cases, straightening the nail using a broad plate and reduction clamps may be attempted. Other methods include in situ straightening via external force on the femur, sectioning of the nail and removing each piece separately, or sectioning the nail to half its diameter and then breaking it. A unique therapeutic and surgical approach is often required for each case, and the degree of angulation of the nail, the direction and location of the deformity, patient conditions, and surgeon experience are key factors in treatment planning.
The use of a third-generation universal femoral nail extraction tool has also been described for safe, rapid, and effortless femoral nail removal. This tool is a conical, threaded extraction device attached to a bar for impaction with a slotted mallet. The procedure involves placing the patient in a straight lateral position, preparing the leg, buttock, and torso, draping the leg to allow full hip and knee motion, and flexing the hip to almost 90 degrees. The proximal and distal locking screws are then 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 lines are drawn along the wire onto the buttock and thigh to determine nail position. If heterotopic bone needs to be removed, a larger incision is made, and the guidewire is inserted along the scissors until it touches the nail. The guide pin is then adjusted to advance into the nail, and anteroposterior and lateral images of the hip are obtained to confirm placement. Finally, the cone-shaped femoral extractor is inserted into the wound and gently but forcefully screwed into the nail.
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Frequently asked questions
Femoral nails are usually removed after the fracture has healed, or when they cause symptoms.
On average, it takes 84 minutes to remove a stainless steel nail and 110 minutes to remove a titanium nail.
The patient is laid on a radiolucent operating table with their leg, lateral buttock, and torso prepared. The hip is flexed to almost 90 degrees, and the proximal and distal locking screws are removed. A guidewire is then inserted into the patient's thigh, and fluoroscopic images are taken. The guidewire is adjusted to coincide with the femoral nail, and the nail is then removed.
A femoral nail is an intramedullary nail used to treat femoral shaft fractures in adults.
There are several risks associated with removing a femoral nail, including fracture during removal, iatrogenic injuries, and difficulties in removing the nail due to bone overgrowth.
