Removal of Interlocking Nail - It Is Never Impossible
Removal of intramedullary nails is considered a routine procedure but may prove to be challenging. Bone ongrowth or overgrowth, damage to the proximal threads of the nail, and broken nails or locking screws may complicate intramedullary nail removal. Many a times, removal of interlocking nail of femur or tibia is difficult to remove & some times, it becomes impossible too defeating the operating surgeon / surgeons. We have come out with two techniques viz. "Rail Rod technique" & Pull Push technique" which has made every nail removal easy, predictable & possible.
As we know there are many indications for nail removal as follows;
In the short term (a few years), the main reasons to remove an intramedullar nail are:
1. Symptomatic - Fracture has well united but the nail is painful without any reason or with its tip protruding and causing pain at introduction site.
1. Pain in knee even when resting or pain while kneeling. Removal of the nail seems to get rid of the pain in almost all cases. The incidence of pain is about 50% in people getting an intramedullary nail.
2. The screws holding the nail in place irritate the surrounding flesh and produce bursitis type pain. This usually occurs with the screws in the lower leg where they can rub against hiking boots etc. Simple removal of the screws stops this type of irritation.
3. The iliotibial band can hang up on the upper screws as it slides back and forth over the side of the knee like plucking a guitar string. Removal of the upper screw set will stop this problem.
2. prophylactic:Many patients have come for prophylactic removal - for three reasons - children who are operated for nailing for any rare pathology or fracture - to prevent damage to epiphysis as well as nail may get drown into the growing bone and later it becomes difficult to remove. Some patients are feared of infection due to nail or fear of electric shock due to metal inside the body or stress fracture due to nail. In any case removal of nail is ideal once fracture unites and bone consolidates as if the nailed bone fractures then removal and reinsertion of nail becomes difficult.
An asymptotic patient just does not like the idea of having a rod in his/her leg for the rest of their life.
The danger of having the rod in your leg if you ever broke the leg again (the rod gets bent and is difficult to remove or the rod causes addition damage to the bone during the breakage incident). Thomas Anthony
Intramedullary nails are actually hollow. One study examined what was inside the nail after it had been in the bone for several years. The contents included dead bone fragments, dead tissue and other detritus. They cultured this material but it was inactive. The body apparently could not clean it up because there are no blood vessels inside of the rod to transport phagocytes there.
Another risk of intramedullary nailing in the long run (over several years) is avascular necrosis. This happens when the blood vessels (avascular) that enter and feed the bone at various places along the bone are injured or die. Then the bone is left without life support and it dies (necrosis). The bone becomes weak and brittle and will fracture unexpectedly. It is difficult to determine whether this is happening until the unexpected fracture occurs. However, it seems to be more of a problem if the ends of the bone were injured seriously. Some of the major blood vessel entry points are near the ends of the bone and this is probably why there is an association between injury at the ends and avascular necrosis. They also stick the rod in from the end nearest the knee so it makes sense that this location is most susceptible to avascular necrosis if the operation is not done well. The percentage of cases with this problem is very low, about 1-2%.
3.In complicated cases of non union, bent nail or broken nail, for revision surgery, removal of nail becomes compulsory before new nail or implant has been fixed for fracture fixation.
1. Proper record of nails- company make, design & size in the discharge summary, indoor case papers, OT register & to patient records to be given will simplify availability of extractor device. This is not a routine practice and hardly followed or seen any where.
2. AO or Synthes nail designs are made with top screw with threads which fits in the threads at the tip of the nail. This avoids the bone in growth in the nail & over the threads so that on removal once the top screw is removed, the extractor rod threads will fit properly with the threads of the nail tip & removal becomes easier with certain branded nails.
3. Special extractor devices with various sizes of extractor rods are available or graduated conical shaped threaded rod which are universal for use for all types of nail are available. But even though some times fitting of these extractor rod threads in the nail tip threads are difficult & impossible making nail removal difficult.
4. Removal of intramedullary nails is considered a routine procedure but may prove to be challenging. Bone ongrowth or overgrowth, damage to the proximal threads of the nail, and broken nails or locking screws may complicate the removal of intramedullary nails. Multiple techniques including universal extraction sets, guide wires with hooks, and multiple guide wires have been described.
We have devised various methods to remove these nails where the nail tips are not available for removal due to one or the other above mentioned reasons and we are left with alternate measures to remove these nails, many of which have been previously attempted for nail removal but have failed invariably.
1. Once all the interlocking screws are removed, locate & enlarge the appropriate & easily available of the proximally placed bone hole locating one interlocking hole in the nail and make a little longer longitudinal gutter in the bone slot so as to locate the nail hole and introduce either an 4-5 mm Steinman Pin or K nail awl or a thin 4 mm osteotome into the hole of the nail and push it in the proximal direction so as to provide driving force to remove the nail at tips tip. Some times, nail may be jammed so that we may have to repeatedly push the nail through the same hole proximally & distally so as to loosen the nail in the canal so as subsequently make its removal easy. If necessary enlarge the slot or gutter created in the bone proximally and sometimes distally also so as to get more play to pull or push the nail to loosen and remove the nail finally.
2. Rail Rod Technique: Once the tip of the canal of the nail & tip of the nail are cleared of soft & bony tissues and even after fitting of the extractor rod the pulling force may not be sufficient to remove the jammed nail out of the canal, try this technique. After locating the canal of the rod, try to pass simple guide wire of I/L nail through the canal under IITV control and reach up to the distal tip of the nail and go further to the intercondylar area. Some times at the tip of the nail and also to pass through the hard cortical & articular bone of intercondylar area, use power drill to rotate the guide and pass its tip out through the intercondylar area. Remember a very important tip at this point, that while doing this power drilling, keep knee fully flexed so that its tip will pass subcutaneously and be palpable. With a pointed knife put a small incision over this tip so as to pull 2-4 cm of nail tip out of skin. Now using cannulated reamer of about 8 mm diameter, or 8-9 mm another nail, thread it over the extruded guide wire tip through intercondylar area, hammer it proximally gently but firmly under C arm IITV control until tip of the reamer or other nail touches the distal tip of the intramedullary nail to be removed. Now using the 8-9 mm nail which is passed up to distal tip of the nail to be removed, carefully hammer this nail over the distal tip of the nail to be removed so as to get pushing force to remove the nail. This PUSHING force has better impact, effect and driving force in removal of the nail, than the pulling force used to remove by pulling force at proximal tip. With this rail rod technique, and using a pushing force,, it is impossible to fail to remove the femur nail. Some times, the distal hammering nail tip has a tendency to jamm and lock in the distal nail tip of the nail to removed. This is more likely and more common with previously designed and slotted K nail now not being used but may come for removal any time. In this case, this can be avoided by keeping one of the Illizarov bolt or any washer to act as a buffer to prevent locking of the nails. Once enough of the nail is pushed out at its proximal tip by this pushing method, rest of the nail can be easily pulled by any device including vice grip.
3. The previous technique is useful for femur but difficult for tibia as a guide pin maneuvering and drilling through bent tibia nail becomes difficult and hazardous sometimes. For tibia, use the first described technique as described above in column 1. If this fail then following technique will be more useful. Using a strong 5-6 mm ST pin, pass it under C arm IITV control through the hole in the plantar surface of calcaneum.. Guide the tip of ST pin proximally through calcaneul to talus and then enter tibia at its distal end so as to abut the distal tip of the nail against the canal of the nail, impact tip into the canal of tibia nail and gently but firmly hammer the ST pin proximally so as to provide enough driving pushing force so as to push the nail proximally. Once enough of tip is out at its proximal end, it can be easily removed by any device including a vice grip. Jamming of ST pin into nail tip canal can be prevented by using a blunt end of the ST pin to be hammered over the nail tip..
4. For broken nail, after interlocking screws & proximal park of the broken nail is removed, the distal part is difficult to remove. In this case, as mentioned in above column no 2, with rail rod technique, hammer the distal tip of broken nail up above the fracture line, remove the cannulated nail used to push the broken nail. This is followed by passing a ball tip guide pins opposite plain end by rail rod technique as you go on withdrawing the simple guide pin passed from proximal end into distal intercondylar area. Once opposite plain end of ball tip guide pin enters the canal of the distal broken nail, it can be easily maneuvered into the nail canal right up to the tip of the trochanter till the ball touched & engages the distal end of the nail tip. Now hold firmly the guide wire at trochanteric end by a vice grip & hammer it firmly so as to pull guide wire along with which the broken nail also follows. Once enough length of the broken nail is out at trochanter, it can be very easily extracted by plier or vice grip etc.
5. Incacerated nail:
The nail sometimes are found to be seated solidly in place with bone overgrowth and ongrowth in a circumferential fashion for most of its length, without any membranous interface between the bone and the nail. Any attempt to hammer the nail also fail. The bone surrounding the nail is to be removed using the burr and osteotomes. After extensive release, the nail starts moving and eventually nail hammered out using a hook secured with a vice grip.
It recommend that no excessive force be used to extract an incarcerated nail but to approach the problem in a step-wise fashion. Several attempts to extract the nail are often unsuccessful and many instruments are broken. Attempts to place a guide wire into the nail failed due to bone ingrowth into the nail canal. If the nail is still incarcerated and will not move, the tibia needs to be completely open by removing a one-third of circumference longitudinal bone window. It is important to discuss all the possible options with the patient during the consent. The patient may not be aware of the difficulties that can be encountered during nail removal and the fact that it may necessitate a major procedure followed by a prolonged recovery time. It is important to ascertain the reason for nail removal and whether it is necessary to implement even drastic measures to do so. Infection, nonunion, deformity or refracture requiring fixation are indications for nail removal.
As we know there are many indications for nail removal as follows;
In the short term (a few years), the main reasons to remove an intramedullar nail are:
1. Symptomatic - Fracture has well united but the nail is painful without any reason or with its tip protruding and causing pain at introduction site.
1. Pain in knee even when resting or pain while kneeling. Removal of the nail seems to get rid of the pain in almost all cases. The incidence of pain is about 50% in people getting an intramedullary nail.
2. The screws holding the nail in place irritate the surrounding flesh and produce bursitis type pain. This usually occurs with the screws in the lower leg where they can rub against hiking boots etc. Simple removal of the screws stops this type of irritation.
3. The iliotibial band can hang up on the upper screws as it slides back and forth over the side of the knee like plucking a guitar string. Removal of the upper screw set will stop this problem.
2. prophylactic:Many patients have come for prophylactic removal - for three reasons - children who are operated for nailing for any rare pathology or fracture - to prevent damage to epiphysis as well as nail may get drown into the growing bone and later it becomes difficult to remove. Some patients are feared of infection due to nail or fear of electric shock due to metal inside the body or stress fracture due to nail. In any case removal of nail is ideal once fracture unites and bone consolidates as if the nailed bone fractures then removal and reinsertion of nail becomes difficult.
An asymptotic patient just does not like the idea of having a rod in his/her leg for the rest of their life.
The danger of having the rod in your leg if you ever broke the leg again (the rod gets bent and is difficult to remove or the rod causes addition damage to the bone during the breakage incident). Thomas Anthony
Intramedullary nails are actually hollow. One study examined what was inside the nail after it had been in the bone for several years. The contents included dead bone fragments, dead tissue and other detritus. They cultured this material but it was inactive. The body apparently could not clean it up because there are no blood vessels inside of the rod to transport phagocytes there.
Another risk of intramedullary nailing in the long run (over several years) is avascular necrosis. This happens when the blood vessels (avascular) that enter and feed the bone at various places along the bone are injured or die. Then the bone is left without life support and it dies (necrosis). The bone becomes weak and brittle and will fracture unexpectedly. It is difficult to determine whether this is happening until the unexpected fracture occurs. However, it seems to be more of a problem if the ends of the bone were injured seriously. Some of the major blood vessel entry points are near the ends of the bone and this is probably why there is an association between injury at the ends and avascular necrosis. They also stick the rod in from the end nearest the knee so it makes sense that this location is most susceptible to avascular necrosis if the operation is not done well. The percentage of cases with this problem is very low, about 1-2%.
3.In complicated cases of non union, bent nail or broken nail, for revision surgery, removal of nail becomes compulsory before new nail or implant has been fixed for fracture fixation.
1. Proper record of nails- company make, design & size in the discharge summary, indoor case papers, OT register & to patient records to be given will simplify availability of extractor device. This is not a routine practice and hardly followed or seen any where.
2. AO or Synthes nail designs are made with top screw with threads which fits in the threads at the tip of the nail. This avoids the bone in growth in the nail & over the threads so that on removal once the top screw is removed, the extractor rod threads will fit properly with the threads of the nail tip & removal becomes easier with certain branded nails.
3. Special extractor devices with various sizes of extractor rods are available or graduated conical shaped threaded rod which are universal for use for all types of nail are available. But even though some times fitting of these extractor rod threads in the nail tip threads are difficult & impossible making nail removal difficult.
4. Removal of intramedullary nails is considered a routine procedure but may prove to be challenging. Bone ongrowth or overgrowth, damage to the proximal threads of the nail, and broken nails or locking screws may complicate the removal of intramedullary nails. Multiple techniques including universal extraction sets, guide wires with hooks, and multiple guide wires have been described.
We have devised various methods to remove these nails where the nail tips are not available for removal due to one or the other above mentioned reasons and we are left with alternate measures to remove these nails, many of which have been previously attempted for nail removal but have failed invariably.
1. Once all the interlocking screws are removed, locate & enlarge the appropriate & easily available of the proximally placed bone hole locating one interlocking hole in the nail and make a little longer longitudinal gutter in the bone slot so as to locate the nail hole and introduce either an 4-5 mm Steinman Pin or K nail awl or a thin 4 mm osteotome into the hole of the nail and push it in the proximal direction so as to provide driving force to remove the nail at tips tip. Some times, nail may be jammed so that we may have to repeatedly push the nail through the same hole proximally & distally so as to loosen the nail in the canal so as subsequently make its removal easy. If necessary enlarge the slot or gutter created in the bone proximally and sometimes distally also so as to get more play to pull or push the nail to loosen and remove the nail finally.
2. Rail Rod Technique: Once the tip of the canal of the nail & tip of the nail are cleared of soft & bony tissues and even after fitting of the extractor rod the pulling force may not be sufficient to remove the jammed nail out of the canal, try this technique. After locating the canal of the rod, try to pass simple guide wire of I/L nail through the canal under IITV control and reach up to the distal tip of the nail and go further to the intercondylar area. Some times at the tip of the nail and also to pass through the hard cortical & articular bone of intercondylar area, use power drill to rotate the guide and pass its tip out through the intercondylar area. Remember a very important tip at this point, that while doing this power drilling, keep knee fully flexed so that its tip will pass subcutaneously and be palpable. With a pointed knife put a small incision over this tip so as to pull 2-4 cm of nail tip out of skin. Now using cannulated reamer of about 8 mm diameter, or 8-9 mm another nail, thread it over the extruded guide wire tip through intercondylar area, hammer it proximally gently but firmly under C arm IITV control until tip of the reamer or other nail touches the distal tip of the intramedullary nail to be removed. Now using the 8-9 mm nail which is passed up to distal tip of the nail to be removed, carefully hammer this nail over the distal tip of the nail to be removed so as to get pushing force to remove the nail. This PUSHING force has better impact, effect and driving force in removal of the nail, than the pulling force used to remove by pulling force at proximal tip. With this rail rod technique, and using a pushing force,, it is impossible to fail to remove the femur nail. Some times, the distal hammering nail tip has a tendency to jamm and lock in the distal nail tip of the nail to removed. This is more likely and more common with previously designed and slotted K nail now not being used but may come for removal any time. In this case, this can be avoided by keeping one of the Illizarov bolt or any washer to act as a buffer to prevent locking of the nails. Once enough of the nail is pushed out at its proximal tip by this pushing method, rest of the nail can be easily pulled by any device including vice grip.
3. The previous technique is useful for femur but difficult for tibia as a guide pin maneuvering and drilling through bent tibia nail becomes difficult and hazardous sometimes. For tibia, use the first described technique as described above in column 1. If this fail then following technique will be more useful. Using a strong 5-6 mm ST pin, pass it under C arm IITV control through the hole in the plantar surface of calcaneum.. Guide the tip of ST pin proximally through calcaneul to talus and then enter tibia at its distal end so as to abut the distal tip of the nail against the canal of the nail, impact tip into the canal of tibia nail and gently but firmly hammer the ST pin proximally so as to provide enough driving pushing force so as to push the nail proximally. Once enough of tip is out at its proximal end, it can be easily removed by any device including a vice grip. Jamming of ST pin into nail tip canal can be prevented by using a blunt end of the ST pin to be hammered over the nail tip..
4. For broken nail, after interlocking screws & proximal park of the broken nail is removed, the distal part is difficult to remove. In this case, as mentioned in above column no 2, with rail rod technique, hammer the distal tip of broken nail up above the fracture line, remove the cannulated nail used to push the broken nail. This is followed by passing a ball tip guide pins opposite plain end by rail rod technique as you go on withdrawing the simple guide pin passed from proximal end into distal intercondylar area. Once opposite plain end of ball tip guide pin enters the canal of the distal broken nail, it can be easily maneuvered into the nail canal right up to the tip of the trochanter till the ball touched & engages the distal end of the nail tip. Now hold firmly the guide wire at trochanteric end by a vice grip & hammer it firmly so as to pull guide wire along with which the broken nail also follows. Once enough length of the broken nail is out at trochanter, it can be very easily extracted by plier or vice grip etc.
5. Incacerated nail:
The nail sometimes are found to be seated solidly in place with bone overgrowth and ongrowth in a circumferential fashion for most of its length, without any membranous interface between the bone and the nail. Any attempt to hammer the nail also fail. The bone surrounding the nail is to be removed using the burr and osteotomes. After extensive release, the nail starts moving and eventually nail hammered out using a hook secured with a vice grip.
It recommend that no excessive force be used to extract an incarcerated nail but to approach the problem in a step-wise fashion. Several attempts to extract the nail are often unsuccessful and many instruments are broken. Attempts to place a guide wire into the nail failed due to bone ingrowth into the nail canal. If the nail is still incarcerated and will not move, the tibia needs to be completely open by removing a one-third of circumference longitudinal bone window. It is important to discuss all the possible options with the patient during the consent. The patient may not be aware of the difficulties that can be encountered during nail removal and the fact that it may necessitate a major procedure followed by a prolonged recovery time. It is important to ascertain the reason for nail removal and whether it is necessary to implement even drastic measures to do so. Infection, nonunion, deformity or refracture requiring fixation are indications for nail removal.
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