Overview of intramedullary nail removal
Orthopedic surgeons commonly use intramedullary nails as internal fixation devices. Unlike conventional devices, they implant these nails in the bone marrow cavity, which better maintains bone stability and biomechanical properties. Conventional internal fixation devices mostly act on the surface of bones, while intramedullary nails provide support from the inside, which is more in line with the physiological structure of the human body. Intramedullary nail removal is a surgery to remove the implanted intramedullary nail from the body after the fracture heals. It has a long history of application in orthopedic surgery, and with the development of technology, the safety and effectiveness of the surgery are constantly improving.
Medical Definition of Intramedullary Nail
Manufacturers typically make intramedullary nails from biocompatible materials like titanium alloys. They have the characteristics of high strength and low elastic modulus, can effectively transfer stress and promote fracture healing. Its biomechanical principle is to provide axial and rotational stability through the close fit between the intramedullary nail and the bone marrow cavity. For example, for patients with femoral shaft fractures, intramedullary nails can accurately fix the fracture site and reduce the displacement of the fracture ends. Medical professionals began using intramedullary nails in the early 20th century. After years of improvement, it has now become a common method for treating long bone fractures.
Clinical significance of extraction
Long-term retention of intramedullary nails in the body may bring potential risks, such as pain and infection. Therefore, timely removal of intramedullary nails is very necessary. The timing of surgery should take into account the patient’s fracture healing, physical condition and other factors. When patients experience anterior knee pain, internal fixation failure and other conditions, removing the intramedullary nail can effectively relieve symptoms. In addition, for infected patients, removing the intramedullary nail can help control the infection. Pain relief and infection control are the core indications for removing intramedullary nails.
Surgical indications and contraindications
Clear indications
- Anterior knee pain: Clinical studies have shown that about 30% of patients with retained intramedullary nails will experience anterior knee pain, which seriously affects the patient’s daily activities. When the intramedullary nail’s tail end irritates surrounding tissues, it causes pain; removing the nail relieves that pain.
- Internal fixation failure: When an intramedullary nail breaks or loosens, it no longer fixes the bone, which can lead to a shift in the fracture site. Studies have shown that among patients with internal fixation failure, about 80% need to remove the intramedullary nail and re-fix it.
- Subjective symptom assessment: In addition to the above objective indicators, it is also necessary to combine the patient’s subjective feelings, such as local tenderness, degree of activity restriction, etc. for comprehensive judgment.
Contraindications Analysis
Incomplete bone healing and active infection are absolute contraindications. Premature removal of the intramedullary nail can re-displace the fracture, delaying healing; surgeons who operate during an active infection risk spreading it. Elderly patients and osteoporosis patients are relative contraindications. Elderly patients have poor physical function and low tolerance for surgery; osteoporosis patients have low bone strength and surgery is prone to secondary fractures. The risk grading system dictates: doctors deem patients with absolute contraindications as having extremely high surgical risks and thus, they do not recommend surgery; they require full evaluation of patients with relative contraindications to determine if surgery is appropriate.
Intramedullary nail removal procedure
Preoperative evaluation and preparation
- Imaging examination: X-ray and CT examinations allow surgeons to accurately determine the position, number, and status of the locking screws, thereby providing detailed anatomical information and ensuring surgical accuracy.
- Anesthetic plan selection: According to the patient’s physical condition and surgical needs, choose the appropriate anesthesia method, such as general anesthesia, epidural anesthesia, etc., to ensure that the patient is painless during the operation.
- Patient position: Surgeons reasonably position the patient according to the intramedullary nail’s location and the surgical approach to fully expose the surgical site and facilitate their operation.
Surgery steps
- Broken nail removal technique: Surgeons can use a small reamer to wedge into the distal end of broken nails for removal. If the broken nail is deep, they can use new instruments, like the patented design, to improve removal success.
- Distal locking screw treatment: First use imaging positioning, and then use the matching tools to carefully remove it. If the screw is difficult to remove, a special loosening technique can be used.
- Differences between antegrade/retrograde approaches: The antegrade approach enters the medullary cavity from the proximal end, and the operation is relatively direct, but the proximal tissue is more damaged; the retrograde approach enters from the distal end, which has little effect on the joint, but the operation is more difficult. The application of new instruments, such as tools with special guiding functions, can improve the accuracy of the retrograde approach.
Prevention and control of intraoperative complications
Risks such as vascular and nerve damage and secondary fractures may occur during the operation. Surgeons must strictly control the diameter and depth of the medullary expansion technique to avoid fractures caused by excessive medullary expansion. They must ensure timely and effective hemostasis, using compression, electrocoagulation, and other methods to stop bleeding. If vascular and nerve damage occurs, they must take immediate repair measures; if secondary fractures occur, they must select appropriate fixation methods based on the situation.
Postoperative recovery management
Short-term rehabilitation care
- Crutch use cycle: After surgery, patients usually need to use crutches to assist walking, generally partially weight-bearing within 2-3 weeks, and gradually increase the weight-bearing according to the recovery situation. After about 4-6 weeks, crutches can be abandoned and full weight-bearing walking can be carried out.
- Weight-bearing training standard: In the early stage, the affected limb is mainly non-weight-bearing or partially weight-bearing. Patients gradually increase the weight-bearing ratio as pain relief occurs and muscle strength returns. Clinical data demonstrate that within an average of 11 days of sick leave, patients experience significantly reduced pain and swelling, and they can perform mild joint activities.
- Pain management plan: Doctors prescribe non-steroidal anti-inflammatory drugs for analgesia after surgery; therapists use physical therapy, such as ice compresses and massage, to relieve pain and swelling.
Long-term functional recovery
The evaluation indicators of knee joint range of motion recovery include flexion and extension angle, joint stability, etc. There are differences in postoperative rehabilitation between tibia and femur. Doctors observe that knee joint range of motion recovers relatively quickly after tibia fracture surgery, but femoral fracture surgery requires longer recovery due to hip joint involvement. They generally initiate exercise therapy intervention 6-8 weeks post-surgery, when the fracture has essentially healed, allowing patients to perform moderate joint movement and muscle strength training for functional recovery.
Typical case analysis
Broken nail removal technique
- Case details: The patient underwent intramedullary nail fixation for femoral shaft fracture. Postoperative review revealed residual distal screws, followed by secondary fractures. Imaging showed that the residual screws affected the stability of the fracture ends, leading to fracture displacement.
- Advantages of improved instruments: The use of improved removal instruments, whose special head design can better match the broken nails, increase friction, and improve the success rate of removal. At the same time, the guiding function of the instrument can accurately locate the broken nails and reduce damage to surrounding tissues.
- Surgery improvement plan: First, accurately determine the position of the broken nails through CT, and then use the improved instrument to enter through percutaneous puncture and gradually remove the broken nails. For the fracture site, a more stable fixation method is used to promote healing.
Postoperative pain management
Recently, there have been 4 new cases of anterior knee pain. The pathological mechanism is mainly that the tail end of the intramedullary nail stimulates the surrounding soft tissues and patellar tendonitis. The pain in patients who were asymptomatic before surgery may be related to surgical trauma and improper rehabilitation. For these patients, in addition to conventional analgesic treatment, the rehabilitation plan needs to be adjusted to avoid excessive activity. For patients without symptoms before surgery, early postoperative rehabilitation guidance should be strengthened. The key points of patient education include informing the cause of pain, precautions for rehabilitation, and improving patients’ compliance with rehabilitation.
Technology Development Trends
Minimally invasive surgery innovation
- Improved accuracy: The application of navigation systems and robot-assisted technologies has greatly improved the accuracy of surgery. The navigation system can provide real-time three-dimensional images of the surgical site to help doctors operate accurately; the robot can accurately execute surgical instructions and reduce human errors.
- Trauma difference: Compared with traditional open surgery, minimally invasive surgery has less trauma and faster recovery. Traditional surgery has large incisions and serious damage to surrounding tissues; while minimally invasive surgery only requires small incisions, which can effectively reduce postoperative pain and complications.
- Technological breakthrough direction: In the future, navigation systems will be more intelligent and robot-assisted technology will be more flexible, which is expected to enable remote surgical operations and further improve the safety and effectiveness of surgery.
New intramedullary nail design
The new intramedullary nail design uses innovative technologies such as degradable materials and intelligent locking systems. Degradable materials have good biocompatibility and can be gradually degraded and absorbed after the fracture heals, avoiding the trouble of secondary surgery for removal and fundamentally reducing the difficulty of removal. The intelligent locking system can automatically adjust the locking strength according to the growth and healing of the bone to ensure the stability of the fracture site. The bioengineering characteristics of these innovative technologies have brought new breakthroughs in orthopedic treatment and are expected to be widely used in clinical practice in the future to provide patients with safer and more convenient treatment options.