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An aid to femoral nail removal
Injury, Int. J. Care Injured 34 (2003) 229–231
An aid to femoral nail removal J. Ciampolini∗ , K.S. Eyres Princess Elizabeth Orthopaedic Centre, Barrack Road, Exeter, Devon EX2 5DW, UK Accepted 20 December 2001
Abstract We describe a novel technique to aid the removal of a proximally inserted femoral nail by using a guide wire and the starter reamer. By reaming through the scar tissue, a cylindrical track is created and the threaded top end of the nail is exposed. The soft tissue dissection is therefore limited to the absolute minimum with no further damage to the hip abductors. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Technique description
Removal of a proximally inserted femoral nail can be a surprisingly difficult and time-consuming operation. It is well-known amongst trauma surgeons that insertion and removal of the nail often takes approximately the same length of time. A review of 45 cases in 1996, found that a mean operating time of 110 min was required to remove a titanium femoral nail, with 84 min taken on average to remove a stainless steel one [1]. Tornetta and Tiburzi recently found that an average 116 min operating time for antegrade insertion of a reamed titanium femoral nail was required [2]. It is a common experience that the major difficulties are encountered in locating the top end of the implant and in screwing the removal instrument into the nail without cross-threading. The introduction of blocking caps has helped considerably in limiting the in-growth of bone and soft tissue into the top end of the nail. However, scar tissue interposition is still a vexing problem that can sometimes be overcome only by means of extensive dissection and further damage to the hip abductors. We have devised a simple technique to create a track in the scar tissue that will lead directly to the nail top. It requires radiographic control and can be carried out through a minimally invasive approach.
The patient can be positioned supine or laterally. The previous scar is used with sharp dissection to the piriformis fossa. Under image intensifier control, the top of the nail is located. A 4 mm guide wire is then inserted through the wound and on the top of the implant. Under X-ray control, the guide wire is apposed on the exact center of the nail top. In the absence of a locking cap, the wire is inserted into the nail (Fig. 1). In the presence of a cap, it can be inserted in the hexagonal hole for the screwdriver. After confirmation of correct positioning, a 9 mm starter reamer is inserted using the power tool on the guide wire through the scar tissue and down to bone (Fig. 2). An appropriate soft tissue protector should be used: a standard proctoscope is optimal for this purpose [3]. A clean track is thus created through which the cap (if present) can be removed and the threads of the locking screw of the removal device can be readily inserted leading to nail extraction.
∗ Corresponding author. Tel.: +44-1392-403540 E-mail address: [email protected] (J. Ciampolini).
3. Discussion and conclusions We have found this technique useful as it limits the dissection to the absolute minimum and causes no additional damage to the hip abductors. Furthermore, it reduces the operating time for a procedure that not infrequently is a major struggle even in experienced hands [1]. We have used it regularly with consistently good results and no incidents. We recommend it as a safe way of speeding up, an otherwise very time-consuming procedure.
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 0 4 - 9
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J. Ciampolini, K.S. Eyres / Injury, Int. J. Care Injured 34 (2003) 229–231
Fig. 1. The top of the nail is located. A guide wire is inserted into the nail.
Fig. 2. A 9 mm starter reamer is inserted using the power tool on the guide wire through the scar tissue and down to bone. A cylindrical track is created.
J. Ciampolini, K.S. Eyres / Injury, Int. J. Care Injured 34 (2003) 229–231
References [1] Husain A, Pollak AN, Moehring HD, Olson SA, Chapman MW. Removal of intramedullary nails from the femur: a review of 45 cases. J Orthop Trauma 1996;10(8):560–2. [2] Tornetta III P, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Jt Surg [Britain] 2000;82(5):652–4.
231
[3] Devadoss VG, Howell FR. Can the orthopaedic surgeon forget the proctoscope? The proctoscope as tissue protector during intramedullary nailing. J Royal College Surg Edinburgh 1999;44(3): 177–8.
An aid to femoral nail removal J. Ciampolini∗ , K.S. Eyres Princess Elizabeth Orthopaedic Centre, Barrack Road, Exeter, Devon EX2 5DW, UK Accepted 20 December 2001
Abstract We describe a novel technique to aid the removal of a proximally inserted femoral nail by using a guide wire and the starter reamer. By reaming through the scar tissue, a cylindrical track is created and the threaded top end of the nail is exposed. The soft tissue dissection is therefore limited to the absolute minimum with no further damage to the hip abductors. © 2003 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Technique description
Removal of a proximally inserted femoral nail can be a surprisingly difficult and time-consuming operation. It is well-known amongst trauma surgeons that insertion and removal of the nail often takes approximately the same length of time. A review of 45 cases in 1996, found that a mean operating time of 110 min was required to remove a titanium femoral nail, with 84 min taken on average to remove a stainless steel one [1]. Tornetta and Tiburzi recently found that an average 116 min operating time for antegrade insertion of a reamed titanium femoral nail was required [2]. It is a common experience that the major difficulties are encountered in locating the top end of the implant and in screwing the removal instrument into the nail without cross-threading. The introduction of blocking caps has helped considerably in limiting the in-growth of bone and soft tissue into the top end of the nail. However, scar tissue interposition is still a vexing problem that can sometimes be overcome only by means of extensive dissection and further damage to the hip abductors. We have devised a simple technique to create a track in the scar tissue that will lead directly to the nail top. It requires radiographic control and can be carried out through a minimally invasive approach.
The patient can be positioned supine or laterally. The previous scar is used with sharp dissection to the piriformis fossa. Under image intensifier control, the top of the nail is located. A 4 mm guide wire is then inserted through the wound and on the top of the implant. Under X-ray control, the guide wire is apposed on the exact center of the nail top. In the absence of a locking cap, the wire is inserted into the nail (Fig. 1). In the presence of a cap, it can be inserted in the hexagonal hole for the screwdriver. After confirmation of correct positioning, a 9 mm starter reamer is inserted using the power tool on the guide wire through the scar tissue and down to bone (Fig. 2). An appropriate soft tissue protector should be used: a standard proctoscope is optimal for this purpose [3]. A clean track is thus created through which the cap (if present) can be removed and the threads of the locking screw of the removal device can be readily inserted leading to nail extraction.
∗ Corresponding author. Tel.: +44-1392-403540 E-mail address: [email protected] (J. Ciampolini).
3. Discussion and conclusions We have found this technique useful as it limits the dissection to the absolute minimum and causes no additional damage to the hip abductors. Furthermore, it reduces the operating time for a procedure that not infrequently is a major struggle even in experienced hands [1]. We have used it regularly with consistently good results and no incidents. We recommend it as a safe way of speeding up, an otherwise very time-consuming procedure.
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 0 4 - 9
230
J. Ciampolini, K.S. Eyres / Injury, Int. J. Care Injured 34 (2003) 229–231
Fig. 1. The top of the nail is located. A guide wire is inserted into the nail.
Fig. 2. A 9 mm starter reamer is inserted using the power tool on the guide wire through the scar tissue and down to bone. A cylindrical track is created.
J. Ciampolini, K.S. Eyres / Injury, Int. J. Care Injured 34 (2003) 229–231
References [1] Husain A, Pollak AN, Moehring HD, Olson SA, Chapman MW. Removal of intramedullary nails from the femur: a review of 45 cases. J Orthop Trauma 1996;10(8):560–2. [2] Tornetta III P, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Jt Surg [Britain] 2000;82(5):652–4.
231
[3] Devadoss VG, Howell FR. Can the orthopaedic surgeon forget the proctoscope? The proctoscope as tissue protector during intramedullary nailing. J Royal College Surg Edinburgh 1999;44(3): 177–8.