george.s.thomas at gmail
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Apr 16, 2008, 7:58 PM
Post #17 of 23
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Re: [ORT-L] intramedullary nail removal ?
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I know just how this feels Dr. Bruce. Down in India, I tried it once for a
patient who was very poor, brought to me by a Catholic priest. After two
hours of struggle and having destroyed several instruments, I hammered the
nail back in (it had come out approx 8cms), apologized to the patient and
anaesthesiologist, and went home.
I guess these are just stuck in and an extended femoral osteotomy is the
only way if one really believes it should come out. I for one, do not think
so, and would leave it alone.
On Wed, Apr 16, 2008 at 9:28 PM, <Bruce_Ziran@hmis.org> wrote:
>
> An interesting case. I must admit, I have had this problem in someone with
> an old K nail, that was left so proud, it needed to come out (see pics).
> My
> patient was also obese and had a previous attempt at removal locally. The
> nail was medially placed (essentially through the base of the neck) and
> was
> "cut off" shorter as a partial solution. Instead, it impinged on capsule.
> In any case, some of the same problems and attempted solutions.
> There was nothing to grab (no slot)
> There was real risk of breaking the neck, without getting the nail out
> The bone had grown into the slot.
> We tried the following:
> Reaming out the inside of the nail, both with hand, and small
> flexible reamers. No way.
> Small flex osteotomes (from joint revision set) to try to loosen nail
> a bit above then work it. Definitely no way.
> Use "impact driver" technique to loosen bond between bone and nail.
> OK, not a mechanic and not pneumatic impact driver.
> Go from below, via retrograde portal of knee, and use tamp and push
> from below, while pulling from above: Nice idea, bad outcome = SC fracture
> Ultimately, the only way this would come out is what Dr. Van
> Scherpenzeel was trying to avoid: An extended femoral osteotomy to open
> the
> canal and literally chip away at the nail from all sides, and for length
> of
> femur. The osteotomy was done maintainng all muscle attachments and
> hinging
> on periosteum. Repair was with a very long distal femoral LCP. In our
> case,
> since the hole proximally was literally at the base of the neck, I felt
> prophylactic protection of the neck against this stress riser was
> indicated. No plate long enough so we overlapped another LCP. See pic.
> Patient healed (lucky more than anything else), and did well. While I
> anctipated some of the issues with a pre-op plan, and was prepared for
> most of them, it just seemed like and endless folly of failures. Those
> nails can be a real SOB to get out when there is length long ingrowth! At
> least the neck didnt break.
>
> I must say, that was probably one of the worse days in my career. I went
> home, told my wife I should quite surgery, drank a stiff scotch and went
> to
> bed. May God be with you if you need to do the same.
>
> (See attached file: Knail.ppt)
>
> Bruce H. Ziran, M.D.
> Director of Orthopaedic Trauma
> St. Elizabeth Health Center
> Associate Professor of Orthopaedic Surgery
> Northeast Ohio Universities College of Medicine
>
>
>
> "Tim Harris"
> <tharris@wakeorth
> o.com> To
> Sent by: <ORT-L@www2.aaos.org>
> ORT-L-owner@www2. cc
> aaos.org
> Subject
> RE: [ORT-L] intramedullary nail
> 04/16/2008 09:55 removal ?
> AM
>
>
> Please respond to
> ORT-L@www2.aaos.o
> rg
>
>
>
>
>
>
> Have you tried introducing iced saline into the canal prior to removal
> attempts?
>
> You could also consider combined approach by opening distal femur (like
> inserting a retrograde nail) and impacting the nail to drive it out the
> knee w/ crochet hook on distal end of nail.
>
> Tim Harris
>
> -----Original Message-----
> From: Karine van Scherpenzeel
> [mailto:karine.vanscherpenzeel@charite.de]
> Sent: Wed 4/16/2008 9:35 AM
> To: ORT-L@www2.aaos.org
> Cc:
> Subject: RE: [ORT-L] intramedullary nail removal ?
>
>
>
> He complaints of progressive pain of the proximal femur
> radiating toward
> the knee and has a positive scintigraphy with signs of
> osteomyelitis.
> Although he has an ataxic gait with a positive Trendelenburg
> sign, there
> are no neurologic signs that can explain his pain neither does
> his spine
> examination. Laboratory is negative.
>
> Karine van Scherpenzeel
>
> > Why is it being removed?
> >
> > William T Obremskey MD MPH
> > Vanderbilt Orthopedic Trauma
> > Associate Professor Divsion of Orthopedic Trauma
> > Director of Orthopedic Trauma Research and Education
> > Suite 4200 Medical Center East - South Tower
> > Nashville, TN 37232-8774
> > 615-936-0112- office
> > 615-936-1566- fax
> >
> > -----Original Message-----
> > From: ORT-L-owner@www2.aaos.org
> [mailto:ORT-L-owner@www2.aaos.org] On
> > Behalf Of Karine van Scherpenzeel
> > Sent: Wednesday, April 16, 2008 4:10 AM
> > To: ORT-L@www2.aaos.org
> > Subject: [ORT-L] intramedullary nail removal ?
> >
> > Dear list members,
> >
> > we are looking for some help to remove a 30 year old
> intramedullary
> > Kuentscher nail of the femur in a 56 year old man, after two
> previous
> > failures. X rays are included. The nail was extremely and
> very rigidly
> > fixed after extraction of +/- 5 cm, both times the proximal
> part was then
> > removed. Reaming of the proximal part, opening of the
> complete (hollow)
> > inner part and very forceful extraction with a pneumatic
> hammer did not
> > help. We sacrificed a few instruments and gave up after a
> few hours. The
> > first time elsewhere same thing happened. I wonder if there
> is a
> > possibility to ream the complete nail with a 12 mm reamer,
> but haven't
> > found a company who offers a hollow reamer like that. I am
> not willing to
> > open the complete femur and using a long chisel
> circumferential of the
> > nail seems to be risky. Any ideas or suggestions are very
> welcome. Many
> > thanks in advance and greetings from Berlin,
> >
> > Karine van Scherpenzeel, MD
> > Centrum für Muskuloskeletale Chirurgie
> > Klinik für Unfall- und Wiederherstellungschirurgie
> > Charité - Universitätsmedizin Berlin
> >
> > E mail: karine.vanscherpenzeel@charite.de
> >
> >
> >
> >
> >
> >
> >
> >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
>
> (See attached file: winmail.dat)
>
>
>
> CONFIDENTIALITY NOTICE: This message, including any attachments, is for
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>
--
George Thomas,
Chief Orthopaedic Surgeon,
St. Isabel's Hospital,
Mylapore,Chennai 600004,
India.
Phone +91-44-24991081/82/83
Editor, Indian Journal of Medical Ethics,
www.issuesinmedicalethics.org
www.ijme.in
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