Research Article

Research Article

Evaluation of a modified technique for gamma nail removal

Ole Ackermann1, Lothar Roslawski2 Christoph von Schulze Pellengahr3

1. EVKM Mettmann, Mettmann, Gartenstrasse 4-8, 40822 Mettmann, Germany.

2. CPDU Chirurg. Gem. Praxis. Dr-Alfr-Herrhausen-Al 21, 47228 Duisburg, Germany.

3. Department Accident Surgery, Agaplesion EV. Bathildiskrankenhau. Maulbeerallee 4, 31812 Bad Pyrmont, Germany.

Corresponding author: Ole Ackermann, PhD. MD. EVKM Mettmann, Gartenstrasse 4-8, 40822 Mettmann, Germany. Tel: +49 (0)2104 773-0; email: dr.med.ackermann@gmx.de.


Citation:   Ackermann O, Roslawski L, von Schulze Pellengahr C. Evaluation of a modified technique for gamma nail removal. J Minim Invas Orthop, 2015, 2(3):e10. doi:10.15383/jmio.10.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: 2015 By the Editorial Department of Journal of Minimally Invasive Orthopedics. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 

Abstract: The indication for removing intramedullary nails in young patients is controversial. The principal reason is the comparably high operating morbidity, which basically results from the exposing of the nail head which may cause postoperative symptoms. The aim of this study was to develop and evaluate a nail explantation technique that protects the bones and soft tissue. In the modified technique, the nail head was exposed via a targeting wire and the hand reamer of the nail instrumentarium under soft tissue protection. The result of the operation was recorded based on a follow-up examination of the patients and the incision-suture time was compared to that of the conventional operation. From 5th September to 3rd October, 2004, the explantation was conducted with the new technique in 5 patients. Another 10 patients were selected as control that was treated conventionally beforehand. The new technique revealed a significantly reduced mean OP time (31.0 vs. 74.8 minutes, P<0.05). All of the patients had less or no symptoms postoperatively in comparison to the findings in controls. The modified technique used in the operation with existing instrumentarium resulted both in a lowering of nail removal morbidity and a significant reduction in the operation time.

 

Keyword: Gama nail removal; Implant.

 

 

 

 

 

 

 

 

 

 


 


Introduction

The indication on the removal of intramedullary nails following fractures in the region of the hip joint is the subject of heated debate. While it is agreed that in elder patients to leave these implants in place when there are no compelling reasons to remove them such as infection, prosthetic implantation, fracture close to the implant, material failure, and dislocation. The data available in younger patients is mixed [1,2,4,6,13]. In comparison to other implants, the removal of intramedullary nails is critically regarded [1,2,10,17]. It is particularly due to the comparatively high operation morbidity [10], which appears to be a reason for the only limited success of this operation in relation to the patients' reduction of pain [4,7]. The major difficulties are the exposing of the nail head and the insertion of the extraction bolts when particularly if ossification is present.

The aim of this study was to develop and evaluate a modified operation to reduce the morbidity by simplifying the technique and cutting the operation time.

Materials and methods

The prerequisite for this method of operation is the standard instrumentarium and the mastery of the standard approach for the implantation of the specific intramedullary nail, since this is the basis for the removal. The positioning follows the requirements of the access method and the fluoroscopy on the extension or hip table with

 

Figure 1. K-wire positioning under X-ray.

adducted leg (for better access to the nail head); the ipsilateral arm and the contralateral leg are elevated to allow the axial fluoroscopy of the operated hip. The removal of the distal locking bolt and the insertion of the instruments for removing the femoral neck screw are performed using the normal method. The old scar is reopened for preparing the nail head.

In contrast to the standard technique (exposing the nail head with a luer or small chisels), a targeting wire is inserted into the trochanter major and centrally positioned using anterior-posterior and axial image-intensifier control in the nail head (Figure 1). A discernible bump should be felt here which is important to obtain the precise central position of the nail head. If required, a quadruple targeting sleeve can be used as in the implantation. Then the tissue protection sleeve is inserted and the cortical bone is opened up to the nail using the hand reamer (Figure 2). Attention must be paid here that the cutting parts of the reamer are not damaged by the nail.

When a sufficient channel has been created to remove the nail, large scale ossification may be present. If required, the channel can be enlarged with a sharp spoon and cleared of bone fragments. Any sealing plug present should be removed and the antirotation screw should be counter-rotated until the femoral neck screw can be freely rotated. It is not necessary to completely remove the antirotation screw while it can be left in this position in the nail head.

Figure 2. Opening the cortical bone under X-ray.

The extraction rod with the large cone is then inserted into the nail head and the femoral neck screw is removed. Major ossification can be overcome using this technique without causing large-scale trauma. In this regard, the positioning of the targeting wire is critical.

In this manner, it is possible to reduce the access morbidity for the removal of the nail to the same extent as in the implantation. Furthermore, the removal itself ensues significantly more quickly compared to the conventional method.

As part of a prospective analysis, the data in which used this technique was recorded and compared with the findings of patients who underwent surgical removal in the past by means of the conventional technique. The data included the age of the patient at the time of the explantation, the operating side, diagnosis, implant type, date of implantation, date of removal, and incision-suture time.

All the patients in our clinic since July 2004 who had undergone implantation were excluded because this surgery is performed in our clinic with the patient in a lateral position. The follow-up examination of patients underwent the new technique took place between 4 and 20 weeks following the metal removal. The evaluation ensued with MS-EXCEL (Microsoft Corp, Redmond, WA, USA), the comparison of the operation time with the T-test for unmatched samples. The effect of operator qualification was tested using the chi-square test. Two sided P value less than 0.05 is considered to be significant.

Results

From 5th September to 3rd October 2004, the explantation was conducted with the new technique in 5 patients. Ten patients were served as the control group, for whom metal removal using the conventional technique was undertaken in the same period. The clinical data are shown in Table 1.

For patient b.g, the nail removal ensued as part of a reosteosynthesis. Following the complete metal removal (10 minutes), a further 5 minutes was therefore added to adequately image the wound closure. Patient b.b. was not considered when calculating the significance for the operation time, because in this case only the nail shaft was removed. The femoral neck blade and the locking bolt had previously been removed in a different hospital, although it was not possible to remove the nail shaft in that operation. The mean operation time for modified technique was significantly less than that for the conventional technique (31.0 minutes vs. 74.8 minutes, P<0.05).

Primary healing ensued for all patients; mobilisation initially ensued with partial weight bearing for all patients; full weight bearing was achieved not later than the 5th day. The follow-up examination revealed that three patients had no pains, while two patients stated having pains with an intensity of between 1 and 2 on the visual analogue scale (VAS) of 10. Four patients had less pains compared to their pre-operative situation, while one patient already had no pre-operative pains. All the patients stated that they had benefited from the operation and would undergo it again. The X-ray controls revealed a proper metal removal with no additional pathological symptoms in all patients.

Discussion

While the indication for metal removal is generally interpreted on an extremely restricted basis in the Anglo-American world [2], it is under discussion particularly with regard to intramedullary implants in adults. An uncontrollable infection, prosthetic implantation, nail fracture as sign of lack of bone healing, dislocation (e.g. proximal cut-off) and a fracture close to the implant (depending on localisation and the form of the fracture) are regarded as absolute indications [3,16]. In elder patients, the consensus exists that implants should be

left in place if none of the indications specified for removal are present. The situation in younger patients is unclear. There appears to be evidence for the existence of abraded particles in remote visceral organs when titanium implants remain in the body over a long period [17] and for the occurrence of detached metal ions, which may be the reason for aseptic loosening [18].


 Table 1. The clinical data of two groups of patients.

Initials

Side

Implant

Age of patient on removal date (years)

Duration of implant in patient's body (days)

Incision-suture time (minutes)

Remarks

 

 

 

 

 

 

 

 New technique

 

 

 

 

 

 

b.h.

Left

Proximal femoral nail

38

494

60

no special circumstances

b.f.

Right

Gamma nail

44

451

90

difficulties in screwing in the extraction bolt

c.h.

Right

Proximal femoral nail

83

432

95

marked exostosis

k.m.

Right

Gamma nail

76

419

80

no special circumstances

k.c.

Right

Gamma nail

52

430

35

no special circumstances

l.j.

Right

Proximal femoral nail

72

622

85

no special circumstances

r.i.

Right

Proximal femoral nail

77

375

40

no special circumstances

s.g.

Right

Gamma nail

71

664

55

no special circumstances

s.m.

Right

Gamma nail

55

435

120

no special circumstances

w.c.

Right

Proximal femoral nail

72

488

88

no special circumstances

Average

 

 

64

481

74.8

 

 

Traditional technique

 

 

 

 

 

 

p.w.

Right

Undrilled femoral nail

56

833

35

no special circumstances

b.c.

Right

Gamma nail

61

404

35

no special circumstances

b.g.

Left

Gamma nail

77

342

15

OP as part of reosteosynthesis with long nail

n.n.

Left

Gamma nail

44

451

49

incl. 2 cerclage removal

b.b.

Left

Friedel nail

50

1409

21

Previous removal attempt in a different hospital not successful

Average

 

 

58

688

31.0

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The effects of these events on the organism and quality of life of the patients, however, are still unclear. Furthermore, delayed infections [8], allergenic sensitisations [9] and implant-related arthritis [15] are described as rare consequences. It should also be considered that massive implants in the body may impede (or even make impossible) diagnostic or therapeutic measures considered necessary as a result of an accident. With young, active patients in particular, subsequent sports injuries in a region close to the implant may also represent a challenge [14,16].

The issue of morbidity of the metal removal is critical in relation to intramedullary implants. Minimally invasive metal removal procedures such as for a retrograde femoral nail [5] have not been described for antegrade nails. Relevant soft tissue damage occurs as part of the conventional technique. In a study on the removal of intramedullary nails from the lower extremities differentiated by age, indication and risk factors, Hora [10] found complication rates of between 9.4% and 44.4%, whereby wound healing disorders and infections amounted to 85% of the complications.

An improvement in pre-operatively existing pains can be achieved with metal removal [13] and is specified with a rate of 64-78% [4,8]. However, the authors also found a deterioration of the pain symptoms in 17% of cases as a result of the operation.

While the removal of locking bolts and femoral neck screws causes few problems in our experience, the preparation at the nail head can be difficult and time-consuming particularly if ossification is present, as well as associated with a corresponding morbidity. We perceive the principal cause of the complications in this area. For this reason, a few authors only recommend metal removal with symptomatic patients [1,6,7], while Schwarz [13] recommends metal removal for patients who are younger than 60 years of age and whose implants have an expected service life of greater than 5 years. Removal can also be undertaken if the patient requests it which is followed by a differentiated clarification [11]. Our own approach recommends metal removal in otherwise healthy patients up to the age of 65 years, and only to older patients in the event of impairing, painful symptoms or if expressly requested by the patient. In all cases, however, the indication should be individually discussed and clarified for the patient in accordance with the Pertrochanteric Femoral Fracture Guidelines of the German Association of Trauma Surgery [10,12].

A technique, which protects soft tissue and is less traumatic, is essential because the vast majority of intramedullary nail removals are carried out on young and/or active patients. With the technique presented here, it is possible to achieve the same order of morbidity for metal removal as in implantation in almost all cases. The benefits are evident if ossification is present, whereas few difficulties exist in the case of a free and well palpable nail head. Though the argument of a reduced morbidity appears obvious, further investigations with higher case numbers are still needed in order to evaluate the long-term outcome and functional benefit. Nevertheless, we expect a positive effect on function and frequency of infection.

One obvious benefit can be seen in the markedly shorter operation time for our patients. The removal of a UFN is also included in the investigation because the essential problem of the preparation of the nail head is identical here. It is necessary to the removal of the femoral neck screw is dispensed instead to extract not 1 but 4 locking bolts, although it is time consuming. In our opinion, the time involved is comparable here.

The disadvantages of this method are the extra effort involved in the positioning and the increased exposure to radiation close to the gonads. In view of the stochastic character of radiation damage and the radiation dose already applied as part of diagnostic, implantation and postoperative controls; however, we find this acceptable.Another disadvantage can be perceived if the hand reamer is damaged on the nail which would result in considerable costs as a consequence of careless preparation. This error requires technical discipline on the part of the operator.

Conclusion

Compared to the standard method, the technique presented here for removing intramedullary nails is quicker, better at protecting soft tissue and does not require any additional instrumentarium.

References

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13.    Schwarz N. Eingeladener Kommentar zu: Analyse der Indikationen zur Metallentfernung nach proximalen Femurfrakturen. European Surgery. 2000;2000:199.

14.    Sen RK, Gul A, Aggarwal S et al. Comminuted refracture of the distal femur and condyles in patients with an intramedullary nail: a report of 5 cases. J Orthop Surg (Hong Kong). 2005;13: 290-295.

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18.    Wooley PH, Nasser S, Fitzgerald Jr RH. The immune response to implant materials in humans. Clin Orthop. 1996; 326: 63-7.


 

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