Intramedullary collar is considered the gold standard proficiency for the treatment of femoral rotating shaft fractures. A rare complication of this technique is nail deflection after a new injury. In these cases nail removal might be actually challenging. The present paper provides a brief recapitulation of surgical techniques purposed in the literature for flex nail removal and describes a clinical case. ( www.actabiomedica.it ) Keywords:
bent intramedullary nail, femoral shaft fracture, bent femoral nail, bent nail removal
Intramedullary pinpoint is considered the gold standard proficiency for the treatment of femoral cheat fractures ( 1 ). In rare cases, a second injury to the femoral cheat might lead to complete bend, which may be associated to a new fracture or displacement of the chief unhealed fracture. A bended nail is more unmanageable to remove in comparison to a break one, because of the impossibility to pass the straight proximal intramedullary duct. In these unmanageable cases key factors for treatment plan are the degree of angulation of the breeze through, the steering of the disfigurement, the location of the disfigurement, patient local and general conditions and surgeon have. Since the rarity of the pathology there is no wide accepted algorithm for the removal of a bent femoral smash ( 2 ). On the other hand, some literature issues regarding technical aspects and discussion proposals can be retrieved. Furthermore, authoritative treatment of the fracture after complete removal may still deserve a discussion. The present newspaper provides a brief review of surgical techniques purposed in the literature for bent nail removal and describes a clinical case .
Bent nail removal: surgical techniques
Standard removal of a bent nail as a straight nail is described by different authors ( 2, 3 ). The advantage of this operation is soft tissue preservation and no indigence for especial equipment. The feasibility of this proficiency depends on the severity of the nail and the degree of disfigurement. consequently, indications for this technique are in character of 15-20° of nail deformity, thin titanium nails, bare fracture and anterolateral disfigurement. unlike authors have reported this technique as successful ( 2, 3 ). Patterson et alabama. described the technique of close straightening using a perineal post as fulcrum associated with external maneuvers and home removal without opening the fracture locate for smash resection ( 4 ). however, this technique is unmanageable to perform in lawsuit of antero-posterior angulation. In this cases Haffernan et alabama. advised the use of F® ( Synthes West Chester, PA ) tool for manual reduction of hanker bones. On the other hired hand, in case of blockheaded nails the excessive pull required may produce soft tissue injury and secondary fractures ( 5 ). The locate of disfigurement placement excessively proximal or besides distal requires higher forces for reduction and is more predisposed to iatrogenic injuries. Beck et alabama. reported a secondary fracture during attempts of deformity decrease in such a casing ( 6 ). The most normally used technique is partial weakening at the vertex of the deformity of the nail and manual of arms roll out. location of the vertex of collar disfigurement is the key factor for this technique. In case of valgus deformity indeed exposure of the medially oriented vertex may be surgically hazardous and demanding ( 7, 8 ). transdermal overtone weakening proficiency at the vertex of nail deformity using a drill bite has besides been described. This proficiency has the advantage of being indulgent weave sparing while the disadvantage of unmanageable alloy debris irrigation and fluoroscopy colony ( 9 ). The total cut at the deformity vertex of the flex breeze through requires open proficiency and adequate instruments to cut the nail down ( 10, 11 ). sum abridge of the nail and removal of the parts requires no wedge application for the reduction of the nail deformity therefore reducing the risk of secondary fracture. This technique has the obvious disadvantage of greater soft tissues invasiveness while the advantage of low device demand and specify use of fluoroscopy. furthermore, the use of continuous irrigation at the cutting site decreases the gamble of weave necrosis, nonunion and contagion. The border on can be used both for pinpoint cut, anatomic bone reduction and fracture osteosynthesis as the vertex of the disfigurement normally corresponds to the fracture locate. Cases when nail down removal is not feasible even after smash cut are reported in literature. In such cases the nail is normally stuck in the femoral canal, thus approach extension for longitudinal cram window opening should be considered as an option. A rectangular cram window and sum nail down exposure is necessity. The nail is extracted from this window in the proximal part and if not wholly resected could be twisted for an easier extraction of the distal part of the nail. The bone window should then be fixed with cables or plate osteosynthesis. Nonetheless, wide-eyed soft tissue dissection to obtain an adequate bone window may lead to major complications ( 12 ). The independent limitation of this proficiency is that in case of valgus disfigurement a medial femoral shaft approach might be necessary. Another option for straightening the nail has been described using a broad home plate and reduction clamps. The complete is straightened increasingly using the forceps to gradually compress the shaft against the plate under fluoroscopy control ( 13 ). In cases of dangerous disfigurement and osteoporosis this technique should be used with caution due to high risk of secondary coil fracture. successful application of this proficiency through a minimally invasive approach path has been described by some authors ( 14 ) .
A 19 years old world was admitted to our hospital after a high energy motorcycle accident in February 2018. The patient presented with a severe varus disfigurement of the left thigh and an ipsilateral assailable fracture of the distal femur, without neurovascular injuries. Associated injuries were a leave wrist trans-scaphoid trans-styloid perilunate fracture-dislocation and a right occipital condyle fracture. The patient height was 1,95 meter and weight 115 kilogram. The patient had a previous motorcycle accident with a femoral diaphyseal fracture treated with an antegrade T2 Recon collar ( StrykerTM ) about 2 years before the recent injury. Anamnestic datum revealed full weight bearing without aids and wax return to everyday liveliness at the latest follow-up outpatient evaluation ( 18 months after surgery ). however, the affected role referred muffle trouble at the fracture locate at weight bearing, with radiographic signs suspect for hypertrophic nonunion ( ). Plain radiogram obtained at the emergency department showed a refracture of the femoral shaft in parallelism to the nonunion web site with 145° breeze through angulation in the wreath plane. The distal interlock screws were besides bent ( ). A grind fault of the distal femur ( AO type 33 C3 ) was confirmed, occurring at the point of the previously implanted nail. The patient was treated in the inaugural hours with a damage control operation. An external fixator bridging the knee joint was applied in order to gain length, axis and rotation at the distal femur fault site ( ). Accurate debridement of the loose fault was carried out, classifying the lesion as Gustilo ( 15 ) type II open fault after the procedure. primary coil blockage of soft weave was achieved. After operation the affected role was kept under observation for three days in intensive care unit of measurement and transferred to our orthopedics and traumatology unit afterwards. definitive treatment was scheduled on the seventh day after trauma .Open in a separate windowOpen in a separate window
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Under general anesthesia, the patient was positioned resistless on the fracture table and previously implanted external fixator left in stead. The hurt arm was prepped and draped. manual straighten of the nail was attempted under fluoroscopy control without achiever. Under fluoroscopy the vertex of the bent smash was identified. A limited lateral pass approach to the femur over the fracture deformity was performed. A modest cortical bone window over the vertex of the pinpoint deformity was necessary to expose the nail for milling ( ). The nail was resected with diamond bur until easy rupture was obtained at the vertex of the deformity. continuous irrigation and sucking were used for tissue cooling and metallic debris removal ( ) .Open in a separate windowOpen in a separate window lateral set about to the proximal femur was used for the removal of the proximal separate of the tear complete after removal of the 2 cephalic blocking screw. The distal function was removed from the diaphyseal fault site after removal of the distal block screws. Under fluoroscopy the diaphyseal fracture was stabilized with stainless steel cerclage and definitively fixed with a 11×340 millimeter T2 Recon StrykerTM smash in electrostatic shape. Two suction drain were positioned during wound blockage. New aseptic prepping and drape was used for the osteosynthesis of the complex articular distal femoral fracture after removal of the external fixator. lateral pass approach to the distal femur was performed, with distal extension through a tibial nodule osteotomy to obtain adequate photograph. The fracture was reduced and definitively fixed with a ZimmerTM NCB distal femoral plate. Morcellized trabecular bone homograft was used to treat metaphyseal bone loss. The tibial tubercle was fixed with 2 3.5 millimeter cortical screws. A suction drain was inserted during weave closure after abundant irrigation with saline solution solution. The post-operative rehabilitation protocol allowed immediate passive knee and hip mobilization with progressive range of motion while no weight unit yield was allowed for the first 60 days. overtone system of weights bear was allowed after two months and full weight bearing after three months. At the end clinical and radiographic follow-up at 10 months the patient was able to walk with slender limp without aids. Left stifle was stable but slenderly stiff, with ROM 0-85° ( ).
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The removal of a bent femoral smash represents a challenge for the trauma surgeon. unlike authors have reported unlike techniques for the removal of a flex smash but there is no wide accepted algorithm for their treatment ( 10, 16 – 18 ). The option of the technique depends on the degree of disfigurement, on the direction of the deformity, the location of the disfigurement, on affected role conditions and on the surgeon feel. An adequate preoperative imaging is compulsory for precise individuality of magnitude and direction of the deformity and to plan both nail removal and definitive fracture treatment. furthermore, the huge majority of femoral bent nails present to the clinician after a high department of energy new injury, differently from broken nails which normally occur in case of nonunion and frequently without trauma ( 13 ). consequently, more indulgent tissue price and associate lesions together with worse general conditions may be expected. In sheath of associate lesions, a damage master approach may be advantageous as it allows to stabilize the patient and to accurately plan definitive operation. The proficiency described in the confront paper resulted to be safe and effective, comparably to other techniques already reported. furthermore, it allowed to consecutive treat consociate lesions without complications .