What are intramedullary nails?

What is intramedullary nail?

Intramedullary nailing is surgery to repair a broken bone and keep it stable. The most common bones fixed by this procedure are the thigh, shin, hip, and upper arm. A permanent nail or rod is placed into the center of the bone. It will help you be able to put weight on the bone.

What is intramedullary nail used for?

Most femoral shaft fractures are treated surgically. Several studies have indicated that early surgical stabilisation is associated with a reduction of complications and mortality . An intramedullary nail is a metal rod that is inserted into the medullary cavity of a bone and across the fracture in order to provide a solid support for the fractured bone. Intramedullary nailing is currently considered the "gold standard" for treatment of femoral shaft fractures. Proposed advantages of intramedullary nailing include short hospital‐stay, rapid union of the fracture and early functional use of the limb .

There are numerous different types of intramedullary nail and associated surgical techniques in use. One key controversy is whether the nail should be inserted into the canal at the knee and pushed up the canal (retrograde nailing) or at the hip and pushed down the canal (antegrade nailing). The entry point for antegrade nailing (piriformis fossa versus greater trochanteric entry) is also in dispute. Another issue is whether intramedullary nails should be inserted with reaming (where the medullary cavity is expanded before nail insertion) or without reaming. Likewise, there has been no agreement about the effects of different types of nails, such as interlocking nails (with locking bolts placed across the bone at the ends of the nail to secure it in position) or Ender nails, where two or more nails are placed within the medullary cavity in a specific way to hold them in place.

Does an intramedullary nail need to be removed?

Intramedullary nails used for fixation of femoral fractures may require removal for a variety of reasons. Some recommend that all such nails be removed after fracture healing,whereas others prefer to remove only those that cause symptoms.Regardless of the reason, removal of an intact femoral nail can be difficult and time-consuming.

How to remove the intramedullary nail？

Place the patient in the straight lateral position using a beanbag or other positioning device on a radiolucent operating table. Prepare the entire leg, lateral buttock, and torso to the ribs. Drape the leg out to allow full hip and knee motion for positioning. Flex the hip to almost 90°. Remove the proximal and distal locking screws in standard fashion. Lay a guidewire on the thigh and obtain a fluoroscopic image of the proximal hip. Adjust the wire to coincide with the femoral nail on the lateral view. Draw a line along the wire, extending it onto the buttock. Externally rotate the thigh and mark a line in a similar fashion to determine the anteroposterior nail position. The intersection of the two lines indicates the site of the incision for placing the extractor. If heterotopic bone is to be removed, the incision must be made larger. The wound is bluntly expanded with large Mayo scissors. Once the nail is reached the scissors are used to hold the wound open, and a 3.2 guidewire is inserted along the scissors until it touches the nail. The scissors are removed, and the guide pin is adjusted until it advances into the nail. Anteroposterior and lateral images of the hip are obtained to confirm placement of the guidewire into the nail. The cone-shaped femoral extractor on the extraction bar is inserted into the wound, over the guide pin. The extractor is gently but forcefully screwed into the nail. The first pass may not fully engage the nail, but it will remove much of the interposed soft tissue. The extractor is reinserted over the guide pin or wire and tightened onto the nail with force sufficient to require the use of the wrenches. The slotted mallet is used to hammer the nail out. The wound is irrigated and closed in the standard fashion.

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