Technique of Difficult Intramedullary Nail Removal Utilizing the Midas Rex

 1. The increasing popularity of the use of metallic implants in the field of orthopaedics has resulted in later operations of their subsequent removal. Most authors now believe that hardware used in the fixation of fractures should be retrieved, especially in the younger patients. It is generally accepted that hardware used to fix long bone fractures should be removed after approximately 18 to 24 months. Fractures of other bones can usually have hardware removed after six months to one year. Many of us have all too frequently heard “it is just a simple hardware removal’' at a preoperative conference. Often the task is left to the more junior residents and an easy hardware removal turns into a several hour flail. Unfortunately, at our institution, we are often removing implants that have been inserted elsewhere. A relatively simple, safe method of intramedullary nail extraction utilizing the Midas Rex is presented for those instances in which the routine extraction method fails. This method is especially useful for those cases in which the eye or threads have been altered in some manner that prevents use of normal extraction instruments. It can also be used in those rare instances where the extraction instrumentation is not available for one reason or another. A case report will illustrate the procedure.

CASE REPORT

2. MR is a 45-ycar-old white male who was involved in a motorcycle accident in 1978. He sustained, among other injuries, fractures on the left femur, left tibia, and left ankle. Treatment at the original hospital included use of a Schneider rod for the femur fracture and a subsequent ankle fusion. The patient had chronic left ankle pain after the original accident, and a subsequent injury resulted in a left BKA in 1982.

3. The patient presented to our institution complaining of recurrent episodes of pain, swelling and draining from the rod implant site. The patient underwent an unsuccessful attempt at removal in December 1981. It was noted at the time of surgery that the Schneider rod had been altered at the time of original insertion. The threaded proximal portion of the nail had been cut with a saw. The normal extraction couple would not fit and was, therefore, useless. The surgeon at that time utilized several different devices, even resorting to vice grips and mallet, without success. Following this attempt, the patient was placed on tetracycline, and the drainage resolved as long as he took the medication. However, the pain persisted.

4. The patient presented to our clinic desiring removal of the rod, complaining of chronic pain, with only moderate relief by narcotics. He had visited another large medical centre in the interim and was told that they would not even attempt an extraction because of the previous failure. Examination revealed tenderness to palpation over the left greater trochanter and a large mass. The prior incision was healed but found to be warm to touch. The surrounding area was characterized by chronic skin and very dark pigmentation changes; however, the wound was not actively draining. The patient’s sedimentation rate was slightly elevated at 22. It was decided that another attempt at extraction was warranted, and the patient consented.

5. OPERATIVE APPROACH: Prior to the scheduled, date of operation, a carbide dissecting tool was ordered and received. Utilizing the original skin incision, the standard approach was made. Once through the skin and subcutaneous tissues, a large volume of chronic granulation tissue almost amyloid-like in nature was expressed from the wound. No gross pus was noted, but the end of the rod appeared to have "chewed up” the surrounding soft tissues. The absent threads of the rod were visualized and appeared to have been cut with a hacksaw. Using the Midas Rex B-l dissecting tool, a unicortical kerf 5 cm long was made in the greater trochanter down to the rod from the exposed portion of the rod laterally. This was done to relieve tension on the rod, which would ease removal. The carbide dissecting tool was then used to fashion an oval-shaped hole through the substance of the rod. Dissecting the hole through the rod took less than five minutes and was accomplished gradually. The heat of the metal on metal dissection was easily dissipated with frequent application of cool saline to the surfaces. Once the hole was dissected, the Kuntscher extraction device was seated in the newly formed hole, and the rod removed in about five minutes with gentle misleading. Total surgical time for the procedure was approximately 30 minutes.

6. The wound was vigorously irrigated out to remove all metallic fragments and closed in the standard fashion. The patient was discharged the following day and kept on crutches without his prosthesis for approximately two weeks. The patient was seen in follow-up with the wound well healed and resolution of the pain.

7. The above case illustrates a relatively simple method of nail removal utilizing the Midas Rex. The availability of the carbide tool is the key. Several modifications can be easily made depending upon the extraction device available. Just as an oval-shaped hole was drilled with the carbide dissecting tool, it could have easily made a slot or circular hole. This method is only limited by the ingenuity of the operating surgeon. The increasing variety of implants and their use will lead to subsequent operations for removal. If the implant has been altered or if proper extraction instrumentation is not available, the Midas Rex with the proper carbide dissecting tool provides another avenue for successful retrieval.