Answer the following questions.
Please indicate the proper order of these steps in the spaces provided.
What happened during the operation to remove a metallic implant from M. R.’s body.
Write NO MORE THAN THREE WORDS AND/OR NUMBERS from the passage for each answer.
Technique of Difficult Intra medullary 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 intra medullary 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.
What are the metallic implants used for?
When should the metallic implants be removed?
Why is it sometimes difficult or even impossible to remove nail implants?
What is "the medication” mentioned in Paragraph 3?
For the patient M. R., when was the Schneider rod inserted?
A large volume of chronic granulation tissue was expressed.
An oval-shaped hole was made using the carbide dissection tool.
The wound was closed.
Metallic fragments were removed.
An incision was made using the standard approach.
A kerf was made using the Midas Rex B-l tool.
The rod was removed.
What is most important in an operation like the one described in detail in the passage related to availability?
AI explanationShows the answer. Tap to open.
Question Focus: Understanding the purpose of metallic implants
Correct Answer: Fix bone fracture
Why this is correct: The passage clearly explains that metallic implants are used in the fixation of fractures. This directly answers what they are used for.
Passage Reference: 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 fracture
Common Mistake: Students sometimes write support bones, which is not the exact wording from the passage. This is a synonym trap.
Paraphrasing: Passage: 'fixation of fractures' = Question: 'used for'
Tips: Always use the exact words from the passage when possible.
Key Vocabulary:
- fixation = holding firmly
- fracture = broken bone
Question Focus: Time reference for implant removal
Correct Answer: After 18-24 months
Passage Reference: It is generally accepted that hardware used to fix long bone fractures should be removed after approximately 18 to 24 months.
Why this is correct: The passage states clearly when implants should be removed, giving the exact time frame.
Common Mistake: Some students write after two years, which changes the wording. This is a synonym trap.
Paraphrasing: Passage: 'removed after approximately 18 to 24 months' = Question: 'When should be removed'
Tips: Copy numbers and time expressions exactly as written.
Key Vocabulary:
- approximately = about
- removed = taken out
Question Focus: Reason for difficulty in removal
Correct Answer: Eye or threads are altered
Passage Reference: 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.
Why this is correct: The passage explains that removal is difficult when the eye or threads have been altered, stopping normal tools from working.
Common Mistake: Students may write tools unavailable, which is only part of the idea. This is a partial truth trap.
Paraphrasing: Passage: 'eye or threads have been altered' = Question: 'difficult or impossible to remove'
Tips: Look for cause words like 'prevents' or 'because'.
Key Vocabulary:
- altered = changed
- threads = spiral grooves
Question Focus: Identifying a specific medication
Correct Answer: tetracyline
Passage Reference: Following this attempt, the patient was placed on tetracycline, and the drainage resolved as long as he took the medication.
Why this is correct: Paragraph 3 names the medication directly as tetracycline.
Common Mistake: Writing antibiotics is too general. This is a partial truth trap.
Paraphrasing: Passage: 'placed on tetracycline' = Question: 'the medication'
Tips: Names of drugs must be copied exactly.
Key Vocabulary:
- medication = medicine
- placed on = given
Question Focus: Date reference
Correct Answer: 1978
Passage Reference: MR is a 45-ycar-old white male who was involved in a motorcycle accident in 1978.
Why this is correct: The rod was inserted during treatment after the accident in 1978.
Common Mistake: Some students choose 1982, which refers to a different event. This is a wrong section trap.
Paraphrasing: Passage: 'accident in 1978' = Question: 'when was inserted'
Tips: Check that the date matches the correct event.
Key Vocabulary:
- sustained = suffered
- inserted = put in
Question Focus: Operation sequence
Correct Answer: 2
Passage Reference: Once through the skin and subcutaneous tissues, a large volume of chronic granulation tissue almost amyloid-like in nature was expressed from the wound.
Why this is correct: This happens after the incision, so it is step 2.
Common Mistake: Placing it first ignores the incision step. This is a sequence trap.
Paraphrasing: Passage: 'once through the skin' = Sequence after incision
Tips: Follow the order exactly as described.
Key Vocabulary:
- granulation tissue = healing tissue
Question Focus: Operation sequence
Correct Answer: 4
Passage Reference: The carbide dissecting tool was then used to fashion an oval-shaped hole through the substance of the rod.
Why this is correct: The oval hole is made after the kerf, making it step 4.
Common Mistake: Mixing this with the kerf step is a context shift trap.
Paraphrasing: Passage: 'fashion an oval-shaped hole' = Step in operation
Tips: Underline verbs to track actions.
Key Vocabulary:
- fashion = make
Question Focus: Final operation step
Correct Answer: 7
Passage Reference: The wound was vigorously irrigated out to remove all metallic fragments and closed in the standard fashion.
Why this is correct: Closing the wound is the final step, so it is 7.
Common Mistake: Placing it earlier ignores irrigation. This is a sequence trap.
Paraphrasing: Passage: 'closed in the standard fashion' = 'The wound was closed'
Tips: End actions usually come last.
Key Vocabulary:
- irrigated = washed
Question Focus: Operation sequence
Correct Answer: 6
Passage Reference: The wound was vigorously irrigated out to remove all metallic fragment
Why this is correct: Fragments are removed just before closure, making it step 6.
Common Mistake: Some students place it too early. This is a sequence trap.
Paraphrasing: Passage: 'remove all metallic fragments' = 'Metallic fragments were removed'
Tips: Look for cause-effect order.
Key Vocabulary:
- fragments = small pieces
Question Focus: First operation step
Correct Answer: 1
Passage Reference: Utilizing the original skin incision, the standard approach was made.
Why this is correct: The incision is clearly the first action, so it is 1.
Common Mistake: Starting with tissue removal is a sequence trap.
Paraphrasing: Passage: 'original skin incision' = 'An incision was made'
Tips: The first verb usually signals step one.
Key Vocabulary:
- incision = cut
Question Focus: Operation sequence
Correct Answer: 3
Passage Reference: 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.
Why this is correct: The kerf is made after exposure but before the hole, so it is step 3.
Common Mistake: Confusing kerf with hole is a context shift trap.
Paraphrasing: Passage: 'unicortical kerf' = 'A kerf was made'
Tips: Note technical terms carefully.
Key Vocabulary:
- kerf = narrow cut
Question Focus: Operation sequence
Correct Answer: 5
Passage Reference: 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.
Why this is correct: The rod is removed after the hole is made, making it step 5.
Common Mistake: Placing it last ignores closure steps. This is a sequence trap.
Paraphrasing: Passage: 'rod removed' = 'The rod was removed'
Tips: Removal often happens before cleaning and closing.
Key Vocabulary:
- extraction = removal
Question Focus: Key factor for success
Correct Answer: availability of carbide tool
Passage Reference: . The availability of the carbide tool is the key.
Why this is correct: The passage directly states this is the key to the operation.
Common Mistake: Writing surgeon's skill is not stated. This is a Not Given trap.
Paraphrasing: Passage: 'is the key' = Question: 'most important'
Tips: When the passage says 'the key', copy that idea.
Key Vocabulary:
- availability = being obtainable
General Tips:
- Summary and note completion questions follow passage order.
- Always copy exact words from the passage.
- Check grammar clues around the gap before choosing an answer.
- For sequence questions, underline verbs to track actions.
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