If an opinion poll was taken on whether or not to remove intramedullary nails from fractured tibias after healing, what would it reveal? Are there risks to leaving nails in the tibial medulla indefinitely? Are they the cause of chronic pain? Refracture and bent nails have been known to present challenges.
A.H. Karladani et al (Acta Orthop Scand. 2007; 78(5):668-671.) reviewed 72 tibial shaft fractures among 71 patients treated by intramedullary nailing. Nails were removed an average of 17 months (range, 4-50 months) after nail insertion. Eighty-eight patients whose nails were not removed were not included in this report. The authors concentrated on nail removal to relieve anterior tibial pain thought to be related to the presence of the nail. Nail removal was, therefore, not routine.
The total series consisted of 162 tibial shaft fractures in 159 patients treated by intramedullary nailing during a 4-year period. In the nail removed group (n=72), mean patient age was 35 years (range, 15-75 years), 2 fractures were in the proximal third, 34 in the middle, and 36 in the distal third of the tibia. Mean fracture healing time was 21 weeks (range, 10-51 weeks). Prior to nail removal, constant pain was reported by 16 patients, pain after moderate activities by 15, occasional pain by 13, and no pain by 14. Pain was reported in the anterior part of the knee, the leg, and the ankle.
Of 35 patients who underwent nail removal specifically for pain relief, 10 became asymptomatic, and others experienced little or no relief. The authors concluded that the outcome after nail removal to alleviate pain is generally poor.
If the nail is retained and the tibia refractured, removal of the bent nail can be a challenge. Kuntscher (Practice of Intramedullary Nailing. Springfield, Illinois: Charles C. Thomas; 1967: 322) described an easy way to remove the bent nail. He stated, a nail which has become bent is usually surprisingly easy to remove by the simultaneous effort of strong pull and external manual straightening of the extremity. It is indeed simple, and it really works!
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Charles Sorbie, MB, ChB, FRCS(E), FRCS(C)
Dr. Charles Sorbie is Professor of Surgery at Queens University and a member of the Attending Staff at the General and Hotel Dieu Hospitals in Kingston, Ontario.
A former chairman of the Department of Surgery at Queens University, Dr. Sorbie has been President of the Canadian Orthopaedic Research Society, the Canadian Orthopaedic Association, and the Societé Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).