A sonography assisted technique for the removal of a femoral interlocking nail – a technical note
© Tsai et al; licensee BioMed Central Ltd. 2005
Received: 19 May 2005
Accepted: 17 October 2005
Published: 17 October 2005
Open methods for removal of femoral interlocking nails involve an incision (up to 10 cm) over the trochanter to find the tip of the nail. The distal locking screws are some times difficult to palpate and an incision (up to about 5 cm) is often needed for exposure. Intra-operative fluoroscopy is often used as an adjunct technique to minimize the surgical wound. However, patients and surgeons are exposed to a radiation hazard. Sonography can provide a real-time and efficient alternative to fluoroscopy.
Sonography of soft tissue has been established to identify a foreign body. A metallic implant has a hyperechoic image; therefore, we can identify the correct position of the screws preoperatively and intraoperatively.
We have developed a technique using sonography and minimal incisions for the removal of a femoral interlocking nail. The proximal wound is 2.5 cm in length and the wound is 0.5 cm in length for each distal locking screw.
The sonography can be used to minimize the length of incision and prevent radiation exposure in the removal of intramedullary femoral nails.
The development of closed interlocking intramedullary nailing has allowed the treatment of femoral diaphyseal fractures to become safer and more effective [1, 2]. The nail is usually inserted under fluoroscopic control which brings concern over the radiation exposure . There have been efforts to minimize the fluoroscopic radiation . Ultrasound, on the other hand, is cheaper and more easily available and can be used to monitor alignment during closed femoral nailing . Thus, using ultrasound can reduce the fluoroscopic monitoring time and reduce the radiation exposure to the patient and the surgeon.
It is often necessary to remove femoral nails after bony union. Conventional open methods require up to a 10 cm incision over the trochanter. The distal locking screws are difficult to palpate, and open distal incisions are often needed. Fluoroscopy is frequently used in an attempt to decrease the size of the wound.
Sonography for evaluation of soft tissues has been in use for years. The sonographic signal is reflected by cortical bone , and any metallic implant has a hyperechoic image. Therefore sonography can identify the position of locking screws. We applied sonography for the wound of the removal of distal locking screws using a minimal incision. We report on this technique that was used successfully in three patients.
Preoperative localization by sonography
Locking screws removal
The 2.5-cm incision on the tip of the long axis over the buttock
The applications of sonography to removal of surgical implant have been documented in gynecology literature. Nelson et al reported on real-time sonographic localization and guidance could enable safe removal of deeply placed, nonpalable and intramuscular contraceptive capsules . High resolution sonography allowed accurate localization of a foreign body in the soft tissue in spite of radio-lucent or radio-opaque .
Gynaecologists are familiar with sonography, while orthopaedic surgeons are familiar with fluoroscopy. Intra-operative fluoroscopy has been widely used for many procedures, such as closed reduction, internal fixation and removal of implant. However, the removal of implant can also be achieved by sonography, because the metal implants located on the surface of bone and have high echogenecity and are well distinguished from the other tissues .
The sonography of musculoskeletal system has various applications including detection of an occult fracture, reduction of fracture, assessment of joint fluid, and identification of a foreign body[5, 6, 12, 13]. During the removal of a metal implant, the sonography can provide real-time guidance to apply the screw driver to the screw head and thus assist in the removal of screws.
The authors have used this procedure to remove three femoral interlocking nails. However, most high frequency probes have a limited depth of view, typically 3–4 cm at 12 MHz. When assessing deeper structures, 5-MHz curvilinear probes can give a deeper and wider view . Therefore, the morbidity obesity, heterotopic bone growth or deep seated implant in bone may be not feasible for this technique. The surgeons should consider another modality such as intra-operative fluoroscopy or conventional open procedures.
The sonography can be used to minimize the incision length and radiation exposure in the removal of intramedullary femoral nails.
- Kempf I, Grosse A, Beck G: Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Joint Surg Am. 1985, 67: 709-720.PubMedGoogle Scholar
- Winquist RA, Hansen STJ, Clawson DK: Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am. 1984, 66: 529-539.PubMedGoogle Scholar
- Levin PE, Schoen RWJ, Browner BD: Radiation exposure to the surgeon during closed interlocking intramedullary nailing. J Bone Joint Surg Am. 1987, 69: 761-766.PubMedGoogle Scholar
- Tremains MR, Georgiadis GM, Dennis MJ: Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001, 83-A: 674-678.PubMedGoogle Scholar
- Mahaisavariya B, Suibnugarn C, Mairiang E, Saengnipanthkul S, Laupattarakasem W, Kosuwon W: Ultrasound for closed femoral nailing. J Clin Ultrasound. 1991, 19: 393-397.View ArticlePubMedGoogle Scholar
- Hubner U, Schlicht W, Outzen S, Barthel M, Halsband H: Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000, 82: 1170-1173. 10.1302/0301-620X.82B8.10087.View ArticlePubMedGoogle Scholar
- Gibbon WW, Long G, Barron DA, O'Connor PJ: Complications of orthopedic implants: sonographic evaluation. J Clin Ultrasound. 2002, 30: 288-299. 10.1002/jcu.10065.View ArticlePubMedGoogle Scholar
- Tsai KJ, Liaw JK, Lin CC, Hou SM: Minimally invasive technique in compression hip screw insertion. Journal of orthopedic surgery, Taiwan, ROC. 2001, 18: 130-135.Google Scholar
- Nelson AL, Sinow RM: Real-time ultrasonographically guided removal of nonpalpable and intramuscular Norplant capsules. Am J Obstet Gynecol. 1998, 178: 1185-1193.View ArticlePubMedGoogle Scholar
- Amann P, Botta U, Montet X, Bianchi S: Sonographic detection and localization of a clinically nondetectable subcutaneous contraceptive implant. J Ultrasound Med. 2003, 22: 855-859.PubMedGoogle Scholar
- Cardinal E, Chhem RK, Beauregard CG: Ultrasound-guided interventional procedures in the musculoskeletal system. Radiol Clin North Am. 1998, 36: 597-604. 10.1016/S0033-8389(05)70048-8.View ArticlePubMedGoogle Scholar
- Grechenig W, Peicha G, Clement H, Fellinger M, Mayr J: [Ultrasonography in trauma]. Orthopade. 2002, 31: 143-153. 10.1007/s00132-001-0235-3.View ArticlePubMedGoogle Scholar
- Graif M, Stahl-Kent V, Ben-Ami T, Strauss S, Amit Y, Itzchak Y: Sonographic detection of occult bone fractures. Pediatr Radiol. 1988, 18: 383-385.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/6/51/prepub
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