New method to remove tibial intramedullary nail through original suprapatellar incision: A case report

INTRODUCTION

The advantages of intramedullary nail internal fixation, such as small trauma, central fixation, and closed reduction, are consistent with the biological osteosynthesis concept; thus, intramedullary nail internal fixation has become the gold-standard treatment for tibial shaft fracture[1].

The patient had a history of internal fixation.

Removal of the tibial intramedullary nailthe infrapatellar approach is simple,and it is performed under direct vision through the original incision. Thus, researchers tend to use the infrapatellar approach to remove the internal fixation insertedthe suprapatellar approach[2]; however, with this approach, new scars form, and the patellar ligament and the infrapatellar fat pad can become damaged[3].

The other option is to remove the tibial intramedullary nailthe suprapatellar approach. However, this method remains controversial because there are many difficulties in using the original incision to remove the internal fixation. In this paper, a quick and simple method of nail extractionthe original suprapatellar incision is proposed. To the best of our knowledge, this is the first report of this type of removal.

CASE PRESENTATION

Chief complaints

A 33-year-old man requested for the implant to be removed.

智慧城市的PPP项目生命周期包括以下几个阶段：设立阶段，政府与第三方资本成立项目公司；融资阶段，项目公司利用银行贷款、回租资产等方式进行外部融资；设计阶段，项目公司开展经营结构及财务框架设计；建设/存量设施转移阶段，购买或建造运营该项目所需设施；运营阶段，项目公司在合同期限内自行运营项目或分包获得盈利；推出阶段，项目公司终止。本部分主要对各阶段的增值税、企业所得税及其他税收风险提出针对性措施。

History of present illness

Multiple surgical scars were visible on the left calf, and there was no sign of limited motion in the left knee joint.

History of past illness

汉语词汇丰富，许多近义词看似意思相近，但运用时有细微差别。为了让学生仔细辨别词语，可以在阅读文本时让近义词语对对碰，引导正确辨析、使用词语。

The patient was examined before surgery and had no contraindications. After administering epidural anesthesia, the proximal locking nail was removed. Then, the knee was bent 30°, and a multi-holed guide pin sleeve was fine-tuned to allow a 2-mm guide needle to be accurately inserted into the cavity of the intramedullary nail with a depth of at least 2–3 cmthe original suprapatellar incision. The results were confirmed by intraoperative X-ray (Figure 2). A hollow jig was used to screw the end of the nail along the guide needle. This process accurately removed the bone on top of the nail without damaging surrounding structures, such as the meniscus and ligaments. After the jig was screwed into the end of the intramedullary nail and tightened, intraoperative fluoroscopy was used for confirmation (Figure 3). The proximal and distal locking nails were removed, and the intramedullary nail was retracted using a mallet (Figure 4).

Personal and family history

The patient’s final diagnosis was bony union after multiple fractures.

前面已经对非均匀衰减性介质中采用的地波干涉法进行了证明，接下来要探讨空间自相关法与地震波干涉法之间的关系。这个问题的设立如图1所示。首先，选取衰减性无限介质中的两个观测点（三角形标记），假设噪声源（星形标记）在介质中呈体积分布。在这种情况下，可以对两点间的波动场进行标准化的交叉谱分析，明确其与格林函数之间的理论关系。此外，在无衰减的情况下，由于假设平面波向观测点各向同性入射（例如，Nakahara，2006；Sanchez－Sesma and Campillo，2006），因此必须注意条件的变化。

Physical examination

The patient who was hit by a car in 2019 had a history of multiple fractures. These fractures, including left mid-tibial fracture, were fixed with a 10-mm × 330-mm suprapellar tibial nail. The end cap of the nail was purposely not inserted. Two years later, the patient requested for the implant to be removed.

Laboratory examinations

No abnormalities were observed on preoperative examination.

Imaging examinations

An X-ray examination showed that the broken end of the tibia had bony union(Figure 1).

FINAL DIAGNOSIS

The patient had no genetic or familial disease history.

1.2 方法 对119名发生血源性暴露医务人员的人群分布、暴露方式及部位、暴露源种类、暴露后处理方式、预防用药及结果等情况汇总分析。

TREATMENT

玉米倒伏病害的防治除了合理种植，还要根据不同玉米品种的差别安排玉米种植密度，同时也要注意钾、氮及磷肥的合理使用，根据当地土地的情况进行适当的补给。此外，为了预防在玉米拔节后氮肥量施加过多，可以将其分为苗期、穗期2次追肥。通过在玉米拔节后期采取一定措施可以有效防治玉米倒伏，在玉米拔节后期也要注意中耕培土的实施，促进玉米根部发育，从而提升玉米植株抗倒伏能力；在玉米拔节后期可以进行植物生长抑制剂的喷施，控制玉米植株高度。

OUTCOME AND FOLLOW-UP

Two weeks postoperatively, the patient’s wound had healed well. At the 4-mo postoperative follow-up, the patient did not complain of pain in the left knee joint. The left knee could extend 0° and flex 120° (Figure 5). The Kujala score was 95 on the left knee.

DISCUSSION

Tibial intramedullary nail placement can be achieved by both suprapatellar and infrapatellar access. The suprapatellar approach has more advantages than the infrapatellar approach[4-8]; however, how best to remove the nailthe original suprapatellar incision used for nail insertion is uncertain.

When using the traditional method to remove the intramedullary nail through the original suprapatellar incision, it is necessary to first remove the bone above the intramedullary nail with a hollow drill, remove the end cap, and take out the end of the intramedullary nail and screw it into the target device to remove the intramedullary nail. Because the whole process is not performed under direct vision,the operation is difficult and time-consuming. The main difficulty lies in how to accurately remove the bone above the intramedullary nail. If care is not exercised, the meniscus and anterior and posterior cruciate ligaments can become damaged. The cap should then be safely removed without being lost in the joint space. Therefore, most surgeons have no choice but to use the infrapatellar access to remove the internal fixation, but this often leads to new scar formation. Moreover, surgical incision can also damage the saphenous nerve, the patellar ligament, and the infrapatellar fat pad,resulting in a high probability of postoperative knee pain.

A previous study has shown that the end cap of an intramedullary nail stops bony in-growth of tissue[9]. To facilitate the method presented in this paper, the end cap was not used in the initial nail placement, and bony in-growth of tissue enclosed the end of the nail. To remove the tibial intramedullary nail, a guide needle was inserted into the cavity of the intramedullary nail. The results were confirmed by intraoperative X-ray. A hollow jig was used to screw the end of the nail along the guide needle. This process accurately removed the bone on top of the nail. Thus, the difficulty in removing the nailthe original incision was greatly reduced. The whole process was easy, and no special tools were needed. Due to the use of a sleeve during surgery to protect important tissues within the joint, the likelihood of damage to the patellofemoral joint was greatly reduced.

However, this novel approach has some potential limitations that should be noted.First, removal of the bone above the intramedullary nail may lead to possible entry of large bone fragments into the articular cavity. Second, after intramedullary nail removal, the intramedullary content entering the joint cavity may lead to joint cavity extravasation and increase the risk of infection.

CONCLUSION

In this study, removal of the intramedullary nailthe original suprapatellar incision was simple and reliable, did not require special equipment, and did not require infrapatellar access, which reduced the likelihood of complications.

对于此类屡禁不止的疫苗违法犯罪行为，微信朋友圈、各大社群、微博评论等都出现了各种针对要不要打疫苗、打了问题该怎么办、如何选择进口疫苗等问题的咨询。随着长春长生等国内排位靠前的疫苗生产企业被曝出诸多问题，动摇的不仅是人们对国产疫苗的信任，也动摇了人们对整个监管部门甚至国家的信心。与长生生物一起登上质量“黑榜”的武汉生物和长生生物一样，疫苗销售屡涉行贿案，其不合格疫苗甚至多于长春长生。无独有偶，近年来，诸如三鹿奶粉和郴州血铅事件等侵害儿童健康权的事件也屡有发生。这些事件不仅触动了家长们的神经，也挑战了社会的底线。

The authors would like to thank the patient for providing consent for publication of this case report and accompanying images.