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項目生命周期包括以下幾個階段：設立階段，政府與第三方資本成立項目公司；融資階段，項目公司利用銀行貸款、回租資產等方式進行外部融資；設計階段，項目公司開展經營結構及財務框架設計；建設/存量設施轉移階段，購買或建造運營該項目所需設施；運營階段，項目公司在合同期限內自行運營項目或分包獲得盈利；推出階段，項目公司終止。本部分主要對各階段的增值稅、企業所得稅及其他稅收風險提出針對性措施。

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

漢語詞匯豐富，許多近義詞看似意思相近，但運用時有細微差別。為了讓學生仔細辨別詞語，可以在閱讀文本時讓近義詞語對對碰，引導正確辨析、使用詞語。

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.

前面已經對非均勻衰減性介質中采用的地波干涉法進行了證明，接下來要探討空間自相關法與地震波干涉法之間的關系。這個問題的設立如圖1所示。首先，選取衰減性無限介質中的兩個觀測點（三角形標記），假設噪聲源（星形標記）在介質中呈體積分布。在這種情況下，可以對兩點間的波動場進行標準化的交叉譜分析，明確其與格林函數之間的理論關系。此外，在無衰減的情況下，由于假設平面波向觀測點各向同性入射（例如，Nakahara，2006；Sanchez－Sesma and Campillo，2006），因此必須注意條件的變化。

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 對119名發生血源性暴露醫務人員的人群分布、暴露方式及部位、暴露源種類、暴露后處理方式、預防用藥及結果等情況匯總分析。

TREATMENT

玉米倒伏病害的防治除了合理種植，還要根據不同玉米品種的差別安排玉米種植密度，同時也要注意鉀、氮及磷肥的合理使用，根據當地土地的情況進行適當的補給。此外，為了預防在玉米拔節后氮肥量施加過多，可以將其分為苗期、穗期2次追肥。通過在玉米拔節后期采取一定措施可以有效防治玉米倒伏，在玉米拔節后期也要注意中耕培土的實施，促進玉米根部發育，從而提升玉米植株抗倒伏能力；在玉米拔節后期可以進行植物生長抑制劑的噴施，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.

對于此類屢禁不止的疫苗違法犯罪行為，微信朋友圈、各大社群、微博評論等都出現了各種針對要不要打疫苗、打了問題該怎么辦、如何選擇進口疫苗等問題的咨詢。隨著長春長生等國內排位靠前的疫苗生產企業被曝出諸多問題，動搖的不僅是人們對國產疫苗的信任，也動搖了人們對整個監管部門甚至國家的信心。與長生生物一起登上質量“黑榜”的武漢生物和長生生物一樣，疫苗銷售屢涉行賄案，其不合格疫苗甚至多于長春長生。無獨有偶，近年來，諸如三鹿奶粉和郴州血鉛事件等侵害兒童健康權的事件也屢有發生。這些事件不僅觸動了家長們的神經，也挑戰了社會的底線。

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