Faculty of Medicine. Chiang Mai University

Transcription

1 Faculty of Medicine Chiang Mai University

2 RUNGSINEE TEEYASUNTARANONN Registered Nurse ; Operating Room Maharaj Nakorn Chiang Mai Hospital Trained; AO Course for ORP - Bangkok ; 2005 AO Educators Course for ORP - Chiang Mai ; 2006 AO Educators Course for ORP - Bangkok ; 2014 AO Fellowship in Trauma field ; Inselspital, University of Bern, Switzerland ; April - May 2008 AO Trauma Faculty Education and Chairperson Training Program for ORP - Davos, Switzerland ; Dec Experience; AO Educator for ORP Thailand ; Nurse in Orthopaedic surgery 15 yrs.

3 Implant removal Rungsinee Teeyasuntaranonn AO course for ORP Implant removal Bangkok, July.26, 2015

4 Learning outcomes At the end of this lecture you will be able to : Outline the role of ORP in planning for implant removal Discuss what is required to remove broken and damaged implants

5 Introduction Unglamorous surgery Often delegated to the least experienced team members Highest incidence of complications No such thing as an easy case Implants are like fish-hooks: They are easier to put in than to take out!

6 Planning for implant removal Never underestimate implant removal It requires meticulous planning and communication Failing to plan is planning to fail Benjamin Franklin

7 Rule of W s Knowledge about implant is key to success 1. What 5. Who? 2. Why 4. Where 3. When

8 Rule of W s 1. What needs to be removed? 2. Why does the implant need removal? 3. When was the implant inserted? 4. Where is the implant located? 5. Who will do the removal?

9 1. What needs to be removed? A. Plate, screws, and washers B. Wires and screws C. Nails and bolts A. C. D. B. D. Pediatric nails

10 1. What needs to be removed? Broken or intact implants?

11 1. What needs to be removed? Broken or intact implants? All implants or only a few? What is the surgical plan? Titanium or steel? Who manufactured it? Is it a standard known implant?

12 2. Why does the implant need removal? After consolidation of fracture Timing Wires and screws 3 months IM nails 18 months Long bone plates 18 months Periarticular plates 18 months Different regions, countries Different regulations

13 2. Why does the implant need removal? Before consolidation of fracture Nonunion of fracture Breakage of implant Dynamization of fracture ( with nail ) Pain

14 2. Why does the implant need removal? Sequential screw removal due to joint penetration B C A

15 2. Why does the implant need removal? Protruding implant that causes pain Courtesy of S Bavonratanavech

16 2. Why does the implant need removal? Plate failure - fatigue Broken screws ( A and C ) Broken plate ( B )

17 2. Why does the implant need removal? Implant failure fatigue Plate : LCP Screws : LHS

18 2. Why does the implant need removal? Infection - Fracture not yet healed but infected 1. Implant stays in situ - Treated surgically and pharmaceutically ( Twaddl e, 2006 ) 2. Implant has to be removed - Deep and severe infection - Chronic infection

19 ORP preparations for removal Provide equipment and broken implant removal set Consider bone grafting In case of infection: Debridement and lavage Local antibiotics ( eg, beads) Special dressing Consider alternative fixation method External fixator

20 3.When was the implant inserted? The longer an implant has been in place, the more difficult it may be to remove Ingrowth of tissues in threads of implant Connective tissues on smooth implant surfaces Severe corrosion Titanium implants may be more difficult to remove Search for date of implantation

21 4. Where is implant located? Location of implant will determine perioperative considerations Positioning, etc

22 5. Who will do the removal? Experienced or less experienced team The insertion/extraction technique must be known by the entire team Ideally the surgeon who implanted should also remove the implant Assistance for advice Should be available

23 How to get all the information? 1. Communication Find out surgical plan 2. X-rays Count implants Plates,screws,washers,wires Define size of implants Assess for breaks and damage Get AP and lateral view

24 How to get all the information? How many distal bolts are there?

25 How to get all the information? How many distal bolts are there? What about the AP bolt?

26 Difficult implant removal 1. Broken screws a) Screw with stripped recess b) Shallow seated screw shaft c) Deep seated screw shaft d) Jammed locking head screw 2. Intramedullary nails

27 1. Removal of broken screws Information Not always communicated Damage might have happened Insertion Removal During healing process Use of set required

28 Difficult implant removal 1. Broken screws a) Screw with stripped recess b) Shallow seated screw shaft c) Deep seated screw shaft d) Jammed locking head screw 2. Intramedullary nails

29 Procedure to remove a. Screw with stripped recess Prevention - Insert screw manually ( final tightening ) - Loosen the screw manually - Use the correct screwdriver - Use a standard screwdriver

30 Procedure to remove a. Screw with stripped recess Prevention - Insert screw manually ( final tightening ) - Use torque limiter for insertion of LHS - Loosen the screw manually - Use the correct screwdriver - Use a standard screwdriver also for removal of LHS

31 Procedure to remove a. Screw with stripped recess 1. Try to insert the conical extraction screw anticlockwise and remove screw 1

32 Procedure to remove a. Screw with stripped recess 1. Try to insert the conical extraction screw anticlockwise and remove screw 2. Destroy screw recess with high speed drill bit - Note the large amount of metal debris 2

33 Procedure to remove a. Screw with stripped recess 3. Attach hollow reamer to screw shaft 4. Remove screw with extraction bolt 3 4

34 Removal procedure b. Shallow seated screw shaft 1. Enlarge access to screw shaft with gouge 2. Remove shaft anticlockwise with pliers 1 2

35 Procedure to remove c. Deep seated screw shaft 1. Countersink screw hole, clockwise 2. Drill anticlockwise around shaft with hollow reamer. 1 2

36 Procedure to remove c. Deep seated screw shaft 3. Insert extraction bolt over shaft 4. Remove shaft anticlockwise 3 4

37 Procedure to remove d. Jammed LHS Problems Cross threading Cold welding of screw to plate Screw head recess is stripped

38 Procedure to remove d. Jammed LHS 1. Use a high-speed, hardened drill bit to detach screw from plate 1

39 Procedure to remove d. Jammed LHS 1. Use a high-speed, hardened drill bit to detach screw from plate 2. Attach hollow reamer to screw shaft 3. Remove screw with extraction bolt 2 3 Same procedure as conventional screws

40 Use a Do It Yourself ( DIY ) kit A sharp hook Best screwdrivers Worst osteotomes / gouges Different pliers Old needle holder

41 2. Removal of intramedullary nails Problem Interlocking screws are broken Recess of screws / nail is damaged Procedure Prepare correct instruments Remove screws first Leave proximal screw in place Remove nail Attach extraction bolt to nail Remove proximal screw Remove nail

42 3. Removal of pediatric implants Much care is needed Growth plates still open Overgrowth of bone Difficult to access and remove Special pliers are useful

43 Question

44 1. LHS should be removed with : 1. High - speed hardened drill bit, hollow reamer and extraction bolt 2. Hollow reamer and conical extraction screw are enough 3. High-speed drill bit, extraction bolt and conical extraction screw 33% 33% 33% Answer Now 7 Countdown

45 Which one is correct? 1. A normal screwdriver is needed in procedure of removal LHS 2. The conical extraction screw are 3 sizes available for removal 3. A softened high-speed drill bit is used to detach locking screw head from shaft part 33% 33% 33% 45 Answer Now Countdown

46 Which one is correct about the removal of intramedullary nail? Attach conical extraction screw to remove nail from intramedullary canal 2. The last screw is left in nail before removal is the proximal screw 3. Instrument in set of interlocking nail can remove every nailing Answer Now 33% 33% 33% Countdown

47 Summary You will now be able to: Outline the role of ORP in planning for implant removal Discuss what is required to remove broken and damaged implants

48 คำแนะน ำเพ มเต มในผ ป วยแต ละรำย รำยท ผ ำต ดหล ง - กรณ ร บประทำนอำหำรบนเต ยงให นอนตะแคงหน ำ ใช ม อข ำงท ถน ดอย ด ำนบน - กรณ ท ย นร บประทำนอำหำรข ำงเต ยง ต องย นต วตรงลง น ำหน กท ขำเท ำก นท ง 2 ข ำง พร อมสวมอ ปกรณ พย งหล ง - ให ล ก น ง เท ำท จำเป น เช น เวลำข บถ ำย พร อมสวมอ ปกรณ พย ง หล งเม อล กจำกเต ยง - ระว งกำรเอ ยวต ว หร อเอวแรงๆ