What is the operative note for a patient undergoing removal of a Proximal Femoral Nail (PFN) A2 implant for a healed right intertrochanteric femur fracture with symptomatic hardware?

Operative Note for PFN A2 Implant Removal from Healed Right Intertrochanteric Femur Fracture

The removal of a Proximal Femoral Nail (PFN) A2 implant should be performed with careful consideration of the risk of post-removal femoral neck fractures, which occur at a median incidence of 14.5% following hardware removal in healed trochanteric fractures. 1

Preoperative Assessment

• Patient with history of right intertrochanteric femur fracture previously treated with PFN A2 implant, now presenting for hardware removal due to symptomatic hardware 2
• Preoperative radiographs should confirm complete fracture healing and assess for any signs of implant loosening or failure 2
• Evaluate bone quality and osteoporosis status, as systemic and local osteoporosis are significant risk factors for post-removal fractures 1

Anesthetic Considerations

• Spinal/epidural anesthesia is recommended unless contraindicated, as it may reduce postoperative confusion in elderly patients 2
• If general anesthesia is chosen, consider additional peripheral nerve blockade for postoperative pain control 2
• Prophylactic antibiotics should be administered within one hour of skin incision 2

Operative Technique

Patient Positioning and Preparation

• Position patient supine on fracture table or radiolucent operating table 2
• Prepare and drape the operative site using standard sterile technique 2
• Confirm availability of appropriate extraction instruments specific to PFN A2 system 3

Surgical Approach

• Make incision along the previous surgical scar at the greater trochanter 3
• Dissect down to the proximal end of the nail, identifying the end cap and proximal locking mechanisms 3, 4
• Carefully expose the proximal aspect of the nail without excessive soft tissue stripping 1

Hardware Removal Steps

1. Remove the end cap using the appropriate extraction tool 3
2. Identify and remove the proximal locking elements:
   • Remove the anti-rotation screw/helical blade first 3, 5
   • Remove the lag screw/femoral neck screw 3, 5
3. Remove any distal locking screws through small incisions guided by fluoroscopy 3, 4
4. Attach the extraction device to the proximal end of the nail 3
5. Extract the nail using gentle, controlled force along the axis of the implant 3, 5
6. Irrigate the wound thoroughly to remove any debris 2

Closure

• Ensure hemostasis throughout the wound 2
• Consider filling the void left by the implant with bone graft or bone substitute to prevent fracture, especially in osteoporotic patients 1
• Close the wound in layers with attention to fascial closure 2
• Apply sterile dressing 2

Postoperative Management

• Implement thromboprophylaxis according to hospital protocol (typically low molecular weight heparin or mechanical compression devices) 2
• Consider protected weight-bearing for 4-6 weeks to reduce risk of post-removal fracture 1
• Maintain vigilance for signs of femoral neck fracture, which can occur spontaneously and may present subtly with hip pain even in ambulatory patients 1
• Schedule follow-up radiographs at 2 weeks, 6 weeks, and 3 months post-removal 1

Special Considerations and Potential Complications

• Post-removal femoral neck fracture risk: This is a significant concern, especially in osteoporotic patients. Consider prophylactic measures such as bone grafting of screw holes 1
• Incomplete hardware removal: Ensure all components are removed to prevent continued symptoms 3, 5
• Intraoperative fracture: Use controlled extraction techniques and avoid excessive force 1
• Infection: Maintain strict sterile technique and administer appropriate prophylactic antibiotics 2

Documentation Elements

• Preoperative diagnosis: Healed right intertrochanteric femur fracture with symptomatic PFN A2 hardware
• Postoperative diagnosis: Status post removal of right PFN A2 implant
• Procedure: Removal of right proximal femoral nail (PFN A2)
• Implants removed: PFN A2 nail with associated proximal and distal locking elements
• Estimated blood loss
• Complications: None
• Bone quality assessment
• Weight-bearing instructions: Protected weight-bearing recommended for 4-6 weeks 1