What are the operative steps for the removal of a Proximal Femoral Nail (PFN)-A2 nail?

Operative Steps for Removal of Proximal Femoral Nail (PFN)-A2

The removal of a Proximal Femoral Nail Antirotation II (PFN-A2) should follow a systematic approach that prioritizes patient safety, minimizes tissue damage, and ensures complete implant removal while maintaining bone integrity.

Pre-operative Preparation

• Adequate anesthesia (typically spinal) should be administered and patient positioned supine on a fracture table with the affected limb draped free after standard aseptic preparation 1
• Ensure appropriate imaging equipment (C-arm) is available and properly positioned for intraoperative guidance 1
• Verify all necessary extraction instruments are available before beginning the procedure 2

Surgical Approach

1. Incision and Exposure

• Utilize the previous proximal incision over the greater trochanter region 2
• Dissect carefully through subcutaneous tissue down to the fascia lata 1
• Incise the fascia lata in line with the skin incision and split the gluteus medius in line with its fibers 1
• Identify the proximal entry point of the PFN-A2 2

2. Removal of Distal Locking Screws

• Reopen the distal locking incisions (typically two small incisions) 2
• Carefully dissect down to expose the screw heads 2
• Remove the distal locking bolts using the appropriate screwdriver under C-arm guidance 2
• This step is critical as failure to remove all locking screws will prevent nail extraction 3

3. Removal of Proximal Screws

• Extend the lateral incision over the proximal femur as needed for adequate exposure 2
• Identify both the hip screw (lag screw) and anti-rotation screw heads 4
• Remove both screws sequentially using compatible screwdriver under fluoroscopic guidance 4
• In cases with significant tissue ingrowth or ossification around the proximal end, a guidewire and standard reamer can be used to clear the path to the nail end, reducing operative time and tissue damage 2

4. Nail Extraction

• Attach the appropriate extraction device to the proximal end of the PFN-A2 2
• Apply gentle, controlled hammering and manipulation under C-arm guidance 2
• Extract the nail in its entirety, avoiding excessive force that could cause femoral fracture 3
• If resistance is encountered, reassess for any remaining locking mechanisms or bony ingrowth 2

5. Wound Closure

• Irrigate all wounds copiously with saline solution 1
• Achieve meticulous hemostasis 1
• Close in layers: fascia lata with absorbable sutures, subcutaneous tissue approximation, and skin closure with staples or sutures 1
• Apply sterile dressing 1

Post-operative Considerations

• Patients should be monitored for pain, neurovascular status, and early mobilization 1
• Prophylactic antibiotics should be administered according to hospital protocol 1
• Thromboprophylaxis should be continued as appropriate 1
• Weight-bearing restrictions may be necessary depending on bone quality and healing status 5

Technical Tips and Pitfalls

• Ensure all locking mechanisms are completely removed before attempting nail extraction to prevent iatrogenic fracture 3
• Use fluoroscopic guidance throughout the procedure to confirm complete removal of all components 4
• The modified technique using guidewire and reamer for proximal end preparation can reduce operative time from approximately 75 minutes to 32 minutes in cases with significant soft tissue scarring 2
• Be prepared for difficult extraction in cases where bony ingrowth has occurred around the nail 2
• Maintain alignment of extraction forces along the axis of the nail to prevent cortical perforation 3

This systematic approach to PFN-A2 removal ensures a safe and efficient procedure while minimizing complications and operative time 2.