What are the potential complications of intramedullary (IM) nail placement and how are they managed?

Complications of Intramedullary Nail Placement and Their Management

The most common complications of intramedullary (IM) nail placement include implant failure, cutout, infection, and systemic complications, which should be managed through careful preoperative planning, meticulous surgical technique, and appropriate postoperative monitoring. 1

Common Complications

Mechanical Complications

• Implant failure/breakage: Occurs in approximately 1-2% of cases, with risk factors including:

  • Low ASA score (younger, healthier patients who place more stress on the implant) 2
  • Subtrochanteric fracture location 2
  • Pathological fractures 2
  • Delayed or non-union of the fracture 2

• Cutout: When the nail or screws penetrate the femoral head and acetabulum, particularly in osteoporotic bone 1

  • Management involves revision surgery with either replacement of the nail or conversion to arthroplasty depending on fracture healing status and bone quality 1

• Fracture propagation: Can occur during nail insertion, particularly at insertion sites 3

  • Occurs in approximately 10% of tibial nailings 3
  • Management involves recognition of the propagation and possibly additional fixation if stability is compromised 3

Infectious Complications

• Wound infection: Can be superficial or deep, with deep infections potentially leading to osteomyelitis 1
  • Management includes:
    • Antibiotics for superficial infections
    • Surgical debridement, irrigation, and antibiotic therapy for deep infections
    • Implant removal may be necessary in established osteomyelitis once fracture healing is achieved 3

Neurological Complications

• Nerve injuries: Occur in up to 30% of tibial nailings, primarily affecting the peroneal nerve 3
  • Most (89%) are transient sensory neuropraxias resolving within 3-6 months 3
  • Management includes observation for transient cases and neurology consultation for persistent deficits 3

Pain-Related Complications

• Anterior knee pain: Common after tibial nailing, affecting up to 40% of patients 4

  • May persist even after nail removal 4
  • Some previously asymptomatic patients may develop knee pain following nail removal 4
  • Management includes physical therapy, analgesics, and consideration of nail removal if symptoms persist 4

• Patellar tendinitis: Develops in approximately 22% of tibial nailings 3

  • Management includes anti-inflammatory medications, physical therapy, and consideration of nail removal 3

Systemic Complications

• Pulmonary embolism: More common with reamed femoral nailing due to:

  • Increased intramedullary pressure during reaming 5
  • Embolization of bone marrow contents 5
  • Risk factors include volume deficit, shock, lung contusion, and pre-existing pulmonary impairment 5
  • Management includes careful reaming technique, consideration of unreamed nailing in high-risk patients, and vigilant postoperative monitoring 5

• Cardiac complications: Particularly in patients with pre-existing conditions 1

  • Patients with congestive heart failure have 1.91 times higher odds of major complications 1
  • Patients with hypertension have 1.67 times higher odds of major complications 1

Prevention and Management Strategies

Preoperative Considerations

• Thorough assessment of fracture pattern and location to determine optimal nail length and diameter 6
• Evaluation for associated injuries, especially in high-energy trauma 6
• Consider temporary external fixation followed by delayed definitive nailing in patients with:
  • Severe associated injuries
  • Circulatory shock
  • Respiratory failure 6

Intraoperative Techniques to Minimize Complications

• Careful nail insertion technique to minimize embolization and fracture propagation 5
• Appropriate nail size selection - choosing thinner nails with correct length can reduce embolization 5
• Complete removal of locking screws before nail extraction to prevent iatrogenic fractures 4
• Thorough assessment of the entire femur before nail placement to avoid missing proximal lesions that could lead to implant failure 7

Postoperative Management

• Close follow-up of patients with risk factors for nail breakage until bony union is achieved 2
• Provision of crutches after nail removal, as most patients will require them to alleviate leg pain 4
• Patient education regarding expected recovery time, including potential need for approximately 2 weeks away from work after nail removal 4

Special Considerations

• Patients on anticoagulation have 1.70 times higher odds of major complications and require careful perioperative management 1
• Patients with liver disease have 5.19 times higher odds of complications leading to reoperation 1
• Metastatic lesions: No advantage to routine use of cephalomedullary nails for diaphyseal metastatic lesions as there does not appear to be a high frequency of new femoral neck lesions after intramedullary nailing 7

Pitfalls to Avoid

• Failure to diagnose femoral neck lesions before implanting an intramedullary nail increases risks of implant failure and need for additional surgery 7
• Inadequate preoperative imaging can lead to missed pathology and suboptimal implant selection 7
• Removing nails without removing all locking screws can result in iatrogenic fractures 4
• Unrealistic patient expectations regarding pain relief after nail removal, particularly for anterior knee pain 4