We analyzed the data for locking bolt removal and entire IMN removal separately. Removal was considered to be the removal of any portion of the IMN - either locking bolt(s) alone or the entire IMN (nail and locking bolts). Symptomatology included anterior knee pain, tibial pain and pain over locking bolt sites and needed to be at a level that compromised work or leisure activities. Patients who requested that their IMN be removed had their symptoms documented. We did not consider patients for implant removal until fracture union had occurred. We subsequently excluded patients who needed to have their IMN removed because of nonunion or infection. Fracture union was defined as patients being more than 9 months postinjury with evidence of healing of 4 cortices on 2 tangential radiographs. The senior author followed each patient until fracture union. The IMN used was a titanium locked reamed tibial nail (either Synthes or DePuy ACE). Implantation was performed either by the senior author (R.E.B.) or under direct supervision of the senior author according to standard, previously described techniques. Bilateral fractures were treated as separate fractures. We also excluded patients under age 16 years or over age 70 years. We excluded patients if the fracture was pathological. Patients were those seen at a level I trauma centre who sustained a tibial fracture from a traumatic mechanism of injury. Ethics approval was obtained from the Calgary Health Region. We undertook a retrospective chart review of patients in the senior author's practice who sustained a traumatic tibial fracture treated with an IMN between January 1996 and February 2005. 13, 14 This study examined the rate of IMN removal in tibial diaphyseal fractures after healing, as well as the characteristics of patients requesting IMN removal. Some authors argue for an improvement in symptomatology after removal, whereas others have not found any significant improvement. 11, 12 Little evidence exists in the literature regarding the efficacy or characteristics of patients who request IMN removal. 9 Most orthopedic surgeons rely on patient symptoms, especially knee and/or leg pain, to determine whether or not the implant should be removed after healing.
6–10Ĭurrently, there is little consensus among orthopedic surgeons regarding criteria for tibial IMN removal postunion. Within the literature, previously listed criteria for implant removal include symptomatic hardware, skeletally immature patients, broken hardware, compromised skin, nonunion, malunion, infection, fear of carcinogenesis, peri-implant failure, prevention of postunion stress-shielding, prevention of future bacterial colonization, avoidance of difficult surgery owing to the potential for refracture or implant failure and the possibility that removal will improve functional outcome. 4 Implant removal is a procedure with various known morbidities such as refracture, hematoma, lengthy operative times and implant breakage. Implant removal represents one of the most common operations in bone and joint surgery. 2 IMN treatment provides a high rate of union and a decreased incidence of malunion and joint stiffness, compared with other treatments. For displaced diaphyseal tibial fractures, intramedullary nails (IMNs) have become the treatment of choice. Currently methods used include casting, plate fixation, external fixation and intramedullary nailing. 1 The method of fracture treatment depends on the characteristics of the fracture and on surgeon preference. Tibial fractures are the most common long bone fracture.
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