A bstract Aim To present a novel technique developed in our institution to remove incarcerated and broken intramedullary (IM) tibial and femoral nails. Background IM nails are commonly used to treat diaphyseal fractures in both the tibia and femur. These nails can become problematic for the orthopaedic surgeon when they need to be removed, especially in the rare event that the nail has failed and broken. This can leave part of the nail deep in the bone and incarcerated. Multiple techniques have been described to remove a broken nail but we present a novel technique developed based on our experience. Technique After all other methods to remove the broken nail have failed, a window technique can be employed. This requires a small window of bone to be removed from the cortex overlying the remaining IM nail. A carbide drill is then used to drill a hole into the nail to gain purchase. The edge of an osteotome is placed in the hole in the nail through the window and gently hammered upwards to push the nail towards the over-reamed nail entry point. The nail is repeatedly drilled and pushed until the nail can be removed. The bone window is then replaced. Conclusion This is a novel technique that works when all other options including hooks, wire stacks and specialist nail removal techniques have failed. It is simple, efficient and effective for both the tibial and femoral nails. How to cite this article Somerville CMB, Hanschell H, Tofighi M, et al. A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail. Strategies Trauma Limb Reconstr 2022;17(1):55–58.
AimWe seek a simple and reliable tool to predict malignant behavior of pheochromocytoma and paraganglioma (PPGL).MethodsThis single-center prospective cohort study assessed size of primary PPGLs on preoperative cross-sectional imaging and prospectively scored specimens using the Pheochromocytoma of the Adrenal Gland Scaled Score (PASS). Multiplication of PASS points with maximum lesion diameter (in mm) yielded the SIZEPASS criterion. Local recurrence, metastasis or death from disease were surrogates defining malignancy.Results76 consecutive PPGL patients, whereof 58 with pheochromocytoma and 51 female, were diagnosed at a mean age of 52.0 ± 15.2 years. 11 lesions (14.5%) exhibited malignant features at a median follow-up (FU) of 49 months (range 4-172 mo). Median FU of the remaining cohort was 139 months (range 120-226 mo). SIZEPASS classified malignancy with an area under the curve (AUC) of 0.97 (95%CI 0.93-1.01; p<0.0001). Across PPGL, SIZEPASS >1000 outperformed all known predictors of malignancy, with sensitivity 91%, specificity 94%, and accuracy 93%, and an odds ratio of 72 fold (95%CI 9-571; P<0.001). It retained an accuracy >90% in cohorts defined by location (adrenal, extra-adrenal) or mutation status.ConclusionsThe SIZEPASS>1000 criterion is a lesion-based, clinically available, simple and effective tool to predict malignant behavior of PPGLs independently of age, sex, location or mutation status.
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