Chapter 57

"Intramedullary nail internal fixation, know the general procedure?" Fang Ziye stood fully gowned and gloved beside the operating table; Associate Professor Xie Jinyuan had already checked and verified all the instruments needed for the surgery on the kidney dish, and while handing them to Fang Ziye, he asked in advance.

This is the final safety check before surgery; if you don't know, you can say so, and your superior can give you a free reminder once more.

Fang Ziye nodded, took a deep breath, and glanced at Teacher Deng and Associate Professor Xie: "The main procedure I won't get wrong; it's just the operation might not be that smooth."

Joking aside, internal fixation device removal surgery is the most entry-level, least technically demanding operation in orthopedics; if he couldn't even remember the surgical procedure, Fang Ziye's Master's studies these past few years would have been for nothing.

"Intramedullary nail removal surgery is somewhat more difficult to operate than plate and screw internal fixation device removal surgery, but the key steps still lie in exposure."

"This patient's intramedullary nail is a femoral retrograde intramedullary nail, so the intramedullary nail's fixed blade is in the knee joint's intercondylar fossa, and the locking screws are respectively at the proximal end of the femur and the supracondylar ridges of the medial and lateral femoral condyles at the distal end."

"The operation you need to do is actually to first remove the blade of the locking cap, and then remove the locking screws of the intramedullary nail fixation device one by one." Associate Professor Xie still explained it simply once.

Fang Ziye nodded again, no excitement, no particular nervousness; right hand holding the knife in a pen-grip, left hand stroking the scar of the original lateral patellar incision approach on the patient, showing he had made full preparation.

"Surgery begin." Teacher Deng was even more pressure-free; he gave the order, and the circulating nurse and anesthesiologist naturally started recording the skin incision time.

Fang Ziye didn't struggle either; following the original surgical incision at the lateral patella, he used the willow leaf knife to incise the scarred skin, one cut to the bottom, clean and neat.

One forceps handed to Teacher Deng, one forceps gripped in his palm; after Associate Professor Xie used a cotton pad to wipe away the small amount of blood from the first incision, Fang Ziye and Teacher Deng each retracted one side of the skin with forceps, and advanced layer by layer with the electrocautery.

The first cut broke through the superficial layer of the skin scar; using the electrocautery is the true start of making the incision approach.

"Don't be nervous; the scar formed by a surgical incision is just tougher than normal tissue in ordinary people; the electrocautery cuts slower, and it's fine if the duration is slightly longer." Teacher Deng saw Fang Ziye was a bit hesitant to cut, and spoke up to give guidance.

Immediately after, quite a few people in the operating room began moving over to watch.

Fang Ziye gathered his focus, and only then peeled away layer by layer downward.

This surgery is extremely simple; the exposure stage has no overly exquisite maneuvers — it's all about whether basic skills are solid; unsolid basic skills mean a messy surgical field, solid basic skills mean a relatively clean surgical field.

Fang Ziye's surgical field belonged to the relatively clean camp.

The incision technique and hemostasis technique practiced in the training room, at this moment, just-rightly completed the exposure of a clean surgical field; and while excising the scar, Fang Ziye could still very precisely control the cutting trajectory, not deviating.

And this is the benefit of cutting tofu or even carving characters with the incision technique; control of force and cutting depth had long been mastered to the point of ease, and the speed was not slow!

Seven or eight minutes later, Fang Ziye broke through the healed joint capsule of the scar, exposed the femoral intercondylar fossa, excised the small amount of excess scar tissue as if carving tofu into shape, leaving relatively neat edges.

Only then did Fang Ziye let out a slight breath of relief, and continued using the electrocautery to circle the scar around the end cap of the intramedullary nail internal fixation device.

This kind of excision is actually a kind of debridement; compared to carving the three-dimensional character 'kou', it is simply effortless; Fang Ziye slid the knife conveniently, and only then looked toward Associate Professor Xie and Teacher Deng, understanding the benefit of setting those standards in the training room.

The four words "accumulation leads to breakthrough," at this moment, Fang Ziye experienced to the fullest.

The first assistant and second assistant were both professors; seeing Fang Ziye expose the distal end, they immediately handed over the corresponding subsequent instruments, interpreting the two words "feeding" clearly and plainly.

Next comes an extremely critical step: removing the intramedullary nail end cap screw, also commonly called the blade.

This step of the operation has been practiced in the training room; it requires special attention — once thread stripping or thread damage occurs, those two professors might fly into a rage.

Steadily connecting the screwdriver to the end cap, increasing the vertical pressure stress against the joint surface, then feeling the engagement of the screwdriver with the screw tail, slowly applying force, evenly increasing the strength!

Until—

"Click—" a rather crisp sound rang out, and only then did everyone breathe a sigh of relief.

The gazes directed at Fang Ziye retracted their nervousness.

And Fang Ziye didn't dare get happy or negligent either; he continued sliding the screwdriver until the end cap screw was completely removed, and carefully examined it three times in his palm.

And also twisted it up with thumb and forefinger to look it over well; no screw fracture or breakage found, only then did he breathe a sigh of relief.

"Instrument nurse, please carefully verify again whether there is thread damage." Fang Ziye described it quite professionally.

Thread stripping and thread damage are the most feared things during internal fixation removal.

But these two are different. Thread stripping refers to damage to the mating part of the screw and screwdriver, making it impossible to turn. Thread damage refers to damage to the contact part between the screw and the object, causing the screw to be able to turn but not advance or withdraw.

Both are very hard to handle; and even without thread stripping or thread damage, one must still pay attention to whether the screw threads show damage or fracture, and whether residual fragments need to be searched for.

Otherwise, after the internal fixation device is removed, discovering something wasn't taken out — that problem is even more troublesome.

After handover, the next part is of higher difficulty: removing the intramedullary nail locking screws. The locking screws are at both the proximal and distal ends of the thigh, and are located in relatively free areas.

It's possible that the incision position from the previous internal fixation surgery no longer matches the current screw fixation positions; if you continue advancing via the original incision approach, you'll only see emptiness — it can only serve as reference, not absolute depth.

This requires reviewing the imaging to carefully compare against the patient's skin surface, then after percutaneous technique breaks through the superficial skin layer, taking the intermuscular approach to avoid important vessels, nerves, and muscles, in order to reach the screw end cap position.

Naturally, there are also those who are not particular — only avoiding vessels and nerves, cutting straight to the bone end to take the screw — and they are not few; but such rough operations generally would not be allowed to appear in Zhongnan Hospital's orthopedic operating room.

Therefore, although there are only five locking screws, this is the most difficult point; it not only requires you to precisely position, but also to reach the screw hole through the most relatively minimally invasive way.

The preoperative preparation, Fang Ziye had long placed outside the operating room; therefore after removing the distal locking screw, Fang Ziye roughly compared the patient's thigh length and murmured: "Proximal anterior thigh has strip-like scar tissue; lower thigh has one strip."

"These two screws should be directly removable; but the other few strips..."

While Fang Ziye was still pondering, his eyes suddenly brightened.

What wool yarn am I spinning here; where the internal fixation device went in is generally where it comes out; if it was put in inside Zhongnan Hospital, Associate Professor Xie and the others' previous operations were absolutely by the book and wouldn't produce a scar-blocking situation; I just need to normally walk the intermuscular gaps.

Hurry and advance the knife via the original approach; no need to worry about some difficulties mentioned in some literature or on forums.

(Chapter End)