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IM Nail causing severe ankle joint pain

Anyone with IM nailing thats migrating into ankle joint?
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replied October 19th, 2011
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CeeLoo,

If the nail is about to, or has, penetrated the ankle joint, it should be removed. If the nail violates the ankle joint, that will cause significant damage to the mortise and talar dome. That is best prevented.

Good luck.
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replied October 19th, 2011
Thanks Gaelic, I just got my new set of x-rays and the nail is mere millimeters from touching my ankle joint, the bone looks very weak to hold without nail but sending it off to my Ortho for some insights... thanks again.

Cheers!
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replied October 19th, 2011
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CeeLoo,

It also makes a difference if the nail is locked or not. If the nail have interlocking screws placed in the distal tibia, then the chances of it progressing into the ankle joint is small.

But, if the nail is not locked, then it is possible. It usually occurs if there is a collapse at the fracture site and the nail is locked proximally, but not distally.

It is not too common for it to just migrate into the ankle joint. Most IM nails used now days, have a bend in the nail up at the proximal end (helps in placing the nail), that usually keeps it from going anywhere.

But, when there is metal implants involved, strange things can happen. And, usually, the surgeons like to have the distal tip of the nail at the level of the physeal scar, or about 1 to 2 cm from the tibial plafond. So, if the nail is within millimeters, it is basically in the subchondral bone, which is really a little too close for comfort.


It is a good idea to have your surgeon take a look at a picture of the whole nail, to see why the nail has moved. Good luck.
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replied October 21st, 2011
Thanks Gaelic, my IM nail is not locked and a big portion of my bone is not normal bone so maybe has contributed to the nail migrating, radiographical it looks to be in the same positon but the continued ankle pain last 5 months indicates an intrusion into the ankle joint area... here is what my doc had to say about the situation:

Hello there
Do not be deeply worried.
The X-rays actually showing new bone formation- be it incomplete.
We might have to add some bone, but it is looking quite nice and promising.
Please be patient and remember that you are quite a unique success story- so far anyway- and over 18 cmm tibia bone transport on a pathological bone are nowhere to be found in world literature.

See you in few months.
Regards, Retter
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replied October 22nd, 2011
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CeeLoo,

That is AMAZING!!

Usually getting 6 to 8cm of bone to transport is big deal. Most patients cannot stand being tied up for much longer than that. You must have outstanding self control.

You are sort of in that "between a rock and a hard place" area. You have the problem at the ankle, but you do not want to remove the nail before the bone is strong enough to take the stresses that will be applied to it. You do not want to do anything that would destroy that 18cm of new bone growth.

It is also possible that the nail is sitting on the subchondral bone at the tibial plafond. This is the very dense bone just under the articular cartilage. By putting pressure on this bone, it can produce joint pain. Hopefully, this is what is happening, because it is usually reversible.

But, if the nail has truly penetrated the joint, then usually, the joint needs to be immobilized (till the nail can be removed). The reason being, with the nail protruding into the joint, the articular cartilage on the talar bone can be ground away, producing loose bodies in the joint at the same time.

Usually, patients can tell if the nail is cutting into the talar dome, as it causes a grinding sensation and extreme pain with motion. If the ankle is held still, the pain decreases greatly.


So, again, you are a truly amazing person. I'm sure your case will be written up for the literature. Hopefully, the nail hasn't gotten to the point of touching the talar dome yet.

Good luck with the rest of your treatment.

If you don't mind, why was the bone transport necessary? Was it due to trauma, infection, or a tumor? You do not have to answer if you do not want to. I may be too curious.

Again, good luck.
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replied October 24th, 2011
Hi Gaelic,

Thanks for your insights, always a pleasure to read your views, quite informative. Actually you will be amazed at what happened. I was diagnosed with Fibrous Displasia at age 12 had an iliac crest bone graft then +10 years later started to have debilitating pain. I had the unfortunate surgery that killed my bone in 2003 after my Ortho then suspected a tumor during the op. A year down the road, I had non-union and he suggested to remove the plates and put in carbon fibres but when I checked online I found he was involved in an "experiment" of sorts with Carbon Fibres at some University in the UK that was a total failure in 1992 so I decided against it. A second, third and fourth opinion revealed that all the excised bone was sclerotic and pathologically dead! So I decided to go to South Africa (by the way am Kenyan) to have a review and map way forward as I was informed that they had a bone bank and I could get portion of the 22cm that I was about to loose off my tibia replaced in this way. When I arrive at the Milpark Hospital in Aug 2005, the Ortho was shocked at the huge amount of bone that I had to loose. In his experience the biggest gap he had dealt with was 11cm on an 8 year old, here I was with a 22cm deficit at 24 yrs old! So they did a comprehensive histology on the bone, they found no trace of FD nor tumor actually the found nothing at all in the meantime I go the illizarov (external fixator) on and start growing my bone for 7 months. Upon removal following bone transport, the proximal tibia had done very well and I had grown at least 5cms or so, the distal tibia was doing poorly so I had grafts introduced (iliac crest) and artificial bone and a plate and screws to strengthen it (Mar 2006). In Dec 2008, we removed the plate and screws and introduced the expanding intramedullary nail which I have till now. Its been a journey, my Ortho says its not a text-book case and everything we've done so far has been on a trial and error basis but I am now more than anxious to get back on my feet, 8 years is a long time to be on crutches but besides the ankle pain I am generally doing great I believe... you should see my x-rays they look really great! in terms of callous formation i.e.!
Cheers!
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replied October 24th, 2011
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CeeLoo,

Again, that is just amazing.

Thank you for relating the information. It is wonderful that you have made so much new bone.

Hope that you will soon be able to get off the crutches. I was on crutches for three years, and that was really the pits, I could not imagine having to do it for 8. But, again, hopefully, you will be able to get the nail out soon, decrease the ankle discomfort, and get on with life.

Wishing you the best. Good luck.
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replied October 25th, 2011
Thanks Gaelic. I really am hopeful that the end of this whole saga is close by.

All the best!
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replied September 28th, 2016
IM nail troubles again
Hey Gaelic, I wonder if you are still in this cyber space and wonder how you are doing? Still struggling with tibia albeit now with a tibia-fibula transposition +25 months later....

How you doing my friend?
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replied September 28th, 2016
Hey Gaelic, I wonder if you are still in this cyber space and wonder how you are doing? Still struggling with tibia albeit now with a tibia-fibula transposition +25 months later....

How you doing my friend?
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replied September 28th, 2016
Hey Gaelic, I wonder if you are still in this cyber space and wonder how you are doing? Still struggling with tibia albeit now with a tibia-fibula transposition +25 months later.... It is actually more of Tibialisation of the Fibula only I have a significant portion of bone missing middle of tibia plus the IM nail still in place.

How you doing my friend?
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