Using Bone wax at the proximal end of the Tibia intramedullary nail at primary surgery to facilitate easy nail removal if needed later – A Case Series

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REDDY, Somasekhara R. NALLAMILLI, Mohan Krishna Althuri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7348390/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Intramedullary (IM) nail removal can be challenging for several reasons. The problem may start with difficulty in locating the proximal end of the nail. This study presents a novel technique to apply bone wax to the proximal end of the tibial IM nail and fill the entry point in selected cases as per our criteria during the primary procedure to see if it prevents bone and soft tissue overgrowth and ingrowth and facilitates easy exposure of the proximal end of the nail during the nail removal procedure at a later date if necessary. In a case series of 28 patients, this procedure was performed in nine patients, and nineteen patients did not require it according to the protocol. We compared the ease of exposure during nail removal in 5 patients from these two groups who underwent nail removal. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Tibial diaphyseal fractures are effectively treated with IM nailing due to its biomechanical advantages, minimally invasive nature, immediatestability, and early mobilisation 1 , 2 , 3 . The indications for elective removal of the nail are sparse, as numerous complications were reported during nail removal 4 . Re-fracture, failed attempts at nail removal, long operating time, persistent anterior knee pain, and wound infection were reported 5 , 6 . Apart from the patient's personal choice, the real indications are infection and any other pathology needing further surgery 7 , 8 . As an elective procedure, it also adds to the operating theatre time constraints of a hospital and financial burden on health authorities 9 . But when it is subsequently necessary, the nail removal can be difficult and time-consuming due to bone and soft tissue ingrowth, sometimes requiring aggressive techniques that risk iatrogenic complications 10 . The problems may start with difficulty in finding the proximal end of the nail, about which there is a paucity of literature to our knowledge. An image intensifier may be needed to localise it, but exposing the tip of the nail may still be difficult, requiring removal of bone and soft tissue, which can be time-consuming. Even if a specialised nail extraction kit is available, the extraction bolt may not fit in the nail unless all the soft tissue inside it is carefully scooped out. This study was designed based on our experience with some cases where it was difficult to find the proximal end of the nail. Hence, we evaluated the efficacy of applying bone wax at the proximal end of the nail during primary fixation of tibial fractures to see if it facilitates easier identification of the implant and to engage the extractor bolt in subsequent nail removal procedures. Various other potential difficulties in nail removal are not included in this study. We tried a simple, readily available, and cost-effective adjunct: the application of bone wax to the proximal end of the IM nail during initial surgery in selective cases, and compared them with other cases where bone wax was not used. Materials and Methods This is a prospective study from August 2018, which is continuing. For an interim assessment of results, we selected cases done between August 2018 and February 2020 (19 months), to check how many of these patients (a total of 28), who had surgery during this period, and came back for nail removal before September 2024. A total of 28 cases over a total period of 19 months, out of which 5 patients came for nail removal. Patients who had tibial diaphyseal fractures deemed suitable for IM nailing based on standard surgical criteria were included in this study 1 , 2 . Our inclusion criteria were restricted to closed and type I open (Gustilo-Anderson) tibial diaphyseal fractures 11 . Within these inclusion criteria, a specific criterion was followed for this study, which is described below. Open fractures (G-A type II and III), cases with severe comminution requiring additional fixation, and significant bone loss, were excluded. During this period, twenty-eight patients matching the inclusion criteria were admitted under one consultant (mean age: 38 years, range 25–55; 19 men, 9 women) who underwent primary closed IM nailing of the tibia. Consent was taken from all the patients to use any additional procedures that may become necessary as part of the surgery. All patients were followed up till the fracture healed. During the first three months, special attention was given to cases in which bone wax was used to look for any complications at the wound. Technique: The standard intramedullary nailing procedure was done in the supine position under spinal anaesthesia through a patellar tendon splitting approach under image intensifier control. The medullary canal was reamed over a guide wire after closed reduction of the fracture. A nail of appropriate length was selected using an image intensifier and the measuring scale provided with the set. Dynamic or static interlocking was done depending on the fracture configuration. Upon completion of the procedure, the nail insertion jig was removed, and in nine cases, the proximal end of the nail was found to be just below the tibial cortical margin or a little deep into the entry point hole (Fig. 1 , 1 a). These cases are going to be referred to as group-1. In the other nineteen cases, the tip of the nail was at or just above the cortical margin (Fig. 2 ). These are group-2 patients. The group-1 patients had an additional procedure where bone wax was used to fill the proximal end - the threaded part- of the nail and the raw bony canal at the entry point (Fig. 3 , 4 ). Standard closure of the wound was done. Bone wax filling was not done for group-2 patients with the assumption that if and when the nail needs to be removed in any of these cases, it wouldn't be difficult to find the proximal end of the nail. Results Post-operative follow-up was the same for all 28 cases, and all the cases had uneventful healing of fractures within the expected time frame of 10 weeks to 18 weeks, an average time was 15.5 weeks. Patients were allowed unaided full weight-bearing walking when the fracture had healed and they were discharged from the trauma clinic. Patients were not routinely advised on implant removal, but when any patient came for implant removal, the records were updated. In September 2024, one of the authors reviewed the records of the cases done between August 2018 and February 2020 and found five patients had come with a request for nail removal by then, 13 months to 21 months after they were originally discharged from the clinic. The reasons were as follows (Table 1 ) Table 1 Group 1 Patient-1 Wanted to join the army services and did not want any metallic implants in the body(Male) Patient-2 Worried about potential problems in the future due to metal in the body, and was keen to get it removed (Female) Group 2 Patient-1 Heavy feeling in the leg, especially after walking for long distances (Male) Patient-2 Prominent heads of interlocking screws with pain on touching (Male) Patient-3 Anterior knee pain, especially during gym workout (Male) Nail Removal: The initial procedure of nailing, as well as the nail removal, was done by the same surgeon or under his direct supervision. The ease of finding the proximal end of the nail was subjectively assessed by the surgeon based on the presence of significant bone/soft tissue coverage of the nail, ingrowth, and the need for any additional instruments or manoeuvres. Operative time was recorded from the time of incision to finding the upper end of the nail and tightening the extraction bolt. For the third patient in Group 2, the exposure of the proximal end of the nail was a little difficult, and the image intensifier was kept ready, though at the end it was not used. Nails were successfully removed from all five patients. Group-1 patients: A soft spot covered with fibrous tissue could be easily palpated after splitting the patellar tendon. Bone wax could be seen after reflecting the fibrous tissue, and the extraction bolt could be easily pushed into the nail through the bone wax (less than 8 minutes). No time was spent on finding and clearing the entry point (Fig. 5 ,6). Group-2 patients: For patients 1 and 2, it took a few minutes (4 & 7 minutes) to find the proximal end of the nail. But clearing the bony overgrowth onto the edges of the nail and soft tissue ingrowth inside the nail took nearly 10 minutes before the extraction bolt could be inserted into the nail (12 & 17 minutes). Patient 3 had a prominent bony-fibrous mass over the tibial condyle, and it took 14 minutes to elevate the same from the proximal end of the nail and another 5 minutes to clear the tissue from the threaded part of the IM nail. Discussion From the earlier days of orthopaedic practice, when most of the fractures were treated conservatively, we moved on to internal fixation using metallic implants. Then there was the discussion on whether those implants were to be left in situ or to be removed when they served their purpose. Initially, there was this enthusiasm to remove them after the healing of the fractures. But surgeons experienced difficulties in metal removals with iatrogenic complications, making the patient worse 10 . The present accepted practice is to leave the implants in situ if there are no implant-related problems 12 , 13 , which can also be applied to Tibial I M nails. However, there may be some genuine cases where removal may be necessary. But it always carried its share of problems with difficulty in finding the nail and ultimately abandoning the procedure due to various reasons. The present study is limited to the difficulty in locating the proximal end of the nail and assembling the extraction bolt. It could be difficult due to excess soft tissue ingrowth, necessitating additional soft tissue dissection. Sometimes, ectopic bone formation may completely obscure the entry point, and it may need multiple C-arm exposures even to find it. It is not uncommon to find the proximal end of the nail a little deep in the entry point after removing the insertion jig at the end of a successful completion of nailing. It can be due to inadvertent miscalculation of the nail length with a ruler, even with the use of an image intensifier. Sometimes a given tibia may measure between the available nail length sizes of the manufacturer, forcing to use of a shorter nail to avoid patellar tendon impingement with the next, one length longer nail. Some manufacturers supply 'end caps' to extend a short nail, but not all companies, and it also adds to the cost. We believe that it is a common assumption that finding the proximal end of the nail is not difficult in cases where the nail is a little proud at the end of the procedure, but it can be difficult in cases where it is left deep in the entry point. However, we found that exposing the proximal end of the nail, which is prominent above the bony cortex, can also take extra time to clear the soft tissue ingrowth and to expose the threaded part of the nail (group 2). Since there are very few indications for routine removal of the tibial IM nails, it is difficult for any single centre to achieve a large case series of nail removals. Genuine indications for implant removal are only infections and non-unions needing revision nailing 7 , 8 . Literature doesn’t support routine removals of nails even in younger patients, or people with anterior knee pain 4 . However, there may be cases where implant removal is required at a later date for various reasons, including the patient's personal preferences. There is no way to predict which one will be removed later and for what reason. With our experience of finding the proximal end of the nail difficult in some cases, we started this study with the hypothesis that it is difficult to find the proximal end of the nail in cases where it is a little deep, and it won't be a problem in cases where the nail ends up a little proud. Hence, we started filling the proximal end of the threaded part of the nail and the remaining exposed deep entry point with bone wax (9 cases out of 28). The same was not done in cases where the nail is a little proud above the cortical margin (19 cases out of 28). Bone wax is biocompatible and has been widely used for haemostasis without any adverse effects for a long time 14 . It was applied on the surface of the tibial condyle and is away from the diaphyseal fracture site without any worry of it potentially interfering with fracture union. In the 9 cases where it was used, there were no wound infections or allergic reactions due to bone wax. At the time of removal, there were no bone wax-related complications at the site of application, and the bone wax did not get resorbed by the body. Our results suggest that bone wax helped in locating and defining the proximal end of the nail very easily in cases where the nail is deeper than the surface of the bone (group 1). On the contrary, in cases where the bone wax was not used in cases where the nail was a little prominent, it took a little extra time for dissection to clear the bony and soft tissue growths over and into the nail (group 2). The significant reduction in subjective difficulty and shorter exposure times in our cases with bone wax needs to be compared with experience in other institutions, as our series so far is very small. However, after observing the practical benefits of this procedure, at almost no extra cost and time, at the primary surgery, this practice is being implemented by surgeons in other units of our hospital. The practice has been extended to use even for nails that are a little prominent. Conclusion This small case series provides preliminary evidence suggesting that bone wax application at the proximal end of the nail during primary tibial IM nailing is a simple and cost-effective technique to ease the finding of the proximal end of the nail at subsequent nail removals when required. It reduced operative time and may improve patient outcomes and reduce surgical complications. There were no wax-related complications. This technique is useful not only in cases where the nail is a little deep at the entry point but also in cases where the nail can be seen and felt above the tibial condyle cortex at the end of the primary procedure. Further prospective, randomised controlled trials with larger sample sizes are needed to validate these findings and establish the long-term efficacy and safety of this technique. Declarations Funding (information that explains whether and by whom the research was supported) No funding was received for this study Conflicts of interest/Competing interests (include appropriate disclosures) All three authors declare that there is no conflict of interest in conducting this study An ethical committee waiver was granted for this study A specific consent form, permitting the use of the material for any academic purpose, including publication, was obtained from the participants, and the same was submitted to the Ethical Committee Written/signed consent was taken from the participants Not applicable Not applicable Authors' contributions : First Author: R.N.R.: Original research idea, preparation of draft manuscript, Final manuscript Second Author- Corresponding Author: S.R.N: Surgeon, Models & Per-operative pictures, final manuscript Third Author: M.A.: Software assistance, collating all the available material to fulfil submission criteria, selecting and placing relevant figures in the manuscript, Final manuscript References Hooper GJ, Boden SD, Gibson MJ, Poole RV, Ness ER. Conservative management or closed nailing for tibial shaft fractures, randomized prospective trial. J Bone Joint Surg Br. 1991;73(1):83–5. Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. J Bone Joint Surg Am. 1997;79(9):1336 – 1 41. Lewallen LP, Ready A, Warner JJ. Intramedullary nails for tibial shaft fractures: techniques and results. Clin Orthop Relat Res. 1993;(291):214–22. Boerger TO, Patel G, Murphy JP. Is routine removal of intramedullary nails justified? Injury. 1999;30(2):79–81. Takakuwa M, Funakoshi M, Ishizaki K, Aono T, Hamaguchi H. Fracture on removal of the ACE tibial nail. J Bone Joint Surg Br. 1997;79(3):444–5. Zenios M, Malik MH, Al-Mesri AR, Vhadra R, Khan SA. Current intramedullary nail insertion and removal practice in the UK. Eur J Orthop Surg Traumatol. 2004;14:19–22. Tsang ST, Mills LA, Frantzias J, Baren JP, Keating JF, Simpson AH. Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure. Bone Joint J. 2016;98-B(4):534–41. Miller ME, Ada JR, Webb LX. Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails. Clin Orthop Relat Res. 1989;(245):233–8. Böstman O, Pihlajamäki H. Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units. J Trauma. 1996;41(5):846–9. Bezak M, Hasanović I, Endicott JR, Perić M, Alajbeg A, Kolundžić R, et al. Methods of bone fixation: intramedullary nails. J Bone Joint Surg Am. 1994;76(5):745–55. Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br. 1990;72(4):605–11. Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006;14(2):113–20. Vos DI, Verhofstad MH. Indications for implant removal after fracture healing: a review of the literature. Eur J Trauma Emerg Surg. 2013;39:327–37. Pearn JH. Bone wax: a reappraisal. Br J Surg. 1993;80(4):513–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 Nov, 2025 Reviewers agreed at journal 02 Nov, 2025 Reviewers invited by journal 24 Oct, 2025 Editor assigned by journal 05 Sep, 2025 Submission checks completed at journal 05 Sep, 2025 First submitted to journal 11 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7348390","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539107455,"identity":"54038477-e040-4c84-8ff4-bfaae8a4169b","order_by":0,"name":"Rajyalakshmi N. 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06:41:17","extension":"xml","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45725,"visible":true,"origin":"","legend":"","description":"","filename":"4b56005d0e1c4d63974e9512d87f31551structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/9999d21ebebd16f65f9cabe6.xml"},{"id":95173216,"identity":"80478e85-d197-4188-87b9-9e3a8e0961c3","added_by":"auto","created_at":"2025-11-05 06:41:17","extension":"html","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54996,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/7a819c9c688309c8b41deba0.html"},{"id":95173196,"identity":"c1729310-dfed-417f-9997-8604315bbd93","added_by":"auto","created_at":"2025-11-05 06:41:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":855302,"visible":true,"origin":"","legend":"\u003cp\u003eX-ray showing the proximal end of the nail well below the tibial condyle cortical surface\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/e9ff68bbd71b59dad21f081c.jpeg"},{"id":95173198,"identity":"5ffd7656-7cbe-483f-9b44-a380b89582f8","added_by":"auto","created_at":"2025-11-05 06:41:17","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39028,"visible":true,"origin":"","legend":"\u003cp\u003eX-ray showing the proximal end of the nail at and just above the tibial cortex\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/827e661d1b461c75eadfa3bf.jpeg"},{"id":95227284,"identity":"a252f59e-f6cb-4086-b4c4-3f59625487b3","added_by":"auto","created_at":"2025-11-05 16:32:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":67962,"visible":true,"origin":"","legend":"\u003cp\u003eA model showing the proximal end of the nail deeper into the tibial condyle\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/4e49f7903e1f7c9492196482.jpeg"},{"id":95227462,"identity":"d2192b48-af45-45ba-bb19-cd54a7dcc898","added_by":"auto","created_at":"2025-11-05 16:32:31","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":76983,"visible":true,"origin":"","legend":"\u003cp\u003eA model showing where bone wax was used to push into the proximal threaded part of the nail and to fill the entry hole\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/563ed4ba73cee67c24f8a536.jpeg"},{"id":95226967,"identity":"72668ddf-3501-464d-b5a1-a04c9b3fe76a","added_by":"auto","created_at":"2025-11-05 16:31:57","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":129933,"visible":true,"origin":"","legend":"\u003cp\u003eA soft spot after splitting the patellar tendon\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/cf94d86e64f767742108a224.jpeg"},{"id":95173213,"identity":"d5176b6e-f2f9-451d-b80a-701f6e981a5c","added_by":"auto","created_at":"2025-11-05 06:41:17","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":117466,"visible":true,"origin":"","legend":"\u003cp\u003eExcess bone wax being removed before pushing the extraction bolt\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/eca2088324fbc6f219e3e812.jpeg"},{"id":95230784,"identity":"593fc428-30e8-4e78-b7d6-f35abfcd15b9","added_by":"auto","created_at":"2025-11-05 16:38:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1615007,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7348390/v1/ef3f5fcf-1207-4b34-bd19-959c7c531db7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using Bone wax at the proximal end of the Tibia intramedullary nail at primary surgery to facilitate easy nail removal if needed later – A Case Series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTibial diaphyseal fractures are effectively treated with IM nailing due to its biomechanical advantages, minimally invasive nature, immediatestability, and early mobilisation \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The indications for elective removal of the nail are sparse, as numerous complications were reported during nail removal \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Re-fracture, failed attempts at nail removal, long operating time, persistent anterior knee pain, and wound infection were reported \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Apart from the patient's personal choice, the real indications are infection and any other pathology needing further surgery \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. As an elective procedure, it also adds to the operating theatre time constraints of a hospital and financial burden on health authorities \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. But when it is subsequently necessary, the nail removal can be difficult and time-consuming due to bone and soft tissue ingrowth, sometimes requiring aggressive techniques that risk iatrogenic complications \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The problems may start with difficulty in finding the proximal end of the nail, about which there is a paucity of literature to our knowledge. An image intensifier may be needed to localise it, but exposing the tip of the nail may still be difficult, requiring removal of bone and soft tissue, which can be time-consuming. Even if a specialised nail extraction kit is available, the extraction bolt may not fit in the nail unless all the soft tissue inside it is carefully scooped out. This study was designed based on our experience with some cases where it was difficult to find the proximal end of the nail. Hence, we evaluated the efficacy of applying bone wax at the proximal end of the nail during primary fixation of tibial fractures to see if it facilitates easier identification of the implant and to engage the extractor bolt in subsequent nail removal procedures. Various other potential difficulties in nail removal are not included in this study. We tried a simple, readily available, and cost-effective adjunct: the application of bone wax to the proximal end of the IM nail during initial surgery in selective cases, and compared them with other cases where bone wax was not used.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis is a prospective study from August 2018, which is continuing. For an \u003cem\u003einterim assessment\u003c/em\u003e of results, we selected cases done between August 2018 and February 2020 (19 months), to check how many of these patients (a total of 28), who had surgery during this period, and came back for nail removal before September 2024. A total of 28 cases over a total period of 19 months, out of which 5 patients came for nail removal. Patients who had tibial diaphyseal fractures deemed suitable for IM nailing based on standard surgical criteria were included in this study \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Our inclusion criteria were restricted to closed and type I open (Gustilo-Anderson) tibial diaphyseal fractures \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Within these inclusion criteria, a specific criterion was followed for this study, which is described below. Open fractures (G-A type II and III), cases with severe comminution requiring additional fixation, and significant bone loss, were excluded. During this period, twenty-eight patients matching the inclusion criteria were admitted under one consultant (mean age: 38 years, range 25\u0026ndash;55; 19 men, 9 women) who underwent primary closed IM nailing of the tibia. Consent was taken from all the patients to use any additional procedures that may become necessary as part of the surgery. All patients were followed up till the fracture healed. During the first three months, special attention was given to cases in which bone wax was used to look for any complications at the wound.\u003c/p\u003e\n\u003cp\u003eTechnique:\u003c/p\u003e\n\u003cp\u003eThe standard intramedullary nailing procedure was done in the supine position under spinal anaesthesia through a patellar tendon splitting approach under image intensifier control. The medullary canal was reamed over a guide wire after closed reduction of the fracture. A nail of appropriate length was selected using an image intensifier and the measuring scale provided with the set. Dynamic or static interlocking was done depending on the fracture configuration. Upon completion of the procedure, the nail insertion jig was removed, and in nine cases, the proximal end of the nail was found to be just below the tibial cortical margin or a little deep into the entry point hole (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e,\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ea).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese cases are going to be referred to as group-1. In the other nineteen cases, the tip of the nail was at or just above the cortical margin (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;These are group-2 patients. The group-1 patients had an additional procedure where bone wax was used to fill the proximal end - the threaded part- of the nail and the raw bony canal at the entry point (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e,\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eStandard closure of the wound was done. Bone wax filling was not done for group-2 patients with the assumption that if and when the nail needs to be removed in any of these cases, it wouldn't be difficult to find the proximal end of the nail.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePost-operative follow-up was the same for all 28 cases, and all the cases had uneventful healing of fractures within the expected time frame of 10 weeks to 18 weeks, an average time was 15.5 weeks. Patients were allowed unaided full weight-bearing walking when the fracture had healed and they were discharged from the trauma clinic. Patients were not routinely advised on implant removal, but when any patient came for implant removal, the records were updated. In September 2024, one of the authors reviewed the records of the cases done between August 2018 and February 2020 and found five patients had come with a request for nail removal by then, 13 months to 21 months after they were originally discharged from the clinic. The reasons were as follows (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWanted to join the army services and did not want any metallic implants in the body(Male)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWorried about potential problems in the future due to metal in the body, and was keen to get it removed (Female)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeavy feeling in the leg, especially after walking for long distances (Male)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProminent heads of interlocking screws with pain on touching (Male)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient-3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnterior knee pain, especially during gym workout (Male)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNail Removal:\u003c/p\u003e\u003cp\u003eThe initial procedure of nailing, as well as the nail removal, was done by the same surgeon or under his direct supervision. The ease of finding the proximal end of the nail was subjectively assessed by the surgeon based on the presence of significant bone/soft tissue coverage of the nail, ingrowth, and the need for any additional instruments or manoeuvres. Operative time was recorded from the time of incision to finding the upper end of the nail and tightening the extraction bolt. For the third patient in Group 2, the exposure of the proximal end of the nail was a little difficult, and the image intensifier was kept ready, though at the end it was not used. Nails were successfully removed from all five patients.\u003c/p\u003e\u003cp\u003eGroup-1 patients: A soft spot covered with fibrous tissue could be easily palpated after splitting the patellar tendon. Bone wax could be seen after reflecting the fibrous tissue, and the extraction bolt could be easily pushed into the nail through the bone wax (less than 8 minutes). No time was spent on finding and clearing the entry point (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e,6).\u003c/p\u003e\u003cp\u003eGroup-2 patients: For patients 1 and 2, it took a few minutes (4 \u0026amp; 7 minutes) to find the proximal end of the nail. But clearing the bony overgrowth onto the edges of the nail and soft tissue ingrowth inside the nail took nearly 10 minutes before the extraction bolt could be inserted into the nail (12 \u0026amp; 17 minutes). Patient 3 had a prominent bony-fibrous mass over the tibial condyle, and it took 14 minutes to elevate the same from the proximal end of the nail and another 5 minutes to clear the tissue from the threaded part of the IM nail.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrom the earlier days of orthopaedic practice, when most of the fractures were treated conservatively, we moved on to internal fixation using metallic implants. Then there was the discussion on whether those implants were to be left in situ or to be removed when they served their purpose. Initially, there was this enthusiasm to remove them after the healing of the fractures. But surgeons experienced difficulties in metal removals with iatrogenic complications, making the patient worse \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The present accepted practice is to leave the implants in situ if there are no implant-related problems \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, which can also be applied to Tibial I M nails. However, there may be some genuine cases where removal may be necessary. But it always carried its share of problems with difficulty in finding the nail and ultimately abandoning the procedure due to various reasons. The present study is limited to the difficulty in locating the proximal end of the nail and assembling the extraction bolt. It could be difficult due to excess soft tissue ingrowth, necessitating additional soft tissue dissection. Sometimes, ectopic bone formation may completely obscure the entry point, and it may need multiple C-arm exposures even to find it. It is not uncommon to find the proximal end of the nail a little deep in the entry point after removing the insertion jig at the end of a successful completion of nailing. It can be due to inadvertent miscalculation of the nail length with a ruler, even with the use of an image intensifier. Sometimes a given tibia may measure between the available nail length sizes of the manufacturer, forcing to use of a shorter nail to avoid patellar tendon impingement with the next, one length longer nail. Some manufacturers supply 'end caps' to extend a short nail, but not all companies, and it also adds to the cost. We believe that it is a common assumption that finding the proximal end of the nail is not difficult in cases where the nail is a little proud at the end of the procedure, but it can be difficult in cases where it is left deep in the entry point. However, we found that exposing the proximal end of the nail, which is prominent above the bony cortex, can also take extra time to clear the soft tissue ingrowth and to expose the threaded part of the nail (group 2). Since there are very few indications for routine removal of the tibial IM nails, it is difficult for any single centre to achieve a large case series of nail removals. Genuine indications for implant removal are only infections and non-unions needing revision nailing \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Literature doesn\u0026rsquo;t support routine removals of nails even in younger patients, or people with anterior knee pain \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, there may be cases where implant removal is required at a later date for various reasons, including the patient's personal preferences. There is no way to predict which one will be removed later and for what reason. With our experience of finding the proximal end of the nail difficult in some cases, we started this study with the hypothesis that it is difficult to find the proximal end of the nail in cases where it is a little deep, and it won't be a problem in cases where the nail ends up a little proud. Hence, we started filling the proximal end of the threaded part of the nail and the remaining exposed deep entry point with bone wax (9 cases out of 28). The same was not done in cases where the nail is a little proud above the cortical margin (19 cases out of 28). Bone wax is biocompatible and has been widely used for haemostasis without any adverse effects for a long time \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. It was applied on the surface of the tibial condyle and is away from the diaphyseal fracture site without any worry of it potentially interfering with fracture union. In the 9 cases where it was used, there were no wound infections or allergic reactions due to bone wax.\u003c/p\u003e\u003cp\u003eAt the time of removal, there were no bone wax-related complications at the site of application, and the bone wax did not get resorbed by the body. Our results suggest that bone wax helped in locating and defining the proximal end of the nail very easily in cases where the nail is deeper than the surface of the bone (group 1). On the contrary, in cases where the bone wax was not used in cases where the nail was a little prominent, it took a little extra time for dissection to clear the bony and soft tissue growths over and into the nail (group 2). The significant reduction in subjective difficulty and shorter exposure times in our cases with bone wax needs to be compared with experience in other institutions, as our series so far is very small. However, after observing the practical benefits of this procedure, at almost no extra cost and time, at the primary surgery, this practice is being implemented by surgeons in other units of our hospital. The practice has been extended to use even for nails that are a little prominent.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis small case series provides preliminary evidence suggesting that bone wax application at the proximal end of the nail during primary tibial IM nailing is a simple and cost-effective technique to ease the finding of the proximal end of the nail at subsequent nail removals when required. It reduced operative time and may improve patient outcomes and reduce surgical complications. There were no wax-related complications. This technique is useful not only in cases where the nail is a little deep at the entry point but also in cases where the nail can be seen and felt above the tibial condyle cortex at the end of the primary procedure. Further prospective, randomised controlled trials with larger sample sizes are needed to validate these findings and establish the long-term efficacy and safety of this technique.\u003c/p\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003eFunding (information that explains whether and by whom the research was supported)\u003cbr\u003eNo funding was received for this study\u003c/li\u003e\n \u003cli\u003eConflicts of interest/Competing interests (include appropriate disclosures)\u003cbr\u003eAll three authors declare that there is no conflict of interest in conducting this study\u003c/li\u003e\n \u003cli\u003eAn ethical committee waiver was granted for this study\u003c/li\u003e\n \u003cli\u003eA specific consent form, permitting the use of the material for any academic purpose, including publication, was obtained from the participants, and the same was submitted to the Ethical Committee\u003c/li\u003e\n \u003cli\u003eWritten/signed consent was taken from the participants\u003c/li\u003e\n \u003cli\u003eNot applicable\u003c/li\u003e\n \u003cli\u003eNot applicable\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Authors\u0026apos; contributions :\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFirst Author: R.N.R.: \u0026nbsp;Original research idea, preparation of draft manuscript, Final manuscript\u003c/p\u003e\n\u003cp\u003eSecond Author-\u0026nbsp;Corresponding Author: S.R.N: Surgeon, Models \u0026amp; Per-operative pictures, final manuscript\u003c/p\u003e\n\u003cp\u003eThird Author: M.A.: Software assistance, collating all the available material to fulfil submission criteria, selecting and placing relevant figures in the manuscript, Final manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHooper GJ, Boden SD, Gibson MJ, Poole RV, Ness ER. Conservative management or closed nailing for tibial shaft fractures, randomized prospective trial. J Bone Joint Surg Br. 1991;73(1):83\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. J Bone Joint Surg Am. 1997;79(9):1336\u0026thinsp;\u0026ndash;\u0026thinsp;\u003csup\u003e1\u003c/sup\u003e41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLewallen LP, Ready A, Warner JJ. Intramedullary nails for tibial shaft fractures: techniques and results. Clin Orthop Relat Res. 1993;(291):214\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoerger TO, Patel G, Murphy JP. Is routine removal of intramedullary nails justified? 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Clin Orthop Relat Res. 1989;(245):233\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026ouml;stman O, Pihlajam\u0026auml;ki H. Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units. J Trauma. 1996;41(5):846\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBezak M, Hasanović I, Endicott JR, Perić M, Alajbeg A, Kolundžić R, et al. Methods of bone fixation: intramedullary nails. J Bone Joint Surg Am. 1994;76(5):745\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCourt-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br. 1990;72(4):605\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBusam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006;14(2):113\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVos DI, Verhofstad MH. Indications for implant removal after fracture healing: a review of the literature. Eur J Trauma Emerg Surg. 2013;39:327\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePearn JH. Bone wax: a reappraisal. Br J Surg. 1993;80(4):513\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7348390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7348390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntramedullary (IM) nail removal can be challenging for several reasons. The problem may start with difficulty in locating the proximal end of the nail. This study presents a novel technique to apply bone wax to the proximal end of the tibial IM nail and fill the entry point in selected cases as per our criteria during the primary procedure to see if it prevents bone and soft tissue overgrowth and ingrowth and facilitates easy exposure of the proximal end of the nail during the nail removal procedure at a later date if necessary. In a case series of 28 patients, this procedure was performed in nine patients, and nineteen patients did not require it according to the protocol. We compared the ease of exposure during nail removal in 5 patients from these two groups who underwent nail removal.\u003c/p\u003e","manuscriptTitle":"Using Bone wax at the proximal end of the Tibia intramedullary nail at primary surgery to facilitate easy nail removal if needed later – A Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:41:12","doi":"10.21203/rs.3.rs-7348390/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-03T05:27:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179661072757354590150736129646469727661","date":"2025-11-03T03:38:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-24T10:17:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T12:15:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-05T12:10:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-08-11T16:30:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"038feccc-ec13-43f0-8ca3-8b0f6e444600","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T06:41:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 06:41:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7348390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7348390","identity":"rs-7348390","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}