A Precice nail is a device, surgically placed within the bone, which is used to grow new bone and change the length of the limb (fig 1). The nail contains a magnet and a gear system, this enables the nail to lengthen or shorten. It is activated when a programmed external handset is placed on the limb.
The operation involves the nail being inserted into the centre of your bone and secured with screws. Your bone is also divided in a specific place. You will have surgical wounds where the nail and screws are inserted and also in the area where the bone has been divided.
You will normally start to lengthen your nail 6-7 days after your operation. Individual instructions will be given on how to use the handset and other equipment and you will be supported until you are confident and feel competent to carry out the adjustments independently. The handset is normally used 3 times per day. It needs to be placed in a specific place on your limb for the device to work. Your surgeon will advise you or mark where this is.
After a week, the division in the bone will be in the early stages of healing, as the bone is pulled apart using the nail, new bone starts to form along a line of tension created by the device and then continues to grow in the gap. (fig. 3). This is a slow process.
As your bone is lengthened, your soft tissues also get stretched. Muscles become very tight and it is of prime importance to maintain movement in the hips, knees and ankles. You will find that they will become stiff, in severe cases this can become permanent. The physiotherapists will provide you with exercises to help prevent this.
You may already be experiencing pain for which you are taking medication. Please inform nursing and medical staff about these and how effective they have been.
Immediately following surgery you may either have an epidural, or patient controlled analgesia (PCA). The PCA enables you to press a button to feed pain relieving drugs straight into your blood system. Once the initial pain has eased this will be changed to pain killing tablets. On discharge you will be given a week’s supply. These should be renewed via your GP. Do ensure your new supply of medication is ordered before the supply given by the hospital runs out.
At home you may experience pain during the lengthening process as the bone stretches alongside the nerves, muscles and blood vessels. This can be relieved with the appropriate medication or adjustments to the rate at which we lengthen, so please do inform us if your symptoms change or pain is not well controlled.
There are some pain killers that you should avoid as they are thought to interfere with the process of bone healing. These are aspirin and Non Steroidal Anti-inflammatory Drugs (NSAIDS). NSAIDS include Diclofenac, Ibuprofen, Ketoprofen, Naproxen, Fluribiprofen, Indomethacin, Mefanamic Acid, Piroxicam. Please note that this is not an exclusive list and that these are generic names and commercial names may be different. Ask your chemist / nurse / GP for help if you are unsure.
Surgical wounds go through several stages of healing.
- Day 1-5: Inflammation, some swelling, reddening, clear non-smelly discharge and slight pain
- Day 5-14: Formation of scab - a protective covering over the wound
- Day 14 onwards: Strengthening and flattening of scar tissue
It is normal to have:
- Tingling or itching
- Slight lumpy feeling as new tissue forms
- Bruising around the wound
- A pulling feeling around your wound closure
Your wound may be closed using Steri-strips, absorbable stitches or non- absorbable stitches.
Non-absorbable stitches will need to be removed by your GP’s practice nurse or district nurse 10-14 days after surgery.
You will have a dressing on your wounds after surgery. This can stay in place for a week if there are no concerns about infection. Once the wound is dry it can be left open to the air. It is important to wash your hands with soap and water and dry them on a clean towel before touching your wound or dressing.
To grow new bone and change the length of the limb.
The handset contains a strong magnet. Please be aware that when the handset is turned on, the strong magnet is activated. Metal objects, watches, mobile phones and credit cards should not be placed near the device. Family members or carers with a heart pacemaker should not be present when the device is turned on.
The nerves in your limb are also stretched as the limb is lengthened. If you notice a change in sensation, get pins and needles or numbness it is important that you contact a member of the limb reconstruction team.
The Precice nail is not MRI compatible and you must not have a MRI scan whilst you have a Precice Nail. Please ensure that you inform all medical staff and radiographers that you had this treatment.
Deep Vein Thrombosis (DVT)
There is a risk of developing a DVT. This is a blood clot which is treated by medication that thins the blood. Your risk factors for this occurring will be assessed by medical staff and if necessary you be placed on anticoagulation therapy.
The following may be signs of an infection in your surgical wound. If these are present contact your GP as soon as possible.
- Increased pain in the area
- Spreading redness of the skin
- Increased discharge or pus)
- Increased swelling
- You have a temperature or feel unwell
- The wound is not healing
Joint stiffness and soft tissue tightness
This can be a problem and may affect your ability to mobilise. It is of prime importance that you perform the exercises that the Physiotherapists provide, or wear any necessary splints as instructed. In severe cases, surgery may be required to release tightness in the soft tissues to allow a full range of movement.
Following long lengthening procedures there is a small risk of dislocation of the surrounding joint. This particularly applies to the hip and the knee when lengthening a femur and to the knee when lengthening a tibia. This is monitored during the lengthening process and whilst it can be prevented with aggressive physiotherapy, its occurrence may lead to abandoning further lengthening.
Nerve and blood vessel injury
Rarely nerves and blood vessels can become damaged. This can be either at the time of surgery or during the subsequent lengthening of the bone. You should inform nursing and/or medical staff if you experience pain, numbness or pins and needles. Should this occur during the lengthening process this may mean that we slow down the rate of adjustment or even stop lengthening. Usually, this wears off, but in some cases it may become permanent. It is important that you inform a member of the Limb Reconstruction Team should these symptoms occur.
Failure to gain length/delayed union
This may occur if the bone does not form during lengthening or takes a long time to mature. Other reasons for failure to gain length relate to problems with stretching the nerves, blood vessels, muscles and tendons. Your consultant will advise you about treatments should this arise.
Problems with the nail
The nail or screws holding it in place may become loose, or there may be a problem with the mechanism in the nail. Should this occur, further surgery such as replacing the nail or treatment with an external fixator may be required.
Following removal of the nail, fractures are a rare problem. If this were to occur it would possibly require further surgery or a period in a cast or brace
Can I be worse off?
The worst case scenario is that if there were an uncontrolled infection, damage to the arteries and nerves or interruption of the blood supply to the muscles, there is a risk that this could lead to amputation of the limb being necessary.
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