Faizan Iqbal * , Mehroze Zamir , Nasir Ahmed , Syed Wajahat Kamal and Nouman Memon
Department of Orthopaedic Surgery, Patel Hospital, 75300 Karachi, Pakistan
Received: 12 October 2020
Accepted: 10 February 2021
A broken intramedullary nail is a well-known complication of non-union of femur shaft fractures. Numerous surgical techniques have been presented before in patients with non-union of long bone fractures. We report the surgical technique used to perform removal of the broken distal segment of a nail in a patient who achieved uneventful union after intramedullary nailing of closed femur shaft fracture. A ball-tipped guidewire was inserted through the broken segment of the femur nail. A pre-bend plain wire was then inserted. With the help of a vise-grip, both wires were twisted in order to make a secure handle between guidewires and a broken implant. With the help of a mallet upward-directed blows were applied to extract a broken segment of the nail. We found ball-tipped guidewire technique a useful and effective technique in removing the broken distal portion of the nail.
Key words: Femur fracture / Intramedullary nail / Union / Broken nail / Guidewire
© The Authors, published by EDP Sciences, 2021
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A broken intramedullary nail is a well-known complication after non-union of long bone fractures. On other hand, the broken intramedullary nail is not frequently encountered once the union has been achieved [ 1]. Several techniques have been described previously for extracting a distal broken portion of nail especially after non-union [ 2, 3]. Extracting a broken distal portion of the nail is a challenging surgery even for experienced surgeons [ 4]. Therefore surgeon must be aware of techniques of extracting the broken distal portion of the nail and must keep all required instruments available during the removal of broken hardware. In this article, we described our simple ball-tipped guide-wire technique of removing a distal broken portion of the nail which was not amenable to remove with the nail extracting techniques described previously. A full written and informed consent was taken about the submission of the concerned case for publication.
In 2005, a 33-year-old male experienced a closed left femur mid-shaft fracture after a motor vehicle accident (MVA). The very same day, he underwent for the interlocking nail of the left femur. There was an uneventful postoperative period and the union was achieved after 12 weeks. After 15 years, he presented with pain over the left thigh area primarily localized to the distal screw site with prominent distal-most screw-on local examination. This discomfort was presumed to be due to implant-related, so a decision was made to remove the hardware. Pre-operatively broken distal segment of the nail was not anticipated as it was very difficult to pick that segment radiographically (Figure 1). The device for removing the broken distal portion of the nail was not arranged pre-operatively. The patient was laterally placed and the previous incision was utilized to extract the nail. Before removing the proximal and distal locks, a universal jig for nail removal was tightened initially. After extracting the proximal and distal locks, a mallet was used to extract the nail. It soon becomes clear that only the proximal portion of the nail has come out and the remaining distal portion of the nail remains in situ (Figure 2). A long hook tool that was originally built to retrieve the broken part of the nail is not readily available in the operation room, so alternate plans have been quickly implemented. Initially, an effort was made to remove a broken nail portion with a pre-bend ball-tipped wire, but ultimately failed. Then a ball-tipped wire was threaded through the broken nail to engage the distal portion of the nail (Figure 3). In order to ensure optimum interference fit between two guidewires, a pre-bend simple guidewire was then threaded through a broken nail segment (Figure 4). Vise-grip was used to proximally hold two wires together and then a mallet was used to apply continuous upward force by direct blows on ball-tipped guidewire to retain plain guidewire in situ (Figure 5). Sadly, this effort failed as well. In order to make a secure handle between guide wires and broken implant, both wires were also twisted with the help of vise-grip, and then mallet was used to apply upward guided force by direct strikes, leading to the extraction of the distal broken portion of the nail, which was then verified in the radiograph intensifier (Figure 6).
Antero-posterior view of full-length X-ray of the left femur showing broken femur nail with complete bony union.
Proximal portion of the nail removed with distal broken portion of nail remains in situ.