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Bouaicha W, Jlidi M, Sioud A, Mallek K, Nouicer S, Jaziri S, Achref A, Daas S. Surgical management of tibia refracture with a bent intramedullary nail: A case report and review of the literature. SAGE Open Med Case Rep 2024; 12:2050313X231225338. [PMID: 38205142 PMCID: PMC10777793 DOI: 10.1177/2050313x231225338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Intramedullary nailing is the gold standard for long bone fractures in the lower limbs. Fractures of the tibia with bending of the intramedullary nail is a very uncommon complication. Removing a bent nail is an unpredictable and challenging procedure for any trauma surgeon. We report the case of a 34-year-old man presenting a refractured tibia with a bent intramedullary nail following a motor vehicle accident. We describe the management of this patient as well as a substantial review of the literature to depict the peculiarities of this entity compared to its more commonly reported femoral counterpart. When approaching a deformed tibia nail, standard extraction techniques should be attempted and are more likely to be successful than in deformed femoral nails.
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Affiliation(s)
- Walid Bouaicha
- Department of Orthopedics and Traumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Jlidi
- Department of Orthopedics and Traumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Amine Sioud
- Department of Orthopedics and Traumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Karim Mallek
- Department of Orthopedics and Traumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Saffet Nouicer
- Department of Rheumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Salma Jaziri
- Department of Anesthesia and Intensive Care, Mohamed Bourguiba Hospital, Kef, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Abdennadher Achref
- Department of Orthopedics and Traumatology, Military Hospital of Instruction, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Selim Daas
- Department of Orthopedics and Traumatology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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van Oyen DW, Kernkamp WA, van Molenbroek G, Jakma T, Bosman WMPF. Removal of a Bent Humeral Intramedullary Nail: A Case Report and Review of Removal Techniques. JBJS Case Connect 2023; 13:01709767-202312000-00019. [PMID: 37889993 DOI: 10.2106/jbjs.cc.23.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
CASE We present a case of a (65°) bent intramedullary nail (IMN) in a humerus after a pseudoarthrosis in a 65-year-old man. Bent IMNs have been described in femurs and tibias, but are considered rare. Possibly even rarer is the bending of a humeral IMN. This report provides an overview of removal techniques and our approach to this uncommon complication: open sectioning of the bent IMN and 2-piece extraction through the fracture site. CONCLUSION Removal of a bent or broken IMN is a rare and challenging surgical problem. A bent humeral IMN requires a different and more careful approach for extraction than bent nails in the lower extremity, given the greater potential for neurovascular disruption.
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Affiliation(s)
- D W van Oyen
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats, Dordrecht, the Netherlands
- Department of Surgery, Noordwest Hospital, Wilhelminalaan, Alkmaar, the Netherlands
| | - W A Kernkamp
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats, Dordrecht, the Netherlands
| | - G van Molenbroek
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats, Dordrecht, the Netherlands
| | - T Jakma
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats, Dordrecht, the Netherlands
| | - W M P F Bosman
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats, Dordrecht, the Netherlands
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Arif H, Molina S, LeBrun C. Removal of a Bent Tibial Intramedullary Nail Through Osteotomy and Partial Sectioning: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00047. [PMID: 37590403 DOI: 10.2106/jbjs.cc.23.00186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
CASE An 18-year-old male patient presented with a closed fracture of the left tibia and fibula and a bent intramedullary nail after a repeat motorcycle accident. The patient was 5 weeks postoperative from intramedullary nailing of a closed left tibia fracture. The site of angulation of the tibial nail was noted to be more proximal than the fracture site. Partial sectioning of the nail through an osteotomy permitted the removal of the nail and revision tibial nailing. CONCLUSION This is the first reported use of an osteotomy and partial sectioning during the extraction of a bent tibial intramedullary nail.
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Affiliation(s)
- Haad Arif
- School of Medicine, University of California Riverside, Riverside, California
| | - Steven Molina
- School of Medicine, University of California Riverside, Riverside, California
| | - Christopher LeBrun
- School of Medicine, University of California Riverside, Riverside, California
- Department of Orthopaedics, Riverside Community Hospital, Riverside, California
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Lam AW, Richardson D, Kang KK. Technique for Extraction and Revision of a Bent Intramedullary Nail for a Subtrochanteric Femur Fracture: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00031. [PMID: 36763704 DOI: 10.2106/jbjs.cc.22.00453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
CASE A 17-year-old adolescent boy presented 2 months after initial intramedullary nail (IMN) fixation of a comminuted subtrochanteric fracture with refracture at the previous site and approximately 20° varus angulation of the nail. The bent femoral nail was successfully extracted using an open technique using Lohman bone-holding clamps and a broad plate. At the 1-year follow-up, fracture union was achieved. CONCLUSIONS Removal of a deformed IMN is rare. No standardized protocol exists in guiding orthopaedic surgeons. A thorough review of techniques is discussed on this unusual complication.
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Affiliation(s)
- Aaron W Lam
- Maimonides Medical Center, Brooklyn, New York
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Mencia MM, Moonsie R. Removing a bent femoral nail - man versus metal: A case report. Int J Surg Case Rep 2022; 99:107679. [PMID: 36181739 PMCID: PMC9568771 DOI: 10.1016/j.ijscr.2022.107679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/04/2022] [Accepted: 09/17/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Intramedullary nailing is the treatment of choice for femoral shaft fractures in adults with excellent clinical results and low complication rates reported in the literature. However, in situ bending of a femoral nail is a rare complication that merits special attention. While there are several extraction techniques and algorithms the scientific evidence to support these decision-making tools is unconvincing. Presentation of case A 26-year old man presented to the Accident and Emergency Department with a deformed thigh following a low-energy injury. Radiographs showed a bent femoral nail in situ and the patient disclosed that he had surgery four weeks earlier for a fractured femur sustained in a motor vehicle accident. A treatment algorithm was followed in planning the surgical strategy, but ultimately a simple hacksaw blade was used to cut and remove the nail. The fracture which was stabilised by exchange nailing went on to uncomplicated union and the patient recovered fully. Discussion Non-invasive methods of removing a bent femoral nail are often unsuccessful and may result in iatrogenic injuries. Surgeons should assess the available local resources and first consider using simple open methods when attempting to remove a bent femoral nail. Conclusion Open extraction methods often disregard the low-resource environment in which many surgeons work. We describe a simple and economical technique that uses a regular hacksaw blade to cut and remove a bent femoral nail. Using modern implants, insitu bending of a femoral nail is a rare occurrence. Closed extraction methods are often unsuccessful and may lead to iatrogenic injuries. An open technique using a simple hacksaw can be used in low-resource settings without access to sophisticated extraction tools.
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Sa'aid SH, Bajuri MY, Dzeidee-Schaff FN, Abdul-Suki MH. Removing a Bent Femoral Intramedullary Nail Cost Effectively: A Case Report. Malays Orthop J 2021; 15:163-165. [PMID: 34429838 PMCID: PMC8381661 DOI: 10.5704/moj.2107.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/20/2021] [Indexed: 11/30/2022] Open
Abstract
A bent intramedullary (IM) nail becomes challenging and technically demanding to the orthopaedic surgeon for nail extraction. A broken nail can be easily removed through the fracture site. However, a bent nail has to be broken before it can be removed. Several studies and case reports outline the strategies and techniques for removing a bent IM nail. However, there is a paucity of guidelines and standard protocol describing the best and inexpensive strategy. We report a case where two years following surgery for intramedullary nailing of the right femur, the IM mail was bent following secondary trauma. We used a technique based on the principles of an ability to fully cut the nail and extract it in two pieces by using a Jumbo cutter which is available in the orthopaedic armamentarium. This technique is simple yet economical, with the likelihood of causing less soft tissue damage and thermal necrosis.
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Affiliation(s)
- S H Sa'aid
- Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - M Y Bajuri
- Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - F N Dzeidee-Schaff
- Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - M H Abdul-Suki
- Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Maharjan R, Shrestha BP, Chaudhary P, Rijal R, Shah Kalawar RP. Functional outcome of patients of tibial fracture treated with solid nail (SIGN nail) versus conventional hollow nail - A randomized trial. J Clin Orthop Trauma 2021; 12:148-160. [PMID: 33716440 PMCID: PMC7920208 DOI: 10.1016/j.jcot.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/05/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trauma related disabilities disproportionately affects low and middle income countries due to lack of resources, skills and optimal implants. Despite adequate animal studies, biomechanical studies, cohort studies and comparison studies we are not aware of any randomized trial to compare the functional outcome of SIGN (Surgical Implant Generation Network, US) solid nailing with a hollow nailing for tibial shaft fracture. METHODS Sixty patients (≥16 years) of closed and Gustilo grade I traumatic fractures of the leg were randomized into SIGN solid nailing or hollow nailing group. Cases with compromised soft tissue and grossly deformed medullary canal were excluded. Functional outcome and need for resurgery were the primary outcomes while the secondary outcomes were duration of surgery, intraoperative blood loss, overall pain (VAS), radiological union (RUST), surgery related complications (infection, malalignment, shortening, nonunion) and pain/range of motion (ROM) of knee/ankle. All SIGN surgery related data were entered and retrieved online from www.signsurgery.org. RESULT The demographical parameters were symmetrically distributed between the groups (p > 0.05). 2 cases in SIGN nailing and 4 cases in hollow nailing needed open reduction. The functional outcome, as assessed by blinded physiotherapist using Johner and Wruh criteria, was excellent in 18 (62.06%), good in 6 (20.68%), fair in 3 (10.34%) and poor in 2 (6.89%) for SIGN nail whereas it was 16 (57.14%), 8 (28.57%), 3 (10.71%) and 1 (3.57%) respectively for hollow nail. There was 1 case of implant failure and 1 case of infection. Intraoperative blood loss (397 ± 94.47 ml versus 350 ± 75.43 ml, p = 0.037) and duration of surgery (94.8 ± 14.57 min versus 82.0 ± 12.36 min, p = 0.001) were significantly more in hollow nailing group. At final follow up, overall pain on weight bearing (VAS score) and radiological union (RUST score) were 2.1 and 11.7 for SIGN nailing while they were 2.7 and 11.3 respectively for hollow nailing.(p = 0.41 and 0.45 respectively) The malrotation (p = 1.000), shortening (p = 1.000), varus-valgus angulation (p = 0.511), AP angulation (p = 0.706), ROM ankle (p = 0.239) and ROM knee (p = 0.086) were similar. CONCLUSION Solid SIGN nailing gives comparable functional outcome as conventional hollow nailing for tibia shaft fracture. For developing world with limited resources, SIGN nail is useful which is supplied freely and is designed to be used without image intensifier and fracture table.
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Dunleavy ML, Burton A, Reid JS, Copeland CE. Surgical management of angulated femoral intramedullary nails associated with closed fractures: A systematic review of the literature. J Orthop 2020; 21:314-320. [PMID: 32581458 PMCID: PMC7303915 DOI: 10.1016/j.jor.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/04/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Femoral nail bending is a rare complication of intramedullary (IM) fixation of femoral diaphyseal fractures. Published literature regarding this injury pattern has thus far been limited to case reports or case series, thus no universally accepted surgical treatment strategy has been developed. METHODS A systematic review was conducted using the Pubmed/MEDLINE and Scopus/EMBASE databases. A standardized template was used to extract data including author, year of publication, patient demographics, degree of angulation, mechanism of injury, time since initial procedure to reinjury, surgical treatment, and clinical outcomes. A case report from our institution was described as well. RESULTS 27 cases in 25 reports were included in the qualitative analysis. All of the patients were males, and the ages ranged from 17 to 66 (mean age = 27.8). The degree of deformity ranged from 18 to 85° (mean 35.6), most commonly in a varus or apex anterior orientation. The nail deformities were corrected via one of six general surgical techniques: full transection of the nail, partial sectioning and manual straightening, limited corticotomy or longitudinal bone window, straightening with the assistance of a plate and reduction clamps, closed manipulation, or extraction without the need for manipulation. The fractures were then most commonly treated with revision IM nail. CONCLUSIONS The bent IM nail is a rare and challenging injury to treat. No one technique has been identified as "the gold standard" and each case must be approached with its unique characteristics in mind.
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Affiliation(s)
- Mark L. Dunleavy
- Department of Orthopaedics, Penn State Health Milton S, Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Alex Burton
- Department of Orthopaedics, The Medical College of Wisconsin, 8701 Watertown Plank RdC, Wauwatosa, WI, 53223, USA
| | - J. Spence Reid
- Department of Orthopaedics, Penn State Health Milton S, Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Carol E. Copeland
- Department of Orthopaedics, Penn State Health Milton S, Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
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Pathak SK, Gautam RK, Anjum R, Sharma A. Bent Tibial Nail with Refracture: A Cost-Effective Removal Method: A Case Report. JBJS Case Connect 2020; 10:e1900542. [PMID: 32649146 DOI: 10.2106/jbjs.cc.19.00542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 45-year old man presented with a right open tibial fracture with a prominent, fixed deformity because of a retained right tibial intramedullary nail from a previous tibial fracture. After multiple futile intraoperative attempts to extract the bent nail, it was finally sectioned using an industrial drill bit that permitted its removal and revision tibial nailing. CONCLUSIONS A tibial fracture resulting in a retained, bent nail presents unique challenges for nail extraction and subsequent exchange nailing. Failed implant removal can be limited by the equipment available in the operating theater. In this setting, the judicious use of inexpensive industrial materials and instruments may be effective in select cases.
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Affiliation(s)
- Subodh Kumar Pathak
- 1Department of Orthopaedics, MM Deemed to be University, Ambala, India 2Department of Orthopaedics, ASCOMS & Hospital, Jammu, India
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Hoit G, Bonyun M, Nauth A. Hardware considerations in infection and nonunion management: When and how to revise the fixation. OTA Int 2020; 3:e055. [PMID: 33937680 PMCID: PMC8081462 DOI: 10.1097/oi9.0000000000000055] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/09/2019] [Indexed: 06/12/2023]
Abstract
The occurrence of both nonunion and fracture-related infection provides challenges for both the patient and the treating orthopaedic surgeon, with the potential need for complex reconstructive procedures to achieve union and/or eradicate infection. In addition to addressing the multiple different factors that often contribute to nonunion, surgeons are often forced to deal with difficult hardware issues at the time of revision surgery including infected hardware, loose or failing hardware, malaligned hardware, or inappropriate hardware constructs. This article reviews common causes of nonunions with emphasis on infection management and provides indications and techniques for hardware removal in the context of an algorithmic approach to nonunion management with illustrative case examples.
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Affiliation(s)
- Graeme Hoit
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto
| | - Marissa Bonyun
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto
| | - Aaron Nauth
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto
- Department of Orthopaedic Surgery, St. Michaels Hospital, Toronto, ON, Canada
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McChesney GR, Gurbani BN, Hagedorn JC. Extraction of a Bent Tibial Nail After Refracture: A Case Report. JBJS Case Connect 2019; 9:e0385. [PMID: 31584900 DOI: 10.2106/jbjs.cc.18.00385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 65-year-old man previously treated by intramedullary nailing for a left tibial shaft fracture presented 6 years later with an open refracture of his left tibia after a motorcycle accident. Treatment required extraction of the bent nail before revision nailing. CONCLUSIONS Extraction of deformed intramedullary devices is a skill that will continue to be demanded of orthopaedic surgeons. In this case, standard extraction though the entry point proved successful. Standard extraction offers the safest form of removal and should be contemplated before considering more morbid methods of extraction while examining the fracture's morphology and the device's deformity.
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Affiliation(s)
- Grant R McChesney
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas
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Canton G, Haxhaj B, Fattori R, Murena L. Bent femoral intramedullary nail: a case report and review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:187-191. [PMID: 30715023 PMCID: PMC6503421 DOI: 10.23750/abm.v90i1-s.8072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 11/23/2022]
Abstract
Intramedullary nailing is considered the gold standard technique for the treatment of femoral shaft fractures. A rare complication of this technique is nail bending after a new trauma. In these cases nail removal might be really challenging. The present paper provides a brief review of surgical techniques purposed in the literature for bent nail removal and describes a clinical case. (www.actabiomedica.it)
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