Stuffing the nail: A simple technique for the extraction of a broken femoral nail

Removal of a Broken Intramedullary Nail: A Case Report and Technical Description

The removal of a broken intramedullary nail is a challenging procedure. Several surgical techniques have been described to remove the distal end of the nail. Here, we report the surgical technique for removing broken Fitbone® lengthening nail using a cerclage wire. This is an effective and reproducible technique that does not require specialized equipment, the development of a cortical window, or an arthrotomy and is applicable for all types of intramedullary nails.

The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review

Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.

A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail

Aim

To present a novel technique developed in our institution to remove incarcerated and broken intramedullary (IM) tibial and femoral nails.

Background

IM nails are commonly used to treat diaphyseal fractures in both the tibia and femur. These nails can become problematic for the orthopaedic surgeon when they need to be removed, especially in the rare event that the nail has failed and broken. This can leave part of the nail deep in the bone and incarcerated. Multiple techniques have been described to remove a broken nail but we present a novel technique developed based on our experience.

Technique

After all other methods to remove the broken nail have failed, a window technique can be employed. This requires a small window of bone to be removed from the cortex overlying the remaining IM nail. A carbide drill is then used to drill a hole into the nail to gain purchase. The edge of an osteotome is placed in the hole in the nail through the window and gently hammered upwards to push the nail towards the over-reamed nail entry point. The nail is repeatedly drilled and pushed until the nail can be removed. The bone window is then replaced.

Conclusion

This is a novel technique that works when all other options including hooks, wire stacks and specialist nail removal techniques have failed. It is simple, efficient and effective for both the tibial and femoral nails.

How to cite this article

Somerville CMB, Hanschell H, Tofighi M, et al. A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail. Strategies Trauma Limb Reconstr 2022;17(1):55-58.

Removal of a Broken Stainless-Steel Intramedullary Lengthening Stryde Nail: A Case Report and Review of the Literature

CASE

We report a 15-year-old female patient who underwent femur lengthening with a stainless steel intramedullary lengthening Stryde nail that broke at the end of the lengthening course and required removal. Given the solid noncannulated nature of the nail, this required special strategy to remove broken parts.

CONCLUSION

Stryde nails are stainless steel lengthening nails that were developed to allow more freedom with weight bearing. Regardless of this change, hardware failure remains possible. In addition to maintaining regenerate integrity, a surgeon must be creative when attempting to remove solid nail types because many techniques for removing failed hardware were developed for cannulated devices.

Drill-guided femoral nail extraction: a novel technique

Femoral nail extraction, although it is considered a challenging procedure for orthopedic surgeons, can be simplified. We present a new technique to aid the removal of a proximally (antegrade) inserted femoral nail by applying drilling consecutively in order to identify the margins and depth of the nail into the intramedyllary canal of the femur. The damage to the bone is minimal as we use k-wires or drilling and in our practice was uneventful. This technique is the first to be reported in literature. Most authors suggest techniques that enable radiolucent table and fluoroscopy techniques using C-arm. With this technique, traction table and fluoroscopy techniques seem to be less essential to accomplish the removal of a proximally (antegrade) inserted femoral nail.

Removal of broken PRECICE Stryde intramedullary lengthening nails

This paper describes two different techniques for removal of broken Precice Stryde intramedullary bone lengthening nails, which unlike trauma nails are solid containing mechanical components. Consequently, surgeons face unique challenges when these implants brake within medullary canal. Here, we present our surgical approach for removal of three broken implants. In one patient (46kg) both Ø10mm femoral Stryde implants (max. weight allowance 68kg) broke through the proximal locking screw hole preoperatively on the right side and intraoperatively on the left side (413 and 504 days after index surgery respectively). The third Ø11.5 femoral nail broke through the area containing the magnet (55kg patient, 325 days after index surgery). LEVEL OF EVIDENCE: IV.

Functional outcome of patients of tibial fracture treated with solid nail (SIGN nail) versus conventional hollow nail - A randomized trial

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.