Open Access
Issue
SICOT-J
Volume 7, 2021
Article Number 10
Number of page(s) 4
Section Lower Limb
DOI https://doi.org/10.1051/sicotj/2021010
Published online 08 March 2021

© The Authors, published by EDP Sciences, 2021

Licence Creative Commons
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.

Introduction

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.

Case report

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).

thumbnail Figure 1

Antero-posterior view of full-length X-ray of the left femur showing broken femur nail with complete bony union.

thumbnail Figure 2

Proximal portion of the nail removed with distal broken portion of nail remains in situ.

thumbnail Figure 3

Ball tipped guidewire inserted through a broken segment of the nail.

thumbnail Figure 4

Both wires (Plain & Ball tipped) protruded through the broken portion of the nail.

thumbnail Figure 5

Extraction of the broken nail with plain guide wire remains in situ.

thumbnail Figure 6

Complete removal of the broken distal segment of the nail.

Discussion

Removal of broken hardware is a challenging surgery even for an experienced trauma surgeon. Therefore, the surgeon must be aware of the simple and efficient techniques for removing broken hardware. A ball-tipped guide-wire technique is a simple and efficient technique for extracting a broken distal portion of nail and can be performed in a situation where it is not easy to access special equipment for extracting broken nail. Before our surgical technique, various methods for removing broken nail segments have also been implemented (Table 1). Most techniques involve special instruments to extract a distal broken portion of the nail that might not actually be present at the time of surgery, especially in times when it was difficult to anticipate broken segment of the nail on radiographs pre-operatively.

Table 1

Techniques of removing broken nail.

The surgical technique we used in our case is recommended in situations where the union has already been achieved or the fracture site opening is not desirable (e.g., when treating hypertrophic non-unions). Our technique is also effective in cases where special surgical equipment for removing a broken portion of the nail is not readily available in operation theatre [5].

The only limitation of our surgical technique is that it would not be used in a situation when small diameter nails were used to fix long bone fractures. We recommend using this method only when dealing with a nail of the diameter of 10 mm or above that allows easy placement of a ball-tipped wire and one or more plain guide wires. In our technique, cortical windows are not needed to remove distal broken nails, which is an added advantage [6].

Previous literature supports the use of kuntscher nails, small diameter nails, small reamers, and extraction hooks in circumstances where nail diameter is small [7]. The standard technique of removing broken hardware with a hook is not effective due to multiple reasons such as inadequate grip, unable to engage nail tip buried deep into subchondral bone, and failure to remove a large distal broken portion of the nail because of inadequate strength [8]. We were lucky to have a nail diameter large enough to allow both wires (plain and ball-tipped wires) to pass through the nail. In cases when dealing with a large diameter nail; the broken distal portion may be extracted with a long nail extractor with a distal hook, multiple ball-tipped guidewire, or a long Kirschner wire with a curved tip [9, 10].

In order to remove damaged Kuntscher nails, Maini et al. [11] used the Enders nail as an extraction method. While intramedullary nailing in an orthopedic culture has gained attention for long bone fractures. During implant removal, hardware breakage must not be overlooked [12, 13]. In order to achieve a good outcome, surgeons must be aware of easy and efficient procedures. We felt that our mentioned technique is an efficient method to remove broken nail fragments.

Conclusion

We believe that the ball-tipped guide wire surgical technique is an easy and reliable approach for extracting the broken distal segment of the nail in a situation where special equipment for removing broken hardware is not readily available. This technique also avoids cortical window to prevent complications such as an iatrogenic fracture.

Conflict of interest

The authors declare no conflict of interest.

Funding

The authors declare that no funding was involved in this study.

References

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Cite this article as: Iqbal F, Zamir M, Ahmed N, Kamal SW & Memon N (2021) Ball tipped guide wire for broken nail removal: a case report. SICOT-J 7, 10

All Tables

Table 1

Techniques of removing broken nail.

All Figures

thumbnail Figure 1

Antero-posterior view of full-length X-ray of the left femur showing broken femur nail with complete bony union.

In the text
thumbnail Figure 2

Proximal portion of the nail removed with distal broken portion of nail remains in situ.

In the text
thumbnail Figure 3

Ball tipped guidewire inserted through a broken segment of the nail.

In the text
thumbnail Figure 4

Both wires (Plain & Ball tipped) protruded through the broken portion of the nail.

In the text
thumbnail Figure 5

Extraction of the broken nail with plain guide wire remains in situ.

In the text
thumbnail Figure 6

Complete removal of the broken distal segment of the nail.

In the text

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