TECHNICAL TRICKS

Removal of a Broken Distal Closed Section Intramedullary Nail

Report of a Case Using a Simple Method
Ely L. Steinberg,* Elhanan Luger,* Aharon Menahem,* and David L. Helfet

Summary: A simple method to remove a broken distal closed section intramedullary nail is presented. The surgical technique and a case report are described. This technique eliminates the need for an additional exposure, other than that required to insert the nail, or any specialized equipment. Key Words: broken nail, reaming, extraction devices (J Orthop Trauma 2004;18:233235)

any methods have been published on the removal of the distal piece of a broken distal closed section intramedullary nail.17 Some additional extraction devices also have been designed to remove a broken distal nail that is buried inside the medullary canal and that cannot be accessed from the standard incision (Table 1). This article describes a simple method that can be used to remove a broken distal hollow nail remnant (closed or open) without using a special extraction device.

3.5-mm Steinmann pin is inserted in one of the distal holes that previously contained a removed screw. A 3-mm guide is introduced in the distal nail, and the proximal medullary canal is reamed to a larger diameter, at least 2 mm greater than the diameter of the broken nail. It is recommended to begin the reaming with a 9-mm reamer that has end cutting reamer blades to remove the entrapped soft tissue inside the medullary canal and the pseudarthrotic tissue (Fig. 1A). To ensure that no soft tissue will interfere with nail removal, reaming should be performed to the proximal edge of the broken nail. An 8- to 10-mm Kuntscher nail (one that is rarely used any more) is tested for size and interference fit using the previously extracted proximal nail portion; then only the Kuntscher nail is used to extract the distal piece (Fig. 1B). The 3-mm guide and the locking Steinmann pin are removed from the bone, and the nail is removed gently using rotatory movements. After nail removal, the medullary canal is reamed to the desired diameter for a new nail insertion.

Tibia
The same technique is applied as described for the femur. The standard tibial approach is the access used, however.

MATERIALS AND METHODS

The technique used is the same for broken intramedullary nails of either femur or tibia, with the exception of the approach to the bone.

CASE PRESENTATION
A 29-year-old man was injured in a motorcycle accident. His multiple injuries included a combined fracture of the neck and midshaft of the left femur and an open Gustilo type IIIA fracture of the left tibia. The midshaft femoral fracture was fixed with an AO unreamed intramedullary nail (400 mm 9 mm), and three cannulated screws were used to secure the neck fracture. An external fixator was applied to the tibia. Three months after injury, the tibial fracture had healed, and the external fixator was removed. One year after injury, a nonunion of the midshaft femoral fracture was noted, and the nail was changed to a larger reamed diameter (13 mm). Two years after the accident, a hypertrophic nonunion of the femur was treated with an iliac bone graft. One year later, the patient had a sensation of instability at the site of the fracture, and radiographs showed a broken nail and a hypertrophic nonunion of the left femur (Fig. 2). During the last year of follow-up, the patient

Femur
The proximal part of the broken nail is accessed through a proximal incision over the greater trochanter. All locking screws and the proximal part of the broken nail are removed. A

Accepted for publication March 23, 2003. From the *Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, and Hospital for Special Surgery, New York, NY. No benefit in any form has been or will be received from a commercial party related directly or indirectly to the subject of this article. The devices that are the subject of this manuscript are FDA approved. Reprints: Ely L. Steinberg, MD, Department of Orthopaedic Surgery B, TelAviv Sourasky Medical Center, 6 Weitzmann Street, Tel-Aviv 64239, Israel (e-mail: eli_st@netvison.net.il). Copyright 2004 by Lippincott Williams & Wilkins

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J Orthop Trauma Volume 18, Number 4, April 2004 TABLE 1. Various Methods That Have Been and Can Be Used to Extract a Broken Distal Nail Hollow Nails Custom-made hook Beaded guides8 High-speed drill to cut a hole in the nail4 Modified Kuntscher reaming guide6 Smaller size nail12 Vise grip locking pliers9 Multiple guidewires13 Cerclage wire14 Smaller size nail11 Corkscrew extractor15 Long hooks16
2

Solid Nails Percutaneous osteotomes and grasping device1,2 K-wire mounted on a concave instrument3 Push-out technique10 Synthes extraction kit5 Laparoscopic forceps17 Metal drill and push-out technique18 Long hooks19

gained more than 80 lb to reach a total weight of 270 lb. The nail was removed using the above-described technique, the medullary canal was reamed to 16.5 mm inner diameter, and a new expandable nail (Fixion) with an expanding diameter from 12 mm to 19 mm was inserted (Fig. 3). At the 6-month follow-up, the femur was united, and the patient had no pain.

the surgeon. Many extraction devices and methods have been described. These usually include a grasping sleeve,1 beaded guides,8 hooked rod, a modified Kuntscher reaming guide,6 vise-grip pliers,9 methods for drilling the proximal part of the

DISCUSSION
Intramedullary implant failure requiring removal, especially in the presence of a nonunion, may be a difficult task for

FIGURE 1. Schematic of the described technique for a broken distal closed section intramedullary nail removal. A, A 3.5-mm Steinmann pin is inserted in one of the distal holes from a previously removed screw. A 3-mm guide is introduced in the distal part, and the proximal medullary canal is reamed to a larger diameter. B, An 8- to 10-mm Kuntscher nail is wedged into the distal broken nail; the 3-mm guide and the Steinmann pin are removed. C, The broken nail is removed gently with rotatory movements.

FIGURE 2. Lateral view of the left thigh shows a hypertrophic nonunion of the femur with a broken nail. 2004 Lippincott Williams & Wilkins

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Broken Distal Closed Section Intramedullary Nail

the distal piece that is buried in the medullary canal of the bone. Reaming and enlarging the proximal part of the medullary canal and insertion of the Steinmann pin are mandatory to prevent nail fragment rotation and to decrease friction between the nail and the bone, making passage easier. Our additional technical steps increase the success of nail fragment removal compared with a technique described earlier.11

CONCLUSIONS
Based on our experience, the advantages of this technique are no additional exposure to the bone, other than the nail insertion through the original incision, and no special equipment is required, which is especially useful when the nail abuts the articular surface, which can be endangered by hooks and other such instruments. REFERENCES
1. Dawson GR, Stadler RO. Extractor for removing broken stuck intramedullary nail. Am J Orthop Surg. 1968;10:150151. 2. Franklin JL, Winquist RA, Benirsche SK, Hansen ST. Broken intramedullary nails. J Bone Joint Surg Am. 1988;70:14631471. 3. Frima AJ, Karthaus AJ. Entfernung eines gebrochenen massiven Tibiamarkenagels. [Removal of a massive broken tibial intramedullary nail.] Unfallchirurg. 1998;101:235237. 4. Georgiadis GM, Heck BE, Ebraheim NA. Technique for removal of intramedullary nails when there is failure of the proximal extraction device: a report of three cases. J Orthop Trauma. 1997;11:130132. 5. Giannoudis PV, Matthews SJ, Smith RM. Removal of the retained fragment of broken solid nails by the intra-medullary route. Injury. 2001;32: 407410. 6. Incavo SJ, Kristiansen TK. Retrieval of a broken intramedullary nail. Clin Orthop. 1986;210:201202. 7. Khan FA. Retrieval of a broken intramedullary femoral nail. Injury. 1992; 23:129130. 8. Cohn BT, Bifield L. Fatigue fracture of a tibial interlocking nail. Orthopedics. 1986;9:12151218. 9. Yoslow W, LaMont J. Alternative method for removing an impacted AO intramedullary nail. Clin Orthop. 1986;202:237238. 10. Krettek C, Schandelmaier P, Tscherne H. Removal of a broken solid femoral nail: a simple push-out technique. A case report. J Bone Joint Surg Am. 1997;79:247251. 11. Sivananthan KS, Raveendran K, Kumar T, et al. A simple method for removal of a broken intramedullary nail. Injury. 2000;31:433434. 12. Levy O, Amit Y, Velkes S, Horoszowski H. Brief reports: a simple method for removal of a fractured intramedullary nail. J Bone Joint Surg Br. 1994;76:502. 13. Middleton RG, McNab IS, Hashemi-Nejad A, et al. Multiple guide wire technique for removal of the short distal fragment of a fractured intramedullary nail. Injury. 1995;26:531532. 14. Marwan M, Ibrahim M. Simple method for retrieval of distal segment of the broken interlocking intramedullary nail. Injury. 1999;30:333335. 15. Wise DJ, Hutchins PM. Novel method for removal of a broken GK femoral nail. Injury. 1996;27:294295. 16. Zimmerman KW, Klasen HJ. Mechanical failure of intramedullary nails after union. J Bone Joint Surg Br. 1983;65:274275. 17. Charnley GJ, Farrington WJ. Laparoscopic forceps removal of a broken tibial intra-medullary nail. Injury. 1998;29:489490. 18. Rangger C, Klestil T, Inderster A, et al. Problems in removal of a broken unreamed tibial nail. Unfallchirurg. 1996;99:6870. 19. Schmidgen A, Naumann O, Wentzensen A. A simple and rapid method for removal of broken unreamed tibial nails. Unfallchirurg. 1999;102: 975978.

FIGURE 3. Radiograph at 6-month follow-up.

nail for solid nails,4 percutaneous osteotomies,2 push-out techniques,10 and others as illustrated in Table 1. All of these methods are helpful because of the wide use of different kinds of nailssolid, cannulated, clover leafwith or without extraction slots (like the Kuntscher nail), and the surgeon needs to be familiar with as many methods as possible. The simple technique described here for removing a hollow cross-section nail needs no special devices and may be applicable to all open nails. The open section of the Kuntscher nail is an excellent tool for extracting closed and open section nail fragments because it can be forced into the nail. The elastic open cross-section Kuntscher nail is forced easily into the nail fragment and gains impingement fit as it is passed further into the nail until it is stuck. The measured inside diameter of the most commonly used nails, Synthes or Howmedica, is greater than 8.5 mm. The desired Kuntscher nail is tested for size and interference fit using the previous extracted proximal nail portion, after which only the Kuntscher nail is inserted to extract

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