Drs Heffernan and Li are from the Division of Orthopaedic Surgery, and Dr Leclair is from the Division of Orthopaedic Trauma Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts.
Drs Heffernan, Leclair, and Li have no relevant financial relationships to disclose.
Correspondence should be addressed to: Xinning Li, MD, Division of Orthopaedic Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655 (email@example.com).
Several surgical options exist for the management of diaphyseal femoral shaft fractures; however, intramedullary nailing has consistently led to a high fracture union rate, with a low incidence of complications.1,2 Intramedullary nailing is considered the gold standard for the treatment of closed diaphyseal femoral shaft fractures. Complications of intramedullary nailing include malunion, nonunion, malrotation, infection, and hip or knee pain depending on the site of nail insertion.3,4 Refracture of the femoral shaft due to secondary trauma around a stable intramedullary nail with subsequent nail bending has been reported in the literature.5–16 Some authors describe the technique of opening the femur at the fracture site, sectioning the nail, and removing the proximal and distal nails through the fracture site.10,12,16 Other techniques include straightening the bent intramedullary nail in the coronal plane with the perineal post11 or using a percutaneous technique,6 a fish hook technique,5 or a combination of these techniques.8,11,13,14,17–19
A review of the literature regarding bent femoral intramedullary nail extraction indicated that the majority of treatments were for coronal plane deformities, with the most common deformity being in the apex-lateral direction.7 These reports typically involve weakening of the intramedullary nail, then using the perineal post to manually straighten and extract the nail. However, the perineal post may not provide enough counter force to straighten a bent intramedullary nail.
This article describes a novel technique using a combination of a Midas Rex MR7 high-speed burr (Medtronic, Minneapolis, Minnesota) and the F-Tool (Synthes, West Chester, Pennsylvania) to facilitate the extraction of a bent intramedullary femoral nail. This was performed in a patient who sustained a femoral fracture around a previously placed intramedullary femoral nail that resulted in significant sagittal plane apex-anterior deformity. This article will help orthopedic surgeons who are confronted with this complication after intramedullary nailing. The patient consented for this case to be reported.
A 36-year-old man presented after being in a motocross accident. On initial evaluation, the patient was hemodynamically stable, with a Glascow Coma Score of 15. He reported right leg pain but no motor function loss or numbness. No other associated pain existed in the bilateral upper extremities or the left lower extremity. The patient’s medical history included a femoral fracture, which had been treated with an intramedullary nail (Synthes) at another hospital approximately 4 months previously. He had recently returned to full activities of daily living. On physical examination, the patient’s skin was intact and had a significant deformity of the right thigh. He had full motor and sensation on the right lower extremity distal to the injury site. Anteroposterior and lateral radiographs were obtained (Figure 1). The femoral fracture was classified as AO/OTA 32-B2 type with apex-anterior angulations of 33° in the sagittal plane and 7° apex-lateral angulations in the coronal plane.
Figure 1: Preoperative anteroposterior (A) and lateral (B) radiographs revealing an apex-anterior deformity around a bent femoral intramedullary nail.
The patient was placed in the lateral decubitus position. A lateral approach to the femur was undertaken at the level of the fracture site. When the fracture site was exposed, tissue from the callus and a swab sample were sent for culture to rule out infection. An osteotome was used to open the previous fracture site to further expose the bent nail at the apex of the deformity (Figure 2). A Midas Rex MR7 high-speed burr was used to partially section the bent femoral nail at the apex. We started on the convex (anterior) side of the apex and worked posteriorly, leaving a thin remnant of metal at the posterior aspect of the nail. Continuous irrigation and suction was performed during this step of the procedure. The F-Tool was used to manually straighten the bent intramedullary nail (Figure 3), which was confirmed with intraoperative fluoroscopy (Figure 4). The distal and proximal locking screws were also removed using a percutaneous technique. The Winquest III Universal Intramedullary Nail Extraction System (Synthes) was attached to the proximal aspect of the nail, and extraction was performed with no difficulty (Figure 5). The proximal entry hole from the previous surgery was located and reused for the anterograde insertion of a T2 Femoral Nail (Stryker, Mahwah, New Jersey) measuring 13×380 mm.
Figure 2: Intraoperative picture showing the intramedullary nail after sectioning with the Midex Rex MR7 high-speed burr (Medtronic, Minneapolis, Minnesota) at the deformity.
Figure 3: Photograph of the F-Tool (Synthes, West Chester, Pennsylvania) being used at the apex of the deformity to straighten the bent intramedullary nail after partial sectioning with the Midas Rex MR7 high-speed burr (Medtronic, Minneapolis, Minnesota).
Figure 4: Intraoperative imaging showing the partial sectioning of the femoral nail with the Midas Rex high-speed burr (Medtronic, Minneapolis, Minnesota) and subsequent straightened nail following use of the F-Tool (Synthes, West Chester, Pennsylvania).
Figure 5: Photograph of the Winquest III Universal Intramedullary Extraction System (Synthes, West Chester, Pennsylvania) used to remove the femoral nail after straightening.
The patient tolerated the procedure well and was made weight bearing as tolerated postoperatively. He had no complications during his postoperative hospitalization course and was discharged.
At 4-month follow-up, he was pain free and fully weight bearing on his right lower extremity. Anteroposterior and lateral radiographs demonstrated callous formation at the fracture site, and the patient was permitted to perform all activities of daily living as tolerated.
Intramedullary nailing is the standard method of treatment for closed diaphyseal long-bone femoral shaft fractures. Results in the literature have shown up to 98% union rates, with few complications.1,2 Known complications of antegrade femoral nailing include neuropraxia associated with traction, angular or rotational malalignment, heterotopic ossification, hip pain, refracture, malunion, nonunions, and implant complications.3 Broken implants, especially involving locking bolts, are relatively common, and removal techniques have been described.9,14,20 Due to the relative rarity of bent intramedullary nails secondary to trauma, only case reports are found in the literature addressing the treatment options. In the current article, we highlight a novel technique of the combined use of a Midas Rex MR7 high-speed burr and the F-Tool to facilitate the removal of a bent intramedullary femoral nail.
The essential components for the successful extraction of a bent femoral intramedullary nail include weakening of the nail at the apex of the deformity and manually straightening the nail to facilitate removal. A Midas Rex MR7 high-speed burr with diamond cutting head was used to section the nail at the apex of the deformity until a small wall of metal remained (Figure 3). Other authors have also supported the use of a Midas Rex MR7 high-speed burr to weaken the nail; however, care must be taken to irrigate and suction while drilling to reduce heat and facilitate metal debris removal.7,10 Other techniques have also been described, including making drill holes in the nail,21 using a trochar and 3.5-mm drill bit to perforate the nail at the apex of deformity,6 and using a pin cutter.12 Although using a drill bit can be an attractive alternative option, it can be difficult to place and stabilize the drill bit or trochar on the apex of deformity. Other than weakening the nail, several authors reported complete sectioning of the nail and extraction of the proximal and distal segments.10,12 Nicholson et al10 used a Midas Rex MR7 high-speed burr to section the intramedullary nail, and removal of the distal segment was performed via the femoral incision while the proximal segment was removed from the original trochanteric insertion site. Singh et al12 used a pin cutter to section the intramedullary nail, then the proximal and distal segments were removed from the original femoral incision site. To remove the sectioned nail through the femoral incision, more dissection and manipulation of the soft tissue is required, especially with the removal of the distal segment.
The second component of extracting a bent intramedullary nail is straightening the nail through a manual technique or with the use of assistive devices. We used the F-Tool to facilitate straightening the nail. The F-Tool allows focused forces to be concentrated at the apex of the deformity to generate significant force while minimizing damage to the local soft tissues. Other techniques have also been described, including the perineal post7,11 and compression plate with bone-holding forceps22 to facilitate reduction. These techniques are an alternative to removing bent nails; however, the perineal post may not provide enough counter force, whereas compression plating results in significant soft tissue dissection. Because the deformity in our patient was in the sagittal plane, we put the patient in the lateral position to allow better access for placement of the F-Tool at the apex of the deformity. Banerjee and Posner7 also supported putting the patient in the lateral position when the deformity is in the sagittal plane. They partially sectioned the nail, and reduction was performed with the perineal post. The Table presents the other reported cases on removal of a bent intramedullary nail.
Table: Previously Described Techniques for Bent Intramedullary Nail Removal
Our technique of partial nail sectioning with a high-speed burr followed by the use of the F-Tool to straighten the nail is a simple, effective method to remove a bent femoral intramedullary nail. Advantages include limited dissection around the fracture site, removal of the nail in 1 piece, and localizing the force required at the apex of deformity to minimize soft tissue damage.
- Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am. 1984; 66(4):529–539.
- Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999; 46(3):392–399. doi:10.1097/00005373-199903000-00007 [CrossRef]
- Nork SE. Femoral shaft fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1655–1718.
- Benirschke SK, Melder I, Henley MB, et al. Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma. 1993; 7:118–122. doi:10.1097/00005131-199304000-00003 [CrossRef]
- Acharya M, Alani A, Almedghio S. The Fish Hook Technique of extracting broken intramedullary nails. Acta Orthop Belg. 2008; 74(5):686–688.
- Apivatthakakul T, Chiewchantanakit S. Percutaneous removal of a bent intramedullary nail. Injury. 2001; 32(9):725–726. doi:10.1016/S0020-1383(01)00066-3 [CrossRef]
- Banerjee R, Posner M. Removal of a bent intramedullary nail with a posttraumatic sagittal plane deformity. J Trauma. 2009; 66(5):1500–1503. doi:10.1097/TA.0b013e31818a6d4b [CrossRef]
- Burzynski N, Scheid DK. A modified technique for removing a bent intramedullary nail minimizing bone and soft tissue dissection. J Orthop Trauma. 1994; 8(2):181–182. doi:10.1097/00005131-199404000-00018 [CrossRef]
- Franklin JL, Winquist RA, Benirschke SK, Hansen ST Jr, . Broken intramedullary nails. J Bone Joint Surg Am. 1988; 70(10):1463–1471.
- Nicholson P, Rice J, Curtin J. Management of a refracture of the femoral shaft with a bent intramedullary nail in situ. Injury. 1998; 29(5):393–394. doi:10.1016/S0020-1383(98)00061-8 [CrossRef]
- Patterson RH, Ramser JR Jr, . Technique for treatment of a bent Russell-Taylor femoral nail. J Orthop Trauma. 1991; 5(4):506–508. doi:10.1097/00005131-199112000-00021 [CrossRef]
- Singh R, Sharma AK, Kiranpreet. An innovative technique to cut and extract loose bent Kuntscher nail. Indian J Med Sci. 2004; 58(10):439–441.
- Sonanis SV, Lampard AL, Kamat N, Shaikh MR, Beard DJ. A simple technique to remove a bent femoral intramedullary nail and broken interlocking screw. J Trauma. 2007; 63(2):435–438. doi:10.1097/TA.0b013e318076b4be [CrossRef]
- Stahel PF, Flierl MA, Morgan SJ, Smith WR. Management of a trochanteric fracture complicated by a bent solid intramedullary femoral nail in situ: description of technique. J Orthop Trauma. 2010; 24(3):e25–e30. doi:10.1097/BOT.0b013e3181b2f70d [CrossRef]
- Yip KM, Leung KS. Treatment of deformed tibial intramedullary nail: report of two cases. J Orthop Trauma. 1996; 10(8):580–583. doi:10.1097/00005131-199611000-00014 [CrossRef]
- LaSalle W, Horwitz T. A method to cut and remove in situ bent intramedullary nail. Clin Orthop Relat Res. 1974; (103):30–31. doi:10.1097/00003086-197409000-00017 [CrossRef]
- Brewster NT, Ashcroft GP, Scotland TR. Extraction of broken intramedullary nails–an improvement in technique. Injury. 1995; 26(4):286. doi:10.1016/0020-1383(95)90020-X [CrossRef]
- Maheshwari R, Tadross TS. Extracting broken intramedullary femoral nails. Orthopedics. 2006; 29(10):880–881.
- Sertakov NN, Kibal’nik VA, Sertakov DN. An extractor for removal of broken hollow nails after intramedullary osteosynthesis [in Russian]. Ortop Travmatol Protez. 1991; (4):67.
- Theivendran K, Cooper JP. Removal of broken solid femoral nail: a modified bent tip guide wire technique [published online ahead of print January 24, 2009]. Arch Orthop Trauma Surg. 2009; 129(12):1667–1671. doi:10.1007/s00402-009-0814-z [CrossRef]
- Ohtsuka H, Yokoyama K, Tonegawa M, Higashi K, Itoman M. Technique for removing a bent intramedullary femoral nail: a case report. J Orthop Trauma. 2001;15(4):299–301. doi:10.1097/00005131-200105000-00011 [CrossRef]
- Shen PC, Chen JC, Huang PJ, Lu CC, Tien YC, Cheng YM. A novel technique to romove bent intramedullary nail. J Trauma. 2011; 70(3):755–758. doi:10.1097/TA.0b013e31820009ea [CrossRef]
Previously Described Techniques for Bent Intramedullary Nail Removal
|Patterson & Ramser11||Russell-Taylor Femoral IM nail||30° varus angulation (coronal)||Closed reduction using perineal post as fulcrum||Reamed exchange nailing, fracture union|
|Banerjee & Posner7||Femoral IM nail||30° apex anterior (sagittal)||Anterior approach, high-speed burr to partially section off nail, perineal post||No complication|
|Sonanis et al13||Femoral IM nail||30° varus angulation (coronal)||Lateral approach, high-speed burr to partially section off nail, perineal post||No complication|
|Ohtsuka et al21||Femoral IM nail||28° varus angulation (coronal)||Lateral approach, drill to partially section nail, manual reduction||Reamed exchange nailing, fracture union|
|Apivatthakakul & Chiewchantanakit6||Kuntscher Femoral IM Nail||35° varus angulation (coronal)||Percutaneous, locking bolt trocar to introduce drill for partial sectioning of nail, manual reduction||Exchange IM Nail, no follow-up data|
|Nicholson et al10||Grosse and Kempf femoral IM nail||42° varus angulation (coronal)||High speed burr to fully section nail, distal portion removed through fx site||Exchange IM Nail, no follow-up data|
|Singh et al12||Kuntscher femoral IM nail||35° apex anterior (sagittal)||Jumbo pin cutters used to section nail, which was removed in 2 pieces through the fx site||Compression plating and bone graft, no follow-up data|