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Extraction of a Bent Tibial Nail After Refracture

A Case Report

McChesney, Grant R. MD1; Gurbani, Barkha N. MD, MPH1; Hagedorn, John C. II MD1

doi: 10.2106/JBJS.CC.18.00385
Case Reports
Free
Disclosures

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.

1Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas

E-mail address for G.R. McChesney: grmcches@utmb.edu

Investigation preformed at The University of Texas Medical Branch, Galveston, Texas

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A846).

The success of intramedullary devices since first established by Gerhard Küntscher during the Second World War is profound1. Intramedullary fixation is the standard of care for diaphyseal lower extremity fractures2. Despite the excellent performance of intramedullary devices, they remain subject to the traditional complications of all orthopaedic implants. Nonunion, malunion, infection, vascular injuries, neurologic injuries, leg length discrepancy, insertional site pain, rotational malalignment, and heterotopic ossification are noted and commonly discussed complications in the review of literature3.

The complication of a posttraumatically deformed intramedullary nail requiring extraction after refracture as presented in this report is much more uncommon. In approaching our patient's treatment, the authors found only 7 cases of posttraumatically bent tibial nails and 25 cases of bent femoral nails. Despite the small number of reported cases, numerous methods of removal have been described in the literature, from standard extraction to more extensive methods requiring an additional incision. In a 2016 case series, Kose et al. provided an excellent review of reported removal techniques4. Approaching this patient, we considered these techniques in terms of their invasiveness, as noted in Table I.

TABLE I - Presently Described Nail Extraction Techniques
Technique Fracture Site Incision Required Description Pros/Cons
Standard extraction No Retrograde extraction of the nail via the original insertion site. Pro: fracture biology preserved
Con: limited by nail deformity and fracture morphology
External manipulation followed by standard extraction No Manual reversal of the deformity curve with 3 points of pressure and/or twisting the nail into recurvatum while attached to the nail extractor, followed by standard extraction. Pro: fracture biology preserved
Con: increased soft tissue injury, possible fracture propagation
Internal manipulation followed by standard extraction Yes Opening of the fracture site followed by an attempt to bend the nail using a lever arm in the form of a long plate and clamps or an F-tool. Pro: allows for possible plate fixation or revision nailing after extraction
Con: second incision and greater soft-tissue injury
Open weakening and standard extraction Yes Opening of the fracture site with removal of bone around the nail, followed by weakening of the nail with a burr, drill bit, or bolt cutter allowing for manual reduction of device deformity. Pro: less invasive than open sectioning
Con: loss of fracture biology, introduction of metal debris, bone loss, and soft-tissue injury
Open sectioning and 2-piece extraction Yes Opening of the fracture site with removal of bone and use of a burr or saw to transect the nail, followed by removal of the nail in 2 pieces. Pro: universally successful
Con: loss of fracture biology, introduction of metal debris, bone loss, and soft-tissue injury

Given the combined annual incidence of the of tibial and femoral shaft fractures estimated to be greater than 50 per 100,000 persons and the popularity of intramedullary devices in the treatment of these fractures since the 1970s, the present literature on deformed hardware extraction remains limited3,5,6. The authors present this case to comment on the utility of standard extraction and continue to assist surgeons in the management of deformed intramedullary devices.

The patient was informed that data concerning the case would be submitted for publication, and he provided consent.

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Case Report

Our patient was a 65-year-old man with a significant medical history who was previously seen at our institution in September 2011 after a roller skating accident resulted in a closed left diaphyseal tibia-fibula fracture. The patient underwent intramedullary nailing. He was discharged from the clinic after signs of union in November 2011 (Figs. 1 and 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

In July 2017, the patient returned to our institution after a motorcycle crash. After fulfillment of the Advanced Trauma Life Support protocol, the patient was stable with his sole injury, an open fracture of his left tibia and fibula. Antibiotics were given, and radiographs were obtained. On orthopaedic evaluation, the patient was noted to have a Gustilo-Anderson type IIIA segmental left tibial shaft fracture and a comminuted left fibular fracture.

The patient was taken to the operating room on the day of presentation. The patient's previous operative report noted his implant as a hollow 8.3 × 300 mm titanium alloy Zimmer nail. Review of injury X-rays revealed the nail presenting an angular deformity of 7° on the anteroposterior film and 38° on the lateral film (Figs. 3 and 4).

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Operatively, a sharp debridement was first undertaken and the wound irrigated thoroughly. Attention then turned to nail extraction. The 2 proximal interlocking screws were located under fluoroscopy and removed through stab incisions. In the same fashion, the distal interlocking screws were located. The more proximal of the 2 was initially removed, leaving the most distal screw in place to stabilize the nail during extractor placement. The knee was then repositioned into flexion over a triangle and the previous incision, a patellar-splitting approach was used to access the tibial plateau. The tip of the nail was located using a 3.2-mm guide pin. At this point, an attempt was made to remove the nail with the universal extractor set from Zimmer, but the device possessed poor hold on the head of the nail. Because of the nail being buried, the collar on the extraction bolt was blocked by the anterior tibial plateau. A Winquist Universal Nail Extractor (Shukla Medical) was trialed, which offered an option to place an extraction bolt without a collar. Once this device was well fitted, the final interlocking screw was removed. The nail was then removed without any difficulties using a back-slap technique.

After extraction, concern for the soft tissue, ankle, and knee ligamentous injuries, infectious risk, closed head injury, and possible intra-articular extension of the fracture directed the patient's care toward external fixation and not internal fixation. The patient was placed in a knee-spanning external fixator. The wound was loosely closed. Postoperative computed topography demonstrated no intra-articular involvement of the fracture. The patient recovered uneventfully and was discharged home on postinjury day 3.

The patient returned 24 days later for ex-fix removal and definitive fixation with a suprapatellar tibial nail (Synthes) to move posterior to the previous nail's starting point. The patient was treated with a reamed 11 × 300 mm Synthes Expert tibial nail. The patient recovered from the operation without issue. At 12 months postoperatively, the patient has returned to his regular work and activities with minimal pain. His 12-month radiographs demonstrate fracture union (Figs. 5 and 6).

Fig. 5

Fig. 5

Fig. 6

Fig. 6

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Discussion

The success of standard extraction in our patient can readily be attributed to multiple factors: implant design, size, and material, the anatomy of the proximal tibia, the direction of the implant's deformity, and the fracture morphology.

The nail extracted in this case was a modern titanium alloy, hollow, and relatively small in diameter for the patient at 8.3 mm. Intramedullary implants are most commonly made of 316L stainless steel or a titanium alloy7. The Young's modulus of titanium alloys is around 110 GPa, although 5 times greater than cortical bone (20.4 GPa), it is almost half that of 316L stainless steel (200 GPa)7-9. The stiffness of a hollow tube is proportional to its radius cubed opposed to a solid cylinder, which is proportional to the radius to the fourth power7. All these factors reduced its stiffness and increased its ability to undergo safe standard extraction with reduced concern for fracture propagation. In addition, device design cannot be overlooked. Older nail designs allowed for bony ingrowth into cannulas along the device10. Recognition of ingrowth along the nail or at the screw interlocks is critical to prevent iatrogenic fracture11.

The first recorded cases of deformed tibial nail extraction by Yip and Leung in 1996 document the removal of 2 stainless steel nails via standard extraction with the deformities of 30° and 20°, respectively. Yip and Leung contribute their success to the anatomy of the tibia itself commenting on how the widening of the proximal medullary canal allows for more play when removing the angled implant. They also note the advantage of an apex posterior curve allowing for ease of clearance over the flexed knee during withdrawal12. These 2 factors were present during our own hardware removal.

Analysis of all successful standard extractions of a tibial nail compared to those which required more extensive open procedures, direction of curve revealed to be a more contributory factor than the degree of the curve. Agerwall et al. reported removal of 25° bent nails with an apex anterior curve, which required opening of the fracture site13. Juxtaposed, a 2012 removal of a 25° apex posterior curve reported extraction with ease via standard extraction offering support that the apex posterior deformity allows for the best chance at standard extraction14. The 20° nail from Yip's series possessed an apex anterior curve, supporting the idea that curves of a certain degree or less can be removed regardless of the direction of deformity12. While not previously described in the literature, an attempt to rotate the nail into an apex posterior position may be a useful technique to ease nail extraction.

Factors yet to receive comment in the literature and which likely assisted in our hardware removal were the presence of an open wound and presence of a comminuted fracture. Both of these factors allow for more mobility of the fracture site and soft tissues while the hardware is exiting the medullary canal, reducing the risk of iatrogenic fracture or further fracture propagation. In the original case series on the subject by Yip and Leung, the more deformed of the two nails removed12. It should be considered that transverse fractures or fractures with shorter fracture fragments would be at a higher risk of fracture propagation.

In approaching a patient with a deformed tibial nail, an attempted standard extraction should be performed before contemplating more complex forms of removal. Advocacy for an attempt at standard extraction stems from the fact opening the fracture site exposes the patient to another incision with possible risk of infection, loss of biology at the fracture site increasing a chance of delayed or nonunion, as well as interventions such as drilling or cutting the metal implant are likely to leave behind metallic debris. Simultaneously, overly aggressive attempts at standard extraction or external manipulation risk fracture propagation, soft-tissue injury, and theoretically compartment syndrome. We advocate consideration of implant properties, direction and degree of deformity, and fracture morphology in preoperative planning (Table II). Intraoperatively, we advise progression from the least to most invasive technique with the awareness to avoid overly aggressive closed attempts and the instrumentation readily available to perform an open procedure, if necessary.

TABLE II - Preoperative Planning Considerations in Deformed Nail Extraction
Deformity Implant Material (Stainless Steel or Titanium) Fracture Morphology (Comminuted vs. Simple) Initial Recommended Removal Technique
All directions <20° Both All types Standard extraction
All apex posterior deformity Both All types Standard extraction
Lateral or anterior deformity >20° Titanium All types Attempt external straightening or rotation to apex posterior followed by standard extraction*
Lateral or anterior deformity >20° Steel Comminuted Attempt external straightening or rotation to apex posterior followed by standard extraction*
Lateral or anterior deformity >20° Steel Simple transverse Plan for opening of the fracture site. Attempt standard extraction without manipulation before opening.
*
Carefully observe throughout external manipulation under fluoroscopy to monitor for iatrogenic fracture.

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References

1. Küntscher G. Die Marknalung von Knochenbruchen: Langenbecks [in German]. Arch Klin Chir. 1940;200:443-55.
2. Bong MR, Koval KJ, Egol KA. The history of intramedullary nailing. Bull NYU Hosp Joint Dis. 2006;64(3-4):94-7.
3. Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009;17(5):296-305.
4. Kose O, Guler F, Kilicaslan OF, May H, Yuksel HY. Removal of a bent intramedullary nail in lower extremity: report of two cases and review of removal techniques. Arch Orthop Trauma Surg. 2016;136(2):195-202.
5. Weiss RJ, Montgomery SM, Ehlin A, Al dabbagh Z, Stark A, Jansson KA. Decreasing incidence of tibial shaft fractures between 1998 and 2004: information based on 10,627 Swedish inpatients. Acta Orthop. 2008;79(4):526-33.
6. Wolinsky PR, Mccarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma. 1999;46(3):392-9.
7. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97-106.
8. Niinomi M, Liu Y, Nakai M, Liu H, Li H. Biomedical titanium alloys with Young's moduli close to that of cortical bone. Regen Biomater. 2016;3(3):173-85.
9. Rho JY, Ashman RB, Turner CH. Young's modulus of trabecular and cortical bone material: ultrasonic and microtensile measurements. J Biomech. 1993;26(2):111-9.
10. Seyhan M, Guler O, Mahirogullari M, Donmez F, Gereli A, Mutlu S. Complications during removal of stainless steel versus titanium nails used for intramedullary nailing of diaphyseal fractures of the tibia. Ann Med Surg (Lond). 2018;26:38-42.
11. Stenroos A, Brinck T, Handolin L. Recommendation of use of checklists in tibial intramedullary nail removal: retrospective study of mechanical complications related to nail removal. Injury. 2018;49(7):1341-7.
12. Yip KM, Leung KS. Treatment of deformed tibial intramedullary nail: report of two cases. J Orthop Trauma. 1996;10(8):580-3.
13. Aggerwal S, Soni A, Saini UC, Gahlot N. Removal of a bent tibial intramedullary nail: a rare case report and review of the literature. Chin J Traumatol. 2011;14(2):107-10.
14. Buunaaim A, Sekimpi P. Anatomic approach to the removal of a bent intramedullary nail in a refractured tibia minimizing soft tissue and bone injury: a rare case report. Intern J Orthop Surg. 2012;19:2.

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