Tips and Pearls
Owing to an ever-increasing number of long bone fractures following high-speed motor vehicular accidents and the use of intramedullary nailing as the preferred technique, breakage of these nails is not uncommon. Their removal, particularly that of its distal fragment, is a challenging task. Various techniques such as custom-made hooks,1 multiple guidewires including beaded and smooth guidewires,2 smaller size nails, vise grip locking pliers, cerclage wires, corkscrew extractors, long hooks, and high-speed drills3 have been used in the past for this purpose. We present a new technique of removing the distal fragment of broken hollow intramedullary nail using an arthroscopic flipcutter, which has not been previously described to the best of our knowledge.
A 64-year-old obese man with a history of being operated 2 years ago for fractured right subtrochanteric femur elsewhere presented to us with complaints of pain in the right thigh and inability to bear full weight on the right lower limb. He had a history of a trivial fall over the right thigh 2 months before presentation. Clinical examination revealed the tenderness in right proximal thigh and radiographs showed fractured nonunion subtrochanteric right femur with broken intramedullary nail in situ with a broken interlocking screw (Fig. 1). The patient was subsequently posted for implant removal and open reduction with internal fixation and bone grafting in the same sitting.
During surgery, the interlocking screws were removed first and then the broken screw was removed using AO damaged screw removal set (Synthes). The proximal part of the broken nail was removed using nail extractor. The remaining part of the broken nail was located very distal from the fracture site and could not be grasped with any instrument. Instead of making another incision and window in the distal femur to remove the broken nail, we decided to use a Flipcutter4 (Arthrex) to remove the broken nail. An arthroscopic Flipcutter (Fig. 2) was then introduced into the femoral canal through the nail entry portal and was then forwarded across the far end of the broken nail, which was confirmed under image guidance (Figs. 3, 4A). The Flipcutter was then flipped (Fig. 4B) to engage the nail (Fig. 4C) following which a T handle and backhammer were applied over the Flipcutter to extract the broken nail. The fracture site was then opened, and the fracture ends freshened ad fixed with condylar blade plate and autologous bone grafting from the ipsilateral iliac crest.
Improper surgical technique, low quality of indigenously produced implants, nonunion at the fracture site because of various factors, premature weight-bearing, recurrent trauma, and many such factors are responsible for the breakage of intramedullary nails.5 Removal of these broken nails often require longer operating time, greater blood loss, large amount of soft tissue and bone dissection, and use of special custom-made instruments.1,6 The option of making a window in the distal femur to remove the broken nail would result in another incision, creation of stress riser, bone loss, and additional fixation of the window.
A Flipcutter is an all-in-one guide pin and reamer used for making tunnels in arthroscopic anterior and posterior cruciate reconstructions. It is a guide pin that changes to a reamer with a push of a button and sliding the hosing downward. Use of an arthroscopic Flipcutter in the manner described by us is a simple and safe method for the removal of hollow broken intramedullary nails requiring short surgical time without the need of any extra dissection and thus preventing any extra local complications. However, inability of this technique to address broken solid intramedullary nails and theoretical chances of breakage of Flipcutter during the process are the limitations of this technique.
The authors thank Dr Ratnav Ratan for assisting in surgery.
1. Franklin JL, Winquist RA, Benirschke SK, et al.. Broken intramedullary nails. J Bone Joint Surg Am. 1988;70:1463–1471.
2. 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;26:531–532.
3. Steinberg EL, Luger E, Menahem A, et al.. Removal of a broken distal closed section intramedullary nail: report of a case using a simple method. J Orthop Trauma. 2004;18:233–235.
5. Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg . 2006;14:113–120.
6. Levine JW, Georgiadis GM. Removal of a broken cannulated tibial nail: a simple intramedullary technique. J Orthop Trauma. 2004;18:247–249.