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Angling Technique for Removal of a Broken Cannulated Intramedullary Nail: A Technical Note

Jain, Gunjar MS Orthopaedics; Nag, Hira L. MS Orthopaedics; Raje, Amrut D. MS Orthopaedics; Goyal, Archit MBBS

Author Information
Techniques in Orthopaedics: March 2019 - Volume 34 - Issue 1 - p 37-39
doi: 10.1097/BTO.0000000000000293
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Abstract

Mechanical failure is a known complication of intramedullary nailing.1 Retrieval of broken nails remains a big challenge for orthopedic surgeons. Commercially available devices for this purpose are costly and not widely available. We are reporting a new method of retrieval of broken nails, which is comparatively less invasive and more reliable than other methods described in the literature. Our method is similar to angling, which is a method of fishing by means of a fishhook. In this method we have used a stainless steel wire to prepare a nail-hook similar to a fishhook. If we describe our hook in the terminology of a fishhook, our hook has a wide mouth, a narrow bend, and a deep throat (Figs. 1A, B). This hook is passed through the broken nail under image guidance. The nail is then hooked and retrieved in a retrograde manner (Figs. 2A, B). It retrieves the nail noninvasively, as no further exposure is required after removal of the proximal part of the nail by traditional methods.

FIGURE 1
FIGURE 1:
A, Anatomy of a fishhook. B, A nail-hook prepared from stainless steel wire.
FIGURE 2
FIGURE 2:
Demonstration of the Angling technique. A, The nail-hook passed through the broken nail. B, The hooked broken nail ready for retrieval.

CASE REPORT

A 20-year-old male presented to the clinic with complaints of pain in his right thigh since 3 months. The patient had a history of road traffic accident 1-year back, in which he had sustained fractures of his right shaft of femur and right proximal tibia, which were treated by internal fixation. On examination mild tenderness was present over the distal thigh. On radiograph nonunion of right distal shaft of femur was evident with moderate amount of callus formation with interlocking nail in situ. The nail was broken distally at the level of the more proximal hole of the two distal interlocking holes (Fig. 3). Routine laboratory investigations including erythrocyte sedimentation rate and serum C-reactive protein level were within normal limits.

FIGURE 3
FIGURE 3:
Radiograph anteroposterior view showing nonunion fracture shaft of femur with broken nail in situ.

Thus a diagnosis of “hypertrophic nonunion fracture shaft of femur with broken cannulated interlocking nail in situ” was made. An exchange nailing was planned to provide better stability at the fracture site. In supine position on a fracture table under regional anesthesia the proximal part of the nail was removed traditionally. Angling technique was used to retrieve the left distal broken part of the nail. A 20-gauge stainless steel wire of length sufficient to reach and retrieve the broken nail was taken. A nail-hook was made at one of its end, as described above. The removed proximal part of the nail was used as a template to make the hook as per the required dimension. Under fluoroscopic guidance, the hook was passed down the medullary canal and then through the broken nail, such that the complete hook was distal to the nail (Fig. 4A). The stainless steel wire was then pulled proximally to hook the broken nail. The wire was then held firmly with a T-handle chuck and the nail was retrieved by gently pulling the stainless steel wire outside (Fig. 4B). After nail removal the nonunion was stabilized with a larger diameter-interlocking nail.

FIGURE 4
FIGURE 4:
Fluoroscopic images while retrieval of a broken nail. A, The nail-hook negotiated through the broken nail. B, The broken nail moved proximally as the nail-hook is withdrawn outside.

DISCUSSION

Removal of broken nails from femur or tibia has many options described in the literature. These options can be either noninvasive or invasive. In noninvasive methods no further exposure is required after removal of the proximal part of the nail. In invasive methods, however, either the knee joint is breached or a window is created in the cortex.2 For obvious reasons invasive methods are not preferable.

Noninvasive methods can be further classified as either impaction methods or hook methods. In impaction methods, some device or instrument like a Nancy nail, Küntscher nail or a T-reamer is impacted in the hollow of the distal fragment of the broken nail, the latter is then retrieved proximally.3,4 In these methods potential risk of fracture of the bone, while impacting the device, is present. In the hook methods the distal fragment is hooked with either some modified guide wires or commercially available devices and retrieved proximally.5 The angling technique follows the hook principle.

Major advantage of our method is that it requires things, which are easily available in a general orthopedic setup. Also, as the hook can be prepared as per the required dimensions, a nail with a narrow hollow can also be retrieved. The hook prepared has a deeper throat compared with other hooks described in the literature, thus the nail is held more securely. The narrow bend allows easy negotiation of the hook through the nail. Lastly, as the nail-hook has a wider mouth the chances to hook the nail is also improved.

We have used a 20-gauge wire to make the hook less bulky and to pass it through the canal easily. It offered substantial rigidity and despite moderate amount of resistance stayed hooked while recovery of the nail. However, a thicker wire can also be used if the hook prepared passes easily inside the canal of the retrieved proximal part of the nail, which acts as a template. Various precautions are taken to prevent straightening of the hook. The bend is made wide enough to accommodate the thickness of the nail so that while recovery all the force is used to extract the nail rather than for unfolding of the hook. The deep throat of the hook also prevents straightening inside the limited space in the medullary canal. The wire inside the canal is properly straightened such that all the force is transferred to the bend of the hook. While preparing the hook, manipulation of the wire at the bend is avoided to prevent any failure of that part of the hook.

We have used this method successfully to extract broken nail thrice. Still we agree that there will be limitations of this method if the nail is stuck inside the medullary canal. In such cases other more invasive methods can be attempted once our method fails. Angling technique is thus a simple, effective and economical method for retrieval of broken cannulated intramedullary nails.

REFERENCES

1. Bhat AK, Rao SK, Bhaskaranand K. Mechanical failure in intramedullary interlocking nails. J Orthop Surg. 2006;14:138–141.
2. Singh SKA, Chopra RK, Sehrawat S, et al. A novel method for the removal of distal part of broken intramedullary femoral nail. Acta Orthop Traumatol Turc. 2014;48:223–225.
3. Kim YM, Joo YB, Lee KY. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury. 2015;46:2498–2501.
4. 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. JorthopTrauma. 2004;18:233–235.
5. Park SY, Yang KH, Yoo JH. Removal of a broken intramedullary nail with a narrow hollow. J Orthop Trauma. 2006;20:492–494.
Keywords:

nonunion; femur; broken intramedullary nail; removal; stainless steel wire

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