A worthwhile attempt to remove a bent intra-medullary femoral nail before attempting extensive procedures

SM Shishir; Pascal Noel Deniese; R Kanagasabai; Syed Najimudeen; James J Gnanadoss

CASE REPORT

Year : 2015 | Volume : 1 | Issue : 1 | Page : 44-48

A worthwhile attempt to remove a bent intra-medullary femoral nail before attempting extensive procedures

SM Shishir, Pascal Noel Deniese, R Kanagasabai, Syed Najimudeen, James J Gnanadoss
Department of Orthopaedics, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission	09-Sep-2015
Date of Acceptance	14-Sep-2015
Date of Web Publication	9-Nov-2015

Correspondence Address:
S M Shishir
Department of Orthopaedics, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
India

Source of Support: None, Conflict of Interest: None

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Abstract

Extraction of the broken/bent nail will be needed in the revision surgery in cases where the fracture is ununited. A broken nail can be removed easily through the fracture site. However, there is no standard protocol that exists in the literature for extraction of a bent nail. We report a case of 5 weeks postoperative bent intra-medullary (IM) interlocking femoral nail in a 33-year-old male who had undergone nailing for femoral shaft fracture, due to a trivial fall during rehabilitation. A radiograph of the affected limb revealed that the IM nail was bent to 30° with a varus deformity. The fracture was still uniting. The nail was unbent after anesthesia and exchange nailing was carried out. A closed manipulation should be attempted prior to any surgical procedure, in order to prevent damage to soft tissue, bone and avoid complications that may arise due to extensive surgery.

Keywords: Bent intra-medullary nail, exchange nailing, femur fracture, nail extraction

How to cite this article:
Shishir S M, Deniese PN, Kanagasabai R, Najimudeen S, Gnanadoss JJ. A worthwhile attempt to remove a bent intra-medullary femoral nail before attempting extensive procedures. J Curr Res Sci Med 2015;1:44-8

How to cite this URL:
Shishir S M, Deniese PN, Kanagasabai R, Najimudeen S, Gnanadoss JJ. A worthwhile attempt to remove a bent intra-medullary femoral nail before attempting extensive procedures. J Curr Res Sci Med [serial online] 2015 [cited 2021 Mar 7];1:44-8. Available from: https://www.jcrsmed.org/text.asp?2015/1/1/44/168923

Introduction

Intra-medullary (IM) interlocking nailing for the treatment of femoral fractures is considered as the gold standard procedure.^[1] A secondary trauma postsurgery to a previously stabilized long bone fracture with an IM nail is very rare.^[2] Such a trauma can result in breakage or bending of the nail at the fracture site if the fracture has not united. A broken nail can be removed easily through the fracture site. However, no standard protocol exists in the literature regarding the removal of bent nails, as very few cases have been documented.^{[3],[4],[5],[6],[7]} Extraction of the bent nail poses an orthopedic challenge. Closed exchange nailing is the preferred method to treat ununited fractures in order to prevent further complications; however, the closed removal of the bent nail can be a very hard task to achieve. Bent nail fails to pass through the IM canal resulting in a mechanical block.

Several case reports have been published regarding different techniques for the removal of a bent femoral nail. Most of these techniques require fracture exposure, special cutting instruments for bone dissection or nail resection resulting in extensive surgical exposure, soft tissue damage, thermal necrosis or metal debris that may affect fracture healing.^{[3],[4],[5],[6],[7]}

In this case report, we present a closed, noninvasive technique to un-bend a femoral nail without opening the fracture, bone resection or nail cutting, followed by exchange nailing.

Case Report

A 33-year-old male patient was treated for a mid-shaft fracture of femur initially with a closed reduction and IM nailing. Five weeks post surgery, during his rehabilitation, he slipped and consequently had severe pain and deformity of the right thigh where the nailing was done [Figure 1]. There were no other associated injuries. The neurovascular status was intact. He presented to us with the complaints of pain, deformity and swelling of the mid-lower 1/3^rd of his right thigh. A plain radiograph of the affected thigh revealed antero-lateral bending of the nail and that the femoral shaft fracture was not united with some attempt to callus formation [Figure 2]. The IM nail had bent to about 30° with a varus angulation, and the continuity of the nail was intact.

Figure 1: Clinical photograph of the patient showing deformity and limb shortening

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Figure 2: Radiographs showing the bent IM nail with 30° varus angulation in an anterior-posterior view (a) and 30° anterior angulation in a lateral view (b)

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Considering the difficulty of removing the bent implant without disturbing the fracture site or performing an extensive osteotomy, meticulous planning was carried out prior to surgery. Techniques of exposing the fracture site and cutting the nail with a rotating carbon saw, placing a locking plate and re-deforming the nail, performing an extensive osteotomy were taken into consideration.

Under general anesthesia, the patient was placed in the supine position on the floor. Closed manipulation of the bent IM nail and femoral deformity using the three-point manoeuvre as described by Patterson and Ramser ^[4] was attempted. The patient was placed on the floor, right thigh abducted, externally rotated and flexed; a sand bag was placed at the apex of the deformity. Using the sand bag as the fulcrum, one assistant stood on the distal thigh and gave a controlled, gentle pressure over the distal femur, distal to the bend. The first attempt did not yield any result. It was decided to try again. This time, the force on the distal thigh was increased. The second assistant who was stabilizing the limb could feel the nail straightening [Figure 3]. The patient was put back on the radiolucent table and the bend was visualized under fluoroscopy [Figure 4] and [Figure 5]. The nail was relatively straightened in situ, which we felt was sufficient for antegrade removal. The interlocking bolts were removed and the bent nail was extracted smoothly through the original incision at the hip [Figure 6] and [Figure 7]. The femoral canal was then reamed to a circumference 1.5 mm greater than the diameter of the original nail, and a new nail, the of same length but 1 mm larger in circumference than the original nail was inserted. After the passage of the new nail, four interlocking bolts were inserted through the new nail as a static mode. The reduction was checked under fluoroscopy and was found to be satisfactory. No additional bone grafting was carried out.

Figure 3: After anesthesia, using the sand bag as the fulcrum, one assistant stood on the distal thigh and gave a controlled, gentle pressure over the distal femur, distal to the bend straightening the nail

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Figure 4: Intra-operative fluoroscopy image showing the straightening of the nail after three point manipulation

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Figure 5: Intra-operative fluoroscopy image showing a small secondary nail bend distal to the fracture site after three point manipulation

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Figure 6: Intra-operative photograph showing antegrade extraction of the bent nail

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Figure 7: The extracted nail with some residual varus deformity

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Postoperatively, there were no complications, and radiographs showed good reduction and the alignment of fracture fragments in the anterior posterior and lateral views [Figure 8]. The patient's deformity was corrected clinically and radiologically [Figure 9]. There was no limb length discrepancy. The patient was started on toe touch mobilization and knee-hip mobilization exercises on day 1 postoperative [Figure 10].

Figure 8: Radiographs showing the exchanged nail without bone grafting (a and b)

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Figure 9: Postoperative clinical photograph showing deformity correction and limb length equalization

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Figure 10: Cross section of the nail after cutting it in vitro with a diamond edge blade to assess the thickness of the nail

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Discussion

IM nailing is the treatment of choice for fracture shaft of the femur, however, the extraction of a bent IM nail can be a difficult task compared to a broken nail as it blocks the IM canal.^{[4],[5],[6],[7]} Bending of the IM nail is relatively rare and occurs after re-injury. Since the femoral nail has a antero-lateral bow, the majority of bending occur in coronal plane with apex of the bent on the antero-lateral side resulting in varus presentation of the lower limb.^[8],[9],[10] The first step in approaching the problem is a well-planned attempt to remove the deformed IM nail. Only a few methods have been described in literature such as manipulation of the bent nail via external force on the femur, percutaneous technique with locking compression plate and collinear reduction clamp, weakening the bent nail using high-speed burr, the sectioning of the nail using diamond edge blades and removal of each piece separately, and the re-bending of the nail with the help of a specialized device and locking plate.^{[3],[4],[5],[6],[7],[8],[9],[10]} Most of these techniques require fracture exposure and are not cost effective. However, there is still no universally accepted method. In 1991, Patterson and Ramser described in situ straightening of a bent Russell–Taylor femoral nail through the application of external force on the femur. However, this technique may not yield results always. Excessive external force applied for straightening the nail may either break the lateral bone cortex or bent the nail in an S-shaped fashion making it further difficult to extract. It may also result in the longitudinal splintering of the bone.^[4]

After reviewing available literature, it was evident that each case was unique and a well devised plan would be required in order to exchange the nail with minimal damage to bone and soft tissue in order to prevent complications such as delayed or nonunion. In our case after much preoperative planning, a decision to try a basic manipulation under anesthesia was attempted and after a few attempts an acceptable re-bending of the nail was achieved followed by exchange nailing. It is necessary to use an image-intensifier to avoid over correction of bend and to avoid iatrogenic fractures.

Conclusion

This technique of manipulation is a simple and effective method for straightening and then removing a bent nail without disruption of the fracture healing, damage of the soft tissues and bone. It also avoids extensive surgery. A closed manipulation should be attempted after anesthesia prior to any surgical procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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