Ava Monroe
Removing a broken femoral nail can be a challenging procedure for orthopaedic surgeons, who should be familiar with a variety of techniques. Broken femoral nails are usually the result of femoral re-injury, which can occur after surgery or due to dangerous sports, traffic accidents, or falls. There are several methods for removing broken femoral nails, including custom-made and long hooks, proximal stacked wires, and multiple guide wires. In this article, we will explore some of these techniques and discuss the benefits and limitations of each approach.
Characteristics and Values of Broken Femoral Nail Removal Techniques
| Characteristics | Values |
|---|---|
| Procedure type | Challenging, requiring familiarity with multiple techniques |
| Nail type | Cannulated, intramedullary, proximal femoral nail (PFN) |
| Patient position | Supine on a fracture table, straight lateral using a beanbag |
| Anaesthesia | General |
| Incisions | Pre-existing incisions preferred, longitudinal over adductor tubercle, extended into periosteum |
| Tools | Guide wires, guide pins, cerclage wire, fluoroscopic image, cone-shaped femoral extractor, slotted mallet, Mayo scissors |
| Technique | Stuffing the nail with guide wires, retrograde removal, knotting wire, bone window, marrow cavity |
| Time | 30 minutes to 110 minutes |
| Post-operative care | Irrigation, wound closure, postoperative imaging |
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What You'll Learn
Using a cerclage wire to hold the nail fragment
Proximal femoral nail (PFN) fixation is a widely used technique for treating femoral fractures. However, femoral re-injury can occur, leading to PFN breakage. Broken nail removal, especially of distal broken nails, is typically challenging.
A novel, feasible, rapid, and cost-effective technique for removing broken femoral intramedullary nails involves using a cerclage wire. This method was successfully used on three patients and does not require any other extraction device.
To use this technique, a sterilized medical-grade cerclage wire (2.0 mm in diameter, Baoji Langtai Titanium, BLTi, China) is inserted via the C-arm until it crosses the broken section of the nail and reaches the distal opening of the PFN. A distal knot is then tied on the wire to hold the distal PFN fragment securely. The knot should not be too sharp to avoid damaging the surrounding tissues.
With the knot in place, the removal trajectory is completed through minimal exposure, a distal femoral bone window located superiorly to the medial femoral condyle, and the femoral marrow cavity. This technique allows for the rapid and effective removal of PFN fragments.
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Removing locking screws and broken nail segments
Patient Positioning:
Place the patient in a supine position on a fracture table, similar to ordinary proximal femoral fracture surgery. Ensure the patient is under general anesthesia to ensure comfort during the procedure.
Incision and Exposure:
Make incisions over the affected area to expose the broken nail and locking screws. Whenever possible, utilize pre-existing incisions to minimize additional trauma.
Locking Screw Removal:
Identify and remove the locking screws that are holding the broken nail segment in place. This step may involve using specialized tools to grasp and extract the screws, ensuring they are removed safely and efficiently.
Guidewire Insertion:
Insert a guidewire in a retrograde manner through the screw hole below the distal end of the broken nail. Choose an appropriate guidewire size to avoid adverse effects on the medullary canal. The guidewire should be carefully manipulated to cross the broken section of the nail and reach the distal opening.
Stabilization and Extraction:
Hold the proximal portion of the guidewire firmly with a pin vise or similar tool. Apply gentle hammer blows to stabilize the guidewire and create a purchase point for nail extraction. Then, use appropriate extraction tools, such as a conical, threaded extraction device, to engage the broken nail segment. This device can be attached to a bar and impacted with a slotted mallet to facilitate removal.
Wound Closure:
Once the broken nail segment and locking screws have been removed, irrigate and close the wound following standard surgical procedures. Ensure that all instruments are accounted for, and the patient is monitored post-operatively for a successful recovery.
These steps provide a general framework for removing locking screws and broken femoral nail segments. Surgeons should adapt these techniques based on the specific circumstances of each case, utilizing their expertise and available resources to ensure a safe and effective procedure.
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Using a guide wire to direct the extractor into place
Using guide wires to direct the extractor is a common technique for removing broken femoral nails. This technique can be used for narrow cannulated nails, providing superior purchase along the length of the nail, easy wire insertion, and limited soft tissue damage.
To begin, two guide wires with a combined diameter slightly greater than the nail cavity are selected. This allows the wires to be jammed in the cavity, enabling easy removal of the nail as one unit. The second guide wire is then reversed so that the pointed end is inserted, providing purchase along the length of the wire rather than just at the olive tip ends, which can easily slide. The guide wires are then bent to facilitate insertion into the proximal nail cavity, which can be difficult to visualise under direct vision, especially in narrow cavity nails.
Once the guide wires are prepared, the first guide wire is inserted into the remaining broken nail under Image Intensifier (II) guidance. The guide wire is progressed until it protrudes 1 cm at the distal end. A wire grasper is then fed up the second guide wire, and a mallet is used to force the second guide wire into the nail until it cannot progress further. With continued strikes of the mallet on the opposite side of the grasper, both guide wires and the nail can be removed together.
In another variation of this technique, a ball-tipped guide wire is used to extract the broken femoral nail. The ball-tipped guide wire is held in place within the canal using a screw inserted through the nail distal locking hole. This method, however, is not suitable if the nail canal is too narrow for the screw and wire to fit together inside.
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Using a universal extraction tool
The third-generation universal femoral nail extraction tool is a conical, threaded extraction device that can be attached to a bar for impaction with a slotted mallet. The device features a cannulated extraction head that can accommodate a standard 3.2-mm guide pin or guidewire.
To remove a broken femoral nail using this tool, the patient is first placed in the straight lateral position using a positioning device like a beanbag on a radiolucent operating table. The entire leg, lateral buttock, and torso up to the ribs are prepared for the procedure. The leg is draped to allow full hip and knee motion for positioning. The hip is flexed to almost 90 degrees, and the proximal and distal locking screws are removed in the standard fashion.
A guidewire is then placed on the thigh, and a fluoroscopic image of the proximal hip is obtained. The wire is adjusted to coincide with the femoral nail on the lateral view. A line is drawn along the wire, extending it onto the buttock. The thigh is then externally rotated, and a line is marked in a similar fashion to determine the anteroposterior nail position. The intersection of these two lines indicates the site of the incision for placing the extractor.
Once the incision site is determined, the wound is expanded using large Mayo scissors. The scissors are used to hold the wound open, and a 3.2 guidewire is inserted along the scissors until it touches the nail. The scissors are removed, and the guide pin is adjusted until it advances into the nail. Anteroposterior and lateral images of the hip are obtained to confirm the placement of the guidewire into the nail.
The cone-shaped femoral extractor is then inserted into the wound, over the guide pin. The extractor is gently but forcefully screwed into the nail. While the first pass may not fully engage the nail, it will remove much of the interposed soft tissue. The extractor is reinserted over the guide pin or wire and tightened onto the nail with sufficient force to require the use of wrenches. Finally, a slotted mallet is used to hammer out the nail. The wound is then irrigated and closed in the standard fashion.
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Stuffing the nail with guide wires
Stuffing the nail is a simple, effective, and cost-effective technique for the extraction of a broken femoral nail. This technique uses two guide wires of variable diameter and has several key points of differentiation from previous methods.
Firstly, the guide wires selected should have a combined diameter greater than that of the nail cavity, preferably 0.5 mm greater. This results in the jamming of the second guide wire in the cavity, allowing both wires and the nail to be removed easily as one unit on extraction. This technique can be easily adjusted for different nails according to the internal diameter of the nail.
Secondly, this method requires reversing the second guide wire so that the pointed end is inserted instead of the olive tip end. This allows the method to be used in narrow-diameter hollow nails and for purchase of the nail along the length of the second guide wire, not just at the olive tip ends which can easily slide.
Finally, the guide wires are bent to allow for ease of insertion into the proximal nail cavity, which is often difficult to visualise under direct vision and can pose a challenge in narrow cavity nails.
The first guide wire is then inserted olive tip first into the remaining broken nail under image intensifier (II) guidance. Once in the inner cavity, the guide wire is progressed until it protrudes 1 cm at the distal end. A wire grasper is then fed up the second guide wire before insertion into the proximal end of the nail with the pointed end. A mallet is then struck against the wire grasper to force the second guide wire into the nail until it cannot go any further. The mallet is then reversed, and while striking the other side of the grasper, both guide wires and the nail will come out together in a few strikes.
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