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Use of a Nancy nail to remove a broken intramedullary nail: A technical note
G Model
JINJ-6307; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Use of a Nancy nail to remove a broken intramedullary nail: A technical note Young-Mo Kim a, Yong-Bum Joo b,*, Ki-Young Lee b a b
Department of Orthopedic Surgery, Chungnam National University, School of Medicine, Daejeon, Republic of Korea Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 July 2015
Intramedullary (IM) nailing is a standard surgical technique for treating long bone diaphyseal fractures. However, one complication is breakage of the IM nail. Many methods have been reported for removing broken nails. We devised another technique, using a Nancy nail, for removing a broken IM nail and report on the surgical technique and a case involving the use of our method. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Intramedullary nail Breakage Removal Nancy nail
Introduction Intramedullary (IM) nails are used for the internal fixation of long bone diaphyseal fractures [1]. The breakage of an IM nail is a complication that can occur with unstable fixation or non-union of the fracture [2,3]. Many methods have been reported for removing a broken nail [4–11]. We describe a new technique to remove the distal portion of the broken nail. Case report A 23-year-old man sustained an open segmental fracture of the left tibial shaft in a motorcycle accident (Fig. 1). This was treated with an unreamed IM nail and skin graft surgery at another hospital. He visited our hospital 12 months postoperatively complaining of pain in the left lower leg and a limb length discrepancy. The soft tissue coverage of the left lower leg was poor due to repeated skin surgeries. Plain radiographs showed a smalldiameter IM nail that was broken at its mid-portion (Fig. 2A and B). An orthoroentgenogram showed an approximately 2 cm limb length discrepancy (Fig. 2C). We concluded that the non-union and nail breakage were due to unstable fixation and planned to replace the implant with a nail with a thicker diameter. Although there was no soft tissue inflammation, the condition of the skin and soft tissues was poor, limiting open surgery.
* Corresponding author at: Department of Orthopedic Surgery, Chungnam National University, School of Medicine, 33 Munwha-ro, Jung-gu, Daejeon 301-721, Republic of Korea. Tel.: +82 42 338 2412; fax: +82 42 252 7098. E-mail address: [email protected] (Y.-B. Joo).
The patient was placed in a supine position on a radiolucent table. First, we removed proximal interlocking screws and the proximal portion of the broken nail using the standard method, and we then measured the nail: the outer diameter was 8 mm and the inner diameter was 4 mm (Fig. 3). Considering the inner diameter of the IM nail, we used a 4-mmdiameter Nancy nail (Synthes1, Oberdorf, Switzerland) (Fig. 4A). The surface of the distal 5 cm of the Nancy nail was ground in a circular manner using a diamond burr (Fig. 4B). We ground down the surface of the Nancy nail, testing whether it could be inserted firmly in the proximal portion of the nail to be removed (Fig. 4C). To achieve firm impaction, our technical tip is that the nail be trimmed gradually. After testing impaction in the proximal portion of the broken nail and confirming firm fixation (Fig. 4D), the Nancy nail was passed through the tibial medullary canal under guidance of a C-arm and impacted in the distal portion of the broken nail. Handling was facilitated by using the T-handle that comes in the Nancy nail set. When pushing the Nancy nail into the distal portion of the broken nail, the distal locking screw must be left in place to prevent the distal nail from being pushed downwards. After confirming that sufficient impaction was attained, the distal locking screw was removed. No additional reaming was required to remove the broken nail, which was extracted with rotatory movements of the Nancy nail (Figs. 5 and 6). Without bone grafting, sufficient medullary reaming was performed up to the distal aspect of the site of nonunion. The original 8-mm-diameter nail was replaced with a thicker 11-mmdiameter nail. We could observe the bony union at radiographs taken 8 months postoperatively (Fig. 7).
http://dx.doi.org/10.1016/j.injury.2015.07.023 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
G Model
JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. A 23-year-old male sustained left lower leg injuries in a motorcycle accident. Radiographs showed a segmental tibial shaft fracture with a distal fibular fracture.
Discussion Intramedullary nailing is the standard surgical technique for treating long bone diaphyseal fractures because it is a minimally
invasive technique that allows early ambulation and has a low complication rate [1]. One rare complication is breakage of the IM nail, and various methods for removing the distal broken nail have been reported [4–11].
Fig. 2. Radiographs taken 12 months postoperatively show the unsuccessful results. (A) Anteroposterior view and (B) lateral view: the tibial shaft fracture did not unite, and breakage of the nail was seen (white arrow). (C) An orthoroentgenogram shows the shortened left tibia, with a limb length discrepancy of about 2 cm due to varus angulation at the fracture site.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
G Model
JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 3. After removing the proximal portion of the broken nail using the standard method, we measured the nail. The outer diameter was 8 mm and the inner diameter was 4 mm.
We encountered a breakage of an IM nail used to treat a tibial shaft fracture and devised a technique for removing the broken nail using a Nancy nail. Some methods similar to our technique have been reported; these involved the extraction of the broken nail using some kind of nail [10,11]. Middleton et al. [10] removed the broken nail by impacting olive-tipped guidewires into the distal fragment of the broken nail. To facilitate removal of the nail fragment, the shaft proximal to the nail fragment was reamed, and the multiple olive-tipped guidewires were then inserted to achieve a firm grip. Steinberg et al. [11] removed the distal portion by inserting a Ku¨ntscher nail. In this technique, a 3.5-mm Steinmann pin was inserted in one of the distal locking screw holes, and the proximal medullary canal was reamed to a diameter larger than that of the broken nail. Then, an 8–10-mm-diameter Ku¨ntscher nail was inserted into the distal broken nail. The differences between these methods and ours include (1) the end of the Nancy nail was trimmed using a burr to obtain firm engagement in the distal broken nail, (2) the distal locking screw was left in place to ensure that the distal broken nail was not
Fig. 5. The distal portion of the broken nail was extracted using the Nancy nail under C-arm guidance.
Fig. 6. A photograph of the removed broken IM nail.
pushed downward during impaction of the Nancy nail, and (3) the broken fragment was removed through the existing medullary canal without additional reaming. Although we were able to remove the broken nail without additional reaming because the nail diameter was small and the Nancy nail was impacted sufficiently firmly, additional reaming might be needed if it is difficult to extract the nail.
Fig. 4. Preparation of the Nancy nail used to remove the distal portion of the broken nail. (A) The size of the Nancy nail was 4(diameter) 450(length) mm. (B) The surface of the distal 5 cm of the Nancy nail was ground superficially using a diamond burr. (C) Nancy nail was trimmed stepwise using the burr until it could be firmly impacted in the canal of the removed proximal portion of the broken nail. (D) On testing, firm fixation was achieved with regard to the impaction of the Nancy nail in the removed proximal portion of the broken nail.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
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JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
Fig. 7. Radiographs taken 8 months after renailing show bony consolidation at the fracture site: anteroposterior (left) and lateral (right) views.
The Nancy nail has sufficient length (450 mm) to reach the distal broken nail and is available in various diameters (2, 2.5, 3, 3.5, and 4 mm), making it useful for removing broken nails of different lengths and diameters. In addition, a Nancy nail is flexible and comes with a T-handle, facilitating its insertion. Our method could also be applied to a broken femoral nail. In conclusion, the Nancy-nail technique is a simple, useful method for removing a broken intramedullary nail. Conflict of interest statement There are no financial or personal conflicts to disclose. References [1] Charles MC, James DH, Margaret MM, William MR, Paul Tornetta III, editors. 8th ed, Rockwood and Green’s fractures in adults, vol. 2, 8th ed 2010. p. 2431– 48.
[2] Zimmerman KW, Klasen HJ. Mechanical failure of intramedullary nails after fracture union. J Bone Joint Surg 1983;65:274–5. [3] Franklin JL, Winquist RA, Benirschke SK, Hansen Jr ST. Broken intramedullary nails. J Bone Joint Surg Am 1988;70(10):1463–71. [4] Levine JW, Georgiadis GM. Removal of a broken cannulated tibial nail: a simple intramedullary technique. J Orthop Trauma 2004;18:247–9. [5] Giannoudis PV, Matthews SJ, Smith RM. Removal of the retained fragment of broken solid nails by the intra-medullary route. Injury 2001;32:407–10. [6] Levy O, Amit Y, Velkes S, Horoszowski H. A simple method for removal of a fractured intramedullary nail. Bone Joint Surg BR 1994;761:502. [7] Brewster NT, Ashcroft GP, Scotland TR. Extraction of broken intramedullary nails: an improvement in technique. Injury 1995;26(4):286. [8] Charnley GJ, Farrington WJ. Laparoscopic forceps removal of a broken tibial intramedullary nail. Injury 1998;29:489–90. [9] Marwan M, Ibrahim M. Simple method for retrieval of distal segment of the broken interlocking intra-medullary nail. Injury 1999;30:333–5. [10] Middleton RG, McNab IS, Hashemi-Nejad A, Noordeen NH. Multiple guidewire technique for removal of the short distal fragment of a fractured intramedullary nail. Injury 1995;26:531–2. [11] Steinberg EL, Luger E, Menahem A, Helfet DL. Removal of a broken distal closed section intramedullary nail: report of a case using a simple method. J Orthop Trauma 2004;18:233–5.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
JINJ-6307; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical Note
Use of a Nancy nail to remove a broken intramedullary nail: A technical note Young-Mo Kim a, Yong-Bum Joo b,*, Ki-Young Lee b a b
Department of Orthopedic Surgery, Chungnam National University, School of Medicine, Daejeon, Republic of Korea Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 July 2015
Intramedullary (IM) nailing is a standard surgical technique for treating long bone diaphyseal fractures. However, one complication is breakage of the IM nail. Many methods have been reported for removing broken nails. We devised another technique, using a Nancy nail, for removing a broken IM nail and report on the surgical technique and a case involving the use of our method. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Intramedullary nail Breakage Removal Nancy nail
Introduction Intramedullary (IM) nails are used for the internal fixation of long bone diaphyseal fractures [1]. The breakage of an IM nail is a complication that can occur with unstable fixation or non-union of the fracture [2,3]. Many methods have been reported for removing a broken nail [4–11]. We describe a new technique to remove the distal portion of the broken nail. Case report A 23-year-old man sustained an open segmental fracture of the left tibial shaft in a motorcycle accident (Fig. 1). This was treated with an unreamed IM nail and skin graft surgery at another hospital. He visited our hospital 12 months postoperatively complaining of pain in the left lower leg and a limb length discrepancy. The soft tissue coverage of the left lower leg was poor due to repeated skin surgeries. Plain radiographs showed a smalldiameter IM nail that was broken at its mid-portion (Fig. 2A and B). An orthoroentgenogram showed an approximately 2 cm limb length discrepancy (Fig. 2C). We concluded that the non-union and nail breakage were due to unstable fixation and planned to replace the implant with a nail with a thicker diameter. Although there was no soft tissue inflammation, the condition of the skin and soft tissues was poor, limiting open surgery.
* Corresponding author at: Department of Orthopedic Surgery, Chungnam National University, School of Medicine, 33 Munwha-ro, Jung-gu, Daejeon 301-721, Republic of Korea. Tel.: +82 42 338 2412; fax: +82 42 252 7098. E-mail address: [email protected] (Y.-B. Joo).
The patient was placed in a supine position on a radiolucent table. First, we removed proximal interlocking screws and the proximal portion of the broken nail using the standard method, and we then measured the nail: the outer diameter was 8 mm and the inner diameter was 4 mm (Fig. 3). Considering the inner diameter of the IM nail, we used a 4-mmdiameter Nancy nail (Synthes1, Oberdorf, Switzerland) (Fig. 4A). The surface of the distal 5 cm of the Nancy nail was ground in a circular manner using a diamond burr (Fig. 4B). We ground down the surface of the Nancy nail, testing whether it could be inserted firmly in the proximal portion of the nail to be removed (Fig. 4C). To achieve firm impaction, our technical tip is that the nail be trimmed gradually. After testing impaction in the proximal portion of the broken nail and confirming firm fixation (Fig. 4D), the Nancy nail was passed through the tibial medullary canal under guidance of a C-arm and impacted in the distal portion of the broken nail. Handling was facilitated by using the T-handle that comes in the Nancy nail set. When pushing the Nancy nail into the distal portion of the broken nail, the distal locking screw must be left in place to prevent the distal nail from being pushed downwards. After confirming that sufficient impaction was attained, the distal locking screw was removed. No additional reaming was required to remove the broken nail, which was extracted with rotatory movements of the Nancy nail (Figs. 5 and 6). Without bone grafting, sufficient medullary reaming was performed up to the distal aspect of the site of nonunion. The original 8-mm-diameter nail was replaced with a thicker 11-mmdiameter nail. We could observe the bony union at radiographs taken 8 months postoperatively (Fig. 7).
http://dx.doi.org/10.1016/j.injury.2015.07.023 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
G Model
JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Fig. 1. A 23-year-old male sustained left lower leg injuries in a motorcycle accident. Radiographs showed a segmental tibial shaft fracture with a distal fibular fracture.
Discussion Intramedullary nailing is the standard surgical technique for treating long bone diaphyseal fractures because it is a minimally
invasive technique that allows early ambulation and has a low complication rate [1]. One rare complication is breakage of the IM nail, and various methods for removing the distal broken nail have been reported [4–11].
Fig. 2. Radiographs taken 12 months postoperatively show the unsuccessful results. (A) Anteroposterior view and (B) lateral view: the tibial shaft fracture did not unite, and breakage of the nail was seen (white arrow). (C) An orthoroentgenogram shows the shortened left tibia, with a limb length discrepancy of about 2 cm due to varus angulation at the fracture site.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
G Model
JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 3. After removing the proximal portion of the broken nail using the standard method, we measured the nail. The outer diameter was 8 mm and the inner diameter was 4 mm.
We encountered a breakage of an IM nail used to treat a tibial shaft fracture and devised a technique for removing the broken nail using a Nancy nail. Some methods similar to our technique have been reported; these involved the extraction of the broken nail using some kind of nail [10,11]. Middleton et al. [10] removed the broken nail by impacting olive-tipped guidewires into the distal fragment of the broken nail. To facilitate removal of the nail fragment, the shaft proximal to the nail fragment was reamed, and the multiple olive-tipped guidewires were then inserted to achieve a firm grip. Steinberg et al. [11] removed the distal portion by inserting a Ku¨ntscher nail. In this technique, a 3.5-mm Steinmann pin was inserted in one of the distal locking screw holes, and the proximal medullary canal was reamed to a diameter larger than that of the broken nail. Then, an 8–10-mm-diameter Ku¨ntscher nail was inserted into the distal broken nail. The differences between these methods and ours include (1) the end of the Nancy nail was trimmed using a burr to obtain firm engagement in the distal broken nail, (2) the distal locking screw was left in place to ensure that the distal broken nail was not
Fig. 5. The distal portion of the broken nail was extracted using the Nancy nail under C-arm guidance.
Fig. 6. A photograph of the removed broken IM nail.
pushed downward during impaction of the Nancy nail, and (3) the broken fragment was removed through the existing medullary canal without additional reaming. Although we were able to remove the broken nail without additional reaming because the nail diameter was small and the Nancy nail was impacted sufficiently firmly, additional reaming might be needed if it is difficult to extract the nail.
Fig. 4. Preparation of the Nancy nail used to remove the distal portion of the broken nail. (A) The size of the Nancy nail was 4(diameter) 450(length) mm. (B) The surface of the distal 5 cm of the Nancy nail was ground superficially using a diamond burr. (C) Nancy nail was trimmed stepwise using the burr until it could be firmly impacted in the canal of the removed proximal portion of the broken nail. (D) On testing, firm fixation was achieved with regard to the impaction of the Nancy nail in the removed proximal portion of the broken nail.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023
G Model
JINJ-6307; No. of Pages 4 Y.-M. Kim et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
Fig. 7. Radiographs taken 8 months after renailing show bony consolidation at the fracture site: anteroposterior (left) and lateral (right) views.
The Nancy nail has sufficient length (450 mm) to reach the distal broken nail and is available in various diameters (2, 2.5, 3, 3.5, and 4 mm), making it useful for removing broken nails of different lengths and diameters. In addition, a Nancy nail is flexible and comes with a T-handle, facilitating its insertion. Our method could also be applied to a broken femoral nail. In conclusion, the Nancy-nail technique is a simple, useful method for removing a broken intramedullary nail. Conflict of interest statement There are no financial or personal conflicts to disclose. References [1] Charles MC, James DH, Margaret MM, William MR, Paul Tornetta III, editors. 8th ed, Rockwood and Green’s fractures in adults, vol. 2, 8th ed 2010. p. 2431– 48.
[2] Zimmerman KW, Klasen HJ. Mechanical failure of intramedullary nails after fracture union. J Bone Joint Surg 1983;65:274–5. [3] Franklin JL, Winquist RA, Benirschke SK, Hansen Jr ST. Broken intramedullary nails. J Bone Joint Surg Am 1988;70(10):1463–71. [4] Levine JW, Georgiadis GM. Removal of a broken cannulated tibial nail: a simple intramedullary technique. J Orthop Trauma 2004;18:247–9. [5] Giannoudis PV, Matthews SJ, Smith RM. Removal of the retained fragment of broken solid nails by the intra-medullary route. Injury 2001;32:407–10. [6] Levy O, Amit Y, Velkes S, Horoszowski H. A simple method for removal of a fractured intramedullary nail. Bone Joint Surg BR 1994;761:502. [7] Brewster NT, Ashcroft GP, Scotland TR. Extraction of broken intramedullary nails: an improvement in technique. Injury 1995;26(4):286. [8] Charnley GJ, Farrington WJ. Laparoscopic forceps removal of a broken tibial intramedullary nail. Injury 1998;29:489–90. [9] Marwan M, Ibrahim M. Simple method for retrieval of distal segment of the broken interlocking intra-medullary nail. Injury 1999;30:333–5. [10] Middleton RG, McNab IS, Hashemi-Nejad A, Noordeen NH. Multiple guidewire technique for removal of the short distal fragment of a fractured intramedullary nail. Injury 1995;26:531–2. [11] Steinberg EL, Luger E, Menahem A, Helfet DL. Removal of a broken distal closed section intramedullary nail: report of a case using a simple method. J Orthop Trauma 2004;18:233–5.
Please cite this article in press as: Kim Y-M, et al. Use of a Nancy nail to remove a broken intramedullary nail: A technical note. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.07.023