Bent Femoral Nail Removal Technique: An Illustrative Case Report

T Revanth¹ https://orcid.org/0009-0001-5015-8717, Giriraj Harshavardhan² https://orcid.org/0000-0001-6683-3468

¹Department of Orthopaedics, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India

²Department of Orthodontics, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India

Corresponding Author: T Revanth, Department of Orthopaedics, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India, Phone: +91 7502980231, e-mail: revarevanth124@gmail.com

Received: 25 December 2023; Accepted: 20 January 2024; Published on: 14 Jane 2024

ABSTRACT

Long bone fractures are more commonly treated by intramedullary nailing for their advantages, such as minimal soft tissue damage, reduced blood loss, and early mobilization. Despite that it has some complications like infection, bleeding, neurovascular deficit, nonunion, malunion. One of the rare complications is in situ bending of nails. In such cases, the removal of the failed implant and re-stabilization of the fracture will be required. In the literature, several extraction techniques and algorithms are available for the removal of such implants. However, there is no specific protocol or guidelines for selecting a particular technique. It depends on the patient, surgeon, and availability of instruments.

How to cite this article: Revanth T, Harshavardhan G. Bent Femoral Nail Removal Technique: An Illustrative Case Report. J Orth Joint Surg 2024;6(2):184–186.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Bent nail removal, Case report, Femoral nail rare complication, Various methods of intramedullary nail removal

INTRODUCTION

Nail bending is a complication of intramedullary nailing that occurs for various reasons. Here, we present a case of a 30-year-old male who presented with a bent femoral nail in situ, which was successfully removed using a hacksaw blade and carbide drill bit.

CASE DESCRIPTION

A 30-year-old male came to the hospital with complaints of pain and deformity over the left thigh for 10 days following a trivial fall at his residence. Around 2 months ago, he had met with a road traffic accident and sustained a left shaft of femur fracture for which he underwent indigenous splinting initially. As the fracture did not unite, open reduction and intramedullary interlocking nailing were done elsewhere. An 8 × 380 mm solid stainless steel pyriform fossa femur intramedullary nail was used. He was mobilizing with walker support. At around 7 weeks after the surgery, he again sustained a fall at his residence and developed pain and deformity over his left thigh. On examination, there was a significant varus deformity of the left thigh (Fig. 1). The previous surgical scars had healed well. There was tenderness over the fracture site but no abnormal mobility. He had a full range of motion of the knee. Radiological findings showed an intact but bent nail with a fracture gap still visible (Fig. 2). He was planned for implant removal and refixation.

Fig. 1: Clinical picture of the patient with varus deformity

Fig. 2: X-ray of left femur AP/lateral showing bent femoral nail with femur nonunion

A thorough preoperative planning was done. The only option to remove the bent but solid nail would be to cut the nail at the bent region and then remove the proximal and distal fragments of the nail. The difficulty in removing the distal fragment of the nail if it would be tight was also anticipated. The instruments needed for cutting and removing the nail were arranged (Table 1).

**Table 1:** Things to be kept ready
1	Hacksaw blade (at least three)
2	Carbide drill bit
3	Broken screw removal set
4	Universal nail removal set
5	Chisel
6	Broken nail impactor

Under spinal anesthesia, the patient was positioned in the right lateral position. The fracture site was exposed by direct lateral approach through a previous surgical scar. Luckily, the patient was also thin. A fracture site was identified, and a bent portion of the nail was exposed (Fig. 3). The entry site of the nail was exposed through the previous surgical scar proximal to the greater trochanter. The proximal end of the nail was identified in the pyriform fossa. The extraction bolt was inserted into the nail and tightened. The bent portion of the nail was cut with a hacksaw blade, as illustrated (Fig. 4). Nearly three-fourths of the diameter of the solid nail was cut. We were able to straighten the nearly cut nail by manual force. We could have removed the partially cut straightened nail as a whole by using the extraction device and slap hammer, but we were worried whether the nail might completely break in the proximal fragment during removal (which would the removal more difficult). Hence we decided to completely transect the nail. We tried using the same hacksaw blade, but the edge of the blade got blunt, and hence, we could not fully cut it (it is advisable to keep an extra hacksaw blade by your side to avoid this issue). We used a carbide drill bit to drill into the partially cut portion of the nail to further weaken it. When weakening the nail with the carbide drill bit, we were able to cut the nail fully with the hacksaw blade. During the whole procedure, two Hohmann retractors were placed under the bent portion of the nail and fracture site and used as a soft tissue protector. Metal debris was washed and suctioned frequently.

Fig. 3: Intraoperative picture showing fracture nonunion with nail in situ

Fig. 4: Cutting of bent femoral nail using a hacksaw blade

The proximal portion of the nail was removed using an extraction device and slap hammer after removing the proximal bolt. Luckily, the distal portion of the nail was loose and easily pulled out after the bolts had been removed (Fig. 5). We were prepared with a broken nail impactor tool to remove the distal part of the nail if it was tightly fitting (Fig. 6). The instrument is inserted retrograde through the knee in line with the nail, and then the distal part of the nail should be hammered out into the fracture site. After the successful removal of the bent nail, renailing and bone grafting was done.

Fig. 5: Intraoperative picture of cut bent femoral nail

Postoperative (post-op) wound check and check X-ray were done and found to be satisfactory (Fig. 7). He was started on in-bed mobilization and knee and ankle ROM exercises. He was discharged on post-op day 4.

DISCUSSION

Since bending a nail is a rare complication, there have been few reported cases. Various techniques have been described. Kose et al.¹ reported two cases with bent nails, and based on a systematic review of the literature, the authors devised an algorithm for the removal of the same. A bent nail of angle <20 will not be subjected to any manipulation and removed as it is, but there is always a risk of refracture and soft tissue damage. If the angle is >20, then at first, the nail is subjected to closed removal techniques by straightening the nail by external manipulation using the perineal post as fulcrum. Partial weakening by using a drill bit percutaneously and external manipulation can also be tried. If closed/percutaneous techniques do not work, then the apex site is opened for transecting the nail or straightening by plate and bone holder technique or by creating a longitudinal window. There are various techniques to transect the bent nail, which include a hacksaw blade, titanium/diamond-tipped/carbide/dental drill bit, and jumbo cutter. Menica² and Nicolaides et al.³ used a hacksaw. Dhanda et al.⁴ used a jumbo cutter. Bielejeski and Garrick⁵ and Lasalle and Horwitz⁶ used a dental burr. We sterilized a hacksaw blade using the ethylene oxide method and a carbide drill bit. Even though there are risks of soft tissue injury and collection of metal debris, they were tackled by appropriate placement of Hohmanns retractors and frequent suctioning of the debris. The hacksaw blade tends to become blunt within a few minutes of use. It is important to keep at least three blades ready so that the nail can be cut without much effort. The carbide drill bit can be used to weaken the nail to facilitate cutting the nail.

Fig. 6: Postoperative X-ray of left femur AP/lateral with nail in situ

Fig. 7: Broken nail impactor

CONCLUSION

Various techniques for the removal of bent nails are described. The bent nail can be cut and removed relatively easily and cost-effectively using a hacksaw blade and carbide drill bit.

ORCID

T Revanth https://orcid.org/0009-0001-5015-8717

Giriraj Harshavardhan https://orcid.org/0000-0001-6683-3468

REFERENCES

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2. Mencia MM, Moonsie R. Removing a bent femoral nail - man versus metal: a case report. Int J Surg Case Rep 2022;99:107679. DOI: 10.1016/j.ijscr.2022.107679

3. Nicolaides V, Polyzois V, Tzoutzopoulos A, et al. Bent femoral intramedullary nails: a report of two cases with need for urgent removal. Eur J Orthop Surg Traumatol 2004;14(3):188–191. DOI: 10.1007/s00590-004-0146-1

4. Dhanda MS, Madan HS, Sharma SC, et al. Jumbo cutter for removal of a bent femoral interlocking nail: a cost effective method. J Clin Diagn Res 2015;9(6):RD06–RD07. DOI: 10.7860/JCDR/2015/13824.6055

5. Bielejeski T, Garrick JG. Method of cutting in situ metallic appliances. J Bone Joint Surg Am 1970;52(3):585–587.

6. LaSalle WB, Horwitz T. A method to cut and remove in situ bent intramedullary nail. Clin Orthop Relat Res 1974;(103):30–31. DOI: 10.1097/00003086-197409000-00017

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