Incarcerated Tibial Nail

Abstract

Removal of intramedullary nails is considered a routine procedure but may prove to be challenging. Bone ongrowth or overgrowth, damage to the proximal threads of the nail, and broken nails or locking screws may complicate intramedullary nail removal. This article presents a case of a 28-year-old patient with an incarcerated tibial nail and describes a salvage procedure for tibia nail extraction after all previously described methods have failed. The authors recommend that no excessive force be used to extract an incarcerated nail but to approach the problem in a step-wise fashion. If the nail is still incarcerated and will not move, the tibia needs to be completely open by removing a one-third of circumference longitudinal bone window. It is important to discuss all the possible options with the patient during the consent. The patient may not be aware of the difficulties that can be encountered during nail removal and the fact that it may necessitate a major procedure followed by a prolonged recovery time. It is important to ascertain the reason for nail removal and whether it is necessary to implement even drastic measures to do so. Infection, nonunion, deformity or refracture requiring fixation are indications for nail removal.

Removal of intramedullary nails is considered a routine procedure but may prove to be challenging. Bone ongrowth or overgrowth, damage to the proximal threads of the nail, and broken nails or locking screws may complicate the removal of intramedullary nails. Multiple techniques including universal extraction sets, guide wires with hooks, and multiple guide wires have been described.^1-9 This article presents a case of an incarcerated tibial nail and describes a salvage procedure for tibia nail extraction after all previously described methods have failed.

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Case Report

A 28-year-old man presented with chronic leg pain after a tibial intramedullary nail placement. The patient sustained a left open tibia fracture in a motorcycle accident 3 years prior while in active military duty in Japan. He underwent a total of 6 surgeries for the treatment of an open fracture including final fixation with an intramedullary nail (Synthes Universal Tibia Nail; Synthes, Paoli, Pennsylvania).

The patient was pain free for 1 year; however, 6 months prior to evaluation the patient had increasing severe pain with physical activity limiting the activities of daily living.

As part of the initial evaluation, an infection workup was obtained including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and a tagged white cell bone scintigraphy, which were all negative for infection (CRP 0.1, ESR 8).

On physical examination, the patient had a well-healed surgical incision in the left leg. Prominent callus formation was noted at the fracture site with minimal tenderness to palpation in this area as well as tenderness over the most distal interlocking screw. The left knee was stable in varus and valgus with full range of motion and a negative Lachman test. The ipsilateral ankle had full range of motion and was stable. Neurovascular examination was normal. Overall alignment of the extremity was anatomic.

Preoperative radiographs showed a healed tibia and fibula fractures in all 4 cortices, an intramedullary nail with proximal, distal interlocking screws in place, and cortical thickening at the fracture site.

The possible but unlikely association of leg pain and retained hardware were discussed with the patient. The patient was also informed that in the absence of signs of infection there was no indication for nail removal. The patient opted to have the nail removed so he could return to full military duty. The surgical risks were discussed extensively with the patient, as well as other risks, including continued pain after hardware removal and failure to remove the nail.

Figure 1: Distal end of the nail with the slot that ends at the proximal margin of the distal hole.

The left lower extremity was prepared and draped. A proximal tourniquet was placed on the thigh and inflated to 250 mm Hg. Using fluoroscopy the proximal interlocking screw was removed. The tip of the distal blocking screw was inside the fibula and broken through the distal tibiofibular joint. Using the Anspach high speed burr, a hole was created in the fibula and the broken screw was removed. A midline approach over the knee was performed using the previous surgical incision. The patellar tendon was retracted laterally after opening the paratenon on the medial side. The proximal tip of the nail was found seated deep in the medullary canal. With difficulty, the conical extraction device was engaged after the overgrowth bone was removed.

Figure 2: Bone ingrowth into the nail preventing passage of the guide wire through the nail.

Several attempts to extract the nail were unsuccessful and finally the connector broke. Attempts to place a guide wire into the nail failed due to bone ingrowth into the nail canal. A proximal and anterior medial window of approximately 4 cm was created using the Anspach burr. An extractor hook was engaged in the proximal interlocking holes, however the nail did not move after multiple attempts. At this point the decision was made to extend the osteotomy. Again the Anspach burr was used, and an anteromedial window of one third of the tibial circumference was created from proximal to distal.

The nail was found to be seated solidly in place with bone overgrowth and ongrowth in a circumferential fashion for most of its length, without any membranous interface between the bone and the nail. A new attempt to hammer the nail also failed. The bone surrounding the nail was removed using the burr and osteotomes. After extensive release, the nailed started to move and was eventually hammered out using a hook secured with a vice grip.

On inspection of the extracted nail, islands of bone appeared solidly attached to the nail without any membranous interface (Figure 1). An attempt to pass a guide wire through the nail failed due to solid bone ingrowth (Figure 2). Bone samples were sent for culture and pathology.

Copious irrigation of the entire wound (Figure 3) was performed and the tourniquet was released after 150 minutes. A quarter inch suction drain was placed and the wound was closed in layers using 2/0 absorbable suture and staples. The leg was placed in a 3-way splint and the patient was admitted to the hospital for intravenous antibiotics and pain control. The patient was discharged home on postoperative day 3 after 48 hours of antibiotics, deep vein thrombosis prophylaxis with low-weight-molecular heparin. Final cultures were negative.

Figure 3: Completed tibial osteotomy after nail extraction.

Discussion

Incarcerated intramedullary nails have been described since Kuntscher’s time.¹ Various reasons were listed for incarceration including ingrowth of bone into the inside of a clover leaf nail, bent nails, excessive callus formation closing the medullary canal, and bone ingrowth through the locking screw holes.

The material of the nail or the bone-metal-interface has not been mentioned as a factor in previous reports. The nail used in this case was a Synthes cannulated tibial nail comprised of 87% titanium, 7% niobium, and 6% aluminum. Clinical observation by the senior author (B.G.P.L.), with approximately 30 years of clinical practice of extracted nails, has revealed a membranous interface between the nail and bone. In this case no membrane was evident. It is also interesting that the bone was solidly adhered to the nail surface and could only be separated from the nail with an osteotome, similar to the ongrowth process in hip arthroplasty.

The authors recommend that excessive force should not be used to extract an incarcerated nail but to approach the problem in a step-wise fashion. If the extraction device can be firmly attached to the proximal part of the nail, make sure that all the locking screws or parts of broken screws left would not interfere with the extraction.

Make sure all bone and soft tissue is properly protected in the proximal pathway of extraction. A sliding hammer mechanism seems to be mechanically advantageous since the line of force application is directly in line with the nail axis rather than at an angle as it will in the case a tamp and mallet are used in a sideways fashion. In the last mentioned scenario, the chance of cracking or breaking the proximal tibia is also larger. Also check that the extraction conical piece is fully screwed in to maximize the number of threads engaged to dissipate the stress to prevent stripping of the extraction device or the proximal nail threads.

If the nail moves proximally 1 or 2 cm and then gets stuck completely, do not use excessive forceful blows. A decision needs to be made immediately: the nail may be driven back to its original location and left in place or if there is an absolute indication to remove the nail, proceed by splitting the tibia proximally followed by sliding blows. If the nail remains incarcerated, consider opening a window all the way down proximal to distal with a saw blade or high speeds burr and wedged slightly open for approximately 2 mm. This allows the nail to disengage, and firm sliding blows may be used. If the nail remains incarcerated and will not move, the tibia needs to be completely open by removing a one third of circumference longitudinal window of bone. Curved osteotomes may then be used to systematically disengage the nail. It may be possible to place the longitudinal window lid of bone back and an allograft filler material may then be used to fill the defect.

References

1. Kuntscher G, Maatz R. 13. Hardware Removal of Intramedullary Nails: A surgical Technique. Leipzig, Georg Thieme Verlag 63-94, 1945.
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6. Park SY, Yang KH, Yoo JH. Removal of a broken intramedullary nail with a narrow hollow. J Orthop Trauma. 2006; 20(7):492-494.
7. Kocher MS, Yett HS. of the trade: Contingency plan for extraction of intramedullary nails. Am J Orthop. 1996; 25(3):237-238.
8. Street D. Intramedullary Nailing of the Forearm. In: Browner BD, Edwards C, eds. The Science and Practice of Intramedullary Nailing. Philadelphia, PA: Lea & Febiger; 1987:325-348.
9. Weinrauch PC, Blakemore M. Extraction of intramedullary nails by proximal stacked wire technique. J Orthop Trauma. 2007; 21(9):663-664.

Authors

Drs Lindeque and Agudelo are from the Department of Orthopedic Surgery, University of Colorado Health Sciences Center, Aurora, Colorado.

Drs Lindeque and Agudelo have no relevant financial relationships to disclose.

Correspondence should be addressed to: Juan Agudelo, MD, Department of Orthopedic Surgery, University of Colorado Health Sciences Center, 12605 E Ave, Aurora, CO 80045.