A technique for extraction of the distal segment of a broken femoral nail using a flexible reamer

Extraction of broken femoral nails in peri-implant fractures is becoming an increasingly common problem faced by orthopaedic surgeons. Different closed and open techniques for removal of broken nails have been previously described but due to variations in equipment and fracture configurations these methods are not always easily reproducible. We describe an open surgical technique using simple equipment that can be utilised when other methods of extraction have failed.

We present a case of a peri-implant fracture secondary to non-union involving a short cephalomedullary nail where the broken distal segment of nail was significantly more distal to the femoral fracture site. After multiple failed attempts at extraction with previously described closed techniques a rectangular cortical window was created 2cm distal to the tip of the broken nail using a saw. An antegrade guide wire was passed through the nail and pulled out of the bony window. A flexible intramedullary reamer was subsequently passed in retrograde fashion over the guide wire and a simple pushout technique was used to push both segments of the broken nail through the original insertion site. An exchange nailing was performed and the cortical window was reattached using a cable.

This is a simple technique that does not require any specialist equipment and does not require the fracture site to be disturbed. The use of a flexible reamer as a pushout device is ideal as there are multiple size options allowing the surgeon to match the size of the medullary canal with the reamer. Furthermore, the flexibility of the reamer allows easy access through a lateral bone window.

Broken femoral nail extraction can be technically challenging and when other closed methods have failed we believe our technique offers a simple alternative that can be added to the armamentarium of solutions.