Rack-and-Pinion Displacement of an Intramedullary Pin During Minimally Invasive Plate-Rod Osteosynthesis of the...

We present a case of unexpected proximal displacement of an intramedullary pin (IMP) during plate-rod repair of a femoral fracture caused by minimally invasive plate osteosynthesis (MIPO), requiring immediate revision. Implant retrieval analysis and ex vivo modelling were performed to characterise the technique failure mode. The case details are reported. Implant retrieval analysis consisted of stereo zoom microscopic examination of the retrieved IMP. Wear patterns formed by conflict with a 2.8 mm, two-fluted surgical drill bit and a 3.5 mm AO locking screw were replicated using a simple paper impression model. The mechanism of pin movement was replicated in a benchtop laminated polyurethane foam block model, and wear patterns produced during drilling and screw insertion were characterised using stereo zoom. The wear pattern visible on the retrieved IMP suggested axial displacement caused by a rack-and-pinion-like mechanism, enacted by contact with either the drill bit or locking screws during placement of the repair construct. Significant axial displacement of the IMP due to conflict with screws during construct placement is possible during the placement of plate-rod fixation. Surgeons should confirm implant positioning if implant conflict is recognised intra-operatively.