Removal of Broken Cannulated Intramedullary Nail After Tibiotalocalcaneal Arthrodesis

Case Report

A 57-year-old female smoker with a history of posttraumatic arthritis of the ankle and subtalar joint presented with worsening ankle and heel pain with a nonhealing wound from prior surgery. She had undergone total ankle arthroplasty 12 years prior to presentation, which lasted 8 years before collapse and failure of the implants occurred. A tibiotalocalcaneal fusion using retrograde intramedullary nailing was performed at an outside institution and was complicated by delayed wound healing. The patient was treated empirically with a short course of oral antibiotics for drainage from her lateral wound; however, cultures failed to isolate an organism at the time of irrigation and debridement. Four years after retrograde intramedullary nailing, she presented to our clinic with wound breakdown and severe, worsening heel and ankle pain. Radiographs demonstrated evidence of an overt subtalar joint nonunion, with concomitant failure of the nail at the level of the nonunion (Figures 1-3). The patient was advised of the hardware failure and nonunion, and because of the nonhealing wound the surgical plan included revision of tibiotalocalcaneal fusion with removal of hardware, application of a spatial frame, and infection work-up with deep cultures at the time of surgery.

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Figure 1.

Preoperative AP radiograph demonstrating failed hardware and nonunion.

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Figure 2.

Preoperative lateral radiograph demonstrating nonunion and failed nail.

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Figure 3.

Preoperative AP view with 2× magnification showing broken hardware with nonunion.

Technique for Nail Removal

With the patient placed in the supine position, removal of the distal segment is achieved through the prior plantar incision. We recommend attaching the threaded extraction device before removal of the distal locking screws to prevent the distal segment spinning while attempts are made to thread the distraction system. All locking screws are then removed percutaneously. The distal segment is then removed through the plantar incision.

The difficulty is removing the proximal portion of the nail. The nail usually fails at 1 of the locking screw holes. The inner aspect of the nail is not threaded at this level, and it is not possible to attach an extraction device even if utilizing a universal extraction system. In addition, the distal end of the nail cannot be directly approached due to its position within the bone.

Our technique involves utilizing a ball tip guide wire. The 2.5-mm ball tip can pass directly through most intramedullary nail devices without difficulty. The guide wire is then pushed proximally to the proximal metaphyseal region. A small incision is made over the medial aspect of the proximal tibial metaphysis. A small round cortical window is then made using a drill bit and small osteotomes approximately one-third of the diameter of the tibia to gain access to the medullary canal of the tibia. The tip of the guide wire is captured through the window and pulled out of the leg. Utilizing a strong set of pliers, a 90-degree bend is made 5 mm from the ball tip of the guide wire. The guide wire is then inserted until the hooked tip and ball engages the free proximal nail (Figure 4). Due to the bend in the guide, the end will now not pass through the proximal hole in the nail. At this point, the straight portion of the guide wire has passed through the heel incision and is captured with a T-handled chuck. Mallet blows on the chuck and steady traction on the guide wire are then used to advance the remaining nail fragment out through the calcaneus (Figure 5).

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Figure 4.

Proximal nail cannulated with ball tip wire.

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Figure 5.

Broken nail after extraction.

If, for any reason, the nail cannot be cannulated through the plantar heel incision, the long 2.5-mm ball-tipped guide wire can be inserted through the proximal tibial window in an anterograde fashion with the nontipped end first down the tibial medullary canal. Using pliers a slight bend is placed along the smooth end of the guide wire and a T-handled chuck is used to help facilitate cannulation of the tip of the intramedullary nail in an anterograde fashion. This occurred in the presented case when a stripped end cap could not be removed from the distal end of the nail, precluding extraction or cannulation. With the end cap still secured to the broken distal nail fragment, the T-handled chuck was struck with a mallet until the distal fragment came out through the plantar heel incision.

With the nail removed, definitive treatment can be undertaken to revise the nonunion. In the presented cases, deep cultures obtained from the nonunion area were positive for methicillin sensitive Staphylococcus aureus. Following appropriate debridement and irrigation, the nonunion was revised utilizing a Taylor Spatial Frame (Smith & Nephew; London, UK) with vacuum-assisted closure over the lateral nonhealing wound.

Discussion

While techniques have been described for removal of intramedullary nails, this is the first to describe removal of a broken nail in the setting of a TTCA.^3,7,8 Advantages of this technique include minimal disruption of soft tissues and the use of basic orthopaedic equipment for both cannulation and extraction with little added expense to the case. Potential difficulties with this technique include initial cannulation of the intramedullary nail in the anterograde fashion. Although it has not occurred in our experience, fracture of the ball-tipped guide wire at the bend is a theoretical possibility. Last, this technique is not possible with a solid nail. Despite these disadvantages, we report a new, inexpensive, soft-tissue-preserving technique for removal of a broken retrograde intramedullary nail using a bent ball-tipped guide wire.