Removal of a bent Knail and reinsertion of an antegrade nail

This is the third case of this sort this year.

Last year, we inserted about a hundred plus K nails for closed as well as open femur fractures, usually for completely transverse fractures of the proximal 3rd and in some cases even middle 3rd fractures.

This year, we're paying the price..

We've had about a 10% implant failure rate with the knails, some nails migrating proximally, and worse, some bent after a recurrent fall.

Most of the fractures were still mobile after the fall.. Clinically not united yet.

Anyway, This case..

a 20 year old male with a knail inserted in the right femur 2 months ago, with the current complaint of a deformed right thigh after a recent fall (post op)

Xrays showed that his knail had bent, approximately 30 degrees..

He was planned for K nail removal and reinsertion of a interlocking nail.

So... we had already done 2 cases of a similar sort before.. here's what we did..

1st option:

Position in left lateral position,

open the fracture site,

osteotomize at the most angulated site, half the circumference of the bone,

use a plate cutter to cut the k nail, remove the nail, both ends from the osteotomized site.

Then.. retrograde insertion of guide wire, Incision at superior to the greater trochanter, pull out guide wire, reduce the fracture, completely push the guide wire in, ream, insert nail.

Use II to establish the length and depth of nail insertion.

Proximal lock then distal lock under II guidiance.


Option 2.

Similar, except that positioning will be on a fracture table.

I find that on a fracture table it is more difficult to get leverage to cut the knail with the massive plate cutter..

However, since it is on a fracture table, insertion of the interlocking nail is more standard.



Any comments? discussions? I'll try to post xrays on request..

sad to say.. this forum is quite dead.. either that or no one wants to comment about my post..

We have always had a hard time getting residents to post in here. I think it is a time factor. Not much free time. However, I think this forum could be very educational if multiple residents from different programs would use it. "There is more than one way to skin the orthopedic cat."

Commenting on your problem: We did most of our femoral nailings in the semi lateral decubitus position on a fully radiolucent Jackson table with the leg prepped free. This allows complete access to the leg for removing broken rods, etc.. You can also hook up traction if needed as well.

i think the lateral decubitus position is the best position for removal of nails and renailing.. We did a removal or nai and renailing in the scissors position and it was difficult to get leverage to cut the bent nail for removal. But in the lateral decubitus position, we have some trouble setting up traction. Prbbly u have a better table