A secondary high-speed trauma to a previously stabilized femoral fault with intramedullary collar is rare. In this newspaper, we present the management of a 40-year-old man presented with a bended intramedullary nail due to secondary trauma. A lateral longitudinal femoral osteotomy was used for the resection of the distorted nail. The femur was reconstructed with a new breeze through, and the fixation of the osteotomy was achieved with denture and cerclage wires. Five months postrevision surgery, callus constitution was apparent and the patient regained a normal compass of gesture and pace, walking with a single cane .

1. Introduction

A secondary high-speed injury to a previously stabilized farseeing bone fracture with an intramedullary complete is very rare. No standard protocol exists in the literature as very few cases have been documented [ 1 – 5 ] .
The purpose of this newspaper is to present the management of a case where an intramedullary smash, placed to fix a correct femoral shaft fracture, was distorted ( bent to about 130° ) 13 months postoperatively, ascribable to a junior-grade trauma.

2. Material and Methods

A 40-year-old male patient, known to be a drug abuser, HCV positive, and a heavy smoker, was admitted to our department after suffering a car accident with an open Gustillo II type fracture of the right femur. An open decrease and internal fixation were performed using a D.C.P. plate and 4.5 millimeter screws, as there was not an off-the-rack handiness of intramedullary nails or external fixators at the time of wound. The operation was performed few hours after entree and did not end to a static fixation .
Two weeks postoperatively, a mechanical failure of the inner fixation was observed ascribable to suboptimal fault fixation ( Figure 1 ) .

The patient returned to the operational room for the substitute of the plate and screw with an interlocking nail. Bone allografts were besides placed on the fault site ( Figure 2 ) .

Four months postoperatively, there was no satisfactory testify of bone healing, but we decided to remove the distal screw of the nail down because the patient already started weight have a bun in the oven randomly, and, as a solution, one of the screw was broken and the early deformed. DBM enhanced by mixing with aspirate bone marrow ( Ignite, Wright Medical Technology, Inc., Arlington, Tenn, USA ) was placed on the fracture web site. The patient was subsequently instructed to increasingly achieve wide weight bearing abilities within a six-week menstruation. At the monthly follow-up, radiographic and clinical images showed a satisfactory rate of calloused bone formation. Three to four months belated, we lost regular reach with the patient .
approximately 13 months postintramedullary nail, the affected role was involved in another cable car accident and was admitted to our department due to pain and contortion of the femur in recurvatum. Plain radiography revealed a refracture of the femoral rotating shaft and a bend deformation of the intramedullary collar ( Figure 3 ) .

At the preoperative evaluation, it was considered impossible to straighten out the collar or to cut it sol as to facilitate its removal. After general anesthesia and despite our best attempts, this proved to be true. therefore, we continued to perform a proper osteotomy as to facilitate the creation of a longitudinal bone window along the anterolateral side of the distal function of the femoral shaft. The osteotomy extended from the fracture web site distally to the greater trochanter proximally, approximately 2 cm in width. subsequently, we easily removed the complete and replaced it with a new one. The osteomized bone strip window was secured with a special buttress denture ( Accord, Smith & Nephew, Inc., Memphis, Tenn, USA ) stabilized by cerclage wires ( Figures 4 ( a ) – 4 ( five hundred ) ) .

As it was certain that the nail was well fixed in place and as the operation meter was quite extended, it was decided to temporarily postpone the distal lock in of the smash. A big come of DBM shuffle with cancellate bone homograft was placed on the fracture web site and alongside the lateral longitudinal osteotomy.

3. Results

The postoperative radiogram showed a good decrease both in the wreath and sagittal planes. A guarantee arrested development was besides observed. subsequently, the wound healed without far complications .
Two months after rewrite, the patient was fitted with a lumbar femoral tibial splint. Furthermore, a nonweight-bearing crutch walk has been initiated. Radiographs uncover good attest of bone reaction and callus formation and a general curative progression ( Figures 5 ( a ) and 5 ( b-complex vitamin ) ) .
(b) Five months after revision, the splint has been removed and the affected role has been instructed to start weight bearing increasingly. subsequent radiogram revealed continue evidence of callus formation ( Figures 6 ( a ) and 6 ( b ) ) .
(b) Twenty four months after revision, the patient has regained full rate of motion of the hip and knee, without kidnapper mechanism lack. The gait has returned to normal without any indigence for extra digest devices. No clinical, radiographic, or lab findings of periprosthetic relax or infection have been identified, while bone heal and callus formation are satisfactory .

4. Discussion

The use of intramedullary nails for the treatment of femoral fractures is the aureate standard [ 6 ]. Less comminution of fractures is observed when the intramedullary nail bends, absorbing much of the energy of the injury. besides more energy is required to cause a refracture and bending of an intramedullary breeze through in wholly healed fractures than in incompletely healed [ 5 ] .
The first step in approaching fractures recurrences is the well-planned undertake to remove the change shape intramedullary nail. Removing a bent intramedullary complete is very unmanageable and requires strategy and inspiration. few methods have been described in literature such as ( a ) in situ straightening via external effect on the femur [ 4 ], ( boron ) the segment of the complete and removal of each piece individually [ 2 ], and ( c ) sectioning the nail to half its diameter and then breaking it [ 3 ].

Reviewing the available literature reveals that each case of contort intramedullary smash removal was approached uniquely [ 1 – 5 ]. technical subscribe played a vital character in the method acting used to removal the pinpoint with the least amount of damage to bone and soft tissue .
In our case and after much slowness, it became apparent that technical digest was unable to give viable solutions to our trouble. Sterilized diamond-edged blades for the segment of the intramedullary collar were unavailable. After much thought it was decided to apply a different strategy to the removal of the intramedullary complete .

5. Conclusion

refracture of the femur diaphysis with an in situ intramedullary collar following a high-speed injury is rare. Nail removal is difficult if the intramedullary nail is flex or distorted. There is a high risk of infection and delayed union or nonunion of the fracture due to multiple damage of the delicate tissue envelope and disruption of lineage supply. however, dealing with such cases is a capital challenge for the orthopedic surgeon due to the fact that every such incident requires a alone curative and surgical set about .

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Category : Nail Technique

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