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Weinrauch, Patrick C. and Blakemore, Martin (2007) Extraction of intramedullary

nails by proximal stacked wire technique. Journal of Orthopaedic Trauma
21(9):pp. 663-664.

Copyright 2007 Lippincott Williams and Wilkins

This is the author-version of the work. The final, definitive version of this article
has been published in the Journal, <Journal of Orthopaedic Trauma 21(9):pp. 663664, 2007 < Lippincott, Williams & Wilkins.

This is author version of article published as:

Weinrauch, Patrick C. and Blakemore, Martin (2007) Extraction of intramedullary
nails by proximal stacked wire technique. Journal of Orthopaedic Trauma
21(9):pp. 663-664.
Copyright 2007 Lippincott, Williams & Wilkins
EXTRACTION OF INTRAMEDULLARY NAILS BY PROXIMAL STACKED
WIRE TECHNIQUE
Patrick C Weinrauch MBBS (Qld) MEng FRACS (Orth)* &
Martin Blakemore MBChB FRCS (Ed)

Published as:
Weinrauch PC, Blakemore M (2007) Extraction of Intramedullary Nails by Proximal
Stacked Wire Technique. J Orthop Trauma. Oct;21(9): 663-664.

Abstract
We describe the use of proximal stacked wires (PSW) for the removal of an
intramedullary nail in the context of difficult extraction and failed attempts by
conventional methods. This percutaneous technique is particularly useful for the
extraction of narrow cannulated or solid intramedullary nails after failure of removal by
extraction bolt devices.

Key Words
Intramedullary nail; Removal; Technique; Difficult

School of Engineering Systems, Queensland University of Technology, Brisbane

Australia.

Department of Orthopaedics and Trauma, University Hospitals Coventry and

Warwickshire, England.

Introduction
Removal of intramedullary (IM) nails used for the internal fixation of fractures is
a common procedure, and is frequently under estimated in terms of potential difficulty.
There are multiple reports in the literature describing techniques for the removal of
broken intramedullary nails, however extraction of intact nails may also represent a
difficult procedure1-4. Intact IM nails are ideally extracted using implant specific threaded
extraction bolts or similar instrumentation. The limitation these devices however is the
reliance on a patent proximal nail thread or other means to attach the extraction device.
Proximal nail threads may be damaged by cross threading of implantation instruments,
nail end caps or extraction bolts; particularly when the nail is manufactured using softer
materials such as titanium alloys. Alternatively, proximal nail threads may be blocked by
the in-growth of bone or fibrous tissue, impeding simple percutaneous nail extraction.
Universal conical extraction devices may be used in situations where proximal nail
threads have been damaged, however these devices may still fail to remove the implant1,
and such instrumentation may not be available unless difficult extraction is anticipated
preoperatively. An alternative method of nail extraction using distally impacted guidewires involves the passage of multiple wires along the length of the IM nail, with one or
more olive tipped ends protruding from the distal end of the nail 5,6. This technique of nail
extraction can only be conducted with nails which have and internal diameter wide
enough to allow the passage of 2 or more guide-wires, therefore solid or narrow
cannulated IM nails7, or nails with distal bone ingrowth8, cannot be removed using a
distally stacked wire technique. We describe IM nail extraction by the use of proximal
stacked wires, a technique which does not require patent proximal nail threads and is also
suitable for the removal of narrow and solid IM nails.

Case Presentation
18 months after management of a closed femoral shaft fracture with a T2
Antegrade Femoral Nail (Stryker Osteosynthesis, Le Lumion, Switzerland), a 24 year old
female patient elected to undertake routine removal of metalwork after the fracture had
successfully united. With fluoroscopic assistance, after removal of the cross locking bolts
and clearance of bone and soft tissue from the proximal nail region, a threaded extraction

bolt was introduced into the proximal nail region to enable nail extraction. Despite
several attempts, firm attachment of neither the extraction bolt nor a threaded conical
extraction device was able to be achieved and the nail was unable to be removed using
these techniques. Subsequently, the passage of an olive tipped guide wire into the nail
lumen to allow extraction by distal wire staking was attempted. This method of removal
also was found to be unsuccessful as the available intramedullary nail guide wires were
thicker than the lumen of the IM nail in situ, and therefore could not be passed beyond
the proximal flare of the implant. After failure to remove the nail using conventional
methods, extraction was successfully accomplished without extending the surgical
approach by the use of multiple proximally stacked guide wires. Two olive tipped guide
wires were fashioned with a bend of approximately 30 degrees in the distal 1cm and
sequentially passed under fluoroscopic guidance into the proximal section of the nail.
Making use of the bend created in the guide wires, the olive tips were positioned to pass
out of the nail through opposing locking holes in the proximal nail region (Figure 1).
Backing out of the olive tipped guide wires was prevented by the passage a smooth guide
wire to occupy the remaining space in the proximal nail lumen. Multi-grip pliers were
then attached to the olive tipped guide wires, allowing extraction by application of a
retrograde force.

Discussion
PSW nail extraction is a simple technique which can be conducted using
equipment which is routinely available in most orthopaedic operating theatres.
Specialized extraction devices such as conical bolts or extraction hooks are often
available only if difficult nail removal is anticipated preoperatively. Unexpected failure
of implant specific extraction devices with narrow cannulated or solid IM nails in situ is a
particularly difficult scenario. Georgiadis et al. describe a technique of IM nail removal in
the context of failure of the proximal extraction device by creating a slot in the proximal
nail using a high speed carbide metal cutting bit, allowing attachment of a hook or punch
for subsequent removal. This technique requires significant additional dissection to
access the proximal nail, which may be extensive in the case of femoral intramedullary
nails1. After failure of nail extraction by conventional methods, the PSW technique can

easily be undertaken as salvage technique without the requirement for extensive

additional surgical dissection. As the nail is removed by securing attachment onto the
proximal portion of the implant, the PSW technique is not suitable for the removal of
broken nails.
In summary, we describe a useful technique for the removal of intramedullary
nails in the context of difficult extraction with failed attempts by other conventional
methods. This percutaneous technique is particularly useful for the extraction of narrow
or solid intramedullary nailing devices.

Figure 1: Olive tipped guide wires are sequentially passed with fluoroscopic guidance
through the proximal locking screw holes. The radio-opaque tip of the guide wire
exchange tube used to facilitate passage of the wires is seen just proximal to the nail.

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