Surgical options for broken intramedullary nail.

To the Editor: We would like to compliment Levine et al on their case report “Removal of a Broken Cannulated Tibial Nail: A Simple Intramedullary Technique” (J Orthop Trauma 2004;18:247– 249) and Steinberg et al on their technical trick “Removal of a Broken Distal Closed Section Intramedullary Nail: Report of a Case Using a Simple Method” (J Orthop Trauma 2004;18:233–235). The problem of a broken nail is often complicated by the technical difficulty of removing retained nail segments. Multiple techniques have already been described for the extraction of the distal segment of a broken nail. Recent publications related to this topic, including the 2 manuscripts previously referenced, emphasize the actuality of this technically challenging problem and the absence of a single best answer. These 2 reports also combine data and details of additional methods. In approaching the problem of broken nail extraction, the clinician must consider the nonoperative option of leaving the nail fragment in place. We think that a bypass fixation using the thin wire Ilizarov circular device is a safe and simple solution in the treatment of nonunions with irretrievable pieces of a broken nail in the distal fragment. Utilizing the Ilizarov device aims at avoiding unnecessary soft tissue injury, bone weakening due to additional osteotomies, significant blood loss, prolonged surgery, and fluoroscopy time that are often inescapable when the removal of instrumentation is attempted. Using the Ilizarov device allows an immediate and simultaneous stabilization of the nonunion site as well. The 3-plane stability of the ring fixation device allows early full weight bearing. Fixation in an elastic circular frame, combined with cyclic loading, creates a favorable biomechanical environment for fracture healing and promotes callus formation while permitting functional gait. We believe that the thin wire Ilizarov frame is a good surgical alternative that provides stable bone fixation and functional treatment of patients who present with delayed fracture healing and a difficult to retrieve distal portion of a broken intramedullary nail.