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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 61-63

Managing intraoperative fatigue failure of proximal jig for interlocking nail – A case report and technical tip


1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Consultant Orthopaedics, Singhal Nursing Home, Jaspur, Uttarakhand, India

Date of Submission17-Oct-2019
Date of Decision17-Oct-2019
Date of Acceptance30-Oct-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_17_19

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  Abstract 


Interlocking nails are widely used implants in the management of long-bone diaphyseal fractures. Interlocking nailing is an easy, predictable, and standard method owing to the presence of ancillary instruments and image intensifier. Proximal jigs help in guiding and inserting nail as well as its proximal locking. Intraoperative breakage of proximal jig may be an uncommon problem that is underreported in the literature. The creative use of variable unrelated instruments may prove instrumental to manage the complication and result in safe surgery. We describe one such uncommon intraoperative failure of proximal jig during femoral interlocking procedure and our experience in getting past the hurdle by an innovative solution.

Keywords: Complication, injury, instrument breakage, interlocking nail, intraoperative complication, treatment


How to cite this article:
Singh B, Dharmshaktu GS, Singhal A. Managing intraoperative fatigue failure of proximal jig for interlocking nail – A case report and technical tip. J Orthop Dis Traumatol 2019;2:61-3

How to cite this URL:
Singh B, Dharmshaktu GS, Singhal A. Managing intraoperative fatigue failure of proximal jig for interlocking nail – A case report and technical tip. J Orthop Dis Traumatol [serial online] 2019 [cited 2020 Apr 3];2:61-3. Available from: http://www.jodt.org/text.asp?2019/2/3/61/273885




  Introduction Top


Internal fixation of fractures is primarily aimed to ensure early return to preinjury level of activity by sound and uncomplicated union. For most diaphyseal fractures of femur and tibia, interlocking nail is the implant of choice. Nails are excellent load-sharing intramedullary splints, and interlocking element has ensured resistance to axial and rotational stresses. The insertion of proximal screw or bolt of the nail is done with the help of the same jig used for insertion of the nail as these have corresponding holes to match those present in nail. Early stabilization of femoral fractures has been reported to be beneficial on many accounts such as early recovery and decreased length of stay.[1] The presence of assistive devices such as jigs and an image intensifier in the operation theater has enabled nailing in a minimally invasive closed way with the preservation of vascularity of femur.[2] Nail jamming, breaking of nails or bolts, and iatrogenic fracture are reported complications of the procedure, but literature is scant regarding problems with proximal jig or insertion handle.


  Case Report Top


A 38-year-old male patient who presented with a closed shaft fracture of the left femur was planned for fixation with an intramedullary interlocking nail. The antegrade nailing was initiated with an uneventful introduction of a guide wire and a nail subsequently under image intensifier guidance, and the locking distal screws were secured following confirmation and securing appropriate length, alignment, and rotation. A slight backslapping over a mountable slap hammer resulted in a well-apposed fracture site before the proximal screws. At this point, we noted the breakage of the proximal portion of the jig or insertion handle that is used as an attachment site for hammering devices and also for removal of the nail.

The broken part was proximal knobbed hexagonal bolt-like portion of the jig used to fasten and attach the nail into the jig. The handle part of the jig was intact and thus, proximal interlocking bolt insertion through the jig was uneventful. Now, the removal of the jig after the fixation of the nail to the bone posed a problem as the broken part of the jig that remain fastened to the inserted nail could not be disengaged from the nail in standard manner as the knobby part that is critical for its disengagement was broken. Few manual attempts made to unfasten the nail from the jig were unsuccessful. The jig also could not be rotated as the full rotation was limited by the patient's body. A thick Schanz pin was hammered into the hollow slot of the part inside the nail, leading to a fortunate snug fit, and the Schanz pin was thus rotated with a T-handle, leading to unfastening and gradual removal of the broken inside part out of the nail [Figure 1]. This innovative use of available resources helped us sail through this uncommon and annoying complication. The broken parts were kept aside for assessment after completion of the surgery [Figure 2] and [Figure 3]. The wounds were thoroughly lavaged and closed in layers followed by well-padded occlusive dressing, and the perioperative period was uneventful. The breakage of jig after a couple of gentle hammering is an uncommon phenomenon and was supposed to result from a fatigue failure of a propagating microcrack, resulting in potential stress riser at the junctional area of the broken parts of the jig with a dissimilar shape. The prolonged use of the same jig might be another factor for wear and tear not visible to naked eyes, and the fact was reconfirmed by the vendor with cautionary periodic evaluation advised to the implant distributor.
Figure 1: Intraoperative image showing fortunate fastening of Schanz pin inside the broken retained part that was later retrieved successfully (a and b). Knobbed part of the jig was broken, leading to fixed jig to the nail, making it difficult to disengage (c). The retrieved parts with the jig assembly (d)

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Figure 2: The image of the broken part of the proximal jig (a and b), compared to normal assembly with an intact counterpart (c)

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Figure 3: Schematic figures depicting the process of removal of the broken part and unfastening of the jig

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The femur fracture united well without any related or remote complication associated with the described technique. A gradual clinicoradiological union was seen, with the patient performing activities of daily living at a follow-up of 18 months.


  Discussion Top


Fatigue failure of jig is a potential yet underreported complication that may complicate the procedure of nailing. Femoral splitting and screw breakage from cyclic loading are two common implant-related problems seen in the practice of intramedullary femoral nailing. Larger diameter nails and nails that conform less to anatomic femoral bow may result in less chances of intraoperative fractures.[3] Presence of interlocking screws has been one of the many features with a positive impact on the stability of the implant.[4] There is a plethora of literature regarding iatrogenic injuries to native femora mostly due to faulty technique of the insertion of nail.[3],[5] The data regarding external jig or other assistive device-related complication are limited. Transitional-site failure of implant such as nails has been seen widely apart from the usual location of failure of nails at nonunion site, and it might apply to other metallic instruments such as jigs as these areas are prone to stress concentration.[6] Stresses on any material object are not uniform if the shape of the object is not uniform, and there is stress concentrator effect at junctions of radical change of shape. A microscopic crack thus may progress into failure under cyclic loading. Besides it, a small scratch itself can act as a local stress riser and makes vulnerable point for failure of any construct. Fretting results when two metal surfaces rub against each other and is another mode of corrosion, leading to implant or instrument failure. Due to continuous use often accompanied by regular autoclaving and use of hammering, the jigs might develop a small microscopic crack more so at the junction of screw threads and the proximal piece. Besides it, a fretting due to corrosion of the proximal end of the nail surface to that of the aforementioned junctional area might be the reason for increased stress concentration at the junction site, making it a potential failure site. One important cofactor in the causation of failure may be bad fitting or mismatch of the nail on the jig, leading to micromotion that compounded by the effect of hammering results in the described failure. There is a need for increased reporting of every instrument- and technique-related complication for wider readership so that all these complications could be anticipated for preparedness and learning for remedial tricks. A clinical approach mixed with wit and presence of mind is required in these situations for timely and safe procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bone LB, Johnson KD, Weigelt J, et al. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am 1989;71:336-340.  Back to cited text no. 1
    
2.
Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H, et al. Minimally invasive plate osteosynthesis: Does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Orthop Trauma 1999;13:401-6.  Back to cited text no. 2
    
3.
Johnson KD, Tencer AF, Sherman MC. Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations. J Orthop Trauma 1987;1:1-1.  Back to cited text no. 3
    
4.
Schandelmaier P, Farouk O, Krettek C, Reimers N, Mannss J, Tscherne H, et al. Biomechanics of femoral interlocking nails. Injury 2000;31:437-43.  Back to cited text no. 4
    
5.
Gausepohl T, Pennig D, Koebke J, Harnoss S. Antegrade femoral nailing: An anatomical determination of the correct entry point. Injury 2002;33:701-5.  Back to cited text no. 5
    
6.
Franklin JL, Winquist RA, Benirschke SK, Hansen ST Jr. Broken intramedullary nails. J Bone Joint Surg Am 1988;70:1463-71.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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