PMC6025502_01
Subtrochanteric fracture in 69-year-old woman. A) Fixation using PFNA. B) Non-union and broken nail developed three months after initial operation. C) Second operation performed with locking plate. The broken distal nail tip remained after removal of the proximal portion of the PFNA. D) Non-union and hardware failure developed six weeks after second operation. E) Anteroposterior view of left femur after nailing. F) Radiograph at 6 months after surgery.
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A 69-year-old woman with left subtrochanteric femur fracture resulting from a fall underwent internal fixation using a proximal femoral nail antirotation (PFNA) (diameter: 9 mm, length: 200 mm) at another hospital. (Figure 1A) Three months postoperatively, breakage of the nail passing through the distal locking screw hole was observed, along with signs of injury. (Figure 1B) Because the fragment of the broken nail could not be completely removed, it was left in situ, and revision surgery was performed at the same hospital using a locking plate. (Figure 1C) Six weeks after the second surgery, the patient was admitted to our hospital due to pain at the site of the subtrochanteric fracture. Radiography showed non-union of the fracture, breakage of the proximal part of the plate, and the remaining distal nail fragment. (Figure 1D). After removal of the locking plate and remaining nail fragment, the femur was reconstructed using a new Synthes Expert Antegrade Femoral Nail (A2FN nail, Synthes, Oberdorf, Switzerland). (Figures 1E and F) The surgery lasted 125 minutes; 250 ml of blood was lost during the procedure, and the patient received transfusion (2 units).  However, because the fracture reduction was not stable, a circular-shaped wire and crimp system were also employed. (Figure 1E) Because the inserted retrograde bulb tip wire still remained, a bendable Schanz screw was employed as an external fixator. (Figure 3A) By bending the screw, its contours were adjusted to prevent any damage to the reamed cortical bone.
A) Small-sized burr used in reaming. B) Guidewire retrogradely delivered through distal end. C) Large-sized burr used in reaming. D) Schanz screw delivered through widened hole. E) Extraction of broken distal nail tip. F) Fracture reduction with bone clamp.
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In order to extract the remaining distal nail fragment, the second screw hole below the distal end of the broken nail was enlarged by burring its upper edge medially and its lower edge laterally with a reamer, (Figure 2A) and a bulb-tipped guidewire was inserted in a retrograde manner. The screw hole was further reamed upwards and downwards. (Figure 2C) The screw was tapped cautiously with a slotted hammer to prevent damage to the cortical bone, and transferred the broken nail fragment slightly toward the proximal end. The fragment was then extracted by pulling back the guidewire. (Figures 2D and E) The cortical bone remained undamaged during the extraction process. After fracture reduction with the bone clamp, (Figure 2F) the A2FN nail was inserted.
A) Schanz screw before and after bending. B) Bent Schanz screw and guide wire used to remove broken proximal femoral nail through screw hole.
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However, because the fracture reduction was not stable, a circular-shaped wire and crimp system were also employed. (Figure 1E) Because the inserted retrograde bulb tip wire still remained, a bendable Schanz screw was employed as an external fixator. (Figure 3A) By bending the screw, its contours were adjusted to prevent any damage to the reamed cortical bone.