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  • Assess underlying root cause of failure of fixation in orthopedic trauma

  • Understand technical salvage strategies for failed fracture fixation

  • Provide stable revision fixation in order to avoid recurring subsequent complications


Intramedullary nailing represents the “gold standard” for fixation of long-bone fractures, particularly in the femur and tibia. Key principles must be respected to allow successful outcomes and mitigate potentially preventable complications.


Case Study 14.1

Outline of the problem: Bending of an intramedullary nail prior to complete fracture healing caused by another accident.

The story: A 22-year-old male motorcyclist sustained a closed femur shaft fracture that was treated by reamed locked nailing. Within 6 weeks, he went back to his bike and had another accident. He was admitted to a level II trauma center and a gross deformity of his left leg was noted. The patient was unable to straighten the leg. An x-ray was taken and it showed bending of the nail in the previous fracture area (see Figure 14.1).

Figure 14.1

Bent IM nail caused by a motorcycle accident 7 weeks after IM nailing. The fracture was not healed yet.

During revision surgery, it was tried unsuccessfully to straighten the nail. Therefore, an open revision was performed and the nail was sawed in half at the area of the fracture. Following removal of all locking bolts, the proximal and the distal half of the nail was extracted without complications. Subsequently, the bone was straightened with little effort and a plate was applied (see Figure 14.2).

Figure 14.2

The nail was bent back in the normal position, requiring open reduction and removal. It was then stabilized by a plate.

The patient’s outcome: Uneventful clinical and radiographic fracture healing with full functional long-term outcome.

How to prevent this error in the future? Advise the patient towards full compliance in postoperative treatment protocols. There was no technical error during surgery.

Case Study 14.2

Outline of the problem: Implant failure after a minor fall in the presence of inadequate nail size and working length.

The story: A 28-year-old female was treated for a closed proximal femur fracture by retrograde nailing. Several weeks later, she slipped in the backyard of her house and experienced acute pain. The x-ray revealed hardware failure through the most distal locking hole (see Figure 14.3). The nail and the tip were then removed using the extraction set and an awl (see Figure 14.4).

Figure 14.3

6 weeks after retrograde IM nailing, ...

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