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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 36  |  Issue : 2  |  Page : 38-40

Retrieval of broken guide wire in femoral neck: A novel surgical technique


1 Department of Orthopedics, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India
3 Department of Orthopaedics, AIIMS, Bhopal, Madhya Pradesh, India

Date of Submission10-Jul-2021
Date of Decision14-Jul-2021
Date of Acceptance14-Jul-2021
Date of Web Publication02-Aug-2021

Correspondence Address:
Gautam Chatterji
Senior Resident, Department of Orthopaedics, AIIMS, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_12_21

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  Abstract 


Perioperative breakage of implant or instrument in the hip joint is a nightmare for an orthopedic surgeon. Location of the broken metallic part near neurovascular bundle or joint surfaces necessitates its removal. In this article, we report a case of retrieval of broken guide wire from femoral neck during proximal femoral nailing for pertrochanteric fracture by engaging it in rigid cannulated reamer without causing any further iatrogenic injury. This is a novel and simple technique not described previously in literature and has its own unique advantages over other methods. Large core diameter of rigid cannulated reamer engages broken guide wire easily, is better than any other cannulated instrument, and can be a simple solution to a difficult problem. Regular checking and replacement of used instruments along with cautious use may prevent iatrogenic complications of instruments and implant breakage. However, if the situation arises, the surgeon must be familiar with all the techniques of removal of broken instruments and should choose the technique which is more convenient and less traumatic.

Keywords: Broken, guide wire, implant breakage


How to cite this article:
Jaiswal A, Tanwar YS, Chatterji G. Retrieval of broken guide wire in femoral neck: A novel surgical technique. J Bone Joint Dis 2021;36:38-40

How to cite this URL:
Jaiswal A, Tanwar YS, Chatterji G. Retrieval of broken guide wire in femoral neck: A novel surgical technique. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:38-40. Available from: http://www.jbjd.org/text.asp?2021/36/2/38/322947




  Introduction Top


Perioperative breakage of orthopedic instruments is a common complication in orthopedic surgeries. Drill bits followed by Kirchner wires and guide wires are the most commonly reported instruments that break during an orthopedic procedure.[1],[2] Most of the time, broken instruments can be left in situ as it does not affect the functional outcome, but if the broken instrument is inside the joint or if it has potential for future migration, removal is necessary. Many times, removal of a broken instrument is too difficult due to deep placement, especially near the hip joint. We report a case of a broken guide wire in the femoral neck with intraarticular penetration during proximal femoral nailing in a case of pertrochanteric fracture and its retrieval by our unique technique.


  Case Report Top


A 35-year-old male with pertrochanteric fractured right hip was planned for closed reduction with proximal femoral nail [Figure 1]a and [Figure 1]b and posted for surgery in our elective operation theater. Spinal anesthesia was given, after part preparation and draping surgery was started as planned. Acceptable closed reduction was achieved and trochanteric tip was exposed, entry portal for proximal femoral nail was made at the tip of greater trochanter, and guide wire was inserted under image intensifier guidance uneventfully. Sequential reaming was done over the guide wire in the femoral shaft and size 10 mm &#s215; 380 mm nail was inserted. Guide wires for the neck screws which were 2.5 mm in diameter were inserted after attaching the zig. Both wires passed without any difficulty and their position was confirmed after looking at image intensifier pictures.[3],[4] The inferior guide wire had just crossed the femoral head, but we did not take the wire back. Then, we proceeded for reaming for inferior neck screw. Reaming was being done smoothly and gradually in direction of guide wire when suddenly we felt a loss of resistance and heard an unexpected click. We had a suspicion that guide wire was broken, which was confirmed on c-arm image intensifier. A wire could not be left in situ as a broken part had crossed the femoral head. We tried to remove the wire bypassing the reamer over the broken part and engaging it, but it was not successful as the diameter of the reamer hole was just adequate enough to pass over the guide wire. We struggled for at least 30 min, but the reamer could not be passed over the broken wire segment. We also tried with a laparoscopy grasper, but its jaw could not be opened sufficiently to get a stronghold of the guide wire. Once, we were able to catch the wire tip, but it was so strongly fixed into the subchondral portion of the femoral head that it could not be pulled out. Ultimately, we had an idea that if we use an 8 mm cannulated rigid bone reamer used for interlocking nails, we could pass it over broken wire fragments as its inner diameter is wider. This worked and we were able to pass the reamer over the wire quite easily. We checked that wire was within reamer in both anteroposterior and lateral views, then we started reaming over the guide wire carefully up to the threaded portions of the guide wire. Once we reamed over the threaded portion of the wire, the reamer engaged the guide wire firmly. Then, we rotated the reamer in counterclockwise direction with a minimal force of pull and were happy to see guide wire retrieving back with the reamer [Figure 2]. Then, the inferior neck screw which was 8.5 mm in diameter was inserted in the track created by reamer and surgery was completed. Our reduction had some varus, but fracture united uneventfully. Uptill the last follow-up at 1 year postoperatively, the patient is asymptomatic and is ambulating with unassisted full weight bearing with a mild lurch toward the opposite side [Figure 1]c and [Figure 1]d.
Figure 1: (a-d) Preoperative anteroposterior and lateral and 1-year postoperative radiographs

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Figure 2: Intraoperative pics showing broken wire and its retrieval. (a) Broken guide wire in neck, (b) Rigid Reamer size 8 inserted over guide wire, (c) Retrieval of guidewire started in anticlockwise direction after checking position of reamer in carm, (d) Guide wire retrieved successfully with help of reamer

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  Discussion Top


Every orthopedic surgeon experiences one or the other unexpected complication either during intraoperative or postoperative period. However, intraoperative complications are more difficult to handle as the surgeon has to come out of the problem in limited time span. Instrument breakages are a usual complication in orthopedics. The most common cited causes are repetitive use of the instruments, improper technique, and inexperienced surgeons. Some sites such as distal humerus are more notorious for implant breakage.[5] Few studies have cited increased stress on guide wire from lever effect during reduction, entrapment by vertical compression belt of femoral neck, and deformed guide wire due to repeated use as a cause of intraoperative breakage.[6] There are reports of similar cases of broken guide wire removal with help of inner drill bit of DHS triple reamer, cannulated drill bits, or bone window osteoectomy on the anterior cortex of femoral neck.[7] Our technique of removal of wire through rigid cannulated reamer is easier than through triple reamer as core diameter of the rigid reamer is greater than DHS reamer [Figure 3]. A surgeon gets more leverage as minor manipulation of the reamer to engage the wire is easier. We have experienced two similar cases where the guide wire was broken and was successfully retrieved with this technique. The outer diameter of both is similar so no additional erosion of bone is there. Removal by making bone window requires more dissection, associated with more operative morbidity and should be kept as last resort. Sometimes, bone quality also predisposes to implant breakage. We have experienced incidences of broken drill bits in some benign sclerotic lesions like osteopetrosis and fluorosis.[8]
Figure 3: Difference in core diameter of triple reamer and rigid cannulated reamer

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  Conclusion Top


Guide wires and all instruments should be properly checked before use to avoid intraoperative surprises. Damaged instruments and wires should be routinely replaced, any bending of guide wires during drilling should be carefully observed. Once reduction has been achieved and guide wires have been passed, manipulation of the limb should be avoided. In hip, surgeries guide wire should never be crossed beyond the femoral head. Lateral cortex should be perforated with a drill and not a guide pin as a guide pin usually slips when inserted at an angle to the shaft and does not perforate the cortex at the desired point. If due to any reason retrieval of broken instrument is not successful, then it should be properly documented in operative notes and case sheets and the patient should be well informed regarding this to avoid medicolegal issues.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Roy SP, Lim CT, Tan KJ. A useful surgical technique for retrieval of a broken guide pin in the midfoot. J Foot Ankle Surg 2014;53:120-3.  Back to cited text no. 1
    
2.
Pichler W, Mazzurana P, Clement H, Grechenig S, Mauschitz R, Grechenig W. Frequency of instrument breakage during orthopaedic procedures and its effects on patients. J Bone Joint Surg Am 2008;90:2652-4.  Back to cited text no. 2
    
3.
Li J, Wang L, Li X, Feng K, Tang J, Wang X. Accurate guide wire of lag screw placement in the intertrochanteric fractures: A technical note. Arch Orthop Trauma Surg 2017;137:1219-22.  Back to cited text no. 3
    
4.
Jin L, Zhang L, Hou Z, Chen W, Wang P, Zhang Y. Cephalomedullary fixation for intertrochanteric fractures: An operative technical tip. Eur J Orthop Surg Traumatol 2014;24:1317-20.  Back to cited text no. 4
    
5.
Price MV, Molloy S, Solan MC, Sutton A, Ricketts DM. The rate of instrument breakage during orthopaedic procedures. Int Orthop 2002;26:185-7.  Back to cited text no. 5
    
6.
Zhu QH, Ye TW, Guo YF, Wang CL, Chen AM. Removal of a broken guide wire entrapped in a fractured femoral neck. Chin J Traumatol 2013;16:237-9.  Back to cited text no. 6
    
7.
Mishra P, Gautam VK. Broken guide wire with intrapelvic protrusion: A technique for removal. Injury 2004;35:1324-6.  Back to cited text no. 7
    
8.
Bhargava A, Vagela M, Lennox CM. “Challenges in the management of fractures in osteopetrosis”! Review of literature and technical tips learned from long-term management of seven patients. Injury 2009;40:1167-71.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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