Treatment of Aseptic Femur Non-union With Broken Intramedullary Nail In Situ by Exchange Nailing: A Technical Description

Non-union following intramedullary nailing of diaphyseal long bone fractures represents a serious complication necessitating timely and effective intervention. The situation becomes considerably more complex in the presence of a broken femoral nail, which poses additional technical challenges for the operating surgeon. Conventional management strategies typically entail removal of the existing nail, followed by re-fixation with a larger intramedullary nail, plate fixation, or external fixation constructs. Our case describes a 34-year-old male patient who presented with aseptic femur non-union complicated by refracture and hardware failure. The intramedullary nail had broken at two distinct sites as revealed by radiographs. A novel technique was employed to remove the broken hardware without surgically exposing the fracture site, followed by exchange nailing with a larger-diameter implant. A distal entry point in the femur was created in addition to the proximal entry site. After removal of the broken locking screws, a jig was attached proximally, and a solid reamer was introduced distally to engage the tip of the retained nail fragment. Simultaneous hammering was performed from both proximal and distal directions, enabling the extraction of all three nail fragments through the proximal entry point. The procedure was completed with the insertion of a wider intramedullary nail. The patient underwent successful fixation with exchange nailing, demonstrated progressive radiological healing, and ultimately achieved fracture union. At final follow-up, he had returned to full function without pain or restriction of daily activities. The described approach not only overcomes the challenges of implant removal but also raises awareness and shows a method to overcome its difficulty. This particular technique also reduces the risk of intraoperative and postoperative complications.