Femoral intramedullary nail extraction using the kissing nail technique when primary measures fail.

Introduction: Intramedullary femoral nails (IMFNs) need to be removed for subsequent joint replacement, refracture, nonunion, or infection. The tools used to extract newer IMFNs may not be suited for removal of older implants, especially if broken. The purpose of this study was to describe a novel technique in femoral nail extraction when primary measures fail and a report on 6 cases where it was used. Technical Procedure: The technique is used after standard techniques including the Winquist set fail. A guide rod is passed through the center of the incarcerated nail (IN) to the distal end or to the proximal end if it is a retrograde nail. The femur is approached through a separate incision either through the knee for an antegrade nail or through the proximal femur for a retrograde nail. The guide rod is delivered through the opposite end by either hitting it through the end of the bone or breaching the end with a starting wire and starting reamer. The guide rod is then delivered into the field. Using flexible reamers over the delivered guide rod, the femur is reamed up to the IN. A second IMN slightly smaller in diameter is chosen and passed to touch the distal end of the IN, guided by the guide rod to keep the nails aligned. The second nail is impacted, which pushes the IN out its insertion point. Discussion: Hardware extraction is difficult for any surgeon, and extraction of older or broken nails with lower grade material poses even greater challenges. This technique is meant as an extra tool for avoidance of corticotomy when primary means for nail extraction have failed. We present 6 cases with 5 successful results.