Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 24  |  Issue : 2  |  Page : 53-55

Spontaneous extrusion of a distally migrated Küntscher intramedullary nail from the left femur through a sinus over the knee joint


1 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Acceptance29-Jun-2014
Date of Web Publication21-Jan-2015

Correspondence Address:
Chima C Ihegihu
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, P. O. Box 2333, Nnewi, Anambra State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1116-5898.149604

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  Abstract 

Migration of femoral Küntscher intramedullary nail (K-nail) proximally or distally within the femoral medullary cavity is a well-known documented complication, but spontaneous extrusion of a distally migrated K-nail through a sinus is a complication which has not been previously reported in the literature. This is the case report of a 32-year-old woman who presented with spontaneous extrusion of a Küntscher nail 6 years postinsertion. The underlying etiology and pathogenesis of the extrusion is subject to controversy and speculation. Infection and delayed union with shortening are etiological possibilities. Faulty selection of K-nail size: Loose fitting nail, disuse osteoporosis, and premature weight bearing may also be contributory factors.

Keywords: Extrusion, Küntscher nail, sinus, spontaneous


How to cite this article:
Ihegihu CC, Ihegihu EY. Spontaneous extrusion of a distally migrated Küntscher intramedullary nail from the left femur through a sinus over the knee joint . Niger J Surg Sci 2014;24:53-5

How to cite this URL:
Ihegihu CC, Ihegihu EY. Spontaneous extrusion of a distally migrated Küntscher intramedullary nail from the left femur through a sinus over the knee joint . Niger J Surg Sci [serial online] 2014 [cited 2022 Jan 23];24:53-5. Available from: https://www.njssjournal.org/text.asp?2014/24/2/53/149604


  Introduction Top


Straight Küntscher cloverleaf nail (K-nail) with its longitudinal slot is a type of intramedullary (IM) rod used for fixing simple transverse, short oblique or Winquist-Hensen types I and II comminuted midshaft diaphyseal fractures of the femur. [1] "Elastic nailing" - the concept of long metal IM nails attached to the endosteal surface of the bone was the product of the creative thinking and work of Gerhard Küntscher and his co-worker Professor Fischer and engineer Ernst Pohl, at University in Kiel in Germany in the 1930s. [2] The original nails were in the shape of the letter V, but he later introduced the four-leaved clover form for additional strength and easier use. They are made of stainless steel.

Migration of femoral Küntscher IM nail proximally or distally within the femoral medullary cavity is a well-known documented complication, but spontaneous extrusion of a distally migrated K-nail through a sinus is a complication which has not been previously reported in the literature. This was a case in which the K-nail migrated distally perforating the anterior femoral cortex and was gradually extruding through a sinus over the anterior aspect of the knee. Some of the causes of migration documented in the literature include: Resorption and impaction at the fracture site, positive expulsion from pressure of products of ionization and foreign body reaction accumulating between the nail and the bone, [3] faulty selection of K-nail size: Loose fitting nails permitting repetitive movement at the fracture site and faulty technique. [4],[5]

Distal migration of the nail has also been noted particularly in abnormal bone: Osteogenesis imperfecta, tabetic patients, after infection and delayed union with shortening, [6] chronically infected pseudarthrosis, after operation in association with oblique fractures of the lowermost third of the femoral shaft and premature weight bearing through an extensively comminuted fracture. [7] In this particular case, the cause of migration and subsequent extrusion was uncertain because the patient did not provide previous radiographs for review and was unable to afford any new radiographs before commencement of treatment. However, faulty selection of K-nail size: Loose fitting nail, infection, shortening, positive expulsion by pressure of products of ionization and foreign body reaction that accumulated between the nail and the bone were factors that could be clinically implicated in this patient.


  Case report Top


A 32-year-old female indigent beggar presented at Loveworld Specialist Hospital, a private orthopedic facility in Nnewi with complaints of pain, swelling and stiffness of the knee of 2 weeks duration and a sinus over the anterior aspect of the knee through which an IM nail was protruding of 2 day's duration. The patient was a passenger in a vehicle involved in a road traffic accident about 10 years ago in which she sustained injury to the left thigh. The thigh became painful, swollen, and deformed after the accident. The patient could not bear weight on the limb, and there was no associated wound. She was taken to a traditional bone setter who made a diagnosis of fracture of the left femur. She was treated by several traditional bonesetters over a period of 4 years during which the fracture did not heal. She was then sponsored by a relative to consult an orthopedic surgeon who operated on her 6 years ago. Because of financial constraints, she was unable to see her surgeon for follow-up care for the past 5 years.

On examination at presentation she was obese, walked with a limp and support with one axillary crutch. She was not febrile to touch and not pale. The left knee was moderately swollen; about 6 cm of a straight cloverleaf Küntscher IM nail was protruding through a sinus over the anterior aspect of the left knee [Figure 1]. The sinus was discharging turbid purulent synovial fluid. The knee was tender, not fluctuant with reduced range of motion of about 90΀ from full extension. There was a healed longitudinal surgical scar on the lateral aspect of the left thigh measuring 12 cm and another healed scar over the superior aspect of the left buttock measuring 2 cm. There was no tenderness or abnormal movement in the left thigh, and the patient could do full straight leg raise without pain in the hip. There was a limb length discrepancy of 2.5 cm, the left lower limb shorter than the right. No previous radiographs were available for review, and the patient could not afford any new radiographs before commencement of treatment.
Figure 1: Küntscher nail protruding through the sinus over the knee

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The IM nail was pulled out easily without any difficulty using a pair of Kocher's forceps. This was followed by egress of turbid purulent synovial fluid some of which was collected for microscopy, culture, and sensitivity (M/C/S). The K-nail measured 38 cm in length and 10 cm in diameter [Figure 2]. Other investigations: Plain radiograph of the left femur (anterior posterior and lateral views to show hip and knee), full blood count, erythrocyte sedimentation rate and urinalysis were ordered for. The sinus was dressed, and the patient was commenced on cefuroxime tablets 500 mg twice daily and other medications pending outcome of results of M/C/S of the discharge from the sinus. The patient however defaulted and did not turnup for follow-up with results of ordered investigations.
Figure 2: Extracted Küntscher nail measuring 38 cm in length by 10 cm in diameter

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  Discussion Top


Prior to the introduction of Gerhard KüntscherPs IM nailing technique, treatment of fractures of the femur was limited to traction or cast splintage both of which required long periods of inactivity. Küntscher nailing resulted in an earlier return to activity, sometimes even within a span of a few weeks, since the nails shared the load with the bone, rather than entirely supporting the bone.

However, the biggest problems with K-nails are the failure to prevent migration, collapse or rotation of the fractured fragments, especially in inherently unstable fractures. These have been addressed by the introduction of the concept of "locking" of modern IM nails using bolts at each end of the nail thus fixing the nail to the bony cortex, which is the standard today. Since the advent of closed interlocking nailing of the femur, [8],[9] open Küntscher nailing is no longer the common method of fixation of femoral shaft fractures. However, open Küntscher nailing is still indicated in hospitals where a traction table or image intensifier is not available and when patient is unable to afford the cost of interlocking nailing, which is the situation in most hospitals in Nigeria including some teaching hospitals.

This patient did not make any previous radiographs available on presentation, could not afford any new radiographs before treatment and did not return for follow-up with results of requested investigations. Hence, the underlying etiologies and pathogenesis of the K-nail extrusion in this patient is subject to controversy and speculation, and a variety of the previously mentioned factors may be responsible. It was not possible to determine etiology of migration of the K-nail from radiological features or results of any investigations since none was available. The process of migration and subsequent extrusion may have been initiated by faulty selection of K-nail size: Loose fitting nail permitting repetitive movement at the fracture site. A size 38 cm length by 10 cm diameter K-nail looked small for the patient; but without X-rays it was impossible to confirm this. Infection and delayed union with shortening are etiological possibilities. Disuse osteoporosis and premature weight bearing may also be contributory factors. She had surgery about 4 years after the fracture during which time the bone may have become osteoporotic due to disuse and had been fending for herself after surgery by begging probably necessitating premature weight bearing. The presence of the K-nail in the medullary canal for a long time (6 years) may have also given rise to products of ionization and foreign body reaction which accumulated between the nail and the bone to cause a positive expulsion of the nail through the sinus.


  Conclusion Top


This complication could have been prevented if this K-nail was removed soon after the fracture united though divided opinions have been expressed about extraction of IM nails. Earlier extraction was not possible in this patient because of financial constraints. Some surgeons are of the opinion that unless a patient complains of local symptoms, the nail can be left indefinitely or at least for several years while some advice removal once the fracture is united and consolidated. Although of uncommon occurrence, because of the possibility of late onset migration and spontaneous extrusion it is recommended that K-nails be routinely extracted as soon as union and consolidation of the fracture is radiologically established.

 
  References Top

1.
Winquist RA, Hansen ST Jr. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin North Am 1980;11:633-48.  Back to cited text no. 1
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2.
Fischer MS, Fischer S. Gerhard Küntscher 1900-1972. J Bone Joint Surg Am 1974;56:208-9.  Back to cited text no. 2
    
3.
Watson-Jones R, Bonnin JG, King T, Palmer I, Smith H, Vaughan-Jackson OJ, et al. Medullary nailing of fractures after fifty years; with a review of the difficulties and complications of the operation. J Bone Joint Surg Br 1950;32-B: 694-729.  Back to cited text no. 3
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4.
Bohler J. Results in medullary nailing of ninety-five fresh fractures of the femur. J Bone Joint Surg Am 1951;33-A: 670-8.  Back to cited text no. 4
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5.
Stuck WG, Thompson MS. Complications of intramedullary fixation of fractures of the femur. AMA Arch Surg 1951;63:675-86.  Back to cited text no. 5
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6.
Macausland WR Jr, Eaton RG. The management of sepsis following intramedullary fixation for fractures of the femur. J Bone Joint Surg Am 1963;45:1643-53.  Back to cited text no. 6
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7.
O'brien JP. Fractured femoral shafts. A review of 127 consecutive cases including 53 treated by Kuntscher nail fixation. Aust N Z J Surg 1963;33:91-102.  Back to cited text no. 7
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8.
Williams MM, Askins V, Hinkes EW, Zych GA. Primary reamed intramedullary nailing of open femoral shaft fractures. Clin Orthop Relat Res 1995;318:182-90.  Back to cited text no. 8
    
9.
Wroblewski BM, Browne AO, Hodgkinson JP. Treatment of fracture of the shaft of the femur in total hip arthroplasty by a combination of a Küntscher nail and a modified cemented Charnley stem. Injury 1992;23:225-7.  Back to cited text no. 9
    


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