The breakage of orthopedic hardware is rare during surgical management of proximal femur fractures. Drill bits and guide wires are the most common hardware that breaks during surgery. Broken pieces within the femur can sometimes be left in place without any suspected complications. Rarely, a broken guide wire can extend into the hip joint or migrate partially or completely into the pelvis. These require surgical removal as the broken wire may lead to hip arthritis or cause trauma to intrapelvic structures such as the external iliac vein or pelvic viscera. We report two cases in which the guide wire broke intraoperatively within the femur, and we managed to retrieve it through the same incision, thus reducing morbidity and achieving good outcomes.

Case 1

A 52-year-old man presented to the emergency room with an Evans type 2 intertrochanteric hip fracture. Proximal femoral nailing with a proximal femoral nail antirotation II (PFN A2) implant was planned. Under spinal anesthesia, closed reduction was achieved on a fracture table in the supine position. The guide wire was inserted from the tip of the greater trochanter (GT) using a skin incision 7 cm proximal to the GT. An appropriately sized nail was inserted after proximal reaming. A 3 mm guide wire was then used to insert the helical blade from the lateral cortex to the femoral head. However, while inserting the helical blade, it was observed that a broken piece of the guide wire had been pushed into the hip joint and pelvis with the blade still midway in its tract (Fig. 1a). Various options for the retrieval of the broken guide wire were discussed immediately. The helical blade and nail were removed, and the blade tract was manually followed with a size 8 tibia reamer up to the distal tip of the broken guide wire. Under fluoroscopic guidance, a disc forceps was used to retrieve the free end of the broken piece. The fracture was then ultimately fixed with a dynamic hip screw system (Fig. 1b). The post-operative course was uneventful, and the patient recovered well.

Case 2

A 42-year-old man was admitted with a transcervical neck of femur fracture. A percutaneous three-screw fixation was planned. Under spinal anesthesia, closed reduction was achieved on a fracture table in the supine position. A 1.8 mm guide wire was passed in the calcar region using a power drill. However, due to the inaccurate trajectory of the guide wire, it was planned to withdraw the wire using a drill gun. While removing it, a sudden giveaway was felt and we realized that the tip of the partially withdrawn wire broke. Fluoroscopy revealed the broken guide wire in the subcapital region of the neck, reaching the head without any intra-articular extension (Fig. 2a). To retrieve the broken piece, a 4.5 mm cannulated drill bit was used on a drill gun and advanced over half of the extent of the broken wire under fluoroscopic guidance (Fig. 2a). The broken wire got engaged within the drill bit and was successfully retrieved on withdrawing the drill bit. The fracture was then managed as planned with a three-screw fixation and the recovery was uneventful (Fig. 2b).

Drill bits followed by guide wires are the most common orthopedic hardware that breaks intraoperatively [1, 2]. Literature-recorded techniques for addressing a broken guide pin involve the use of either an intraosseous route through the femur or a separate open approach. Over-reaming of the guide tract and use of long, small bore retrieval forceps is a well-documented technique owing to its simplicity [3, 4]. Arthroscopically assisted methods, although minimally invasive, are not readily available, expensive, and have a long learning curve. The use of intraosseous “bone endoscopy” using the tract made for the blade, to extract the broken piece endoscopically was successfully used by Arora et al. ^[5]. Both of our cases were middle-aged men with considerable cancellous bone quality which may be responsible for the breakage of the guide pin under resistance offered by the strong bone interface. We believe that the chances of such events occurring are less when dealing with osteoporotic or poor bone quality. One must keep this in mind while dealing with hip surgeries that involve good bone quality and not force their way or hammer the wire/pin/drill bit through the tough cancellous bone. Another possible cause may be the use of an old guide pin or a wire that has previously been used multiple times. Breakage is common while using such wires and the risk of failure is when the screw is being inserted over the wire or a tract is being drilled ^[6]. Stakeholders must ensure regular replacement of these wires from the implant set. A particular concern while using PFN A2 implant is the hammering of a larger bore blade over an un-reamed smaller guide pin tract as it is expected to gain better purchase when compared with manual screwing of the blade ^[7]. While this may hold true for an osteoporotic bone, hammering over a smaller bore guide wire in a good-quality cancellous bone may evoke stresses in the guide pin if there is a mismatch in the tracts of the pin and the blade. This we believe was the cause of breakage in the first case. Similarly, forceful progression of a sub-optimally sharp guide pin with a drill gun in a good-quality cancellous bone may bend the guide pin, disobeying a linear path. When this guide pin is withdrawn it fails to contour to the curvilinear trajectory and breaks midway. This was observed in the second case scenario. In both cases, we managed to remove the broken wire safely avoiding arthrotomy or any other approach. Previously (6) authors have successfully retrieved intraarticular broken hardware using surgical approaches such as which can increase the morbidity of the patient Salunke et al. ^[1] However if the broken wire migrates into the pelvis, possible options include laparoscopic retrieval ^[8] or laparotomy with an extraperitoneal ilioinguinal approach ^[9] which may require the expertise of other surgeons. In the first case, we had to remove the in situ nail owing to the nail hindering the path of exploration into the femur head. A similar method was used by Garabadi and O’Brien which needed implant removal and reimplantation ^[4]. Krishna and Chand used a technique involving a manually controlled drill bit on a T handle with sequential drilling of bone just distal to the broken wire with repetitive cleaning of bone debris from the drill bit and using a Kerrison rongeur to retrieve the piece ^[3]. They were able to achieve this without needing implant removal reducing operative time and maintaining fixation. The relatively non-invasive methods have certain drawbacks, first, the use of reamers to enlarge the tract for retrieval with disc forceps causes bone stock loss in the femoral head. Multiple attempts may cause considerable bone loss compromising the hold of the implant needed for fixation of fractures of the proximal femur. There is a considerable risk of pushing the broken pin further in the pelvis by the approaching reamer/drill bit abutting the piece (11). There have been records of neurovascular injuries such as injury to the external iliac vein from broken pins/wires that migrated into the pelvis ^[10]. This complication must be kept in mind while removing the broken guide wire. The use of an image intensifier in two orthogonal planes during the advancement of the reamer/drill bit can reduce the chances of it.

Guide wire breakage can be a sudden and dreaded intraoperative complication during hip fracture surgery. Attempts must be made to retrieve it through the same tract using unconventional instruments such as disc forceps before employing a more invasive separate incision approach.

Orthopedic surgeons must be aware of the possibility of guide wire breakage during hip surgeries and must keep instruments that can be used for wire retrieval as standby for the same. An attempt of less invasive retrieval must be made as the step of choice.