Intraoperative Challenge of Removing a Tibia Intramedullary Nail With the Herzog's Bend Facing Anteriorly- a Case Report

Background: Intramedullary nailing of tibial shaft fractures is a very standard procedure. Removal of implant is done many times for reasons such as infection, breakage, nonunion and in situations where patient demands it. Complications during removal of tibia nail have been described. We report a case wherein an arthrotomy of the knee was necessary because of wrongly inserted nail with the Herzog bend(apex) facing anteriorly.Case presentation: 48 year old gentleman had undergone intramedullary nailing of the right tibia two years ago for treatment of a closed mid-shaft fracture. The fracture healed uneventfully, and the patient returned to all pre-injury activities. He visited us two years after surgery requesting removal of implant. There was difficulty in attaching the extraction jig as the mouth of the nail was facing posteriorly and the complete insertion of the jig was not allowed by the patella. Revisiting the X-ray intraoperatively, we found that the Herzog bend was facing anteriorly. Following this the nail was removed using a medial parapatellar approach.Discussion and conclusions: The studies published regarding removal of the tibia nail usually mentions the complications associated with the implant design or the patient factor. The implant design complicating the removal could be due to the non-slotted distal portion in the older generation nails. We had a complication due to the iatrogenic erroneous implantation of the tibial nail which was only found intra-operatively. The use of medial parapatellar approach was a useful method which helped us in insertion of the extraction jig and thereby helping in removal of the nail.