Removing a broken guidewire in the hip joint: treatment options and recommendations for preventing an avoidable surgical catastrophe. A case report

ABSTRACT CONTEXT: Hardware breakage during hip surgery can pose challenging and difficult problems for orthopedic surgeons. Apart from technical difficulties relating to retrieval of the broken hardware, complications such as adjacent joint arthritis and damage to neurovascular structures and major viscera can occur. Complications occurring during the perioperative period must be informed to the patient and proper documentation is essential. The treatment options must be discussed with the patient and relatives and the implant company must be informed about this untoward incident. CASE REPORT: We report a case of complete removal of the implant and then removal of the broken guidewire using a combination of techniques, including a cannulated drill bit, pituitary forceps and Kerrison rongeur. CONCLUSIONS: We suggest some treatment options and recommendations for preventing an avoidable surgical catastrophe.


INTRODUCTION
Hardware breakage during hip surgery can pose challenging and difficult problems for orthopedic surgeons.2][3][4] Previously reported techniques for removing broken guidewires in the hip joint include use of over-reaming, use of disc forceps, arthroscopically assisted methods and arthrotomy of the hip joint.In this article, we report a case of complete removal of the implant and then removal of the broken guidewire using a combination of techniques including a cannulated drill bit, pituitary forceps and Kerrison rongeur.

CASE REPORT
A 65-year-old woman presented with left hip pain following trivial trauma.She was found to have sustained an Evan's type 4 left intertrochanteric hip fracture (Figure 1).The patient had diabetes and hypertension, which were well controlled with oral medication.We decided to fix the fracture surgically using a proximal intramedullary femoral nail.The patient underwent surgery on the third day after the injury.
During the surgery, the patient underwent routine uneventful combined spinal and epidural anesthesia.She was positioned supinely on a standard orthopedic fracture table.Closed reduction of the left intertrochanteric hip fracture was performed under image guidance.The surgeon performed a standard skin incision at 5 cm proximally to the tip of the greater trochanter, in line with the long axis of the femur.The entry point was into the lateral aspect of the greater trochanter, as per our usual practice.
After reaming, a short proximal femoral nail was inserted easily.
Two guidewires were then placed with the aid of the insertion device, to guide the insertion of the recon screws.A distal hip screw was subsequently placed successfully.
However, during the placement of the proximal hip screw over the cannulated guidewire, a sudden loss of resistance was unexpectedly encountered.Intraoperative images were immediately obtained and the guidewire was found to have broken with its tip lying within the subchondral area of the femoral head.
The broken guidewire had not breached the hip joint.The surgeon therefore decided to leave the guidewire alone, with no further attempt at removing it.
On postoperative day two, plain radiographs were produced, which revealed that the broken guidewire had migrated proximally into the hip joint (Figure 2).The patient therefore underwent a repeat procedure in an attempt to remove the broken guidewire.We began the revision surgery by removing the proximal hip screw.We attempted to reach the broken guide wire with the aid of a cannulated drill bit but we were unable to retrieve the broken wire.We then tried to use the pituitary forceps and Kerrison rongeur to remove the broken guide.Both of the above attempts at removing the broken guidewire were unsuccessful, so we removed the distal hip screw, distal locking screw and intramedullary nail.After complete removal of all other implants, the existing track from the proximal recon screw was enlarged using a cannulated drill bit.We were able to partially engage the tip of the guidewire with the cannulated drill bit.This allowed us to  reverse the guidewire slightly into the track.Once the track was large enough, a 2 mm pituitary rongeur and Kerrison rongeur were used successively to grasp the tip of the broken guidewire and remove it.Following successful retrieval of the broken guidewire, a long proximal femoral intramedullary nail was inserted to achieve fracture fixation (Figure 3).
The patient was mobilized with partial weight-bearing on the third postoperative day.Her postoperative recovery was uneventful and she was discharged five days after the revision procedure.
She underwent routine follow-up in the outpatient clinic.By three months after the operation, her fracture had completely united and she was walking independently without support.

DISCUSSION
We searched for similar cases in different databases (PubMed and Lilacs database) using the terms: "hip joint" AND "guide wire" AND "breakage" (Table 1).We found that few cases have been published.5][6][7][8][9] This literature review suggests that the most commonly broken orthopedic hardware is the drill bit, followed by guidewires.The complications caused by broken hardware include adjacent joint arthritis and damage to neurovascular structures and major viscera.Hardware may break through reuse, or due to technical problems such as drilling at a low angle of incidence or inadvertent bending during insertion.

Price et al. and Sharma et al. studied the reasons for hardware
failure due to repeated use of guidewires.They suggested that repeated use of guidewires over time causes deformation and loss of bending and torsional strength, such that the chances of failure increase while drilling and inserting a screw over the wire. 5,6In addition, technical errors that predispose towards intraoperative guidewire breakage may be due to inadvertent changes in direction and twisting during insertion, penetration of the subchondral bone into the hip joint, or insertion of a reamer or screw improperly at an angle to the guidewire, thereby causing excessive contact stress.
[8][9] It has been shown that the cross-sectional shape of the guidewire changes from round to oval following breakage. 9This was perhaps the reason why we were able to use the cannulated drill bit to engage the broken guide wire, to assist in its removal in the present case.

Figure 2 .
Figure 2. Postoperative radiographs produced after the primary surgery in anteroposterior view (white arrow) and lateral view (black arrow), showing broken guidewire in hip joint and short femoral nail.

Figure 3 .
Figure 3. Postoperative radiographs produced after revision surgery, showing that the broken guidewire was removed and a long femoral nail was inserted (white arrow).

Table 1 .
Results from review of the literature in medical databases for case reports and case series regarding hip fractures with implant breakage.Search conducted onSeptember 10, 2014

Table 2 .
Review of the literature regarding implant removal from hip joint