# When Nail Removal Is Not Benign: Iatrogenic Fractures Associated With Titanium Intramedullary Nail Removal

## TL;DR

This paper discusses how removing titanium intramedullary nails can cause fractures due to bone ingrowth and osseointegration, emphasizing the need for careful planning during extraction.

## Contribution

The paper presents three clinical cases highlighting iatrogenic fractures during nail removal and suggests preventive strategies.

## Key findings

- Three patients experienced fractures during titanium nail removal due to bony ingrowth and osseointegration.
- Fractures healed within three to four months without complications.
- The paper recommends planning and proper instrumentation to prevent such complications.

## Abstract

Intramedullary (IM) nailing is a standard treatment for diaphyseal fractures of long bones. Several factors influence bony ingrowth and osseointegration between the nail and bone. Removal of these nails may be required, especially in younger patients, for multiple indications. Bony ingrowth and osseointegration can cause resistance and complicate nail removal.

We report a series of three patients who had bony ingrowth and osseointegration within the nail and proximal metaphyseal bone, which complicated routine nail removal. One patient sustained an intertrochanteric femur fracture during the extraction of the femoral nail, while the other two patients sustained proximal tibial fractures during the extraction of the tibial nail.

All fractures that occurred during nail extraction healed over a period of three to four months without complications. In this case report, we have addressed the possible reasons for this complication and methods to prevent it. Removal of an IM nail requires adequate planning and instrumentation for safe extraction. Bony ingrowth and osseointegration can complicate routine nail removal. Surgeons should be mindful of these complications and be aware of different techniques for bone removal to ensure safe nail extraction.