the use of the kuntscher nail has been the most important advancement in trauma surgery . he had an acetabulum fracture and a femoral shaft fracture treated 30 years ago with a reamed kuntscher femoral nail . lateral hip approach was performed and after attempting to remove the nail with the specific tools being unsuccessful we decided to be more aggressive . firstly , we performed a simple unicortical osteotomy on the lateral side from the proximal part to below the callus in order to decompress the femoral canal without success . secondly , a trench in the greater trochanter around the proximal hole was performed to hit the nail from below which was still insufficient and furthermore , the hole broke when hitting the nail so we needed to drill a new hole distally . several cerclages closed the osteotomy and a bone graft was used to close the trench . with this case report , we present a new salvage technique to remove an incarcerated kuntscher nail when all the described methods have failed . the use of the kuntscher nailing system for the treatment of long bone fractures has been the most important advancement in trauma surgery in recent history . since its first implementation in a german hospital in the late 30 s , removal of a kuntscher nail is considered a routine procedure but could be really challenging . bone ingrowth or overgrowth , damage to the proximal threads of the nail , and broken nails or locking screws may complicate the removal of intramedullary nails . the biggest challenge appears when all the described methods result in failure of removal of the nail . this article presents a case of an incarcerated femoral nail and describes a salvage procedure for nail extraction after all previously described methods have failed . the patient was involved in a plane accident 30 years before sustaining a femoral shaft fracture treated with a reamed kuntscher nail and a posterior wall acetabulum fracture treated with open reduction and internal fixation with lag screws ( fig.1 ) . the patient came to our outpatient clinic complaining about inguinal pain and chronic leg pain with limitation of activities of daily living , although he was able to walk for more than one hour . on physical examination , the ipsilateral knee had full range of motion and the patient did not need any crutches to walk without limping . the postelmerldaubign scale was 14 points ( 4 for pain , 5 for walking and 5 for range of motion ) . as a part of the initial evaluation , a blood test with infection parameters was performed and was negative for infection . pre - operative radiographs showed a healed femoral fracture in all 4 cortices with an intramedullary kuntscher nail without locking screws and cortical thickening at the fracture site ( fig . pre - operative x - ray of the pelvic ring : intramedullary kuntscher nail in the left femur and osteosynthesis with three screws in the posterior wall of the acetabulum . pre - operative x - ray of the distal part of the femur : fracture site healed and distal tip of the nail . the patient was informed about the incipient arthritis of the hip and the possibility to perform a one - stage or two - stage surgery . the surgical risks were discussed with the patient , including pain after hardware removal and failure to remove the nail , specially this last point because other surgeons had tried to do the same procedure few years before and had failed after many hours of surgery . firstly , remove the nail at all costs and depending on the outcome of this first surgery he would assess the hip replacement surgery . the patient was put in a lateral position and a lateral hip approach was done . the first step was to find the proximal tip of the nail which was found seated deep in the great trochanter . the initial device used to remove the nail was the conical extraction tool that was unsuccessful after several attempts . after the overgrowth bone was removed of the proximal part of the nail a hook extraction system was engaged with difficulty . however , the nail did not move after multiple hits with a 1 kg hammer and finally the hook broke itself . at this point , we decided to use the saw to perform a simple unicortical osteotomy in the proximal third of the femur to decompress the endomedullar canal ( fig . 3 ) . after this decompression osteotomy we tried to hit the nail from below with an impactor engaged in the proximal hole of the nail . however , the implant remained in the same position . clinicalintra operative image : simple unicortical osteotomy in the proximal third of the femur to decompress the endomedullar canal . after trying all these different ways to remove the nail being unsuccessful , we decided to continue the longitudinal osteotomy from proximal to distal in the lateral side of the femur . the nail was found in place with on growth and overgrowth in almost entire length of the nail . a new attempt to hammer the nail from below was performed and the nail started to move gradually until the proximal hole of the nail broke ( fig . 4 ) . after so many attempts , we did not give up and proceeded to drill a new hole distally with a diamond drill ( fig . 5 ) to finish the nail removal . clinical intra - operative image : detail of the moment when the nail started to move gradually until the proximal hole of the nail break . clinical image . subsequently , several cerclages and a bone allograft was used to close the longitudinal osteotomy ( fig . clinical intraoperative image : several cerclages closing the osteotomy with allograft bone used to close the longitudinal osteotomy . the patient was admitted to the hospital for pain and bleeding control . on the second day of hospitalization , the patient underwent a blood transfusion as his hemoglobin was reported to be 7.1 g / dl . the patient was discharged on day 4 after antibiotic prophylaxis , deep vein thrombosis prophylaxis with low - weight - molecular heparin and ambulation with crutches without weight bearing . at 8 weeks of follow - up the patient was satisfied at 1 year of follow - up with no complications and the x - ray showed complete healing of the longitudinal osteotomy ( fig . , the patient is free from pain in the leg with only sporadic hip pain , so there is no indication of hip replacement surgery for the time being various reasons have been described in the literature for nail incarceration , including excessive callus formation closing the intramedullary canal , ingrowth of bone into the nail , bone ingrowth through the locking holes and bent or broken nails . there are different techniques to remove retained intramedullary nails , most of these techniques are designed for broken nails , but others are for incarcerated nails . there is only one case similar to our case report by lindeque et al which describes removal of tibial nail using a large longitudinal osteotomy . we decided to perform a two - stage procedure especially due to the incipient arthritis of the hip . if our patient would have had advanced stage of arthritis , we could have considered a single - staged procedure with nail removal and hip replacement or a hip replacement without removing the nail . goosen et al treated a similar case in which they cut the proximal end of the nail to the length needed in order to implant a hip arthroplasty at the top of the nail . mont et al used this technique on fifteen patients with femoral implants or extraarticular deformities . however , despite the aggressiveness of the procedure , the patient had a good result , and the osteotomy healed normally with no complications . this is the first case published in the literature using this longitudinal osteotomy to remove a femoral nail . it is recommended to remove it as soon as it possible to minimize later complications .
introduction : the use of the kuntscher nail has been the most important advancement in trauma surgery . 
 one of the problems is the difficulty to remove it . 
 a new extraction technique is described in the present case report.case report : a 46-year - old man was referred for hip osteoarthritis . 
 he had an acetabulum fracture and a femoral shaft fracture treated 30 years ago with a reamed kuntscher femoral nail . 
 lateral hip approach was performed and after attempting to remove the nail with the specific tools being unsuccessful we decided to be more aggressive . 
 firstly , we performed a simple unicortical osteotomy on the lateral side from the proximal part to below the callus in order to decompress the femoral canal without success . 
 secondly , a trench in the greater trochanter around the proximal hole was performed to hit the nail from below which was still insufficient and furthermore , the hole broke when hitting the nail so we needed to drill a new hole distally . 
 finally , the kuntscher nail was removed . 
 several cerclages closed the osteotomy and a bone graft was used to close the trench . 
 the patient had a good evolution at one year of follow-up.conclusion:with this case report , we present a new salvage technique to remove an incarcerated kuntscher nail when all the described methods have failed .