Laparoscopic extraction of fractured Kirschner wire from the pelvis.

Kirschner wire is a sharp stainless steel guide wire commonly used in fixation of fractured bone segments. There are case reports of migrated K wire from the upper limb into the spine and chest, and from the lower limb in to the abdomen and pelvis. Here, we present a case report of accidental intra-operative fracture of K wire during percutaneous femoral nailing for sub-trochanteric fracture of right femur, which migrated in to the pelvis when the orthopaedician tried to retrieve the broken segment of the K wire. This case highlights the use of laparoscopy as minimally invasive surgical option.

INTRODUCTION

Intra-operative fracture of K wire with migration in to pelvis is extremely rare. Retrieval of K wire is done in many cases through open surgical approach, and in very few via minimally invasive surgery.

The pelvis has many vital structures, like the bladder, rectum and large blood vessels. In this case, the K wire migrated into the pelvis without injuring any vital structure, thereby avoiding any disastrous consequences for the patient.

CASE REPORT

A 25-year-old male presented to the Accident and Emergency Department with an alleged history of a road traffic accident. On examination, he had a painful right hip with no other injury. On plain radiograph of both hip, he was diagnosed as having a sub-trochanteric fracture of right femur. The patient was posted for percutaneous femoral nailing. During surgery, after threading over the nail when the K wire was to be removed, it fractured and during an attempt at retrieval by the orthopaedician through the same hole, it was further pushed into the pelvis through the acetabulum plate [Figure 1]. The orthopaedic procedure was completed, and the patient was referred to the surgical unit for retrieval of the fractured segment of the K wire.

Figure 1

Plain radiograph of hip showing right femur sub-trochanteric fracture with broken K wire protruding into the pelvis

As the patient was stable, we conducted a contrast enhanced computed tomography (CT) scan of the abdomen and pelvis [Figure 2], in which the broken fragment of the K wire was seen protruding through the acetabulum into the right hemi-pelvis between the bladder and rectum, without any obvious injury to surrounding structures. The patient was planned for laparoscopic retrieval under general anaesthesia with C-arm guidance, if required.

Figure 2

Contrast enhanced computed tomography scan of pelvis showing broken K wire protruding between the rectum and the urinary bladder

A midline infra-umbilical 10 mm camera port was placed, and two 5 mm ports were further placed, both in the left mid-clavicular line, one at the level of umbilicus, and the other at the level of the Anterior Superior Iliac Spine. On inspection, there was no free fluid in the abdomen and no evidence of any bowel or vascular injury. The tip of the K wire was not visible either. In the pelvis, just lateral to the bladder and approximately at the level of the right Cooper's ligament, a blunt protrusion of the peritoneum was identified. The peritoneal flap was raised, and with sharp dissection, of superficial tissues, the pointed metallic K wire was seen [Figure 3], and retrieved with the help of a needle holder. No bleeding was seen, and the peritoneal flap was closed. Post-operatively, the patient recovered uneventfully.

Figure 3

Laparoscopic picture showing retrieval of sharp broken piece of K wire from the pelvis

DISCUSSION

K wire, is a sharp stainless steel wire, which is used as a guide wire to thread the nail over it in sub-trochanteric fractures. It can sometimes accidentally fracture intra-operatively, especially in young adults who have a hard cortex in femoral head, and migrate further if any attempt is made to retrieve it through the same hole. The hole around the guide wire should be enlarged with gentle drilling for smooth retrieval. If this manoeuvre fails then there is no other option but to open the joint, do an osteotomy and retrieve it. If the fractured K wire is lying in the joint cavity then arthroscopic retrieval can be tried. A CT scan in a stable patient is a very useful guide to plan minimal invasive surgery. Use of laparoscopy can definitely decrease the morbidity and the time for recovery in an already operated patient. There have been very few case reports of laparoscopic retrieval of fractured K wire in literature[12] There have been various case reports of complications during nail fixation procedures, such as Knowles’ pin through the external iliac vein,[3] perforation of rectum by a Smith Peterson nail[4] etc. The present case demonstrates an ideal application of laparoscopy. However, it must be remembered that all cases may not be feasible for laparoscopic retrieval,[5] and safety of the patient must not be compromised. Presence of C-arm and vascular clamps in the operating room is also extremely valuable in such cases.