Broken Kirschner Wires Can Migrate: A Case Report and Review of Literature.

INTRODUCTION: Kirschner wires are in use in orthopedic and trauma surgery since the past 80 years. These wires can break due to metal fatigue and migrate which can cause lethal complications. CASE REPORT: A 27-year-old female sickle cell patient with avascular necrosis of the head of femur, drilling, and injection of the osteoblasts in the head of femur was being performed. A 2 cm of 2.0 mm proximal tip of the guide wire broke. Discussion started whether to leave the wire and the young decided to leave the broken wire, but the wisdom directed us to remove it.
CONCLUSION: Migration of wires does occur, we believe not only broken wires should be removed but also even the unbroken wire to be removed once the purpose of use is achieved. Copyright: © Indian Orthopaedic Research Group.

Wires do break due to metal fatigue and technical difficulty. Broken wires do migrate and should be removed to avoid serious complications. Unbroken wires should also be removed once their pupose is achieved.

Introduction

Kirschner wires (K-wires) which were developed and popularized its use since 1932 are widely used in orthopedic and trauma surgeries [1], even though 18% end up in complications related to the K-wires which include infection, loss of fixation, loosening breakage, and migration [2, 3]. Migration of the K-wires away from the site of the insertion to lungs, spinal cord, heart, and abdominal organs has been reported. The question arises if during the insertion if the wire breaks what should be done ? We report a case where the proximal wire broke in the neck of femur and decision was taken to remove, which was done successfully. Later, a review of literature revealed devastating results of migration of the broken K-wires (Table 1).

Table 1

Review of literature with complications of broken K-wires

Case Report

A 27-year-old female patients with Grade II avascular necrosis of the head of femur secondary to sickle cell disease were taken to operating room for drilling and injection of autologous bone marrow derived osteoblasts and are recommended to use a smaller diameter K-wire for instillation of the cells. During the procedure, two guidewires were passed to centralize the area of injection. A 3.2 mm cannulated drill was used to drill on top of the guidewires. During drilling, 2 cm of the proximal guide wire broke (Fig. 1) and we believe that this happened due to metal fatigue as the wire was used before couple of time. A discussion arose whether to leave the broken wire in situ. The risk of migration was always on the cards, hence, the guidewire was pushed back to the edge of the broken part. A 4.0 mm cannulated drill was used to drill over the broken wire (Fig. 2). The drill was pushed till the subchondral bone and slowly the cannulated drill was withdrawn and with it the broken part came out (Fig. 3). The rest of the procedure was carried out as per our protocol. Figure 4 shows the X-ray the right hip after 16 months of the surgery.

Figure 1

Radiographs at presentation broken guide wire in the neck of femur.

Figure 2

Broken guide wire was over drilled with 4.0 mm cannulated drill.

Figure 3

Broken guide wire was successfully removed.

Figure 4

X-ray after 16 months of surgery.

Discussion

Migration of the broken K-wires and other devices is known to occur without any indication and can cause from death to grievous injuries to the various organs of the body. No doubt this complication is rare but does happen and surgeons should be ready to recognize it and remove the broken implant. We reviewed the literature and in the past 30 years and over 60 cases of migration of the broken K-wires have been described in the English language literature causing 11 deaths and serious injuries with extended morbidity in otherwise healthy patients (Table 1).

Among different areas of surgery vulnerable to migration of the K-wires if used during the procedure was the shoulder region. Acromioclavicular joint dislocations, clavicular fractures, and sternoclavicular joint dislocations constitute the majority of reported cases. Most of the literature on K-wire migration. Lyons and Rockwood reviewed 37 reports of pin migration from the shoulder region and found that in 17 patients caused serious vascular injuries causing 8 deaths [4].

There is no age is bar for migration as K wires from pediatric to adults cases haven reported. Over the years, 10 cases of migration of K-wires have been reported in pediatric age group [5, 6, 7] and in one child ended in the demise of the child in which the wire migrated after 7 days of insertion [7]. The second important aspect to ponder is that the wires have migrated from 4 days to 34 years [8, 9].

Based on our review of literature, it is wise to state that K-wires, broken or unbroken, have a tendency to migrate. Once it is on path to move it can cause significant damage to organs and even death. We believe that every attempt should be made to remove the broken wires which happen during surgery and those wires in place should be bent appropriately, monitored and removed once the purpose of insertion is achieved. This will avoid potential complications and morbidity.

Conclusion

Breakage of the K-wires can occur during surgery either due to metal fatigue or due poor technique. In our case, we believe it happened due to metal fatigue as the wire was used before couple of time. Migration of K-wires occur, more so the broken ones, we believe that K-wires should be removed either broken or unbroken once the purpose of use is achieved, second, it is advisable to limit the reuse of K-wire or guide wires.

K-wires are prone to migrate, more so when they get broken inside the bone due to any cause. Attempts should be made to remove them, if the wire is broken during a procedure, which could be much easier.