Removal of

Broken Hardware

David J. Hak, MD
Matthew McElvany, MD

Dr. Hak is Associate Professor,

Department of Orthopaedic Surgery,
Denver Health, University of Colorado,
Denver, CO. Dr. McElvany is
Orthopaedic Resident, Oregon Health
and Science University, Portland, OR.
Dr. Hak or a member of his immediate
family has received research or
institutional support from Synthes USA.
Neither Dr. McElvany nor a member of
his immediate family has received
anything of value from or owns stock in
a commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Hak, Department
of Orthopaedic Surgery, Denver Health,
University of Colorado, Mail Code 0188,
777 Bannock Street, Denver, CO
80204.
J Am Acad Orthop Surg 2008;16:113120
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

Volume 16, Number 2, February 2008

Abstract
Despite advances in metallurgy, fatigue failure of hardware is
common when a fracture fails to heal. Revision procedures can be
difficult, usually requiring removal of intact or broken hardware.
Several different methods may need to be attempted to successfully
remove intact or broken hardware. Broken intramedullary nail
cross-locking screws may be advanced out by impacting with a
Steinmann pin. Broken open-section (Kntscher type)
intramedullary nails may be removed using a hook. Closed-section
cannulated intramedullary nails require additional techniques,
such as the use of guidewires or commercially available extraction
tools. Removal of broken solid nails requires use of a commercial
ratchet grip extractor or a bone window to directly impact the
broken segment. Screw extractors, trephines, and extraction bolts
are useful for removing stripped or broken screws. Cold-welded
screws and plates can complicate removal of locked implants and
require the use of carbide drills or high-speed metal cutting tools.
Hardware removal can be a time-consuming process, and no single
technique is uniformly successful.

ardware removal can pose an

unpredictable level of surgical
difficulty in elective or revision surgery.1 Broken hardware often can be
identified on preoperative radiographs, but it also may be encountered unexpectedly during surgery.
Overlapping hardware may obscure
visualization of broken screws on
preoperative radiographs. Screws
also can be broken during removal
when the screw head is sheared off a
well-fixed shaft. Screwdriver tips can
break during attempted screw removal, and the tip may remain incarcerated in the screw head.
Stripped screws, stripped intramedullary (IM) nail extraction threads,
and cold-welded screws and/or
plates may be discovered intraoper-

atively. The difficulty of removing

broken or stripped hardware can
markedly increase surgical time and
complexity.
Although broken hardware may
be encountered unexpectedly during routine hardware removal, this
commonly occurs in the presence of
nonunion or delayed union of a fracture following trauma. Broken hardware also may occur following tumor resection and reconstruction
when the bone does not heal. Implants placed for prophylactic stabilization of impending pathologic
fracture may fail as a result of improved patient survival (eg, with advances in chemotherapy and radiation therapy). In the presence of
infection, removal of broken hard113

Removal of Broken Hardware

Table 1
Commercially Available Devices Useful for Hardware Removal
Indication
Broken or
stripped
screws

Device
Screw removal instrument system
(DePuy, Warsaw, IN)

Hex screwdrivers, screw extractors, trephines,

extraction bolts, and easy-out extractors

Universal screw removal

instrument system (Innomed,
Savannah, GA)
Implant extraction set
(Stryker, Mahwah, NJ)

Screw extractors, trephines, and various

screwdrivers

Screw Removal System

(Synthes USA, Paoli, PA)
Xtract-All universal broken screw removal
system (S.S. White Medical, Piscataway, NJ)
Xtract-All stripped bone screw removal system
(S.S. White Medical)
Broken
intramedullary nails

Nail extractor hook (Biomet, Warsaw, IN)

Nail extractor hook (Smith and Nephew,
Memphis, TN)
Nail extractor hook (Stryker)

Extraction hook for titanium cannulated nails

(Synthes USA)
Intramedullary Nail Extractor (Innomed)

Offset punches (Innomed)

Solid nail extraction system (Synthes USA)

Intramedullary nail extraction set

(Zimmer, Warsaw, IN)
Cold-welded
plates

Carbide drill bits (Synthes USA)

General

OrthoVise (Innomed)

Screwdrivers, screw-removal bits for stripped

screws, conical extraction bits, trephines, and
intramedullary nail extraction tools
Screwdrivers, screw-removal forceps, conical
extraction screws, hollow reamers, extraction
bolts, and carbide drill bits
Thirteen sizes of extractor shafts with ratcheting
T-handle
Eight sizes of twisted screw extractors (1.5 to 5.0
mm), ratcheting T-handle, parallel jaw pliers,
and mallet
When used for other nail brands, confirm that
extraction hook fits through nail opening
When used for other nail brands, confirm that
extraction hook fits through nail opening
Small and large sizes are available in
implant-extraction set, along with various
intramedullary nail extraction tools
When used for other nail brands, confirm that
extraction hook fits through nail opening
Includes three-eighths inch and one-half inch
conical extraction bolts for removal of both
fluted and nonfluted cannulated nails
Used to push out broken solid nail segments
Various sizes of trephines and extractor heads
for solid 8-, 9-, 10-, 11-, and 12-mm
intramedullary nails
Includes various diameters of smooth and
beaded guidewires, corkscrew extractors, and
extractor bolts
Part of the Synthes Screw Removal System

Diamond wheel burrs (Anspach,

Palm Beach Gardens, FL;
Medtronic Midas Rex, Fort Worth, TX)

ware is indicated to minimize bacterial colonization. When IM nailing

is performed, any broken screw that
impinges on the IM nail path will
need to be removed.
Overall, no single technique is
uniformly successful, and several
different methods may need to be attempted to remove intact or broken
hardware. Additionally, commer114

Equipment/Comments

Vise-grip pliers with attached slap hammer

cially available tools are useful for

hardware removal (Table 1).

Broken Intramedullary
Nail Interlocking
Screws
Because of their narrow diameter, interlocking screws are far more prone
to fatigue failure than IM nails. Fa-

tigue failure of the screw often occurs near the edge of the nail, and
implant migration may lead to angulation of the broken screw. Advancement of the screw fragment may be
necessary to permit removal of the
IM nail. Interlocking screws are often positioned in a metaphyseal location where the cortical bone is relatively thin. This allows the broken

Journal of the American Academy of Orthopaedic Surgeons

David J. Hak, MD, and Matthew McElvany, MD

screw fragment to be advanced with

relative ease. A stout, smooth Steinmann pin or similar device of the appropriate diameter is commonly
used to impact the broken screw segment.2,3 The diameter selected depends on the diameter of the interlocking screw. Using a mallet, the
blunt end of the Steinmann pin is
passed through the nail hole and impacted against the fragment (Figure
1). Depending on the location and
fragment size, a counter-incision
may be necessary to retrieve the broken interlocking screw fragment.
Otherwise, the fragment may be allowed to remain in the adjacent soft
tissues. Alternatively, the screw
fragment alone may be partially advanced to clear the nail pathway,
leaving most of the fragment in the
metaphyseal bone.

Broken
Intramedullary Nails
Removal of broken IM nails may be
particularly challenging and sometimes is difficult. When removing an
IM nail, it is helpful to identify the
brand and diameter of the nail. This
will help in obtaining the correct
instrumentation for nail removal.
When a nail is broken, it is also useful to obtain a sample nail of the
same brand and size. Knowing the
brand and size of the nail will help
to determine the size of the extraction devices (eg, hooks, ball-tip
guidewires) that will fit through the
distal nail outlet.
Problems with IM nail removal
can be encountered even in the absence of a broken nail. Challenging
nail removal may occur when the
extraction threads are stripped or
when the correct extraction device is
unavailable. Several commercial IM
nail extraction sets provide corkscrew extractors that can be crossthreaded into the IM nail and attached to an extraction slap hammer.
The use of an extraction hook, use of
the interference-fit ball-tip technique, or other methods for broken
Volume 16, Number 2, February 2008

IM nail removal may be required.4-6

Numerous technical tips for the
removal of broken solid and cannulated IM nails are available. Regardless of the technique used to remove
the broken nail segment, it is often
helpful to ream the IM canal after removing the threaded end of the nail.
Providing a larger pathway may ease
the removal of the broken nail segment.
Initial methods to remove broken
cannulated IM nails required the use
of a custom-made hook fabricated
from a reverse biting-hook osteotome.4 Extraction hooks also have
been hand-made from a 0.25-inch
Luque rod and a 3-mm smooth
guidewire.7,8 Similar hooks are now
commercially available for this purpose from several vendors (Biomet,
Warsaw, IN; Smith and Nephew,
Memphis, TN; Stryker, Mahwah, NJ;
Synthes USA, Paoli, PA). As noted,
the hook must be small enough to fit
through the distal end of the nail and
engage the tip of the broken fragment.
Reverse extraction is used to remove
the broken nail fragment (Figure 2).
Serial stacking of smooth guidewires into the nail lumen has been
described to help align broken segmental pieces.5 This technique provides pressure against the hook to
maintain its proper position. A plastic exchange tube also can be used to
center the broken distal nail segment.7 In addition to keeping the
hook engaged against the nail, these
techniques also will prevent a short
distal segment from angulating obliquely and becoming jammed during extraction. Open-section nails
(Kntscher type) are best removed
using a hook.
Winquist developed a similar
technique for removal of closedsection cannulated nails.9 A pointed
guidewire is first passed or impacted
through the distal nail hole to remove any adherent bone or fibrous
tissue (Figure 3). Once an adequate
working area has been developed, a
ball-tipped guidewire is passed
through the tip of the broken nail

Figure 1

A Steinmann pin is used to impact a

broken interlocking screw. The
diameter of the Steinmann pin selected
should be as stout as possible while
still able to fit through the
intramedullary nail hole.

fragment. Additional smooth guidewires are then inserted to obtain an

interference fit. Removal of the broken nail segment is performed by reverse extraction of the ball-tip
guidewire. A commercially available
IM nail extraction set (Zimmer, Warsaw, IN) is available with various
sizes of diamond point Steinmann
pins (2.4-, 3.2-, 4-, and 5-mm), bullettip guidewires (2.8-, 4-, 5-, and 6-mm
diameter tips), and smooth guidewires (1.6-, 2-, 3.2-, and 4-mm diameter). This removal set also contains
various sizes of conical corkscrew
extractors for removal of the proximal nail segment.
Another commercially available
nail extraction system uses a conically shaped stainless steel extraction bit attached to a long driveshaft
(Intramedullary Nail Extractor; Innomed, Savannah, GA). Because
most contemporary IM nails consist
of relatively soft titanium alloy, the
stainless steel extraction bit is able
to achieve purchase as it threads the
inner walls of the nail. Rotational
and axial stabilization of the nail
115

Removal of Broken Hardware

Figure 2

Figure 3

Removal of a broken cannulated nail. A hook is passed

through the broken distal nail segment (dashed rectangle),
and the segment is removed with gentle reverse extraction.

Removal of a closed-section cannulated nail. Interference fit

against a beaded guidewire is obtained by insertion of
smooth guidewires, thereby allowing removal of a broken
distal nail segment.

Figure 4

Removal of a solid intramedullary nail. A, A large cylindrical hole is drilled in the

metaphysis, and the broken distal segment is levered proximally with a Steinmann
pin. B, A narrow Hohmann-type retractor is placed beneath the tip of the nail, and
the broken segment is pushed out with a narrow-diameter nail inserted from above.

segment can be achieved either by

leaving the most distal interlocking
screw in place or by temporarily inserting a Steinmann pin into the
most distal interlocking hole.
Removal of the broken nail
segment also has been described using a narrow-diameter open-section
116

Kntscher nail.10 The internal diameter of the broken nail must be of

sufficient size to accept a smalldiameter (8 to 10 mm) Kntscherstyle nail. After enlarging the proximal IM canal via reaming, the
narrow-diameter Kntscher nail is
wedged into the broken distal nail

segment and removed using gentle

rotatory movements while pulling
outward.
Removal of solid IM nails may be
more difficult. The use of a metaphyseal window has been described
to access a short, broken, solid femoral nail from the distal femur.11 A
cylindrical trough is drilled just anterior to the origin of the lateral collateral ligament of the knee. The broken fragment is proximally moved
by levering it with a Steinmann pin
placed in the distal interlocking hole.
A narrow Hohmann-type retractor is
placed just beneath the tip of the
nail. The broken nail fragment is
pushed out distally with the aid of a
smaller diameter nail inserted from
above (Figure 4). A disadvantage of
this procedure is the need to create a
separate surgical approach that violates the intact bone cortex.
When the nail is proximally broken, solid antegrade femoral nails
can be removed by opening the distal femur, similar to performing a
retrograde nailing. An impactor then
can be used to push the nail out in a
retrograde fashion.12 Commercially
available offset punches may be useful to aid solid nail removal. Impaction against the nail can be performed through a bone window
made in the metaphysis or diaphysis.

Journal of the American Academy of Orthopaedic Surgeons

David J. Hak, MD, and Matthew McElvany, MD

An adjustable extractor device

also is commercially available for
the removal of solid IM nails (Synthes USA). The IM canal should be
reamed to a diameter 4 mm greater
than that of the nail diameter to allow clearance for passage of the extractor. A trephine is then used to remove tissue from around the broken
segment. A specialized ratchet grip
extractor is positioned around the
broken end of the nail and tightened
(Figure 5). Nail removal is then accomplished by reverse extraction.6
The use of laparoscopic grasping
forceps also has been described to remove a broken IM nail segment.
However, the jaw width required to
open the clamp may preclude its use
in many circumstances.13
Occasionally, following secondary trauma, a patient may present
with a bent nail. An attempt may be
made to manually unbend an opensection stainless steel nail; however,
many nails are too strong to unbend.14 In this situation, surgical
management will require cutting the
nail at the apex of the bend. Following an open approach, both nail segments may be removed through the
incision used to cut the nail. Several authors also have described less
invasive methods in which the nail
is partially sectioned or weakened by
drilling, then unbent in situ and removed as a single unit.15,16

Broken Solid Screws

Following Plate Fixation
Following screw breakage, the screw
head portion is often loose (as a result of motion) and is easy to remove. Depending on the circumstance, the removal of the distal
screw tip portion may not be required. When fracture nonunion is
complicated by infection, removal of
the distal screw tip may be warranted to eliminate a potential infection
nidus. Removal of the distal screw
tip also may be required when converting to IM stabilization, dependVolume 16, Number 2, February 2008

Figure 5

Figure 6

A hollow reamer is used to remove

bone and tissue surrounding the
remaining shaft of a broken screw.

A commercial ratchet grip extractor

designed for removal of solid
intramedullary nails.

ing on the location of the fatigue

break.
When a portion of the screw shaft
protrudes above the bone, vise grip
type pliers may be used to grasp and
turn the screw. Removal of the broken distal screw tip also can be easily performed by impacting the
screw and driving it through the far
cortex. Unlike IM cross-locking
screws that can be driven easily
through the thin metaphyseal bone,
impaction of broken screw tips that
are well-fixed in the diaphyseal cortical bone may be impossible to remove. When the distal screw tip is
well fixed, removal may be achieved
with the use of one of the commercially available extraction systems
(Table 1).
A centering pin is placed through
the near cortex hole, and multipla-

nar fluoroscopy is used to obtain the

correct trajectory to the remaining
screw tip. An appropriately sized
hollow reamer is implemented to
enlarge the hole in the near cortex
and to clear tissue surrounding the
screw (Figure 6). Hollow reamers
have reverse cutting teeth and are
turned counterclockwise with a
T-handle or power drill in reverse.
The extraction bolts have reverse
threads and are threaded onto the
screw by turning counterclockwise
while applying axial pressure.
Occasionally, the distal screw tip
may become incarcerated in the hollow reamer and the screw is then extracted by turning the hollow reamer
counterclockwise. It is recommended
that the hollow reamer be advanced
to expose approximately 1 cm of the
broken screw shaft. To avoid further
cortical bone loss, an extraction bolt
with reverse threads should be placed
over the broken screw shaft and
turned by hand in reverse while applying pressure in the direction of the
screw axis (Figure 7). When it is not
possible to create purchase on the remaining screw tip, it may be necessary to use a hollow reamer to drill
across the far cortex.
Another commercially available
system is a single integrated device
that is available in 13 different sizes
117

Removal of Broken Hardware

Figure 7

Figure 8

Figure 9

Removal of a distal screw tip after

enlarging the cortical hole with a hollow
reamer. A reverse-threaded extraction
bolt is threaded onto the screw shaft
while axial pressure is applied.

Removal of a broken cannulated screw

by a conical extraction device threaded
into the hollow screw.

Removal of a stripped screw using a

conical extraction device.

(Xtract-All; S.S. White Medical, Piscataway, NJ). The end of this tool
consists of a reverse-cutting, hollowcoring tool with extraction bolt
threads in its inner wall, thereby allowing coring, grabbing, and extracting with a single device.

Broken Cannulated
Screws
In removing a broken cannulated
screw, a guidewire or an appropriately sized Kirschner wire can be used
to determine the correct screw trajectory and clear any fibrous tissue
from the screw removal pathway.
Occasionally, interference fit by impaction of a spade-tipped Kirschner
wire (ie, a spade point that is slightly larger than the inner screw diameter) is sufficient to allow screw removal. More commonly, removal of
broken cannulated screws is performed with a reverse-threaded conical extraction device (Figure 8). Additional use of this extraction device
has been reported in the removal of
a cannulated spiral-locking blade.17
Removal of Screws With
Stripped Heads
Screw stripping is most commonly caused by slippage of a driver that
118

is incorrectly aligned with the screw

axis. This can occur during either insertion or attempted removal. Studies have focused on play and torque
values obtained before and after the
reaming of a screw heads socket
walls. After one event of slippage,
the maximal torque values in both
clockwise and counterclockwise directions were only one half the preslippage values.18 Even when access
to the screw head is unobstructed, it
is important to ensure that the
screwdriver is aligned collinearly
with the screw axis to obtain complete engagement in the screw head.
When slippage and stripping occur,
various techniques may aid removal
of screws with damaged heads.
One technique involves the use of
a gauze swab wrapped around the tip
of the screwdriver.19 Placing gauze
between the screw head and screwdriver creates an interference fit and
provides additional torque necessary
for removal. Additional folds may be
required to increase the gauze swab
thickness. Surgeons also have recommended placing a small layer of
foil from a suture packet into the
screw hole to increase the interference fit. In our experience, these
techniques are successful only with
minimal screw head stripping.

Conical reverse-threaded extraction devices also may be used. These

devices are available from several
manufacturers in sizes for screws
ranging from 1.5 to 7.3 mm. The appropriately sized conical extractor,
based on the size of the screw head
hex, is inserted firmly into the screw
head. The conical extraction device
is turned counterclockwise while
applying pressure in line with the
screw axis. Lightly tapping the extractor with a mallet may be successful when purchase is not initially obtained with manual pressure
(Figure 9).
Also available is a series of twisted screw extractors, which can be
impacted into the stripped hex screw
head (Xtract-All [Captive Twist]).
These are available in 0.5-mm increments from 1.5 to 5.0 mm (Figure
10). Occasionally, removal techniques for cold-welded screws may
be required when these methods fail
to remove stripped screws.
Removal of Cold-welded
Screws
The development of locking plate
technology has led to problems with
the cold welding of screws to plates,
especially in softer titanium implants.20,21 Occasionally, screwdriver

Journal of the American Academy of Orthopaedic Surgeons

David J. Hak, MD, and Matthew McElvany, MD

Figure 10

Captive Twist (Xtract-All) screw

extractors for removal of screws with
stripped heads (S. S. White Medical,
Piscataway, NJ).

tips will break and remain embedded

in the screw head. The use of a carbide drill bit or diamond-impregnated
metal cutting disk will be required to
remove a cold-welded screw. The
cold-welded screw head is then
drilled out through the use of the carbide drill (Figure 11). Techniques described previously for broken screws
may be used to remove the remaining screw shaft.
Alternatively, the plate can be cut
directly at the screw hole with a diamond cutting wheel, thereby releasing the plate from the screw (Figure 12). The screw then can be
removed with a screwdriver or vise
gripstyle pliers when the screw
head is stripped or damaged. The
plate also can be cut adjacent to the
screw, and the remaining plate and
screw twisted counterclockwise
with pliers, thus removing the coldwelded screw from the bone (Figure
13). Adequate clearance of the plate
Volume 16, Number 2, February 2008

Figure 11

A, A carbide drill bit is used to remove the head of a cold-welded screw. Soft
tissues should be protected with saline-soaked gauze and constant irrigation, and
suction should be used to remove metal debris. B, Once the locking plate is
removed, the remaining screw shaft can be removed by various methods.

Figure 12

Figure 13

Removal of a screw cold-welded to a

plate. Each side of the plate is cut
adjacent to the cold-welded screw.

Removal of a screw cold-welded to a

plate. The plate is transversely cut
around the cold-welded screw, and the
plate segment is used as a T-handle
and turned with pliers.

from the bone will be necessary for

the cut plate segments to be used as
a T-handle to turn the screw.
When using metal-cutting tools,
soft tissues should be protected with

saline-soaked gauze to prevent excessive accumulation of metal debris. Irrigation and suction should be
used simultaneously to cool the field
and remove any metal debris.
119

Removal of Broken Hardware

Summary
Removal of broken hardware can be
technically challenging and necessary in surgical management. Preoperative planning is recommended to
have the proper removal equipment
available. Surgeons should be aware
of available equipment for broken
hardware removal onsite in the operating room as well as where other
equipment that may be needed can
be obtained. Anticipating the unexpected may prevent failure that may
occur when necessary equipment is
not available. Because no single removal technique is universally successful, the operating surgeon should
be familiar with several different
techniques to remove broken or bent
IM nails, broken or stripped screws,
and cold-welded screws and plates.

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Journal of the American Academy of Orthopaedic Surgeons