Retrograde Intramedullary Nailing Hardware Failure of a Supracondylar Distal Femur Fracture With Intercondylar Extension

Abstract

This case report presents the failure of retrograde intramedullary (IM) nailing in a supracondylar distal femur fracture in a 72-year-old female after a fall from standing. Multiple medical comorbidities are a known risk factor for fracture nonunion. With the rising incidence of patients having osteoporosis and multiple medical comorbidities, orthopedic surgeons need to be prepared for the treatment of hardware complications. The patient is a 72-year-old severely obese female with multiple medical comorbidities including cardiac valvular disease, hypertension, type II diabetes mellitus, hypothyroidism, acute on chronic blood loss anemia, rheumatoid arthritis, and lupus arthritis. She presented after a fall from standing where she sustained a closed displaced left supracondylar distal femur fracture with intercondylar extension. Open reduction and internal fixation (ORIF) was performed on the left distal femur intercondylar split and retrograde intramedullary nailing for the left supracondylar distal femur fracture. Three-month follow-up X-rays revealed no osseous formation of the supracondylar distal femur fracture and catastrophic failure of the implants with two broken screws and a broken condylar bolt consistent with hardware failure. Treatment options included either non-weight-bearing for three months to evaluate for callus formation, which would require her to be in a wheelchair, or surgical referral for implant removal and distal femur replacement. The patient elected to undergo revision surgery consisting of distal femoral replacement. Following revision surgery, the patient was discharged with physical therapy referral. She disclosed a decrease in pain and increased range of motion (ROM) compared to the preoperative state. This case demonstrates an elderly, obese patient with multiple comorbidities including type II diabetes mellitus and autoimmune conditions that placed the patient at high risk for hardware failure following surgery. Due to pain and quality of life concerns, patients with such injuries may be forced into a situation with limited options. This case highlights the need for optimal surgeon-to-patient communication to ensure that patients and all members of their healthcare team are knowledgeable when certain clinical situations are considered high risk for failure. Moving forward, risk factor consideration and medication adjustments are preoperative topics of discussion that should be discussed at length with the patient in order to provide the best opportunity for a successful surgery.

Keywords: distal femoral hardware failure; distal femoral replacement; distal femur fracture; hardware failure; revision arthroplasty.