Miller Mark D, Perera Jorge, Smith Erin, Burnette Jeffrey
Orthopedics, Lake Erie College of Osteopathic Medicine, Sarasota, USA.
Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Bradenton, USA.
Cureus. 2022 Jun 24;14(6):e26276. doi: 10.7759/cureus.26276. eCollection 2022 Jun.
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.
本病例报告介绍了一名72岁女性从站立位跌倒后发生股骨远端髁上骨折，逆行髓内钉固定失败的情况。多种内科合并症是已知的骨折不愈合危险因素。随着骨质疏松和多种内科合并症患者发病率的上升，骨科医生需要为处理内固定并发症做好准备。该患者是一名72岁的重度肥胖女性，患有多种内科合并症，包括心脏瓣膜病、高血压、II型糖尿病、甲状腺功能减退、慢性失血性贫血急性发作、类风湿关节炎和狼疮性关节炎。她因从站立位跌倒后就诊，导致左股骨远端髁上闭合性移位骨折并累及髁间。对左股骨远端髁间骨折行切开复位内固定（ORIF），对左股骨远端髁上骨折行逆行髓内钉固定。三个月的随访X线片显示股骨远端髁上骨折无骨形成，植入物灾难性失败，两颗螺钉断裂，一颗髁螺栓断裂，符合内固定失败。治疗选择包括三个月不负重以评估骨痂形成，这将要求她使用轮椅，或手术转诊取出植入物并置换股骨远端。患者选择接受包括股骨远端置换的翻修手术。翻修手术后，患者出院并接受物理治疗转诊。与术前状态相比，她自述疼痛减轻，活动范围（ROM）增加。本病例表明，一名老年肥胖患者患有多种合并症，包括II型糖尿病和自身免疫性疾病，这使患者术后发生内固定失败的风险很高。由于疼痛和生活质量问题，此类受伤患者可能会陷入选择有限的境地。本病例强调了外科医生与患者进行最佳沟通的必要性，以确保患者及其医疗团队的所有成员在某些临床情况被认为失败风险很高时具备相关知识。展望未来，风险因素考量和药物调整是术前讨论的话题，应与患者详细讨论，以便为成功手术提供最佳机会。
