Intramedullary Nail Failure in a Subtrochanteric Fracture in a 62-Year-Old Woman

Subtrochanteric fractures in older patients are typically due to low-energy falls. The standard of care is intramedullary nailing. The Smith & Nephew Trigen Intertan (Memphis, TN, US) is an intramedullary nail with a novel design that incorporates two integrated compression screws. We present a case of intramedullary nail failure in a patient with a subtrochanteric fracture. A 62-year-old woman with osteoporosis, a 40-year history of smoking, and consumption of two to three alcoholic beverages daily, weighing 177 pounds and five feet two inches tall (BMI 32.4), experienced a low-energy fall in her home. She presented to the emergency department (ED) with a shortened and externally rotated right leg with pain on manipulation. Her neurovasculature was intact. An X-ray revealed a comminuted, right subtrochanteric femur fracture. The patient underwent open reduction and internal fixation with a Trigen Intertan nail with no intraoperative complications. Her leg returned to pre-injury length, and she resumed ambulating at her pre-injury level. Six weeks later, the patient experienced pain upon standing. She was transported to the ED by ambulance where she presented with a shortened externally rotated right leg with pain on manipulation. An X-ray revealed failure of the intramedullary nail with breakage at the lag screw hole. Her care was transferred to another orthopedic surgeon (JC), where she underwent hardware removal and conversion to a total hip arthroplasty. Postoperatively, her legs were of equal length, and her neurovasculature remained intact. Four months later, at her final follow-up, she was ambulating unassisted at her pre-fracture level. Subtrochanteric fractures in elderly patients pose serious threats to morbidity, mortality, and quality of life. Surgery with intramedullary nail placement and rapid ambulation have generally favorable outcomes. Failure rates are generally very low. Such circumstances generally require hardware removal and total hip arthroplasty, which are generally curative but can confer small risks of morbidity and mortality.