Helical blade compression failure occurred during PFNA implantation: A rare case and ingenious solution

RATIONALE: Femoral intertrochanteric fracture happens easily in the elderly, especially those with osteoporosis. As a standard intramedullary fixation implant, Proximal Femoral Nail Anti-rotation (PFNA) is applied to various types of stable or unstable intertrochanteric fractures of femur. Due to blade-related factors, such as cutting-through into the hip joint, cutting out or back out, there are endless postoperative failure cases of internal fixation, but reports about perioperative failure that the helical blade cannot be tightened are lacking. In this case, we firstly report an intraoperative blade compression failure and an effective technique to help surgeons out of the dilemma by using cannulated hexagonal screwdriver which was already included in the orthopedic instrument box. PATIENT CONCERNS: An 81-year-old lady suffered left hip pain, swelling and limitation of activity, after slipping and falling when she was in the toilet. DIAGNOSES: X-ray and computed tomography (CT)-scan showed comminuted left intratrochanteric fracture with a Jensen classification of IIa type. INTERVENTIONS: The patient was treated by closed reduction and internal fixation with PFNA. We suffered an unprecedented problem that helical blade cannot be tightened by the blade impactor as usual. For fear of helical blade disintegration during removal and a significant decrease in pullout strength after reinsertions, we eliminated the dilemma by using a cannulated hexagonal screwdriver to tighten the “problem” helical blade. OUTCOMES: The “problem” helical blade was finally locked by using the SW4.0 mm cannulated hexagonal screwdriver which was already included in the instrument box. The operation ended successfully after completing subsequent steps. LESSONS: The cannulated hexagonal screwdriver is an effective instrument that can help surgeons out of the dilemma when the blade impactor fails to tighten the helical blade in PFNA implantation.