How Shall We Proceed After Inserting an Unsterile Device for Fracture Fixation: ReTENing or Retaining? A Case Report

Abstract

Background: Limited information is available on how to properly manage to implant nonsterile devices in the medical literature. To the best of our knowledge, there is no guideline for managing nonsterile medical devices implanted inadvertently.
 Case Presentation: A 3.5-year-old boy was operated on because of femur fracture malunion. After the completion of the operation and discharging the patient, we were informed that the nail has not been sterilized. The parents were immediately informed about the complication and the patient was re-admitted to the hospital. The situation and its complication were thoroughly discussed with the family. By active involvement of the parents, infectious specialist, and the orthopedic surgeon, a shared decision was made to treat the complication. The patient was closely observed. In a radiograph obtained at the 4th week after the index surgery, the sign of callus formation was observed. At this time, we decided to remove the Titanium Elastic Nail (TEN) and continue casting for another two weeks.
 Conclusion: The primary “take-away” lesson of this case report is that honest disclosure of our mistake facilitated the additional necessary treatment. One single case is not enough for making a recommendation or offer a guideline for this kind of error during or after an orthopedic procedure; however, this case presents a successful method. Although the consequences of infection could be dire, it is prudent to take “not-to-harm” as the first step in benefiting.