The Paradox of Minimalist Salvage: Biomechanical Destabilization and Failure Following Limited Removal of Exposed Periprosthetic Hardware: A Case Report

Abstract Background: Exposed periprosthetic hardware typically requires formal operative debridement and often flap coverage. In geriatric patients with significant comorbidities, surgeons may attempt "damage control" strategies—such as the isolated removal of exposed hardware—to minimize physiologic stress. This case reports the catastrophic biomechanical failure of such a limited salvage technique. Methods: An 84-year-old male presented three weeks following retrograde intramedullary nailing for a periprosthetic femur fracture with a distal interlocking screw eroding through the skin. The patient was afebrile and denied constitutional symptoms. Physical examination revealed an exposed screw at the lateral knee without erythema, purulent drainage, or warmth. The superficial exposed screw was removed at the bedside. This was followed by limited operative wound exploration and irrigation performed under monitored anesthesia care (MAC). Intraoperative evaluation was performed to assess for hardware-joint communication. Results: Evaluation revealed a moderate knee effusion that did not communicate with the wound. No gross intraoperative signs of infection were observed, and post-procedure blood cultures remained negative. Six weeks post-discharge, the patient presented with acute delirium, severe pain (10/10), and radiographic nonunion. The loss of the distal interlocking bolt converted a stable construct into an unstable one, necessitating three subsequent surgical revisions to salvage the limb and restore weight-bearing function. Conclusion: We caution against the isolated removal of exposed structural hardware in load-bearing fractures. Unlike non-structural implants (e.g., syndesmotic screws), removing a locking screw from a retrograde nail can lead to immediate destabilization, nonunion, and a paradoxical increase in total surgical morbidity. Level of Evidence: Level V (Case Report)