[Consequences of uncritical indication assessment for hardware removal]

A 43-year-old woman sustained a severe ankle dislocation with distal fibular fracture in a domestic accident. This was initially treated with external fixation for 3 weeks. In addition to distal fibular fracture treatment using a fixed-angle locking plate system, a vacuum-assisted wound closure of the medial und lateral malleolus had to be performed due to a persisting difficult soft tissue situation with swelling and necrosis of the medial malleolus. Subsequently, after prolonged wound healing the soft tissue defect over the distal fibula could be covered with a split skin graft and the external fixation was removed. Implant removal was performed 2 years after primary treatment - following radiologically confirmed consolidation of the fracture. Intraoperatively, an iatrogenic oblique fracture of the fibula occurred due to a cold welded screw in the plate, which had to be treated with lag screws. In the further course, there was renewed extensive wound healing with methicillin-resistant Staphylococcus aureus (MRSA) infection. The patient filed a complaint for the iatrogenic fibular fracture during hardware removal and also criticized the insufficient wound closure which led to an impairment of wound healing. The expert opinion of the arbitration board ascertained a medical malpractice in terms of indications. Due to the already prolonged course after the primary osteosynthesis hardware removal was not recommended. In addition, the surgical technique that led to the iatrogenic fracture was criticized. The arbitration board furthermore concluded that with a pre-existing osteoarthritis of the ankle, hardware removal was not indicated. In a critical wound situation implant removal would only be indicated with simultaneous treatment of the osteoarthritis of the ankle. By means of a critical indication assessment the patient should have been advised to leave the plate in place and the complicated course with iatrogenic fracture and severely delayed wound healing could have been avoided.