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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 120-123

Proximal femur segmental resection for the management of prosthetic tip fracture: An innovative procedure


Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Dr. Alok Chandra Agrawal
H2, Sector 2, Agrasen Nagar Raipura, Raipur - 492 013, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_29_17

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  Abstract 


Fractures at the tip or just below the tip of a total hip replacement (THR) prosthesis are treated with a longer prosthetic stem, a longer stem with distal interlocking, a THR combined with a locking compression plate (LCP), and unicortical locking screws in proximal fragment with or without circumferential wiring or cables. As LCP remains weaker construct chances of failure are more and in cases with a failed LCP with THR, one may have to opt for a limb preservation system as an alternate to LCP. None of these techniques were possible in this 40 year patient and we had to opt for some innovation to help him. We are reporting an innovative technique where a proximal femur segmental resection was done for the management of prosthetic tip fracture continuing with the same THR stem.

Keywords: Femur segmental resection, prosthetic tip fracture, proximal fracture segment


How to cite this article:
Agrawal AC. Proximal femur segmental resection for the management of prosthetic tip fracture: An innovative procedure. J Orthop Traumatol Rehabil 2017;9:120-3

How to cite this URL:
Agrawal AC. Proximal femur segmental resection for the management of prosthetic tip fracture: An innovative procedure. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2021 Feb 25];9:120-3. Available from: https://www.jotr.in/text.asp?2017/9/2/120/220764




  Introduction Top


Fractures of the femoral diaphysis are described to occur during and after total hip replacement (THR).[1] However, there may be a fracture of the femoral diaphysis along with an arthritic hip or ipsilateral fractures of the femoral neck and shaft, which need a THR. Similarly, we are reporting a situation of fracture shaft femur with interlocking nailing done that not only progressed to infected nonunion but also had a missed and neglected fracture neck of femur and both required treatment. Following a series of surgeries including implant removal and antibiotic impregnated nailing, reinfection and debridement with antibiotic cement beads, THR by a distal fixation solution stem (Depuy) and distal LCP which failed over time an innovative procedure of proximal femur segmental resection and insertion of distal stem in the distal fracture fragment was done. We are reporting the difficulties encountered in this case and how this procedure helped in salvage of the limb in an economic manner.


  Case Report Top


A 40-year-old male patient presented to us with right-sided un-cemented THR with a fracture just below the nail tip fixed with a locking compression plate (LCP) [Figure 1] where he has a discharging wound for the last 3 months, and the plate was coming out from the proximal fragment, there was a broken screw, and there were unremoved antibiotic impregnated beads both at the hip and fracture site [Figure 2]. The patient gave a history of road traffic accident 2 years back when an interlocking nailing was done on right femur, and the radiograph showed a missed ipsilateral fracture neck of femur. Clinically, he had an operative wound on the thigh and hip with pus pouring from the fracture site as well as nail entry site.
Figure 1: X-ray showing ipsilateral total hip replacement and fracture below tip of prosthetic stem stablized by locking compression plate

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Figure 2: X-ray showing implant failure with locking compression plate coming out from the proximal fragment

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He gave a history of debridement with the removal of the implant and insertion of an antibiotic impregnated nail. Six months later, he was planned for removal of the nail and reconstruction with distally interlocked modular femoral reconstruction prosthesis with a THR addressing both the problems of old neglected fracture neck of femur and shaft of femur. On the table, it was found that the Reef (Depuy) implant was larger than the Indian femur and could not be inserted. On the spot a decision was taken to use a long uncemented solution stem available which could reach only up to the fracture site, and the fracture was stablized with an LCP with bilateral screws on the distal fragment and unicortical screws on the proximal fragment. Insertion of these screws was very difficult as the “Solution” stem being a distal fixation stem does not permit screw passage in the proximal fragment making a very week construct. There was even breakage of a screw head during the procedure making that screw hole ineffective. The patient had a uncomplicated postoperative period and was discharged on a weight-relieving caliper. At 6 weeks, he came back with purulent discharge from a sinus on the thigh incision and was again taken for surgery where debridement of the hip and thigh were done, and antibiotic impregnated beads were inserted. He again had an infection-free period of 3 months when the purulent discharge again started from the thigh, and he had severe pain at the fracture site with inability to do straight leg rising and an X-ray showed the LCP to leave the proximal fragment.

The problem and alternatives

At this juncture with several surgeries done in the past, patient having finished all his money and loan assets, having reached the maximum limit of government aid and being immunocompromised and psychologically strained demanded an amputation. Having discussed all the alternatives available in this situation including debridement, removal of implant and stabilization with external fixator, ilizarov fixator, antibiotic cement-coated LCP, excision of the proximal fragment with antibiotic spacer, and second-stage limb preservation surgery; the patient could not agree to any of the options due to financial constrains. It was decided to do a proximal diaphyseal resection from the fracture site and expose the distal stem for a length of 10 cm and fix the distal fragment by an intramedullary fixation without disturbing the THR, as it had a sound fixation in the proximal fragment [Figure 3]. The patient was explained the consequences of limb shortening, reinfection, and further surgery.
Figure 3: Postoperative X-ray showing distal fragment stabilization with intramedullary stem following proximal femoral resection

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Procedure of proximal diaphyseal resection and exposure of distal stem

The patient was taken on the operation table in lateral position and implant was removed with thorough debridement and pulse lavage. The antibiotic cement beads were removed, and a thorough debridement was done of the hip as well. There was bony ingrowth on the stem ant the bone was brittle, which had to be removed in small pieces by a nibbler and sharp and fine osteotome. The distal fragment was freshened and debrided with intramedullary reaming. With great force, the fragments had to be impacted as the soft tissues surrounding the 10 cm gap resisted the fragments from coming near [Figure 4]. The limb was kept in Thomas's splint in the postoperative period, and the distraction effect of the soft tissues [Figure 5] was countered by an overhead traction through a derotation splint and bar in the foot [Figure 6]. A weight-bearing Knee Ankle Foot Orthosis orthosis was designed to take care of the 4 inches of shortening.
Figure 4: Postoperative X-ray showing the soft-tissue distraction forces at the fracture gap

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Figure 5: Postoperative X-ray showing impaction at the fracture site following overhead traction through the derotation boot and bar in the foot

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Figure 6: The method of overhead traction

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  Discussion Top


Ipsilateral THR and shaft fractures or prosthesis tip fractures can be classified by the Vancouver classification of periprosthetic femoral fractures as Type C and also includes intraoperative fractures and perforations. Type A fractures are considered to be of the proximal metaphysis. Type B fractures involve the proximal diaphysis but can be treated with long-stem fixation. Type C fractures extend beyond the longest revision stem and may include the distal femoral metaphysis. Each type is subdivided into simple perforations (Subtype 1), nondisplaced (Subtype 2), or displaced (Subtype 3).[2] Treatment options include bone grafting, cerclage, long-stem revision, or open reduction and internal fixation depending on the level and displacement of the fracture.[3],[4],[5],[6],[7],[8]

The treatment of periprosthetic femoral fractures depends primarily on the location and the stability of the fracture, whether the stem remains well fixed or is loose, the quality of the remaining bone, and the medical condition and functional demands of the patient. Treatment options include traction, open reduction, and internal fixation of the fracture while leaving the stem in situ, and femoral revision with or without adjunctive internal fixation.[9],[10],[11],[12],[13]

Historically, many authors have described treatment by traction, with union rates of 66%–100%.[1] Malunion occurs, however, in more than 20% of patients; and subsequent stem loosening also is a problem. Elderly, fragile patients tolerate prolonged bed rest poorly, and medical problems are common. Traction should be considered only for the management of fractures in whom a satisfactory reduction can be maintained. Because of the benefits of early mobilization and more reliable outcomes in terms of malunion and subsequent loosening, surgical management of unstable periprosthetic femoral fractures generally is preferable in medically stable patients.[14],[15],[16]

Biomechanical studies have shown greater mechanical stability for constructs with proximal and distal screw fixation than for those fixed proximally with cables only. Allograft struts used alone or in combination with plate fixation, have also shown promise in the fixation of periprosthetic femoral fractures.[1]

A more recent trend involves the use of cementless long-stem femoral components to treat these problematic cases. In a series of 118 periprosthetic femoral fractures, Springer et al. reported improved outcomes using extensively porous-coated cementless femoral components.[15] Proximally porous-coated modular uncemented stems with flutes for distal rotationally stability and extensively porous-coated stems with good success have been reported.[1] Supplemental internal fixation with cerclage or onlay cortical allograft struts frequently is required to restore rotational stability at the fracture site. Additional bone grafting at the fracture site is recommended by most authors.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16]

Type C fractures occur well below the tip of the stem with no stem loosening. These can be treated with conventional techniques of internal fixation, leaving the femoral component undisturbed. As in B1 fractures, locked plates, and less invasive techniques are gaining popularity. Areas of stress concentration between fixation devices and the femoral stem should be avoided. In grossly destroyed bones, one may take help of a limb preservation system.[1]

The given case highlights the problem of infection in the developing world with high temperature where the infection remains quiescent in indoor temperature controlled situations but flares again after discharge. We did not have cable system in our armamentarium although all the other options were available for THR. LCP offers very little strength to the construct with unilateral screws, especially if done with a “Solution stem” and the innovative procedure of “Proximal femur segmental resection for the management of prosthetic tip fracture” remains a viable low-cost option in place of limb preservation systems/amputations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harkess JW, Crockarell JR. Arthroplasty of the hip. Campbell Operative Orthopaedics. 12th ed. Canada: Elsevier Mosby Publishers; 2013. p. 241-309.  Back to cited text no. 1
    
2.
Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.  Back to cited text no. 2
    
3.
Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty 2000;15:59-62.  Back to cited text no. 3
    
4.
Cooke PH, Newman JH. Fractures of the femur in relation to cemented hip prostheses. J Bone Joint Surg Br 1988;70:386-9.  Back to cited text no. 4
    
5.
Currall V, Thomason K, Eastaugh-Waring S, Ward AJ, Chesser TJ. The use of LISS femoral locking plates and cabling in the treatment of periprosthetic fractures around stable proximal femoral implants in elderly patients. Hip Int 2008;18:207-11.  Back to cited text no. 5
    
6.
Dennis MG, Simon JA, Kummer FJ, Koval KJ, DiCesare PE. Fixation of periprosthetic femoral shaft fractures occurring at the tip of the stem: A biomechanical study of 5 techniques. J Arthroplasty 2000;15:523-8.  Back to cited text no. 6
    
7.
Ehlinger M, Adam P, Moser T, Delpin D, Bonnomet F. Type C periprosthetic fractures treated with locking plate fixation with a mean follow up of 2.5 years. Orthop Traumatol Surg Res 2010;96:44-8.  Back to cited text no. 7
    
8.
Greidanus NV, Mitchell PA, Masri BA, Garbuz DS, Duncan CP. Principles of management and results of treating the fractured femur during and after total hip arthroplasty. Instr Course Lect 2003;52:309-22.  Back to cited text no. 8
    
9.
Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: Use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am 2002;84:945-50.  Back to cited text no. 9
    
10.
Holley K, Zelken J, Padgett D, Chimento G, Yun A, Buly R. Periprosthetic fractures of the femur after hip arthroplasty: An analysis of 99 patients. HSS J 2007;3:190-7.  Back to cited text no. 10
    
11.
Kumar V, Kanabar P, Owen PJ, Rushton N. Less invasive stabilization system for the management of periprosthetic femoral fractures around hip arthroplasty. J Arthroplasty 2008;23:446-50.  Back to cited text no. 11
    
12.
Lee SR, Bostrom MP. Periprosthetic fractures of the femur after total hip arthroplasty. Instr Course Lect 2004;53:111-8.  Back to cited text no. 12
    
13.
Lever JP, Zdero R, Nousiainen MT, Waddell JP, Schemitsch EH. The biomechanical analysis of three plating fixation systems for periprosthetic femoral fracture near the tip of a total hip arthroplasty. J Orthop Surg Res 2010;5:45.  Back to cited text no. 13
    
14.
Pike J, Davidson D, Garbuz D, Duncan CP, O'Brien PJ, Masri BA. Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty. J Am Acad Orthop Surg 2009;17:677-88.  Back to cited text no. 14
    
15.
Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures follow total hip arthroplasty with femoral component revision. J Bone Joint Surg 2003;85A:2156.  Back to cited text no. 15
    
16.
Zenni EJ Jr., Pomeroy DL, Caudle RJ. Ogden plate and other fixations for fractures complicating femoral endoprostheses. Clin Orthop Relat Res 1988;231:83-90.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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