Case report, broken femoral stem

Prosthetic femoral stem fracture : 

Presenter- Suresh Dhakar Moderator- Dr. A. K. Tiwari GMC, Kota(Raj) Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Stem fractures are much less common now with stronger alloys. Incidence of 0.27%. This complication should be considered in these patients presenting with proximal thigh pain.

Prosthetic femoral stem fracture : 

Fracture usually begins in the middle 1/3 of anterolateral aspect of the stem and progresses medially Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Factors w/ highest correlation to stem fracture are: 1) Increased incidence with heavy, active and obese patients. Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Factors w/ highest correlation to stem fracture are: 2) Inadequate calcar cancellous bone removal (which leads to undersizing of the femoral stem). Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Factors w/ highest correlation to stem fracture are: 3) Stems with decreased cross sectional area and long necks Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Factors w/ highest correlation to stem fracture are: 4) Poor support in proximal 1/3 (bending cantilever fatigue) When stem is proximally loose and distally well fixed. Cement debonding at proximal-lateral aspect of the femoral stem. Osteolysis underneath the collar of stem. Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Factors w/ highest correlation to stem fracture are: 5) Poor cement mantle is a strong risk factor. 6) Precoating the femoral stem with methylmethacrylate (may lead to posterolateral debonding). 7) Varus positioning of stem. 8) Lateral stem nicks by drilling for greater trochanteric wires. 9) Stainless steel components. Prosthetic femoral stem fracture

Prosthetic femoral stem fracture : 

Technique of Removal distal stem : Over drilling with hollow Trephine Needle-nosed pliers Cortical window Extended trochantric osteotomy Prosthetic femoral stem fracture

Technique of Removal: : 

1) Over drilling with hollow Trephine Use when # through the cylindrical portion of stem Have risk of eccentric reaming and cortical perforation Technique of Removal:

Technique of Removal: : 

2) Needle-nosed pliers Used to grip the edges of the exposed distal stem. Used for removal of loose stem Ineffective in case of cemented and biologically fixed stem Demerit is that limited space available b/w bone and stem Technique of Removal:

Technique of Removal: : 

3) Cortical window It is made in anterior femoral cortex just distal to break in stem. Carbide punch is used to push prosthesis proximally. It weaken the femur. Technique of Removal:

Technique of Removal: : 

4) Extended trochantric osteotomy Technique for removal of fractured cemented or biologically fixed femoral stem. Requires greater soft tissue dissection. Iatrogenic fractures & nonunion at osteotomy site are the problem. Technique of Removal:

Prosthetic femoral stem fracture with intact femur:Removal with retrograde nailing : 

Case report Prosthetic femoral stem fracture with intact femur:Removal with retrograde nailing

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture history 55 yr old female underwent hemiarthroplasty of left hip 4.5 yr back.

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture history One day she had complaint of pain in hip while climbing up stairs. She consult elsewhere and # femoral stem was diagnosed. She also consulted in many higher orthopaedic centres but finally she came to MBS Hospital after 15 days of starting of her complaint. No H/O fever, chills, weight loss, any erythema or discharge.

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Lat. &AP radiographs of left hip at presentation

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Physical examination The incision was well heeled and non tender. Left hip had full range of movement with discomfort on palpation of proximal thigh. Neurovascular status was unremarkable. ESR & T –DLC are normal.

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture In this case femoral stem was noncemented and non HA coated. We have taken the advantage of this and remove the fractured prosthetic femoral stem with the help of retrograde nailing without any osteotomy.

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Clinical course As standard retrograde nailing technique entry in I/c notch was made. Femoral canal was rimed up to the lower limit of broken stem. A posterior approach was used for exposure of hip. Proximal part of broken stem removed easily. A appropriate size k-nail was advanced retrograde up to the lower limit of broken stem. The stem was removed with slow hammering without any femoral osteotomy. Hemiarthroplasty of left hip was done with Corail femoral stem (Depuy).

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Clinical course AP radiograph of the left hip Operated with Corail femoral stem (Depuy)

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Clinical course Pt after fifth post operative day

Prosthetic femoral stem fracture : 

Prosthetic femoral stem fracture Conclusions With the use of retrograde nailing for the removal of this type of fractured femoral stem; patient morbidity and mortality are considerably decrease.