CASE 20: Proximal femoral replacement following multiple failed operations to treat a periprosthetic fracture
The Story
“Priya came under my care as an emergency case, transferred from another hospital in 2016. She was 82 years old at the time, and 16 years prior had received a left total hip replacement which had been very successful.
It had changed her life, enabling her to live unaided, drive, travel and keep fit. She had no concerns with her left hip replacement until in early 2016 she had a fall, leaving her with a periprosthetic fracture. At the time this was managed with a plate, allowing her to mobilise once again.
Despite the successes of the hip replacement, I met her at a challenging time. She had been walking when she experienced sudden onset left thigh pain leaving her unable to walk or stand.
Unfortunately, the plate used to repair the periprosthetic fracture had failed, leaving her bed bound. This left us with a very complicated left femur to reconstruct.”
The Investigation
Priya was examined clinically, and she was unable to mobilise. She had a greatly reduced range of movement in the left leg secondary to pain and discomfort. Fortunately for Priya, there was no neurological or vascular compromise to her left leg and she had no clinical signs suggesting an infection.
The Evidence
Anteroposterior plain radiograph of the left proximal femur demonstrating a break in the plate used to fix the periprosthetic fracture.
Lateral plain radiograph of the left proximal femur demonstrating the complexity of the reconstruction required.
The Diagnosis
Priya was diagnosed with a periprosthetic fracture at the tip of the left femoral stem with broken femoral plates.
The Plan
For Priya, the only way to reconstruct her complex periprosthetic fracture was with a proximal femoral replacement. We planned to remove all of her metal work surround the left hip, perform a proximal femoral replacement and retain the left acetabular socket.
The Operation
The socket was well fixed and so was retained. 5 cultures were sent to microbiology. The proximal femur and metal work was removed slowly and carefully. The femoral was prepared with a transection point to enable trial of a proximal femoral replacement. The modular sections of the implant were adjusted to achieve satisfactory length and stability. The implant was cemented. Savlon and Normal saline wash was used. Closure was with vicryl and clips.
The Outcome
Anteroposterior and lateral plain radiographs demonstrating the proximal femoral replacement in situ with the existing cemented acetabular cup in place. This series of images was taken immediately after the procedure.
Anteroposterior and lateral plain radiographs taken 12-months after the operation. The implant remains in a satisfactory position and Priya is very happy with the result.
Priya had a very good outcome. She was up and mobilising with the physiotherapists the day after her operation.
The Verdict
“When there is extensive damage to the periprosthetic bone stock there is little option but to replace the whole of the proximal femur. This maybe less traumatic than trying to preserve the proximal femur and allows weight bearing immediately after surgery.”
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Please see Case 16