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Retrograde nailing of femoral fracture below

a hip prosthesis
Aart D. Verburg
From Maasland Hospital, Sittard, The Netherlands

n a frail elderly patient a pathological fracture of stem (7 cm) would be covered. The distal end of the slotted
I the femur at the lower end of a loose femoral stem
was treated by the retrograde insertion of an
nail was cut with a handsaw and the tip polished with a file
under aseptic conditions. Through a short medial para-
intramedullary nail over the tip of the prosthesis. patellar incision the medullary canal of the distal femur was
J Bone Joint Surg [Br] 1998;80-B:282-3.
opened after subluxation of the patella. A guide wire was
Received 20 June 1997; Accepted 7 August 1997 introduced and the distal femur reamed to 17 mm before
the nail was introduced. Closed ‘docking’ of the nail and
the tip of the prosthesis was not possible: a lateral vastus-
splitting incision allowed the stem and nail to be aligned.
Fractures of the shaft of the femur in elderly patients with The nail was driven over the prosthesis with a mallet while
total hip replacements present a considerable problem. the position of the loose acetabular component was mon-
itored fluoroscopically. Some pieces of bone cement were
Case Report chipped off the stem by the advancing nail and some were
removed. The nail was advanced until about half of the
In June 1996 a 95-year-old woman confined to a wheel- stem had been covered and the end of the nail was flush
chair for four years because of loose prostheses in both hips with the articular cartilage. The nail was then locked from
sustained a spontaneous fracture of the right femur. Two the anteromedial side, and its distal end was sealed by a
years earlier a fracture of the shaft of the ipsilateral tibia polyethylene plug and bone wax to provide a watertight
had been plated. There was limited function in her arthritic closure. Both incisions were closed without drainage. Knee
right knee. Conservative treatment of the femoral fracture flexion and extension exercises were started on the third
with analgesics and a brace had been unsuccessful; persist- day after operation.
ing pain interfered with nursing care. When reviewed after seven months the patient had no
Radiographs showed marked atrophy of the femur with a pain during transfers and nursing care. Knee flexion was
fracture through a large granuloma at the level of the tip of limited to 100°. Radiological examination showed little
the loose stem (Fig. 1). A limited salvage procedure was callus formation (Fig. 2). The position of the prosthesis and
planned since the patient’s general condition did not allow the nail had not changed (Figs 3 and 4).
extensive surgery. The stem of the prosthesis was templated Retrograde nailing of a tapered hip stem for femoral
and 16 and 17 mm slotted femoral nails (AO/ASIF) were fracture may be useful in a frail geriatric patient. If weight-
obtained. bearing is likely the nail should be inserted deeper and
Operative technique. With the patient supine on a radio- locked dynamically to accommodate shortening of the
lucent table, the knee was flexed over a bolster. The length femur during healing of the fracture.
and diameter of the nail were estimated using an image No benefits in any form have been received or will be received from a
intensifier so that approximately half of the length of the commercial party related directly or indirectly to the subject of this
1. Van Meeteren MC, van der Werken C. Mergpenfixatie van een
A. D. Verburg, MD, Orthopaedic Surgeon femurschachtfractuur, distaal van een DHS. Ned Tijdschr Traum
Department of Orthopaedic Surgery, Maasland Hospital, Walramstraat 23, 1996;4:94.
6131 BK Sittard, The Netherlands. 2. Voggenreiter G, Assenmacher S, Klaes W. Schmit-Neuerburg KP.
Pathological fractures of the proximal femur with impending shaft
©1998 British Editorial Society of Bone and Joint Surgery fractures treated by THR and cemented intramedullary nailing: a
0301-620X/98/28084 $2.00 report of nine cases. J Bone Joint Surg [Br] 1996;78-B:400-3.



Figure 1 – Radiograph showing fracture of the shaft of the

femur at the level of the tip of the femoral prosthesis.
Figure 2 – Composite radiograph of the combined pros-
thesis and the site of the fracture seven months after

Fig. 1 Fig. 2

Figures 3 and 4 – Radiographs after seven months showing

the position of the nail.

Fig. 3 Fig. 4

VOL. 80-B, NO. 2, MARCH 1998