A 64-year-old male with a medical history of hypertension, hyperlipidemia, and pulmonary embolism developed hip arthritis. The patient had a solid antegrade femoral nail placed 22 years ago and had a well healed femoral shaft fracture with good cortical bone (Fig. 1). His arthroplasty surgeon requested hardware removal by the orthopedic trauma service before hip replacement.
After thorough pre-operative discussion of risks and benefits of hardware removal, surgical consent was obtained and standardized "time out" was performed. Pre-operative antibiotics were administered and the patient was placed in the lateral decubitus position on a radiolucent table. The hip and lower extremity were prepped and draped. The previous 3 cm lateral proximal incision was utilized to gain access to the proximal femur, splitting the gluteus in line with its fibers. The nail was carefully exposed and cleared of debris with currettes. A conical extraction bolt was inserted into the proximal aspect of the nail with good interference fit. Once the extraction jig was attached proximally, the two distal interlock screws were removed through previous percutaneous incisions.
The nail was then backslapped using the extraction jig approximately 3 cm at which point the nail unfortunately became incarcerated. Continued attempts at extraction ultimately resulted in iatrogenic basicervical femoral neck fracture. At this point, the decision was made to perform a proximal femoral episiotomy to relieve hoop stresses allowing for nail removal. To do so, the remainder of the femur was exposed distally using an extensile lateral subvastus approach (Fig. 2c). A prophylactic cable was placed distally to prevent fracture propagation. Next, a microsagittal saw was used to make a single linear longitudinal osteotomy down the femur just anterior to the linea aspera (Fig. 2a and b). An osteotome was utilized to expand the bone slightly which released the hoop stress on the nail allowing for successful nail removal.
An acute diaphyseal fitting total hip arthroplasty was then performed by the arthroplasty surgeon. After surgery, the patient was made weightbearing as tolerated following our normal total hip arthroplasty post-operative protocol. He was mobilized by physical therapy on post-operative day 1 and was full weightbearing on the operative extremity. He was discharged home on postoperative day 2. Repeat radiographs demonstrated episiotomy healing and a well-fixed total hip arthroplasty at 3 months (Fig. 3). At 1 year, he was doing well and currently seeks ipsilateral total knee arthroplasty.