A 90-year-old female was admitted to our hospital complaining of pain around the left hip after a fall. She had a history of undergoing hip arthrodesis surgery following onset of tuberculosis in her 40s. Although her left hip was immovable with the affected leg length appearing shortened, she had still been able to walk long distances using a cane prior to the injury.
Radiographs showed both proximal femoral and pelvic fractures. The fracture line started from the ilium, involving the original femoral head, and ended at the basicervical part of the femoral neck (Figures 1(a)-1(e)). The fracture type appeared to be a vertical fracture. A computed tomography (CT) scan of the pelvis revealed ankylosis between the acetabulum and proximal femoral head. The structural border could not be identified between the pelvic bone and femur head. Surrounding tissues including subcutaneous tissue and the muscles were observed to be severely atrophied in comparison with those of the opposite side. Although the amount of displacement was approximately 2 mm, the vertical fracture was believed to be unstable and had a risk of displacement worsening during any increase in weight bearing. At this point, we determined the appropriate surgical intervention.
Although several surgical options have been reported previously in the literature, the proper techniques for certain distinctive scenarios have not yet been well described. In this case, double-plate fixation was thought to be the right surgical option to achieve rigid fixation with pelvis.
Surgery was performed under general anesthesia. Displacement was increased with passive hip adduction, and obvious instability was confirmed (Figure 1(b)).
The patient was placed in the right lateral decubitus position with the injured side abducted. The lateral approach with a single vertical incision was chosen. After splitting the atrophied gluteus maximus, the fascia of the gluteus medius was exposed. The anterior border of the gluteus medius was identified, and the tensor fasciae latae was retracted anteriorly. The gluteus medius was elevated to access the anteromedial part of fracture. The posterior part of fracture line was then similarly exposed by retracting the gluteus medius anteriorly (Figures 2(a) and 2(b)).
A reconstruction plate was placed at the posterior and anterior columns with anatomical bending. Screws were inserted in a bicortical manner. Distal screws were inserted to the original femoral head through the fracture line (Figure 3). Appropriate reduction and rigid fixation were confirmed under the image intensifier (Figures 3(a)-3(d)).
Postoperatively, the patient was immobilized with a hip spica cast for 4 weeks. Then, partial weight bearing was initiated, and full weight bearing was allowed beginning at 8 weeks after surgery. The fracture appeared united on the radiographs examined 3 months after surgery. In the follow-up 10 months after surgery, radiographs and CT revealed bone union without fracture site displacement and no implant complication (Figures 4(a) and 4(b)). She returned her ADL activities as preinjury levels.