A 20-year-old male was transferred to our tertiary level one trauma center from an outlying community-based hospital following a noncontact basketball injury. Earlier that evening, the patient had been playing basketball at a local church when he jumped for a rebound and experienced severe pain in the left hip and thigh upon landing. He was unable to bear weight. At that time, he was taken to a local emergency department where he underwent immediate evaluation. Following the initial evaluation and review of radiographs, it was determined that the patient had sustained a subtrochanteric periprosthetic femur fracture. At that time, he was transferred to our facility for definitive management.
After further investigation and questioning upon arrival at our facility, the patient reported a 5-6 month history of increasing left thigh pain prior to this injury. He had never received any medical care for the new onset thigh pain and attributed it to overuse. New radiographs obtained at our facility demonstrated a transverse periprosthetic femur fracture at the distal aspect of the previously placed dynamic hip screw. Nine years prior at the age of 11, the patient had been involved in a motor vehicle accident sustaining a subtrochanteric femur fracture which was addressed with reduction and placement of a dynamic hip screw (DHS). The surgery was noted to be performed flawlessly with no complications noted, but little is known about the details of the postoperative course as it was done at an outside facility.
Despite discussions with the index surgeon to eventually remove the hardware, his case was never scheduled and the hardware was retained into skeletal maturity. Close inspection of imaging at the time of repeat injury showed evidence of a potential stress riser at the distal DHS/bone junction, with a significant amount of bony overgrowth of the DHS (Figure 1). Additionally, there was evidence of stress shielding with significant cortical thickening involving the entire lateral cortex seen on radiographs taken prior to injury (Figure 2).
The patient was taken to the operating room for explant, fracture reduction, and insertion of a cephalomedullary nail. An extensile approach was necessary to completely expose the retained hardware. Gross intraoperative inspection showed extensive bony overgrowth of the implant (Figure 3). Osteotomies were utilized to remove the bony overgrowth to extract the hardware (Figures 4 and 5). After successful removal of the previous sliding hip screw, the fracture was exposed, reduced, and a long reamed cephalomedullary nail was placed with distal interlocking screws without difficulty (Figures 6(a)-6(c)). Postoperatively, his pain was initially controlled with IV pain medication and he was quickly transitioned to orals only. He was immediately weightbearing as tolerated with the aid of a walker. He progressed quickly with PT, working with them once a day. He was able to walk 120 feet with PT on postoperative day 2 with the use of a walker. He was placed on Lovenox for DVT prophylaxis until he was fully weightbearing using no assistance. He was discharged home on postoperative day #2. He presented to the emergency department two weeks postoperatively complaining of bloody drainage from the incision. The dressing was removed by the ED physician who noted no drainage and was unable to express any blood. The patient was otherwise feeling well. His pain had been controlled, and he denied fevers, chills, nausea, or vomiting. A new dressing was placed and he was discharged home with follow-up with the orthopedic surgeon who performed the case. In outpatient follow-up, the patient continued with Lovenox for DVT prophylaxis as well as physical therapy until he was weightbearing as tolerated without the use of aids. At subsequent postoperative follow-up visits, radiographic imaging revealed complete union of the previous fracture with an abundant amount of bridging callus (Figures 7(a) and 7(b)). The patient reported no other postoperative complications.