We present a 74-year-old, overweight woman with an extensive history with respect to her right knee. She had a right total knee replacement ("TKR") 2 years ago, followed by an open reduction and internal fixation ("ORIF") using a plate and screw construct after she had a fall, resulting in a periprosthetic fracture. The fixation failed and she underwent a revision of the TKR with a distal femoral replacement prosthesis. Her recovery was compromised by a chronic lateral patella dislocation. An extensor mechanism reconstruction and patelloplasty was successfully performed. The patient complained of right knee pain with weightbearing for the following 7 months. Eventually, the pain became unbearable, leading to a second revision to change the femoral component to a long-cemented stem. Her history of recurrent problems with her knee were suspicious for septic loosening of the femoral component due to an indolent prosthetic knee infection. She was treated empirically with Vancomycin while waiting for the culture results that came back negative despite the elevated CRP levels. No further follow up regarding her possible infection was recommended, and antibiotic administration was stopped since no positive culture confirmation was found.
Three months later, she tripped and fell and sustained a Garden 4 subcapital fracture of the ipsilateral hip (Figure 1).
Her co-morbidities consist of hypertension controlled with amlodipine with no end-organ damage, renal insufficiency, and obstructive sleep apnea supported by a continuous positive airway pressure ("CPAP") machine. She takes pregabalin to treat anxiety, olanzapine for bipolar disorder, fluoxetine for depression, and hydromorphone for pain relief.
Upon admission, her physical examination revealed an externally rotated right lower extremity, normal neurovascular status distally, and a well healed midline surgical incision of the knee with bruising around the incision site. Her right lower extremity x-rays showed a long-cemented stem knee tumour prosthesis and a Garden 4 displaced subcapital fracture of the hip.
Given that she was at high risk of developing avascular necrosis of the femoral head, open reduction internal fixation ("ORIF") would be unlikely to succeed, and a bipolar hip hemiarthroplasty would not have fit due to the long-cemented diaphyseal stem. Therefore, a TFR was performed.