King Fahd Hospital

Infection rather than error in fixation is the first thing that comes to mind.

Tip to apex distance not ideal but I have seen worse xrays and fractures go on to heal.
Regards
Christian

Agree. Lateral view is required to make judgement about fixation.
However, the implant does not appear to have cut out of the femoral head on the AP view.

Regards

Christian

Hello

> Infection rather than error in fixation is the first thing that comes to
> mind.
>
> Tip to apex distance not ideal but I have seen worse xrays and fractures go
> on to heal.

Looks like shaft screw holes were drilled larger in diameter than
needed. And the neck screw direction should be more parallel to the
neck, not "diagonal" as it was. One more argument in favour of nailing
against SHS. The failure mode hardly ever can be seen with any nail.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

It need not cut out through in AP view
had seen similar failure earlier reported in Indiaorth Google group
the cause for failure attributed was

" dhs plate was anterior -surgeon tried to pass screws little oblique from anterior to posterior direction (everything look in ap view ok) and shear force at junction (along with axial load and rotational force due to instability together)- shaft of screws with shaft of femur forced posteriorly and plate anterior made failure of screw at head shaft junction - that was the stress riser .(worked like eccentric shear) "

this may be the cause
lets wait for the lat view...
Karthik

dear dr

THERE IS NO ERROR IN FIXATION BUT THE OSTEOPOROTIC BONES GIVE POOR HOLD THOUGH U MAY FEEL THAT THE HOLD IS VERY GOOD(DURING SURGEORY)

in such old patients we normally and routinly do ender nailing

dr rohit shah
A.G.O.T.
INDIA
rohit.rbs@gmail.com

The fracture pattern was not fully appreciated at the time of fixation. This lady had sustained a very complicated fracture. There was fracture neck of the femur in association with the intertronchanteric fracture. She required a CT Scan before fixation and She would have been better served if She has had a Hemi or Total hip replacement on her first admission.

Dear

Many thanks

You can do partial Arthoplasty using Lubch prosthesis with calcure replacement with trochanteric reattachment

Many thanks

Bahaa Kornah

This elderly lady, 95-year-old is with osteoporotic intertrochanteric fracture right femur. The presenting X-ray is not that clear and is only in one view. I would look for the pattern of the fracture, comminution and whether it extend to the subtrochanteric region.

Accordingly, the choice of fracture fixation is not appropriate in this case. The entry whole for the compression screw may have caused fracture separation of the trochanter from the shaft. Blade-plate fixation or DCS could have provided firm fixation of the proximal segment of the fracture to the femoral shaft. Because of the bone quality - osteoporotic, this lead to screw pull-out with time. This is not a firm fixation for such a fracture. Healing takes a long time with supportive treatment.

My preferred choice of surgery would have been cemented hemiarthroplasty with wire loops to secure the trochanter to the shaft.

Presently, I would not think of THR as she has intact acetabulum and this surgery is more demanding for the patient at her age. I would prefer cemented hemiarthroplasty, again the trochanter slide requires cerclage wiring or cables for proper fixation to the shaft. This will give the patient the chance of early mobility and secure weight bearing for the remaining years of her life.

Kind regards.

Dr. Zuhair Al Dahhan, MChOrth, FRCS,

Consultant Orthopaedic Surgeon

Almana General Hospital,

Dammam.

Dear Dr

Eid Mubarak , Kol Sanaa wa int Tayeb .
Regarding this case : In hind sight the cause of the outcome was a lack of understanding that it was a comminuted # basicervical, inter and sub troc and not a simple inter troc # which DHS principle of weight sharing with the patient full weight bearing would not apply.
It would have been OK if the patient had :
1) Long DCS with patient non weight bearing status ( weight bearing device )
2) Long DHS with patient non weight bearing status ( DHS here was weight bearing device )
3) Recon Nail would have would have been the best biomechanical option

Regards
Shenouda Shalaby

Dear ,
BEWARE OF BASICERVICAL/ IT FRACTURE THAT SPIRAL INTO THE NECK OF
FEMUR. These seem like trochanter fractures but behave like neck femur
fractures.
The initial Xrays shows a neck+ trochnater pattern.
Though they seem that they can be fixed by a DHS,they behave as
fracture neck femur...i.e non union, AVN etc.
We do replacement arthroplasty in these type of patients...esp when
they are aged ( Low demands!!).
My gut feeling is infection is not the culprit here. the fracture has
not united and progressive weight bearing has caused the bone-implant
interface to fail. when there is no union all the stress is transfered
to the implant/implant-bone interface.

Dear Dr. : Happy eid for you and your family. I beleive that the solution is in the lateral x-ray ( Pre and post op ). There are two levels of fracture and one may be missed during the evaluation of the fracture before the operation. The tip apex index is longer than should be and there is no additional screw fixation above the lag one. Kindly, let's know what was the problem ?

to my mind:
1.bad decision for this osteoporotic patient.
2.we need lateral view.
3.is the angle too valgus.

salamo alaikm

1. the choice of implant for that age is not Ideal (Hemarthroplasty is preferrable)

2. tip to Apex distanace is not ideal, but That is not the reason of failure

3. the late presentation after 6 months (no symptoms), with another type of fracture (comparing the preoperative and last one), make me suspect another trauma that led to failure.

ie: the DHS is not the reason, but another Trauma.
--
El-Zaher H. El-Zaher

Dear

If the lateral view showed acceptable position of screw and plat centralize at femoral diaphysis

Fixations is acceptable (no telescoping screw hold head)

The error was multi factorial

1=infection

2=osteoporosis

3= no medial support

4=bad comminuted ITF

5=DHSwas at the level of the fracture

6= fall down or early W B

Recon Nail would have been the good biomechanical option

Arthroplasty is the last solution

Thank you Dr., for this case, I don't want to comment, though it is for me it is just a case of osteoporosis, and nothing much wrong with the fixation, but I was interested to read all the responses of the fellow surgeons, which most of them they have their right points of view, the interesting thing is to have such a common case and to put it through the fine slicing dissection knife, and to have all the possible opinions about it.