PMC9844961_01
AP of left femur with transverse subtrochanteric fracture.
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Radiographs revealed blastic metastatic lesions to his left femur (Fig. 1).
(A) Cannulated awl positioned medial to tip of GT on the AP XR; (B) cannulated awl positioned center of GT on the lateral XR; (C) entry reamer over guide pin on the AP XR.
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AP and center on the lateral (Fig. 2B). A (15-mm) entry reamer widened the opening (Fig. 2C). A rigid cannulated reduction rod and forceful malleting allowed the ball-tipped guidewire to cross the close reduced fracture, but too lateral and posterior distally (Fig. 3A and B).
(A) Ball-tipped guidewire slightly lateral position at the knee on the AP XR; (B) ball-tipped guidewire too posterior at the knee on the lateral XR; (C) flexible reamer within the proximal femur abutting blastic lesions.
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A (15-mm) entry reamer widened the opening (Fig. 2C). A rigid cannulated reduction rod and forceful malleting allowed the ball-tipped guidewire to cross the close reduced fracture, but too lateral and posterior distally (Fig. 3A and B). The cannulated flexible reamers encountered impassible blastic lesions within the proximal femur (Figs 3C and 5B).
(A) Canulated cutter tool creating a new path in the proximal femur; (B) rigid canulated reduction rod directing the guidewire across a reduced fracture held with a proximal bone hook and distal ball spike pusher; (C) center positioned ball-tipped guidewire at the knee on the AP XR; (D) center positioned ball-tipped guidewire at the knee on the lateral XR.
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The ball-tipped guidewire was extracted, and a sharp cannulated cutter created a novel path in the proximal segment (Fig. 4A). Closed reduction was lost and so a lateral incision was made at the level of the fracture and a percutaneous reduction was achieved through use of a proximal bone hook and distal ball spike pusher (Fig. 4B). The hip was extended, and a ball-tipped guidewire was successfully passed across the fracture site to a center-center positionwithin the canal at the level of the knee (Fig. 4C and D).
(A) AP radiograph of left hip with implant; (B) lateral radiograph of left hip with implant; (C) reduced fracture site with implant; (D) distal femur with implant.
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The cannulated flexible reamers encountered impassible blastic lesions within the proximal femur (Figs 3C and 5B). Sequential 0.5-mm reaming from 9 to 13 mm prepared for an 11 x 400 mm, 125  Gamma3  intertrochanteric rod (Stryker  Kalamazoo, MI), with a 95-mm cephalomedullary screw and x2 distal lateral to medial interlocking 5.0-mm screws (Fig. 5A-D).
(A) 12-month post-operative AP radiograph of left hip; (B) 12-month post-operative lateral radiograph of left hip; (C) 12-month post-operative lateral femur radiograph; (D) 12-month post-operative AP distal femur radiograph.
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At 12 months, the patient denied pain, and XRs demonstrated robust callus formation and bridging healing at the fracture site (Fig. 6).