PMC6158977_01
Subtrochanteric fracture with displacement with lesser trochanteric fracture of the femur. According to the AO classification: 31-A3.
CRIOR2018-9580190.001.jpg
PMC6158977_01_CRIOR2018-9580190.001.jpg
fig1
An 83-year-old woman, with a height of 1 meter and 65 cm and a weight of 85 kg (BMI = 31.22), was transferred to our department because of a reverse pertrochanteric-subtrochanteric fracture AO 31-A3 (Figure 1).
Trend of the patient's HHS and SF-12 before the proximal femoral fracture, through the Affixus  nail (Zimmer Biomet , Warsaw, Indiana, USA) breakage, and after the definitive THA implantation.
CRIOR2018-9580190.002.jpg
PMC6158977_01_CRIOR2018-9580190.002.jpg
fig2
The patient had a cardiovascular disease of moderate severity, though her social life was very active, and the Harris Hip Score (HHS) and the Short Form 12 Health Survey (SF-12) were both 94 points (Figure 2). SF-12 was 35 (see Figure 2). She underwent revision surgery, with removal of the broken nail (Figure 7) and total hip arthroplasty with a 46 mmO Plasmacup  acetabular cup with a 28 mmO bearing liner in polyethylene (Aesculap, Twelve months after the revision surgery, the HHS was 80 points and the SF-12 was 90 points (Figures 2 and 9).
X-rays at 6 months of follow-up. Displacement of the fracture and aseptic nonunion.
CRIOR2018-9580190.003.jpg
PMC6158977_01_CRIOR2018-9580190.003.jpg
fig3
The shaft was 9 mm wide, the lag screws were 100 mm long, and one distal static locking screw was used (Figure 3). Six months after surgery, at the last control, the HHS was 66 and the SF-12 was 74, and the radiographs showed subtrochanteric nonunion and medial displacement of the distal fragment (Figure 3).
X-rays done in other hospital after 1 year of follow-up showed that the first incomplete breakage was on the hole for the distal static screw. The orthopaedic surgeon did not talk about nail dynamization or nail remotion and revision to the patient.
CRIOR2018-9580190.004.jpg
PMC6158977_01_CRIOR2018-9580190.004.jpg
fig4
Six months later, she underwent radiographic studies which showed incomplete breakage of the nail at the hole for the locking screw (Figure 4), though no surgical treatment was indicated.
X-rays done in other hospital after 2 years of follow-up showed that the second incomplete breakage was through the barrel for the lag screw while the first incomplete breakage was on the hole for the distal static screw. The orthopaedic surgeon did still not talk about nail dynamization or nail remotion and revision to the patient.
CRIOR2018-9580190.005.jpg
PMC6158977_01_CRIOR2018-9580190.005.jpg
fig5
There was no pain in the hip, and 2 years following primary surgery, radiographs done in the other hospital showed further incomplete nail breakage at the hole for the lag screw (Figure 5).
After 3 years, the X-rays (done in Emergency Room) showed the breakage of the nail in its proximal part and distal part.
CRIOR2018-9580190.006.jpg
PMC6158977_01_CRIOR2018-9580190.006.jpg
fig6
One year later, i.e., three years after surgery, the patient seek further assistance because of the sudden severe hip pain, and the radiographs showed complete fracture of the nail at both the proximal and the distal holes (Figure 6).
Pictures of the broken nail.
CRIOR2018-9580190.007.jpg
PMC6158977_01_CRIOR2018-9580190.007.jpg
fig7
Postsurgery X-ray, after nail removal and replacement with revision THA with two screws to fix the cup and three metal cable cerclages to prevent the breakage during the implant of the stem.
CRIOR2018-9580190.008.jpg
PMC6158977_01_CRIOR2018-9580190.008.jpg
fig8
Braun, Melsugen, Assia, Germany) fixed with two screws of 24 and 32 mm length, a 28 mmO Prevision  metal femoral head, and a 240 mm long modular revision stem (Aesculap, B. Braun, Melsugen, Assia, Germany), with proximal segment P1/0 mm and distal segment 12 mmO, with the addition of three free metal cable cerclages (Figure 8).
X-rays at 1-year follow-up after surgery. Image (a) shows the integration of the prosthetic cup into the acetabulum. Image (b) shows the bone reabsorption around the stem where there was nonunion. Image (c) shows the absence of stress shielding along the stem and at the stem's apex and the absence of the tip effect. Image (d) shows the apex of the broken nail deposited in the distal metaphysis of the femur.
CRIOR2018-9580190.009.jpg
PMC6158977_01_CRIOR2018-9580190.009.jpg
fig9
Twelve months after the revision surgery, the HHS was 80 points and the SF-12 was 90 points (Figures 2 and 9).