Retrograde nailing of femoral fracture below
a hip prosthesis
A CASE REPORT
Aart D. Verburg
From Maasland Hospital, Sittard, The Netherlands
n a frail elderly patient a pathological fracture of
I the femur at the lower end of a loose femoral stem
was treated by the retrograde insertion of an
intramedullary nail over the tip of the prosthesis.
J Bone Joint Surg [Br] 1998;80-B:282-3.
Received 20 June 1997; Accepted 7 August 1997
Fractures of the shaft of the femur in elderly patients with
total hip replacements present a considerable problem.
Case Report
In June 1996 a 95-year-old woman confined to a wheel-
chair for four years because of loose prostheses in both hips
sustained a spontaneous fracture of the right femur. Two
years earlier a fracture of the shaft of the ipsilateral tibia
had been plated. There was limited function in her arthritic
right knee. Conservative treatment of the femoral fracture
with analgesics and a brace had been unsuccessful; persist-
ing pain interfered with nursing care.
Radiographs showed marked atrophy of the femur with a
fracture through a large granuloma at the level of the tip of
the loose stem (Fig. 1). A limited salvage procedure was
planned since the patient’s general condition did not allow
extensive surgery. The stem of the prosthesis was templated
and 16 and 17 mm slotted femoral nails (AO/ASIF) were
obtained.
Operative technique. With the patient supine on a radio-
lucent table, the knee was flexed over a bolster. The length
and diameter of the nail were estimated using an image
1,2
intensifier so that approximately half of the length of the
A. D. Verburg, MD, Orthopaedic Surgeon
Department of Orthopaedic Surgery, Maasland Hospital, Walramstraat 23,
6131 BK Sittard, The Netherlands.
©1998 British Editorial Society of Bone and Joint Surgery
0301-620X/98/28084 $2.00
282
stem (7 cm) would be covered. The distal end of the slotted
nail was cut with a handsaw and the tip polished with a file
under aseptic conditions. Through a short medial para-
patellar incision the medullary canal of the distal femur was
opened after subluxation of the patella. A guide wire was
introduced and the distal femur reamed to 17 mm before
the nail was introduced. Closed ‘docking’ of the nail and
the tip of the prosthesis was not possible: a lateral vastus-
splitting incision allowed the stem and nail to be aligned.
The nail was driven over the prosthesis with a mallet while
the position of the loose acetabular component was mon-
itored fluoroscopically. Some pieces of bone cement were
chipped off the stem by the advancing nail and some were
removed. The nail was advanced until about half of the
stem had been covered and the end of the nail was flush
with the articular cartilage. The nail was then locked from
the anteromedial side, and its distal end was sealed by a
polyethylene plug and bone wax to provide a watertight
closure. Both incisions were closed without drainage. Knee
flexion and extension exercises were started on the third
day after operation.
When reviewed after seven months the patient had no
pain during transfers and nursing care. Knee flexion was
limited to 100°. Radiological examination showed little
callus formation (Fig. 2). The position of the prosthesis and
the nail had not changed (Figs 3 and 4).
Retrograde nailing of a tapered hip stem for femoral
fracture may be useful in a frail geriatric patient. If weight-
bearing is likely the nail should be inserted deeper and
locked dynamically to accommodate shortening of the
femur during healing of the fracture.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
References
1. Van Meeteren MC, van der Werken C. Mergpenfixatie van een
femurschachtfractuur, distaal van een DHS. Ned Tijdschr Traum
1996;4:94.
2. Voggenreiter G, Assenmacher S, Klaes W. Schmit-Neuerburg KP.
Pathological fractures of the proximal femur with impending shaft
fractures treated by THR and cemented intramedullary nailing: a
report of nine cases. J Bone Joint Surg [Br] 1996;78-B:400-3.
THE JOURNAL OF BONE AND JOINT SURGERY
 RETROGRADE NAILING OF FEMORAL FRACTURE BELOW A HIP PROSTHESIS 283

Figure 1 – Radiograph showing fracture of the shaft of the

femur at the level of the tip of the femoral prosthesis.
Figure 2 – Composite radiograph of the combined pros-
thesis and the site of the fracture seven months after
operation.

Fig. 1 Fig. 2

Figures 3 and 4 – Radiographs after seven months showing

the position of the nail.

Fig. 3 Fig. 4

VOL. 80-B, NO. 2, MARCH 1998