B George, R S Gaheer,
Address for Correspondence
Dumfries and Galloway Royal Infirmary,
Subcapital and intertrochanteric fractures of
the femur are amongst the most common injuries encountered in
orthopaedic practice. However a combination of these injuries
has rarely been reported. Simultaneous presentation of both
these fractures on the same side has been reported only once[i].
There have been few reports where a subcapital fracture occurred
after internal fixation of an intertrochanteric fracture.
We report a case of a subcapital fracture occurring after
removal of dynamic hip screw in a healed pertrochanteric
fracture. This was subsequently treated with a cemented
A 73-year-old patient presented to us with
a pertrochanteric fracture. This was treated promptly by closed
reduction and DHS fixation(fig 1a,b). She made an uneventful
recovery following the operation and was discharged home after
adequate mobilisation. However 5 years after the DHS fixation
she attended orthopaedic clinic with lateral thigh pain. Check
Xrays at this stage showed the fracture to be healed (Fig
2a,b)and the pain was thought to be implant related. Blood tests
done at this stage did not suggest an infective cause to
symptoms. As this pain was unrelieved in the following months it
was decided to remove the implant. This was done as an elective
procedure following which she started mobilising without any
pain. Few weeks later she re-presented to orthopaedics with
sudden onset of hip pain. X-rays taken showed that she had a
fracture of the subcapital region of the femur (fig 3). No
history of trauma was forthcoming. It was decided to go ahead
with a cemented hemiarthroplasty (fig 4) of the hip, following
which she was again discharged home.
The aetiology of subcapital fracture
following fixation of pertrochanteric fracture is not well
known5. There seems to be two main categories of
these fractures- with the implant insitu and after implant
removal. Attempts have also been made to understand the role of
different types of implant. (Fixed Vs dynamic) Various possible
explanations have been put forward by different authors. Tronzo
postulated that stress fractures at the tip of fixed implant
could occur. He reported two cases where Jewitt nails were used
to treat intertrochanteric fractures[vi].
Suggestions that a dynamic hip implant would prevent these
have been proven wrong as subsequent reports of similar
fractures after DHS has come out 2,[viii],[ix].
Poor positioning of the screw in a DHS has been suggested as a
cause of subsequent fracture of the neck of femur[x].
Reports of subcapital fractures occurring
after the removal of a pertrochanteric fracture fixation device
is even rarer and more difficult to explain with the above
postulations. Buciuto et al reported seven patients with such
fractures5. (3 following DHS and 4 following blade
plate). They however did not give any possible explanation to
the occurrence of such fractures. Taylor et al reporting a
similar case postulated that significant local osteoporosis can
occur in a hip protected by the implant, and subsequent minor
trauma after implant removal may cause a fracture to the hip2. Removal of implant itself may cause the
inferior portion of the neck to be compromised if the screw was
placed too inferiorly in the first place. Retrospectively
analysing our case we believe this may be a possible explanation
in our case.
Although very rare, these complications
discussed above are very significant once they occur and
necessitate another major
operation in most cases. With an ageing population we are likely
to see more and more of such complications. Whatever be the
possible cause of these unusual fractures, the surgeon needs to
be aware of these complications and a period of protected weight
bearing may be indicated in selected patients following implant
removal from the hip.
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- Robert Buciuto,
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