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PROBLEMATICS

A STRANGE FATIGUE FEMORAL FRACTURE AFTER TOTAL HIP ARTHROPLASTY A case report and review of literature. P. Tanchev, P. P. Tanchev* Gorna Bania University Hospital of Orthopaedics, Sofia, Bulgaria * Tsaritsa Johanna University Hospital, Sofia, Bulgaria. PROBLEMATICS. Periprosthetic femoral

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PROBLEMATICS

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  1. A STRANGE FATIGUE FEMORAL FRACTURE AFTER TOTAL HIP ARTHROPLASTY A case report and review of literature P. Tanchev, P. P. Tanchev* Gorna Bania University Hospital of Orthopaedics, Sofia, Bulgaria * Tsaritsa Johanna University Hospital, Sofia, Bulgaria

  2. PROBLEMATICS • Periprosthetic femoral fractures after THA – a well studied reason for revisions • Several classifications proposed (Cook & Newman, 1989; Duncan & Masri, 1995; Brady et al, 2000, etc) • Stress (fatigue) fractures after THA - rare and rarely reported Cook & Newman, 1989 P.Tanchev et al., Int.Orthop., 20,1996,182-184

  3. DEFINITION STRESS (FATIGUE) FRACTURES (SF) ARE DUE TO FATIGUE OF THE BONE CAUSED BY REPEATED STRAIN/STRESS 2 TYPES • TYPICAL STRESS FRACTURES OCCUR IN BONE WITH NORMAL RESISTANCE SUBJECTED TO EXCESSIVE REPETITIVE DEMANDS (YOUNG ADULTS) • INSUFFICIENCY FRACTURES OCCUR IN WEAKENED BONE SUBJECTED TO OVERLOADING (PATIENTS OVER 50)

  4. REVIEW OF LITERATURE • AFTER THA – SIGNIFICANT ALTERATIONS IN THE STRESS PATTERN DELIVERED TO THE FEMUR AND PELVIS OCCUR • NEVERTHELESS, SFAFTER THA ARE RARE AND RARELY REPORTED • INCIDENCE – UNKNOWN • DIFFERENTIAL DIAGNOSIS OF PATIENTS WITH OBSCURE PAIN AFTER THA SHOULD INCLUDE SF !!!

  5. REVIEW OF LITERATURE (cont’d) FEW REPORTS DESCRIBE SF AFTER THA: • Marmour (1976) – a case of stress fracture of the pubic ramus simulating loose total hip replacement • Launder and Hungerford (1981) – a 46-year-old woman with pubic stress fracture 6 years after THA • Lourie(1985) – three cases of spontaneous fractures of the sacrum after THA • Lotke et al. (1986) - a report of two cases of femoral stress fracture in association with a cortical window after revision THA

  6. REVIEW OF LITERATURE (cont’d) - Cory et al. (2003) – 6 cases of pubic ramus insufficiency fractures following THA - Berry (1995) – a report of three cases of periprosthetic acetabular fractures with severe pelvic osteolysis, suggested to be preceded by stress fractures - Several case reports of stress fractures about the hip and femur occurring after TKA (Hardy, 1992; Kumm 1997; Lesniewsky 1982; Rawes,1995

  7. CASE REPORT • R.S. ♀ 52 y. • Coxarthrosis dysplasica bilateralis • 04. 2004 THA left (cemented) – no complaints 5 years later • 02. 2008 THA right – very narrow intramedullary canal; widening with flexible reamers ( 6.5 - 12 mm), insertion of smallest size femoral stem, cemented; normal postoperative course, early loading started R.S. 04. 2004 THA left R R R.S. 02. 2008 THA right

  8. CASE REPORT (cont’d) • 05. 2008 – no complaints at first control examination • X-ray – stable position of a well cemented prosthesis • Walking without crutches and normal loading administered R.S. 52 y. 12. 05. 2008 First follow-up NO VISIBLE BONE CHANGES IN THIS AREA NO CHANGES R

  9. CASE REPORT (cont’d) • 01.10.2008 (8 months after THA) – acute pain in the proximal third of right thigh irradiating to the right knee after some physical overloading ? the day before • Physical exam – painful and restricted ROM no signs for hematoma, no swelling • X-ray – incomplete fracture (fissure) of the lateral aspect of the femur at a site with no stress riser forces; prosthetic stem – well cemented, stable position, no loosening R.S. 1.10. 2008 R

  10. CASE REPORT (cont’d) • Walking on two crutches • Reduction of physical loading and walking distance • NSAID • Physical exercises without loading • Follow-up in 3 months

  11. CASE REPORT (cont’d) • 21. 01. 2009 - complaints subsiding, almost no pain, ROM - better • X-ray – femoral fissure in process of consolidation; stable position of the stem R.S. 21. 01. 2009 R

  12. CASE REPORT (cont’d) • 26. 03. 2009 – no pain, normal movements and walking without crutches or cane • X-ray – femoral fissure in advanced process of consolidation; stable position of the stem R.S. 26.03. 2009 R

  13. HYPOTHESES • Extreme bone removal during reaming of the femoral canal making the lateral cortex very thin and weak • Impaired endosteal vascularization during reaming of femoral canal in combination with ” a very good cementation” causing local changes in bone metabolism • Undiagnosed incomplete fracture (fissure) at insertion of the femoral stem 3. Stress-riser at this unusual site because of incomplete cement filling or local cement breakage at the same site 4. Other reasons?

  14. THANK YOU FOR YOUR ATTENTION ! • - Doctor, what’s that ? • - I am sorry, but I also don’t know • because medicine is not mathematics…

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