A Novel Approach to Atypical Periprosthetic Femoral Fractures with Stem Breakage: A Case Report.

Abstract

Introduction: As the number of total hip arthroplasty (THA) procedures continues to increase annually, periprosthetic femoral fractures (PFFs) have become a more common and significant complication. These fractures present a unique challenge due to the presence of the prosthetic implant, which may complicate the healing process. Atypical femur fractures (AFFs) are a subset of fractures that frequently occur with minimal trauma, often in patients who have been on prolonged bisphosphonate therapy. Although PFFs are excluded from the AFF definition, PFFs that otherwise meet the criteria have been termed atypical PFFs (APFFs). While APFFs are a growing area of interest, there is limited literature on their management, particularly when associated with femoral stem breakage. This case report presents the second reported instance of an APFF with femoral stem breakage, but uniquely, it is the first to involve the preservation of the proximal stem with isolated removal of the distal portion.

Case report: An 88-year-old female with multiple comorbidities, including osteoporosis and a history of bisphosphonate therapy, presented with an APFF of the right femur following a ground-level fall. One year prior, she had undergone uncomplicated THA with a long cylindrical, fully porous-coated femoral stem. Radiographs revealed a transverse fracture at the subtrochanteric region, lateral cortical thickening, and femoral stem breakage. Given the patient's medical history and the complexity of the fracture, revision surgery was indicated. Surgical intervention included the preservation of the proximal femoral stem and the removal of the distal stem segment, combined with periprosthetic plate fixation and cortical strut allograft for stabilization.

Conclusion: This case highlights the importance of individualized surgical planning in the management of APFFs, particularly those involving stem breakage. By preserving the proximal stem, a less invasive approach was achieved, minimizing surgical morbidity and supporting optimal fracture healing. The case underscores the potential benefit of preserving the femoral stem when appropriate, a strategy not widely explored in current literature. The findings contribute to the ongoing discussion of surgical options for APFFs and offer valuable guidance for future treatment approaches, especially as THA and bisphosphonate use continue to rise.