Date: Thu, 31 Oct 2002 00:26:54 +0530

Subject: Proximal Femur Fx - Refracture


Kindly give your opinion on management of this case which has been admitted to my unit yesterday. Male patient about 40 years old . Highly injury prone. Left hip dislocation 17 years back treated by closed reduction and traction. Closed fracture right tibia 10 years back treated by plating and cancellous bone grafting . All the above uneventful recovery so far.

Fracture right femur isthmic region 7 years ago treated with plating. Same femur had basal fracture neck 8 months ago and this was treated with DHS - a contoured plate is seen. Now he has presented with a fracture through the upper shaft of same femur which goes thru the middle screw and has broken the last screw. Patient says he had a deformity of right femur since birth which was not corrected. Biochemically all normal values. One of my colleagues who has operated on this patient earlier said that his right femur was very vascular but histology did not reveal any specific pathology. I am not sure whether you can appreciate the following in the picture I am attaching: The DHS hip screw seems to be just getting out of the head into acetabulum. The texture of bone in the upper half appears abnormal.

My considerations: The deformity needs to be corrected if a recurrence of fracture has to be avoided. Every time he fractured the fracture has healed. The DHS hip screw cannot be retained and the present postion in the head rules out consideration for a recon type nail after deformity correction.


Use the present fracture as one osteotomy and do one more ostetomy at the site where we find an old broken screw. These two should help correct the deformity to an accepable level. Or do an osteotomy between the above two sites and try to correct the deformities thru this.

Stabilisation options:

Use a long contoured plate with the proximal two screws passing into the head. Use a Ilizarov construct with two Schanz screws going into the head and the construct extending to the supracondylar region.

I will be thanful for your valuable opinions and suggestions.

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.

Reply at: Orthopaedic Trauma Association forum

Date: Wed, 30 Oct 2002 16:08:43 -0500

From: James Carr

I like your ideas - how about a double osteotomy, and a nail? I think it will work.

James B. Carr, MD
Palmetto Health Orthopedics

Date: Thur, 31 Oct 2002 !0:30 AM EST

From: Bill Burman


A similar case has been presented by Dr. Rajat Varma from Indore.

An article by Freeman et al JBJS 69A 691 reported good results with multiple osteotomies combined with Zickle Nailing - even in cases of prior hip screw femoral head "cut-out". Freeman's cases were in the 6-13 yr age range.

Bill Burman, MD
HWB Foundation

Date: Thu, 31 Oct 2002 12:32:56 -0500

From: Djoldas Kuldjanov

If this was my case, I would first want to obtain full length, standing (if possible) films as illustrated

in order to determine all apices of limb deformity before deciding where to make the osteotomy(s) and which hardware to apply.

Djoldas Kuldjanov, MD
Detroit Receiving Hospital

Date: Thu, 31 Oct 2002 23:33:50 +0530


Thanks Bill.

I have run through these cases again that you referred to.

My considerations(worries) are:

1) My patient also seems to have an abduction contracture. On maximum adduction the trochanter moves but not enough to get an entry into the pyriform fossa.

2) The neck of femur had a fairly recent fracture that should be protected with an implant.

3) My senior colleague who has operated on this patient's femur before has noted profuse bleeding from the canal.

4) Pathology of lesion not yet known. Previous histology negative for any specific lesion.

5) This patient is around 40 years and hence the contracture is long standing(Deformity present since childhood).

6) Like Rajat , I do not have Zickle nail. However even though Gamma nail may be available, the warning from the previous Surgeon definetely makes it a shaky business to consider an intramedullary device.

I have been narrowing down the option to a long plate with two screws going into the head. Well the D day is arriving soon and I have to decide one way or other.

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.

Date: Fri, 1 Nov 2002 00:07:12 +0530


Thanks Djoldas Kuldjanov.

I had already done a full femur xray and it was based on this I suggested two osteotomies. First one using the present fracture site and the second one going thru the broken screw from the old plate which was removed. Sorry I did not bring out this in the earlier discussion. I have not done full limb x-ray as an ardent Ilizarov man would want. ( I thought I already made too long a problem presentation - testing other's patience - seems to be true if you see the total responses apart from James Carr, Bill and you nothing so far).

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.

Date: Thu, 31 Oct 2002 15:05:08 -0500

From: James Carr

You can do two single plane osteotomies. Direct the saw lateral-medial, and angle it 45 degrees from perpendicular to the floor. The nail will correct the deformity. Lock it antegrade.

James B. Carr, MD
Palmetto Health Orthopedics