Case Report and Literature Review of Periprosthetic Atypical Femoral Fractures After Total Hip Arthroplasty.

We describe a case of periprosthetic femoral fracture with 5 major features of an atypical femoral fracture (AFF) and localized cortical thickening at the fracture site, which is characteristic of an AFF. An 81-year-old female patient had undergone cementless total hip arthroplasty for a right femoral neck fracture at the age of 66, and had been taking oral alendronate since then. At the age of 79, she developed spontaneous right thigh pain. Radiographs showed lateral cortical thickening and pedestal formation around the end of the femoral component. She was advised to discontinue oral alendronate and change to eldecalcitol. At the age of 81, she developed sudden severe pain when standing up from a seated position and was not able to walk. Radiographs showed a periprosthetic femoral fracture with 5 major features of AFF at the site of localized cortical thickening. We diagnosed a Vancouver type B1 periprosthetic femoral fracture. She underwent open reduction and internal fixation (ORIF) with an NCB® Periprosthetic Femur Plate System with cable grips. Daily subcutaneous injection of teriparatide and low intensity pulsed ultrasound therapy were performed to stimulate bone healing. She was able to walk without assistance at 4 months after ORIF. Radiographs showed adequate bridging callus and a disappearing fracture line. This case was diagnosed as a periprosthetic atypical femoral fracture (PAFF), because a periprosthetic fracture is excluded from the definition of AFF. Similar to AFF, PAFF exhibits poor clinical outcomes. The approach to treating PAFF should be decided after considering the pathogenesis.

Troubleshooting in the Treatment of Pseudoarthrosis After a Humeral Diaphyseal Fracture: A Case Report.

We report a case of a patient with a history of surgery for insufficient pseudoarthrosis after a humeral diaphyseal fracture. Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. A-61-year-old man presented at our hospital with pain and deformity in his left upper arm. The humeral diaphyseal fracture had been previously treated elsewhere with open reduction and internal fixation. Some days prior to his visit at our hospital, he had had pain in his left upper arm, without a particular cause, and was admitted to our hospital for initial evaluation. After a complete physical examination, symptoms of infection and any neurovascular deficit were ruled out. Radiographic examination revealed atrophic nonunion of the middle third of the humeral shaft associated with disuse osteopenia. Anterograde intramedullary nailing and bone grafting were performed for the resistant atrophic nonunion of the humeral diaphysis. In addition to the intramedullary nailing, additional fixation was performed for residual rotational instability. A postoperative evaluation revealed a periprosthetic fracture in the distal part of the humerus. Poor bone quality or a deficient plate technique might have lead to the facture. We performed open reduction and internal fixation (ORIF): he underwent fixation with a 2-plate construct for the nonunion of the humeral diaphyseal fracture, together with decortication, debridement, and bone grafting. Eight months after surgery, the patient's bone had healed and he had recovered flexion (110°) and extension (-30°) without complications. An orthopedic surgeon should be aware of these complications when choosing open reduction and internal fixation for the treatment of a history of insufficient pseudoarthrosis. Patients should be closely followed up for evidence of any complications such as infections and malunions. Fracture fixation in patients with pseudoarthrosis requires strategies to overcome the technical difficulties faced during the procedure.

Weekly Teriparatide for Delayed Unions of Atypical Subtrochanteric Femur Fractures.

INTRODUCTION: The occurrence of atypical femur fractures (AFFs) in patients on prolonged bisphosphonate treatment has been gaining medical attention, but the use of pharmacotherapy for these fractures has not been explored in detail. The authors describe a case of AFFs successfully treated with once-weekly administration of 56.5 µg teriparatide (TPTD). CASE PRESENTATION: The patient was a 74-year-old female patient who had been taking alendronate for approximately 6 years and who suffered with a fall while walking. X-rays revealed a subtrochanteric right femur fracture. The contralateral femur showed cortical thickening and a transverse radiolucent fracture line. Based on these specific features, the patient was diagnosed with AFF. The patient underwent osteosynthesis with intramedullary nailing for the right fracture. Alendronate treatment was discontinued. Low-intensity pulsed ultrasonography therapy did not affect the healing of the fracture with delayed union, even after 3 months of application. Prophylactic osteosynthesis was performed for the subtrochanteric left femur. Bone tissue collected from the left fracture site during surgery showed severe suppression of bone turnover. Union of bilateral femurs was achieved after 3 months of a once-weekly administration of TPTD. CONCLUSION: Once-weekly TPTD treatment is shown to be beneficial for improving the healing of AFFs showing delayed union.