Cement detachment from the cephalic blade in an intertrochanteric fracture fixation – A case report

Abstract

Hip fractures are common in the elderly population, with an estimated 18% of women and 6% of men suffering from such fractures globally [1]. It constitutes an important public health problem as there is a trend towards an aging population nowadays, and it is estimated that the disease burden of hip fractures will reach up to 4.5 million hips by the year 2050 [2]. Intertrochanteric (IT) fractures are among the two most common types of hip fractures, with a predilection for the more elderly population compared to femoral neck fractures. The treatment of intertrochanteric (IT) fractures can be divided into non-surgical and surgical. Typically, non-surgical treatment is not recommended, and reserved for patients with high operative risk as well as poor pre-morbid function. Surgical treatment is recommended as fixation allows patients better mobilization, reduced in-hospital stay and reduced mortality [3]. Surgical fixation of IT fractures can be performed via extramedullary fixation or intramedullary fixation. Extramedullary fixation is usually performed via plate and screw fixation, with a dynamic hip screw construct. Intramedullary fixation is usually performed via cephalomedullary nail fixation, which consists of an intramedullary nail in the shaft of the femur as well as a cephalic blade into the femoral head. A common mechanical complication of cephalomedullary nail fixation is implant migration, more specifically cephalic device cut out or cut through [4]. One of the methods to address the problem of cephalic blade migration is cement augmentation of the femoral head. This is performed via specialised fenestrated cephalic devices (blade/screw) and standard bone cement, polymethylmethacrylate (PMMA). Biomechanical studies have shown that cement augmentation around the cephalic blade yields superior rotational stability and increased pull out resistance of cephalic blades compared to non-augmented implants [5]. This benefit was higher in patients with lower bone mineral density (BMD), suggesting that osteoporosis and poor bone quality was a significant risk factor in terms of cephalic device migration. There are many different cephalomedullary nailing systems in the market, but the one most commonly used in our institution is the system developed by DePuy Synthes: TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA) together with their proprietary cement augmentation system Traumacem V+ (DePuy Synthes, West Chester, PA, USA). In this report, we describe the first case of cement detachment from the cephalic blade from the TFNA following fixation of an IT fracture in an elderly lady.