Type 3 periprosthetic fracture Lt hip

 Patient a 78 year old hypertensive underwent bipolar 8 months back elsewhere and refered to my friend for mangement with a periprosthetic fracture after a fall. There is a doubt about peri-operative infection

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Problems ansd solutions/ 
1. ? infection- Hip aspiration being done for cultures as well as leukocyte esterase test( ref Parvizi guidelines in aaos). if we get the bug even if infected would do one stage with local antiobiotic delivery of choice with HA granules or Calcium phosphate granules both of which are commercially available. 2 stage may be too much for a 78 year old.


2. Widening distal canal compromising regular cylindrical distal fixing stems unless stems locking stems like REEF or aescalup are use. I understand there is an local long stem unipolar with locking available but is a stem with no coating and is a long stem austin moore  for those who want to use it. I do not have faith in these stems.
Solutions.

Modified wagner osteotomy( Anterior) ref pic Above makes quicker sand easier operation. In this case i would prefer it to ETO. Cement and uncemented stem distally and use a bipolar head. The osteotomy helps to cement distally easily as well as remove the stem without further collateral damage. Remove the distal porocoat with a carbide burr to have better cement bone fixtion  as compared to cement implant and  hope fully avoid early loosening. ( my longest follow up for simialar case is 5 .3 years in a n 80 year old- will put it up if I can find it in my blog). If successful we could mobilise him FWB day 1 postop

3. if a high demand patient one would need to use an uncemented long HA of grit blasted stem like REEF or Aescalup stem the name of which i have forgotten

Good luck
jake

Comments by the surgeon

Hip aspiration didnot yield anything yesterday. No frank pus seen. Frozen- 10-12 neutophills. tried to dislocate first but invain. did wagner osteotomy. put in HAP granules into the distal fragment down the canal , after centrifuging it in arthrex machine with polymixin B and vancomycin . Took off the distal coating with burr. 1.2  teicoplanin was mixed with 60 gm.Unfortunately put in the cement a bit early before doughy stage  . Hence was a bit difficult to put it in.

Abt 8cm cement mantle seen in the distal fragment  from the fracture site.

Hap with antibiotics packed in at osteotomy sites and gaps proximally

I would  go PWB to FWB  as comfortable as the cement mantle is at least 8 cm  and what prevents will the pain at the fracture site.