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OFFICIAL JOURNAL OF

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Canadian Orthopaedic Trauma Society

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International Society for Fracture Repair

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Special Case Report Series

CASE REPORTS

Intramedullary Nailing of Sequential Bilateral AtypicalSubtrochanteric Fractures and the Management of Distal FemoralIntraoperative Fracture: Contemporary Issues on a Case Report

Theodoros H. Tosounidis, MD, PhD, Kalliopi Lampropoulou-Adamidou, MD,and Nikolaos K. Kanakaris, MD, PhD

Summary: Long antegrade cephalomedullary nailing is the stan-dard of surgical care of atypical subtrochanteric fractures of thefemur. Long nailing of such fractures is a technically demandingprocedure. Our case report discusses the management of sequentialbilateral atypical subtrochanteric fractures in an elderly femalepatient and the technical issues pertaining to nailing of suchfractures. During the nailing procedure of the second fracture, anintraoperative distal peri-implant fracture occurred, and it wasaddressed with the application of a distal femoral locking plate. At2-year postoperative follow-up, the patient was ambulating inde-pendently and had sufficient range of motion in both hips and knees.

Key Words: NOF, Nailing, Bisphosphonates, Atypical Fracture

INTRODUCTIONAtypical femoral fractures constitute a rare entity.1,2 Although

the subtrochanteric region of the femur is particularly susceptible tothe development of these fractures, they can occur anywhere alongthe femur from just distal to the lesser trochanter to just proximal tothe supracondylar flare. The prolonged use of bisphosphonates hasbeen correlated to the increased likelihood of developing suchfractures, especially in the female elderly population.3,4 The inci-dence of bilateral sequential fractures is high, especially when bi-sphosphonate treatment is not discontinued after the index atypicalfracture.1,2

The overall medical and surgical management of atypicalsubtrochanteric fractures remains a challenge. Currently, there ispaucity of high quality evidence in regard to their surgicaltreatment, but they are commonly addressed with long cephalo-medullary intramedullary nailing.5 Long nailing of pertrochantericfractures has been correlated with increased incidence of intraoper-ative periprosthetic fractures from anterior impingement of the nailat the distal femur, mostly due to suboptimal nailing technique,posterior nail entry point, increased femoral bowing, and nonana-tomic nail designs.6

CASE REPORTA 78-year-old woman sustained a left subtrochanteric fracture

after a standing height simple mechanical fall inside her house. Shewas transferred to the hospital by the ambulance service, and afterthe primary and secondary surveys in the Accident and EmergencyDepartment, the left femoral fracture was confirmed to be her onlyinjury. On physical examination, a shortened externally rotated

Accepted for publication June 2, 2015.

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Biomet.

From the Department of Trauma and Orthopaedics, Leeds MusculoskeletalBiomedical Research Unit (LMBRU), School of Medicine, University ofLeeds, Leeds, United Kingdom.

T. H. Tosounidis has been involved in speakers bureau/paid presentations forBiomet. N. K. Kanakaris has been involved in speakers bureau/paid pre-sentations for Biomet, DePuy, A Johnson & Johnson Company, Medtronic,Pfizer, Stryker, Olympus Biotech; acts as paid member of the Europeanclinical advisory board for Stryker Europe and as educational consultant forBiomet; acts as a member of editorial board for the medical/orthopaedicpublications of BioMed Research International, Open Access Trauma, HardTissue, Case Reports in Orthopedics. K. Lampropoulou-Adamidou reportsno conflict of interest.

Reprints: Nikolaos K. Kanakaris, MD, PhD, Leeds General Infirmary,Clarendon Wing, Level A, LS13EX Leeds, West Yorkshire, UnitedKingdom (e-mail: n.kanakaris@nhs.net).

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left lower extremity with crepitus on attempted motion with noperipheral neurovascular deficit was evident. The radiographs ofthe pelvis and femur revealed a subtrochanteric fracture withfeatures consistent with an atypical fracture pattern (Figs. 1A, B).

The patient had a significant medical history consisting of theleft-sided heart failure, hypertension, osteopenia, irritable bowelsyndrome, and kyphosis of the thoracic spine. At presentation, hermedication included furosemide 40 mg twice daily, calciumcarbonate 1250 mg with vitamin D3 500 IU once daily, alendronicacid 70 mg once weekly, loperamide 2 mg once daily, andmebeverine hydrochloride 200 mg once daily.

The patient was taken to theater the same day for surgicalfixation of her left subtrochanteric fracture. This was undertakenunder general anesthesia on a fracture table with foot tractionapplied to the ipsilateral leg and lithotripsy position of thecontralateral lower extremity. The fracture was reduced by closedmeans, and a long trochanteric nail was inserted using standardtechniques. During the nailing procedure, a suboptimal entrypoint (too lateral and too posterior) with a subsequent eccentric(too anterior) nail tip placement was noted, and a subsequent nailimpingement to the anterior lateral cortex was evident. Neverthe-less, the operating surgeon accepted the above, as well as the

fracture reduction in a mild varus position, and the patient wasallowed to immediate postoperative weight bear as pain allowedwith a walking frame. The alendronic acid therapy was discon-tinued (after 6 years of continuous administration), after consulta-tion of the bonemetabolic disorder clinicians, and the fracture wentto healing uneventfully in 9 months (Figs. 2A–D).

During the follow-up period, a lateral cortical beak of thecontralateral (right) proximal femur was noted on the plain pelvicradiographs (Fig. 3). No action was taken at that point in timebecause the patient was completely asymptomatic. Unfortunately,3 years after the left femoral nailing, the patient had anothermechanical low-energy fall and suffered a right subtrochantericfracture (Fig. 4). The medical comorbidities were the same as 4years earlier with the addition of the right-sided heart dysfunction.The patient was on the same medication with the exception ofalendronic acid. No anabolic (teriparatide) or other type of agenthad been added to her antiosteoporotic medication since the diag-nosis and management of the first atypical fracture.

The patient underwent again an antegrade intramedullary pro-cedure with a cephalomedullary nail for the fixation of the rightsubtrochanteric fracture. Standard preparation and positioning wasimplemented with ipsilateral foot traction and contralateral

FIGURE 1. A, Anteroposterior radiograph of the leftproximal femur demonstrating a subtrochantericfracture with the characteristic features of an atypicalfracture including short obliquity, no comminution,periosteal lateral cortical thickening, and a medialspike. B, Anteroposterior radiograph of the pelvisshowing no evidence of a contralateral incompletefracture or cortical beaking from a stress reaction.

FIGURE 2. A–D, Postoperative radiographs at 9 months showing healing of the fracture despite the varus malalignment and theanterior cortical impingement of the distal nail tip.

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lithotripsy lower extremity position. An unsuccessful closedreduction was then attempted, followed by open reduction andnail insertion. Once again, the reduction and the nail entry pointwere suboptimal, resulting in eccentric placement of nail tip withencroachment at the anterior distal cortex—intraoperative corticalbreach (Figs. 5A–C). A senior surgeon was then called to addressthis intraoperative complication. A distal femoral locking plate wasinserted in a minimal invasive manner bypassing level of the cor-tical breach (Figs. 6A–D).

Postoperatively, the patient was instructed to partial weightbearing for the first 6 weeks followed by gradual progression to fullweight bearing within the next 6 weeks. Full weight bearing wasnot instructed from the first postoperative mostly to protect theiatrogenic distal femoral defect and its extramedullary fixation. Nofurther change to her antiosteoporotic medication was recommen-ded from the bone metabolic disorder unit. The patient went toa complete union of the peri-implant fractures in 6 months and ofthe atypical subtrochanteric fracture in 14 months (Figs. 7A–C). At3 years postoperative follow-up after the second nailing procedure,the patient was still ambulating independently and had sufficientrange of motion in both hips and knees.

DISCUSSIONProlonged, that is more than 5 years, use of bisphosphonates has

been associated with atypical femoral fractures.5 When an atypicalfemoral fracture is diagnosed, discontinuation of bisphosphonates isusually indicated alongwith supplementation of an anabolic agent—teriparatide subcutaneous injections—to accelerate bone healing andincrease bone turnover. Supplements of calcium and vitamin D arealso continued.2,5 The patient presented in these series had been usingalendronic acid for 6 years. When the first atypical fracture wasdiagnosed, the bisphosphonates were stopped but no teriparatidewas given besides the referral to the bonemetabolic department. Thiscould be a potential contributing factor to the development of hersecond atypical fracture 3 years later.Of note is the fact that the pelvicradiograph at the time of the initial admission was not indicative ofany stress reaction on the contralateral side and the patient was notcomplaining of pain on that hip/femur (Fig. 1B).

The specifics of both of this patient’s fractures demonstrated theunique radiographic features of atypical fractures including theirshort obliquity, the absence of comminution, the standard perios-teal lateral cortical thickening, and a medial spike. Of note is alsothe fact that the right femur demonstrated abnormal radiographicappearances even before the subsequent low-energy fracture. Thereis still controversy related to prophylactic fixation of pendingbisphosphonate-related atypical fractures, especially in the absenceof clinical symptoms or stress reaction in an Magnetic Resonance

FIGURE 3. Anteroposterior pelvic radiograph 6 months post-operatively showing ongoing healing on the left side and lateralcortical thickening of the right proximal femur (pending atypicalfracture).

FIGURE 4. Anteroposterior pelvic radiograph demonstrating thesecond subtrochanteric atypical fracture at the right femur.

FIGURE 5. A–C, Intraoperative fluo-roscopic views showing (A) a varusmalreduction of the proximal femurafter the attempted closed measures.The open reduction (B) of the fracturedid not significantly correct thereduction (note the lateral cortexindentation because of the previouslyinserted lag screw). C, Distal anteriorcortex impingement.

Intramedullary Nailing of Subtrochanteric Fracture

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Imaging scan.7,8 In the presented case, no prophylactic nailing wasperformed, a decision mainly guided by the absence of pain and ofany radiologic signs of a stress reaction or of an impending fracture.

According to the contemporary understanding,2,5 when an atyp-ical femoral fracture is diagnosed, a radiograph of the contralateralfemur is indicated because it has been shown that stress reactions inthe form of localized ellipsoid thickening of the lateral cortex orbeaking of the proximal femur in plain x-rays or of increased uptakein bone scintigraphy were demonstrated in up to approximately40% of the cases.9 Nonoperative management is indicated whenthe patient is completely asymptomatic and no cortical beaking isevident on plain radiographs, whereas prophylactic nailing is rec-ommended in contrary evidence.

In the absence of anyfindings in plain radiographic control and ifthe patient is symptomatic, then anMRI is indicated. If then a stressreaction is found, usually nonoperative management is recom-mended with protected weight bearing, discontinuation of bi-sphosphonates, and administration of an anabolic antiosteoporoticagent, that is, teriparatide along with vitamin D and calcium. Arepeat MRI is recommended after 3 months. Pain after 3 months ofnonoperative management and/or MRI features suggestive ofnonresolving edema are then indications for prophylactic nailing2,5

(as in suggested algorithm of Fig. 8).When atypical femoral fractures occur, their management is

surgical with long cephalomedullary intramedullary nailing beingthe most commonly used method of fixation. Antegrade long

nailing is the contemporary preferred method of subtrochantericfracture fixation because of its biomechanical superiority comparedwith extramedullary fixation and the protection of the entirefemoral length especially in pathologic and osteoporotic bone.10

Nevertheless, the use of plates can be justified in cases of extremecortical thickening, when nailing is considered too difficult, or asa reduction or an adjunct tool during the nailing procedure.5

Nailing of a subtrochanteric fracture in the presence of preinjuryabnormal femoral anatomy is a technically demanding procedurethat requires careful planning and extreme vigilance during theactual surgical procedure. Knowledge of the specific properties ofthe implant used, implementation of various reduction techniques,correct entry point, and maintenance of reduction during theprocedure (reaming, insertion of implant, and proximal/distalinterlocking) is of paramount importance to avoid 2 of the mostcommonly encountered complications: that is varus malalignmentand anterior encroachment of the nail at the supracondylar region.At the end of the first nailing procedure, both of the above issueswere encountered, but the fracture went to uneventful healing.During the second nailing procedure and because of the suboptimalentry point and the malreduction of the fracture before initiation ofreaming, the distal anterior cortex was breached. The intraoperativesolution that was offered was the minimally invasive application ofa distal locking femoral plate bypassing the tip of the nail and thecortical defect. Proximal plate anchorage was achieved usingmonocortical locking screws, whereas distal fixation was

FIGURE 6. A–D, Intraoperative fluoroscopic views showing the distal femoral locking plate and the reductions achieved for themanagement of the intraoperative fracture.

FIGURE 7. A–C, Postoperative follow-up ra-diographs at 2 years showing complete frac-ture healing of the atypical subtrochantericfractures and the intraoperative peri-implantdefect.

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performed using standard techniques. The above is the standardmethod of bailing out in intraoperative and postoperative fracturesoccurring at the distal femur during or after nailing procedures forthe management of pertrochanteric fractures.11 Both the distal andproximal femoral fractures progressed to union, with the atypicalsubtrochanteric having a protracted healing period, which is notuncommon in bisphosphonate-related fractures.

CONCLUSIONSThe case discussed in this report highlights some of the most

important issues pertaining to the management of atypical sub-trochanteric fractures and the difficulties/complications of longintramedullary femoral nailing. The reported case could serve asa model for further consideration with regard to the medicalmanagement of atypical fractures (discontinuation of bisphospho-nates, administration of anabolic agents), management of pendingatypical fractures (diagnostic imaging and the need for prophylacticnailing), technicalities pertaining to nailing of these fractures, andfinally management of intraoperative distal femoral corticalencroachment/fractures.

REFERENCES1. Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric anddiaphyseal femoral fractures: second report of a task force of the AmericanSociety for Bone and Mineral Research. J Bone Miner Res. 2014;29:1–23.

2. Unnanuntana A, Saleh A, Mensah KA, et al. Atypical femoral fractures:what do we know about them?: AAOS Exhibit Selection. J Bone JointSurg Am. 2013;95:e8.1–e8.13.

3. Schilcher J, Michaelsson K, Aspenberg P. Bisphosphonate use and atyp-ical fractures of the femoral shaft. N Engl J Med. 2011;364:1728–1737.

4. Park-Wyllie LY, Mamdani MM, Juurlink DN, et al. Bisphosphonate useand the risk of subtrochanteric or femoral shaft fractures in older women.JAMA. 2011;305:783–789.

5. Saleh A, Hegde VV, Potty AG, et al. Bisphosphonate therapy and atypicalfractures. Orthop Clin North Am. 2013;44:137–151.

6. Norris R, Bhattacharjee D, Parker MJ. Occurrence of secondary fracturearound intramedullary nails used for trochanteric hip fractures: a systematicreview of 13,568 patients. Injury. 2012;43:706–711.

7. Koh JS, Goh SK, Png MA, et al. Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture? J OrthopTrauma. 2010;24:75–81.

8. Saleh A, Hegde VV, Potty AG, et al. Management strategy for symptom-atic bisphosphonate-associated incomplete atypical femoral fractures. HSSJ. 2012;8:103–110.

9. Lo JC, Huang SY, Lee GA, et al. Clinical correlates of atypical femoralfracture. Bone. 2012;51:181–184.

10. Kregor PJ, Obremskey WT, Kreder HJ, et al. Unstable pertrochantericfemoral fractures. J Orthop Trauma. 2014;28(suppl 8):S25–S28.

11. Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedul-lary nails for treatment of intertrochanteric femur fractures (OTA 31-A1,A2). J Orthop Trauma. 2013;28(5):e96–e100.

FIGURE 8. Algorithm of management of bi-sphosphonate-related pathologic femoralfractures according to the contemporaryunderstanding.2,5

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