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Abstract
Surgery for pathologic hip fracture poses significant challenges regarding the fixation of fracture and management of the original tumor lesion. An extensive destruction of the femoral neck and intertrochanteric region by benign or malignant lesions complicated by a pathological fracture generally necessitates total hip arthroplasty; however, in adolescents and young adults, preservation of the hip is preferable. We present a 14-year-old female patient, who sustained a pathological intertrochanteric fracture through a pre-existing aneurysmal bone cyst. Several operative interventions with internal fixation and bone graft were unsuccessful, and combined nonunion and progression of osteolysis around the compression hip screw eventually caused femoral head collapse, mimicking osteonecrosis. Hip preservation and resolution of the original tumor were achieved by free vascularized fibular graft.
Figures and Tables
Figure 1
Preoperative anteroposterior (A) and lateral (B) radiographs show a large, multiseptated osteolytic lesion centered around the proximal femur with a displaced intertrochanteric fracture. T2-weighted coronal magnetic resonance image shows a well-defined high signal lesion and subtle fluid-fluid levels within the expansile mass (C) and peripheral enhancing rim with gadolinium (D).
Figure 2
(A) Anteroposterior radiographs after the first operation. Three months (B), six months (C), and 10 months (D) follow-up anteroposterior and lateral radiographs show no progression of union, as well as varus displacement and loosening of the proximal screws.
Figure 3
(A) Anteroposterior radiographs after the second operation. Three months (B) and nine months (C) follow-up radiographs show progressive osteolysis around the lag screw in the femoral head. (D) Fourteen months follow-up radiographs show an extensive osteolysis, and subtle femoral head collapse and suspicious subchondral fracture (arrow).
Figure 4
Anterior (ANT; A) and posterior (POST; B) view of technetium-99m bone scintigraphs show a cold area caused by metallic implant and intense uptake in the fracture site, but no significant uptake in the femoral head. (C) Consecutive computed tomographs show a partial union of the anterior portion of intertrochanteric fracture, but clearly show an osteolysis around the lag screw, and subchondral fracture with subsequent collapse of the femoral head.
Figure 5
(A) Immediate postoperative anteroposterior radiograph after the vascularized fibular graft. Six months (B) and one-year (C) follow-up radiographs show progressive union of fracture. (D) Anteroposterior and lateral radiographs five years after the third operation show a complete union of intertrochanteric fracture, a well-incorporated graft, and recovered femoral head collapse.
References
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