Infection Associated With Cortical Allograft Strut Fixation of a Periprosthetic Femoral Shaft Fracture: A Case Report and Review of the Literature

Abstract

A fracture of the femoral shaft after hip arthroplasty is a relatively rare complication. However, the incidence of periprosthestic femoral fractures increases dramatically in patients with established osteopenia or a loss of bone stock. In cases involving periprosthetic femoral fractures around stable implants, cortical allograft strut fixation has emerged as a very attractive treatment option. Cortical allograft struts provide considerable strength and stability while actually increasing the femoral bone stock. Several studies have demonstrated the success of using cortical allograft struts for the treatment of fractures around an implant with union rates ranging from 89% to 100%. 1-3 However, certain complications accompany cortical allograft fixation including extensive periosteal stripping, the potential for disease transmission, and the progressive weakening of the allograft struts as incorporation progresses. 4,5 Perhaps the most serious complication after the use of a cortical strut allograft is deep infection. Numerous studies have examined the use of cortical allografts in revision hip arthroplasty, for reconstruction of large bone defects, and treating periprosthetic fractures, with a significant variation in the rates of postoperative infection. In many cases the origin of the infection is unknown with an abundance of potential sources including contamination of the allograft or hardware either pre-or perioperatively, postoperative wound infection, or systemic bacteremia.We present an unusual case of bilateral femoral shaft fractures sustained by a 35-year-old man with a history of ankylosing spondylitis. The fracture of the left femur was a periprosthetic fracture fixed with a broad 4.5-mm dynamic compression plate in conjunction with two cortical allograft struts. He subsequently developed a deep infection of the left femur that continued to persist after 12 months of antibiotic therapy and two separate irrigation and debridement procedures. The cause of infections related to allograft fixation of periprosthetic femoral fractures is discussed. CASE REPORTA 35-year-old man sustained bilateral femoral shaft fractures after being thrown from his motorized wheelchair when attempting to ascend a steep ramp. He had a 20-year history of severe ankylosing spondylitis with complete vertebral column fusion (except occiput-C1 and C1-C2 articulations), bilateral hip joint fusion, and a fused right shoulder. Before admission he had been confined to a motorized wheelchair for all activities and transfers. The patient had undergone numerous operations including bilateral total knee arthroplasties and a left hip arthroplasty all approximately 15 years earlier. He also had autofusion of his right hip. Before his fall, the patient did not have a problem symptomatically with respect to his knees or hips. Given his history of severe ankylosing spondylitis and his inability to ambulate, his fractures were initially treated nonoperatively at another center.On examination, after 2 months of failed nonoperative treatment, ...

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