Periprosthetic Femoral Fracture Around a Loose Stem in a Frail Elderly Patient
An 81-year-old woman falls in her kitchen and cannot stand. Twelve years ago she had a cementless total hip replacement for osteoarthritis in the same hip and has been pain-free until today. The right leg is 3 cm short and externally rotated, and any movement is agonising. She takes apixaban 5 mg twice daily for atrial fibrillation (last dose 26 hours ago), ramipril and atorvastatin. eGFR is 34 mL/min/1.73 m², BMI 31, and she has mild vascular dementia; she lives alone and her daughter is 3 hours away. Radiographs show a transverse fracture at the level of the femoral stem tip with a lucent line and cortical thinning around the proximal stem; there is no cement mantle and no distal neurovascular deficit. Haemoglobin is 10.9 g/dL, platelets 210 × 10⁹/L and INR 1.1. The anaesthetist is reluctant to anaesthetise her on apixaban and suggests waiting 72 hours; the bed manager proposes discharge to a nursing home for conservative treatment.
1. How would you classify the fracture, and how do you justify surgery over conservative management while dealing with the apixaban?
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This is a Vancouver B2 fracture: the fracture is at the tip of the stem with an associated loose prosthesis but reasonable bone stock. B1, in contrast, has a stable, well-fixed stem and can be treated with internal fixation; B3 has a loose stem with poor bone stock and usually needs a proximal femoral replacement; type C is distal to the stem and behaves like a normal femoral fracture.
The key point is that the stem is loose, so plate fixation would fail, and the hip must be revised. Conservative management is not a real option: a displaced periprosthetic fracture treated with bed rest in an 81-year-old produces non-union, pressure sores, pneumonia, delirium and deep vein thrombosis, and carries a one-year mortality of roughly 25–30%. The same mortality figure, in fact, is what underlies the argument for treating this as an urgent operation rather than an elective one.
Apixaban is the practical problem, and the low eGFR means it clears more slowly than the 26 hours since the last dose suggests. I would not use routine reversal with prothrombin complex concentrate, because it risks stroke in atrial fibrillation and is not indicated for a patient who is not bleeding. Most contemporary guidance permits high-bleeding-risk surgery at around 48 hours after the last dose, and with an eGFR of 34 I would aim for that, checking a calibrated anti-Xa level if it is available and discussing it with haematology and cardiology. Neuraxial anaesthesia should be avoided because of the residual drug, so a general anaesthetic with tranexamic acid, cross-matched blood and cell salvage is my plan. A 72-hour wait would be acceptable only if she were physiologically stable, nursed with traction and daily review; a nursing home placement with no surgical plan is not.
2. What intraoperative findings would change your choice between a long-stem revision, a modular fluted tapered stem and a proximal femoral replacement, and what would you do if you found cloudy fluid and a chronically loose stem?
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The decisions are made on bone stock and on the fracture pattern, not on the radiograph alone. If the proximal femur is reconstructable and the fracture can be bypassed with a distally fixed stem, a long, uncemented, distally anchored stem with cerclage wires and, where needed, cortical strut allograft gives the best chance of bone healing and later function. A modular fluted tapered stem is attractive here precisely because it gains fixation in the diaphysis, allows independent adjustment of version and leg length, and tolerates a comminuted metaphysis. If the proximal femur is unsalvageable, with severe comminution, thin Cortices and a very short remaining isthmus, then a proximal femoral replacement is the more reliable option, at the cost of higher dislocation and infection risk and permanent dependence on a walking aid.
Cloudy fluid with a chronically loose stem changes the diagnosis entirely from aseptic loosening to chronic periprosthetic joint infection with a periprosthetic fracture. I would then stop, send 5–6 tissue samples for culture and histology, and perform a resection with an antibiotic-loaded cement spacer rather than a definitive implant. The fracture should be stabilised with a temporary external fixator or a spacer-based construct. Antibiotics should be started only after sampling, and reimplantation is planned after 6–8 weeks with a defined organism. If a single-stage exchange were being considered, I would need a known sensitive organism preoperatively, which we do not have.
This is why aspiration or intraoperative frozen section is worth arranging when there is any hint of chronic pain before the fall, and why I would ask specifically whether she had groin or thigh pain in the preceding months.
3. Outline the postoperative plan and what you would tell the family about prognosis and discharge.
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Postoperatively she needs a revision construct that allows immediate weight-bearing as tolerated with a frame or sticks; delayed weight-bearing in this age group invites pneumonia and pressure injury. Because of the periprosthetic fracture and revision, I would give 28–35 days of low-molecular-weight heparin rather than a direct oral anticoagulant, and I would not simply restart apixaban on day one without a haematology opinion, given the eGFR of 34. Mechanical prophylaxis and early mobilisation supplement this. Comorbidities that kill these patients - delirium, urinary retention, constipation, dehydration and opiate load - need active daily management.
The bone should not be ignored: this is a fragility fracture. I would arrange dual-energy X-ray absorptiometry, vitamin D and calcium assessment and a fracture-liaison pathway for an antiresorptive agent, along with a falls review at home, home adaptations, and a stair assessment before discharge. Her daughter should be included in a realistic conversation.
That conversation needs to be honest: mortality is around 5–10% within 30 days and 20–30% within a year in this age group and comorbidity profile; many patients never return to their pre-fracture level of function, and she will probably need a walking frame and a period in rehabilitation. I would also record the discussion about capacity, because mild dementia plus a complex decision such as reoperation for infection later raises consent issues, and a nominated decision-maker should be documented early.