Dear Panayot

During the removal of infected components of a total hip arthroplasty  if there is an unstable fracture of the femur one option is to insert a long intramedullary nail , after a previous reaming of medullary canal, wrapped with antibiotic-impregnated with cement, which would allow the treatment of the fracture and at the same time serve as a spacer.

The locking holes must remain  without cement so that the nail can be locked

Thank you, Nelson, for your answer. The IM nail wrapped with cement might be an option if the fracture type is appropriate for nailing and if a re-THR is foreseen. Anyway, if a Girdlestone hip is planned, we prefer to remove all foreign bodies for proper eradication of the deep infection and stabilize the fracture with fixateur externe. Some times this is the only possible solution.

! removal of all type of metal.

2 Good debridement.

3 stabilization of  fracture

4 promotion for fracture healing.

5 appropriate antibiotic.

Dear Akhter, your protocol is concise and seems to be efficient. One question more. How would you stabilize the fracture ?

Dear Panayot,

To make decision is very dificult, because every case is different. It depends on general condition of the patient, local status, dissemination of infection, age, comorbidities etc.

Dear Panayot

We are always prepared for this situation , which can occur in 30% of patients.

Cerclage wires , Dall Miles, plates and meshes sometimes , especially when used cemented long stems and impacted graft.

When we use distal fixation and uncemented stem attempt to set the rod in good bone, but we cerclage this isthmus to prevent the fracture prolonge there.

First you should be sure to use antibiotic loaded cement, which works for the antibiogram. Microbiologic specialist is Lars Frommelt/Hamburg (here in Reasearch center too).

Second: you have to stabilize the fracture either by wire or plate or by a longer hip stem (cemented).