A Complication During Femoral Broaching in Total Hip Arthroplasty: \nA Case Report
A 60 year old male was scheduled for THA for left primary end-stage hip osteoarthritis (OA). (Fig. ) In the operating room, a spinal-epidural anesthesia was administered. After positioning for posterior-approach THA, an 8 cm incision was placed over the left hip. The short external rotators were indentified, released and tagged with stitches. Elevation of the gluteus minimus exposed the capsule which was subsequently incised and tagged. The hip was dislocated, the neck cut and the femoral head removed. The acetabulum was prepared in the usual fashion and a size #58 no-hole shell (R3, smith&nephew, Memphis, TN) was press-fitted.\nTo start the preparation of the proximal femoral canal, a box osteotome was used to open the canal. After reaming for a size #14 stem (Synergy, smith&nephew, Memphis, TN), the femur was broached for a size #14 stem. Trial reduction with a standard offset neck and a plus eight head showed restoration of the lesser trochanter-to-center distance (LTC) and the femoral offset.\nAfter trial reduction, an attempt to remove the broach failed, and despite using a heavy mallet and ultimately a removal slap hammer it was not possible to remove the broach. After trying to remove the broach for 30 minutes, flexible osteotoms were utilized to carefully loosen up the proximal part. After one and half hours of repeated extraction attempts, we decided to stop.\nConsidering the configuration of the proximal femoral canal, it was assumed that the broach got hung up distally. Therefore, the decision for a second incision was made to release the broach distally. The exact length of a #14 broach was measured and an 8 cm skin incision was placed proximal to the distal tip of the implant. After dissection of the vastus lateralis, a drill was placed on the posterior aspect of the femur distal to the broach tip which was confirmed by an intraoperative radiograph (Fig. ).\nMidway between the neck cut and the distal tip, a second posterior drill hole was placed, leaving 5-6 cm of bone proximally. Using an oscillating saw, the two drill holes were connected. After completing the posterior femoral split, the broach could now easily be extract.\nHereafter, a total of 6 Dall-Miles cables (Stryker, Mahwah, NJ) were applied: one just proximal and distal to the lesser trochanter (LT); two along the osteotomy line; and one at the tip of the implant and one distal. The cable wires were tightened and after over reaming the distal canal the same broach was re-inserted. Trial reduction showed restoration of the lesser trochanter to center distance and the femoral offset.\nAt this time, the broach could be smoothly removed and a size #14 stem was impacted achieving excellent press-fit. A +8, #36 head (Oxinium, smith&nephew, Memphis, TN) was added and the hip was reduced.\nThe patient was instructed partial weight bearing 20% for 4 weeks, before weight bearing as tolerated was initiated.\nAt the 6-week and 12-week routine follow-up appointments, the femoral implant was found to be stable with no focal lucencies (Fig. ).