Use of Huckstep nail in the periimplant femoral shaft fracture
An 87-year-old female patient had a comminuted spiral fracture of left distal femur []. She was treated in our hospital with closed reduction and intramedullary nailing (PFN, Synthes, Davos, Switzerland) for the left proximal femoral fracture 5 years ago. A bone density study with Q-CT before the operation revealed osteoporosis with T-score -4.4. After thorough preoperative evaluation, we performed open reduction and anatomical reduction using locking compression plate (LCP, Synthes) under general anesthesia. The tricalcium phosphate (β-TCP) synthetic bone graft substitute Polybone® (Hanmi, Seoul, Korea) was added at the fracture site because of intraoperative bony insufficiency []. The patient was discharged on a wheel chair on the 8th day after the operation. During home care on the 9th day after the operation, the patient reported pain mid thigh after a trivial fall while her family was moving her. On X-ray a fracture between the existing proximal femoral nail and fixed locking compression metal plate [] was diagnosed. It was a stress riser fracture. We decided to insert Huckstep nail after removing proximal femoral nail. The Huckstep nail was being used during ankle fusion by us. Comparing the hole of Huckstep nail to be used with that of the LCP from the previous operation, we were sure that the hole of Huckstep nail corresponded with the one of LCP. Fortunately, we confirmed preoperatively that and we could insert at least two distal interlocking screws through the hole of plate with a lot of distal holes of Huckstep nail. The operation was performed in lateral decubitus position under fluoroscopy. We removed the existing proximal femoral nail. We inserted Huckstep nail connecting to guide and withdrew the existing screws by previous incision of distal under plate. We had some difficulty with reinsertion of the removed screws. We matched the two holes of plate and nail under fluoroscope and inserted Steinmann pin as a guide pin and reinserted the previous screws. Then, we inserted three threaded screws into a transverse hole with a washer in the proximal part []. We mobilised the patient on a wheelchair for 2 weeks after the operation, and she left the hospital after the stitches had been removed in the 2nd week after the second operation. She was followed up for 15 months after she was discharged from the hospital [].