Excellent functional recovery following bicolumnar plating, cerclage wires and nail through screw for peri-implant distal femur fracture after proximal femoral nail anti-rotation-II nailing: a case report from a resource-limited setting
DOI:
https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20262936Keywords:
Peri-implant fracture, PFNA-II, Subtrochanteric fracture, Bicolumnar plating, Cerclage wireAbstract
Peri-implant distal femur fractures occurring before union of the index proximal femur fracture are rare and pose significant surgical challenges due to the presence of existing implants, compromised bone stock, and complex fracture patterns. Optimal management strategies remain poorly defined. A 27-year-old male previously treated with a proximal femoral nail anti-rotation (PFNA-II) for a right subtrochanteric femur fracture sustained a second high-energy road traffic accident approximately three months postoperatively, before radiological union of the index fracture. Radiographs demonstrated an extra-articular peri-implant distal femur fracture at the distal tip of the nail with metaphyseal comminution, displacement of the distal locking screws, and extension of the original subtrochanteric fracture line into the diaphysis. Surgical management consisted of a hybrid fixation construct comprising a lateral distal femoral locking plate, a plate-to-nail screw through the existing distal locking hole, two cerclage wires for fragment control, and a medial buttress plate to achieve bicolumnar fixation. At 12-month follow-up, complete radiological union was achieved at both the distal femur and subtrochanteric fracture sites. There was no implant failure, loss of reduction, or need for revision surgery. The patient regained full independent weight-bearing, demonstrated a full active straight-leg raise, and achieved knee flexion greater than 90°. Bicolumnar plating supplemented by a plate-to-nail screw and cerclage wiring provided stable fixation and successful union in this complex peri-implant fracture. This technique represents a practical and reproducible salvage option for managing distal femoral peri-implant fractures around an in-situ cephalomedullary nail, particularly in resource-constrained settings.
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