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Bremer J, Heilig M, Heilig P, Hölscher-Doht S, Meffert RH, Jordan MC. Is nail-plate docking worth the effort? A biomechanical analysis of docking a plate and a nail in peri-implant femur fractures. Front Bioeng Biotechnol 2024; 12:1392631. [PMID: 38895558 PMCID: PMC11184161 DOI: 10.3389/fbioe.2024.1392631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/16/2024] [Indexed: 06/21/2024] Open
Abstract
Purpose The ideal treatment of peri-implant femur fractures (PIFFs) remains unclear due to the thin clinical and biomechanical evidence concerning the most suitable form of osteosynthesis. The purpose of the present study was thus to determine the biomechanical stability that results from combining a cephalomedullary nail and a plate for proximal PIFFs, especially when the nail-plate docking technique is applied. Methods Twenty four PIFFs were simulated in both 12 foam and 12 composite specimens and were stabilized via a combination of a cephalomedullary nail and a plate. The control group (n = 6) had a nail and a plate without a connection, while the intervention group (n = 6) had a screw that connected the plate with the interlocking screw hole of the nail, thereby creating a nail-plate docking system. The specimens were evaluated under axial and torsional loading using a material-testing machine and a 3D metrology system. Results The data regarding stiffness, failure load, and failure displacement showed significantly higher stability for specimens without nail-plate docking. For docked specimens, a non-significant trend toward a higher resistance to torque was observed. Both techniques displayed no significant difference in fracture gap displacement or total displacement. Conclusion The present study suggests that nail-plate docking of a cephalomedullary nail, and a plate significantly decreases the stiffness and stability of osteosynthesis under axial loading. However, there seems to be a tendency toward higher resistance to torque. Therefore, surgeons should consider this technique if higher torsional stability is necessary, and they should decide against it, if axial stability is preferred.
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Affiliation(s)
- Justus Bremer
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Maximilian Heilig
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Philipp Heilig
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Stefanie Hölscher-Doht
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Rainer H. Meffert
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Martin C. Jordan
- Department of Orthopedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
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Poroh M, Puha B, Gheorghevici TS, Jemna C, Forna N, Sirbu P, Alexa O. A Retrospective analysis of peri-implant fractures: insights from a large volume clinical Study. INTERNATIONAL ORTHOPAEDICS 2023; 47:2859-2868. [PMID: 37612522 DOI: 10.1007/s00264-023-05939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Peri-implant fractures (PIFs) are a concept in evolution for which different diagnostic criteria have been proposed and modified over time. They have not been extensively reported. PIFs are usually located in the distal part of previous osteosynthesis, where fragile bone is in contact with the rigid implant and are a significant complication after orthopaedic surgery, which requires careful management and treatment. This clinical study presents findings from a retrospective analysis of PIF's, providing description of characteristics and outcomes. They provide information about the associated risk factors and description of the effectiveness of various treatments. MATERIALS AND METHODS A retrospective analysis was performed in a clinical study involving patients with PIFs. Data from medical records, radiographic images, and surgical reports were collected and analyzed. The study included patients with refracture of pre-existing osteosynthesis admitted to the hospital between 2015 and 2022. Demographic information, fracture characteristics, surgical interventions, and post-operative outcomes were assessed. Each case was followed for a minimum of one year after surgery, and a critical analysis was performed by senior surgeons. Furthermore, the PIFs were classified according to the type of initial implant and the position of the new fracture in relation to the original implant. RESULTS Between 2015 and 2022, out of 18,813 fractures treated at a Level 1 traumatology hospital, a total of 85 patients with PIF's were identified. Fracture characteristics varied, including location, fracture pattern, and implant type. Most of the PIFs, 71 cases (83.53%), occurred in the femur. Additionally, there were seven cases (8.24%) involving the humerus, four cases (4.71%) affecting the tibia/fibula, two cases (2.35%) in the radius, and one case (1.18%) involving the clavicle. Surgical management was the primary attitude in treatment. Various techniques were used, including the use of longer and stronger implants to achieve high-quality fixation, facilitating early rehabilitation and return to previous activities. Postoperative complications after surgery for PIFs were observed in 16 cases (18.8%). CONCLUSIONS Peri-implant fractures (PIF) are a distinct topic and a challenging condition with a high rate of postoperative complications. Complications after the second surgery may be severe and life threatening in older patients. A classification can be useful to make decisions about the optimal treatment in different anatomic areas and type of implant used for primary osteosynthesis. Currently there are no standardized protocols for management, therefore each case should be carefully discussed and planned before surgery.
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Affiliation(s)
- Manuela Poroh
- Department of Orthopaedics and Traumatology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.
| | - Bogdan Puha
- Department of Orthopaedics and Traumatology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
- Sf. Spiridon' County Emergency Hospital, Iasi, Romania
| | | | | | - Norin Forna
- Department of Orthopaedics and Traumatology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Paul Sirbu
- Department of Orthopaedics and Traumatology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Ovidiu Alexa
- Department of Orthopaedics and Traumatology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
- Sf. Spiridon' County Emergency Hospital, Iasi, Romania
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Binkley N, Nickel B, Anderson PA. Periprosthetic fractures: an unrecognized osteoporosis crisis. Osteoporos Int 2023; 34:1055-1064. [PMID: 36939852 DOI: 10.1007/s00198-023-06695-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/02/2023] [Indexed: 03/21/2023]
Abstract
Total joint replacement is common and increasing. Many of these patients have low bone mineral density preoperatively, and arthroplasty leads to bone loss. As falls are common before and after arthroplasty, it is unsurprising that periprosthetic fractures, defined as those associated with an orthopedic device, whether a joint replacement or other internal fixation devices, are not rare. These fractures engender morbidity and mortality comparable to osteoporosis-related hip fractures but remain largely unrecognized and untreated by osteoporosis/metabolic bone disease clinicians. Indeed, recent osteoporosis guidelines are silent regarding periprosthetic fractures. The purposes of this clinical review are to briefly describe the epidemiology of arthroplasty procedures and periprosthetic fractures, raise awareness that these fractures are osteoporosis-related, and suggest approaches likely to reduce their occurrence. Notably, bone health evaluation is essential following the occurrence of a periprosthetic fracture to reduce subsequent fracture risk. Importantly, in addition to such secondary fracture prevention, primary prevention, i.e., bone health assessment and optimization prior to elective orthopedic procedures, is appropriate.
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Affiliation(s)
- Neil Binkley
- Osteoporosis Clinical Research Program, University of Wisconsin-Madison, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA.
| | - Brian Nickel
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, USA
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Bidolegui F, Pereira S, Munera MA, Garabano G, Pesciallo CA, Pires RE, Giordano V. Peri-implant femoral fractures: Challenges, outcomes and proposal of a treatment algorithm. Chin J Traumatol 2022:S1008-1275(22)00105-5. [PMID: 36336545 PMCID: PMC10388253 DOI: 10.1016/j.cjtee.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/31/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment. METHODS The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviations, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages. RESULTS This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6-48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant. CONCLUSION The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.
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Affiliation(s)
- Fernando Bidolegui
- Orthopaedics and Trauma Surgery Department, Sirio Libanes Hospital, Buenos Aires, Argentina
| | - Sebastián Pereira
- Orthopaedics and Trauma Surgery Department, Sirio Libanes Hospital, Buenos Aires, Argentina.
| | - Mateo Alzate Munera
- Orthopaedics and Trauma Surgery Department, Sirio Libanes Hospital, Buenos Aires, Argentina
| | - Germán Garabano
- Orthopaedics and Trauma Surgery Department, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cesar A Pesciallo
- Orthopaedics and Trauma Surgery Department, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Robinson Esteves Pires
- Department of the Locomotor Apparatus, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vincenzo Giordano
- Orthopedics and Traumatology Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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Vilar-Sastre I, Corró S, Tomàs-Hernández J, Teixidor-Serra J, Selga-Marsà J, Piedra-Calle CA, Molero-García V, García-Sánchez Y, Andrés-Peiró JV. Fractures after cephalomedullary nailing of the femur : Systematization of surgical fixation based on the analysis of a single-center retrospective cohort. INTERNATIONAL ORTHOPAEDICS 2022; 46:2357-2364. [PMID: 35779111 DOI: 10.1007/s00264-022-05490-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
PURPOSES Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population. A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to guide the management of such fractures. METHODS All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comorbidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination. RESULTS The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and those discharged to nursing facilities had more comorbidity. CONCLUSIONS Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.
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Affiliation(s)
- Inca Vilar-Sastre
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sebastián Corró
- Department of Orthopaedic Surgery and Traumatology, Hospital de Manacor, Manacor, Spain
| | - Jordi Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Selga-Marsà
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Carlos-Alberto Piedra-Calle
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Vicente Molero-García
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Yaiza García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - José-Vicente Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
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Videla-Cés M, Romero-Pijoan E, Sales-Pérez JM, Sánchez-Navés R, Pallarés N, Videla S. A pilot agreement study of a new classification system for Peri-implant femoral fractures. Injury 2021; 52:1908-1917. [PMID: 33875249 DOI: 10.1016/j.injury.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/05/2021] [Accepted: 04/03/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peri-implant fractures occur in association with an implant, used to treat a previous injury that is still attached to the bone. We recently published a proposal for a classification system for peri-implant femoral fractures [Videla-Cés, Injury,2019]. AIM To assess the agreement of our classification system for peri-implant femoral fractures among a group of future users of said classification system. METHODS A prospective, multicentre, international agreement pilot study was conducted among a group of independent traumatologists/orthopaedic surgeons (evaluators): senior (a minimum of 10 years' experience) and junior (in fourth or fifth training year). A set of 30 radiographs of peri-implant femoral fractures were selected (stratified into 3 levels of difficulty: low, medium and high). Each evaluator interpreted the radiographs on 2 different occasions separated by a period of one month and in a different order each time. The level of difficulty was masked from the evaluators and they had one week to classify the radiographs each time. Logistic regression and Cohen's kappa coefficient (κ) and its 95% confidence interval (95%CI) were used to assess the accuracy and agreement, both intra- and inter-evaluator. Between senior and junior surgeons was performed an exploratory analysis. RESULTS 35 traumatologists/orthopaedic surgeons (17 senior and 18 junior) from 16 tertiary hospitals from 4 countries acted as evaluators. The accuracy, percentage of correct classifications (2 digits and 3 letters), in the first and second evaluation was: 56% (95%CI: 53-59%) and 55% (95%CI: 51-57%), respectively. (insert space) Negligible differences were found between junior and senior evaluators (first evaluation, OR: 1.46, 95%CI: 0.82-2.61, p-value: 0.199; second evaluation, OR: 1.06, 95%CI: 0.56-2.00, p-value: 0.860). (insert space) Both medium and low radiograph difficulty were associated with a lower probability of an incorrect classification compared with those of high difficulty (first evaluation, OR: 7.60, 95%CI: 5.24-11.05, p-value: <0.001; OR: 14.15, 95%CI: 9.12-21.96, p-value: <0.001, respectively; second evaluation, OR: 7.11, 95%CI: 4.88-10.38, p-value: <0.001, OR: 15.28, 95%CI: 9.77-23.89, p-value: <0.001). (insert space) The kappa for intra-observer agreement between the first and second evaluation was: 0.66, 95%CI: 0.63, 0.69. The kappa for inter-observer agreement considering all 30 radiographs was: 0.40, 95%CI: 0.40, 0.41 in the first evaluation and 0.39, 95%CI: 0.39, 0.40 in the second evaluation. CONCLUSION The proposed classification for peri-implant femoral fractures may be useful and user-friendly. Future studies are needed to assess the how clinically useful this classification system may be (the third phase in the validation process).
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Affiliation(s)
- Miquel Videla-Cés
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain.
| | - Eudald Romero-Pijoan
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - José-Miguel Sales-Pérez
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Rubén Sánchez-Navés
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Natalia Pallarés
- Biostatistical Unit, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sebastián Videla
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital / Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; Department of Pathology and Experimental Therapeutics, Faculty of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Peri-implant fractures of the upper and lower extremities: a case series of 61 fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:467-474. [PMID: 34018018 DOI: 10.1007/s00590-021-03005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.
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Anil U, Ganta A, Konda SR. A Case of Two Consecutive Peri-Implant Fractures After Treatment of an Incomplete Stress Fracture of the Femoral Neck with a Sliding Hip Screw Device in a Young Adult. Surg Case Rep 2019. [DOI: 10.31487/j.scr.2019.05.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We present an atypical presentation of a non-displaced femoral neck fracture in a young adult after a fall from standing sustained 4 days prior to presentation. Patient underwent surgical fixation with a sliding hip screw, the postoperative course of which was complicated by an atraumatic peri-implant greater trochanteric fracture, requiring surgery for open reduction and internal fixation. The course was further complicated by another atraumatic peri-implant femoral neck fracture after which, the patient was definitely treated with a total hip arthroplasty.
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