Hip Pelvis.  2019 Jun;31(2):110-119. 10.5371/hp.2019.31.2.110.

Intrapelvic Migration of the Lag Screw with Wedge Wing from Dyna Locking Trochanteric Nail: A Case Report and Literature Review

• Kim YW
• Kim WY
• Kim KJ
• Lee SW

• KMID: 2448030
• DOI: http://doi.org/10.5371/hp.2019.31.2.110

Abstract

The intrapelvic migration of cervicocephalic lag screws is a rare complication after intertrochanteric fracture synthesis with an intramedullary nail. Only 15 cases of intrapelvic penetration by three different instrument systems have been described in the literature. However, to our knowledge, there is no report of intrapelvic migration of the lag screw with wedge wing designed to increase fixation power using the Dyna locking trochanteric (DLT) nail. We present a case of intrapelvic migration of the lag screw with wedge wing from DLT nail. The patient described herein underwent a two-staged operation of implant removal without intrapelvic approach followed by bipolar hemiarthroplasty. With intrapelvic migration conditions, although it is not uncommon to require an additional intrapelvic approach, this modification can lead to lethal consequences. For this reason, it is recommended to coordinate with the vascular surgery department due to the close proximity of the major vessels.

Keyword

Femur; Intertrochanteric fracture; Complications

MeSH Terms

Femur*
Hemiarthroplasty
Humans

Figure

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  Fig. 1 An 83-year-old woman presented with trauma to the left hip after an accidental fall. On plain radiographs of left femur (A: anteroposterior, B: lateral), an unstable 3-part intertrochanteric fracture was seen (AO/OTA 31-A2).

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  Fig. 2 Postoperative X-ray showing the Dyna locking trochanteric (DLT) nail in the (A) anteroposterior and (B) lateral views. Under general anesthesia on a fracture table, closed reduction was performed, followed by internal fixation with a short (200-mm length) 125° DLT nail at another local orthopedic clinic.

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  Fig. 3 Postoperative radiographs of left femur (A: anteroposterior, B: lateral) at the 2-week follow-up showed no hardware complications or evidence of migration of the implant.

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  Fig. 4 Radiographs showed that the lag screw was disassociated from the nail and had migrated through the acetabulum. The tip of the lag screw was medial to the quadrilateral surface of the pelvis by about 4 cm (A, B). Pelvic three-dimensional computed tomography image showed the possibility of an intrapelvic lesion (C), but the hematoma was formed around the lag screw, and the surrounding tissues were not injured (D–F).

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  Fig. 5 The penetrated lag screw was removed under image intensifier through the previous incision (A). The penetration defect in the posterior medial acetabulum was observed (B). One of the three wedge wings in the lag screw was folded over and appeared to be located on the inferior side of the extracted femoral head (C–E).

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  Fig. 6 We scheduled a two-staged operation. After extraction of the femoral head and neck portion, PROSTALC (prosthesis with antibiotic-loaded acrylic cement) was performed at the first scheduled surgery to maintain leg length and reduce the risk of infection. Postoperative radiographs of left femur (A: anteroposterior, B: lateral)

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  Fig. 7 Postoperative radiographs of left femur (A: anteroposterior, B: lateral). In the second operation at 6 weeks after the removal surgery, an uncemented bipolar hip arthroplasty (Modulus; Limacorporate S.p.A., Udine, Italy) and application of a long AO trochanteric reattachment device (DePuy Synthes, Oberdorf, Switzerland) for the fractured greater trochanteric fragment were performed.

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