pathological femoral shaft fractures are mainly attributed to osteoporosis , preexisting femoral pathology , etc .
[ 1 , 2 ] . uncommonly , there can also be stress fractures of the diaphysis of femur .
treatment includes intramedullary nailing or surface fixation depending on the age , etiology of fracture , surgeon s preference , and clinical scenario .
resection arthroplasty of hip includes removal of necrotic bone in proximal femur along with the prosthesis and cement if present .
although uncommonly done nowadays , it is described as a treatment option in cases of periprosthetic recalcitrant infection , septic sequelae , recurrent hip dislocation , etc . .
pseudarthrosis of neck of femur is a common occurrence because of precarious blood supply to neck of femur , lack of cambium layer in periosteum , inadequate fixation , lack of anatomical reduction , etc . .
resection arthroplasty of hip and pseudarthrosis of neck presents as loss of proximal fulcrum for fracture diaphysis of femur to occur .
we present two cases with the unique scenario of fracture diaphyseal femur concurrent with resection arthroplasty of hip / pseudarthrosis neck of femur operated surgically . till date , only one similar case is reported of subtrochanteric fracture in femur post - girdlestone arthroplasty treated with intramedullary nail . in this report
, we intend to highlight the unusual occurrence , probable mechanism of injury , risk factors , and clinical decision - making in the surgical management of such a condition .
a 70-year - old lady came to trauma center with pain and swelling in the left thigh .
she gave history of slip and fall at home with thigh directly hitting the table .
radiographs of thigh suggested diaphyseal fracture left shaft femur with greater trochanter as a separate fragment and ipsilateral excision arthroplasty of the hip ( fig .
there was no other associated injury , and distal neurovascular examination was within normal limits .
she had resection arthroplasty done in ipsilateral hip 15 years ago for an infected total hip replacement arthroplasty ( cemented ) . before fall
she was operated in the form of open reduction internal fixation with locking compression plate ( fig .
( a ) radiograph showing fracture shaft femur with butterfly fragment and ipsilateral resection arthroplasty done with greater trochanter as separate fragment .
( b ) immediate post - operative radiograph showing fracture fixation with locking compression plate . a 65-year - old lady presented with spiral proximal diaphyseal fracture following a trivial fall at home .
further radiographs suggested that she had pseudarthrosis at neck of femur due to neglected fracture neck of femur ( fig .
after adequate pre - operative work up and planning , she was operated with closed intramedullary nailing ( fig .
( a ) radiograph showing spiral fracture proximal diaphysis femur with ipsilateral pseudarthrosis of neck of femur .
( b ) immediate post - operative radiograph showing fracture fixation with intramedullary nail . ( c )
after surgery , both patients were mobilized nonweight bearing for 6 weeks followed by gradual weight bearing walking .
knee range of motion exercises and quadriceps strengthening was started in immediate post - operative phase . at 3 months
, radiograph showed good callus formation and full weight bearing walking was started ( fig . 2c ) .
presently , at 1 year follow - up , both patients are full weight bearing walking with a stick support and full range of motion of the knee .
a 70-year - old lady came to trauma center with pain and swelling in the left thigh .
she gave history of slip and fall at home with thigh directly hitting the table .
radiographs of thigh suggested diaphyseal fracture left shaft femur with greater trochanter as a separate fragment and ipsilateral excision arthroplasty of the hip ( fig .
there was no other associated injury , and distal neurovascular examination was within normal limits .
she had resection arthroplasty done in ipsilateral hip 15 years ago for an infected total hip replacement arthroplasty ( cemented ) . before fall
she was operated in the form of open reduction internal fixation with locking compression plate ( fig .
( a ) radiograph showing fracture shaft femur with butterfly fragment and ipsilateral resection arthroplasty done with greater trochanter as separate fragment .
( b ) immediate post - operative radiograph showing fracture fixation with locking compression plate .
a 65-year - old lady presented with spiral proximal diaphyseal fracture following a trivial fall at home .
further radiographs suggested that she had pseudarthrosis at neck of femur due to neglected fracture neck of femur ( fig .
after adequate pre - operative work up and planning , she was operated with closed intramedullary nailing ( fig .
( a ) radiograph showing spiral fracture proximal diaphysis femur with ipsilateral pseudarthrosis of neck of femur .
after surgery , both patients were mobilized nonweight bearing for 6 weeks followed by gradual weight bearing walking .
knee range of motion exercises and quadriceps strengthening was started in immediate post - operative phase . at 3 months
, radiograph showed good callus formation and full weight bearing walking was started ( fig . 2c ) .
presently , at 1 year follow - up , both patients are full weight bearing walking with a stick support and full range of motion of the knee .
the mechanism of injury in case of femoral diaphyseal fractures is usually due to direct blow to femoral shaft .
femur like other bones gives away in tension , depending on the direction of force .
elderly patients typically present with spiral fracture due to torsional forces , whereas axial and bending forces act on young patients to produce fractures . in case 1 , since there was a resection arthroplasty of hip done and in case 2 , there was pseudarthrosis at neck of femur suggesting loss of fulcrum proximally for axial , bending , or torsional forces to act and produce fractures . therefore , biomechanically , there were fewer chances of fracture .
we feel that probable mechanism in case 1 was direct blow to femur due to fall , and in case 2 , it was twisting injury due to fall . the long - standing fibrosis would have provided enough leverage for torsional forces to act and produce spiral fracture in pathologically weak bone .
moreover , the femur bone appeared to be weakened due to senile osteoporosis and previous attempt of cement removal during resection arthroplasty ( case 1 ) .
dunn et al . cited similar risk factors of weakening of bone for subtrochanteric fracture in their case .
the goal of resection arthroplasty is to create stable pseudarthritis site with eradication of infection and pain .
resection arthroplasty of hip leads to instability , limb length discrepancy , abductor weakness , etc .
the technique of girdle stone arthroplasty has undergone modification with emphasis on preserving as much bone as possible [ 4 , 9 ] .
however , it is not always possible to preserve bone while removing the earlier prosthesis and cement . in case 1 ,
resection arthroplasty lead to severe bone loss with excision of the proximal end of femur up to subtrochanteric level .
management of this unique case scenario posed several challenges . clinical decision - making in formulating treatment plan included taking various factors into account such as the presence of resection arthroplasty of hip at subtrochanteric level with greater trochanter as a separate fragment ( case 1 ) , pseudarthrosis at neck of femur with intact greater trochanter ( case 2 ) osteoporosis , and post - operative ambulation and rehabilitation .
as in case 1 , the greater trochanter was not intact , so we did not choose an intramedullary interlocking nail .
furthermore , there was a concern about disturbing a stable pseudarthrosis site while doing intramedullary nailing . in case described by dunn et al . , the greater trochanter was intact and they performed open intramedullary nailing .
however , they cited several problems like getting a closed reduction due to lack of adequate traction and difficulties in reaming the canal .
retrograde femoral nailing could have been an option in such cases if intramedullary device is preferred and greater trochanter is shattered .
however , this method would also pose problems with traction and getting a closed reduction . furthermore , there was concern about opening the knee joint which is already arthritis in old age . for these reasons , we chose plate fixation as a modality of fracture fixation .
as the fixation was stable and proximal pseudarthrosis site was not disturbed , we could start early joint mobilization and subsequently patient returned to pre - operative ambulatory status . in case 2 , since the greater trochanter was intact , we preferred intramedullary fixation .
however , the main advantage was that biology of fracture was preserved due to closed technique which aids in union .
thus , we conclude that ipsilateral diaphyseal femur fracture with resection arthroplasty / pseudarthrosis is a rare case scenario
the case requires careful consideration and analysis of various factors in formulating the plan of management .
fracture diaphyseal femur can occur after following nonunion neck femur or resection arthroplasty of hip .
 introduction : although fracture diaphyseal femur is commonly seen in orthopedic practice , its association with ipsilateral resection arthroplasty of hip / pseudarthrosis of neck is rare . 
 the technique of excision arthroplasty has undergone modification with emphasis on preserving as much bone as possible . 
 however , it is not always possible to preserve bone while removing the earlier prosthesis and cement . 
 this often leads to extensive proximal bone loss . 
 associated ipsilateral fracture femur presents a unique scenario . till date 
 , only one case report is published highlighting its surgical management.case report : we report two cases of diaphyseal fracture femur associated with resection arthroplasty of hip at subtrochanteric level with greater trochanter as a separate fragment ( case 1 ) and other with pseudarthrosis of the neck of femur with intact greater trochanter ( case 2 ) . the first case was operated with surface fixation , whereas the second was operated with closed antegrade intramedullary nail.conclusion:decision-making and formulating treatment plan includes taking various factors into account such as level of resection arthroplasty of hip / pseudarthrosis of neck , status of greater trochanter ( intact or separate fragment ) , osteoporosis , and post - operative ambulation and rehabilitation . in this report , we highlight the unusual occurrence , probable mechanism of injury , risk factors for fracture , and decision - making in the surgical management of such a condition . 