Retrograde Removal Technique for Stem Tip Fracture After Total Hip Arthroplasty: A Case Report

Retrograde Removal Technique for Stem Tip Fracture After Total Hip Arthroplasty: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Retrograde Removal Technique for Stem Tip Fracture After Total Hip Arthroplasty: A Case Report Kohei Hashimoto, Yukio Nakamura, Nobunori Takahashi, Takkan Morishima This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6357627/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract The authors report a rare case of stem tip fracture after primary total hip arthroplasty (THA), where the patients underwent the fracture tip removal with revision cemented THA. The aim of this paper is to report the experience with an operation which, in this particular case, required special technical skill and caution. Retrograde removal technique Stem tip fracture Total hip arthroplasty Figures Figure 1 Figure 2 Figure 3 Introduction Total hip arthroplasty (THA) is a highly effective surgical intervention for end-stage hip joint disorders. While common complications, such as infection, dislocation, and prosthetic loosening, are well-documented, very rare complication remains underreported. The reported rate of complications related to the use of THA techniques varies from 3% up to even 56% ( 1 ). Stem fracture is a very rare and devastating complication. The femoral stem fracture has been reported as a result of implant’s design, metallurgical composition, quality of cement mantle, and surgical technique. The estimated occurrence is approximately 0.23–0.27% ( 2 ). However, there have been a few reports on the operative techniques in the stem fracture patients with THA. This study showed a case with stem tip fracture and cup loosening, potentially due to the polyethylene wear debris and associated osteolysis after primary THA at a different hospital. We retrogradely removed the tip successfully without any trouble, and then performed cemented revision THA as usual. Case Description This study presents a case of stem tip fracture without any obvious trauma observed postoperatively in a patient undergoing THA. In this case, left hip and left thigh pain in a 63-year-old woman had started with a T-cane walking in 2022 at a different facility, and the symptoms had gradually worsened thereafter. She had had cemented THA at the hospital 8 years ago. According to the hip plain radiograph and the patient’s symptoms at that time, the primary cemented THA seemed to be successful (Fig. 1 a). Upon the initial visit to our facility in May 2024 with a referral letter, plain radiograph of the left hip revealed a stem tip failure with the stem loosening at proximal femur site and the cemented cup loosening. Radiolucencies were observed in the region surrounding the stem proximal to the stem fracture. Radiolucency of the bone distal to the fracture site was observed just near the fracture ( 3 ) (Fig. 1 b). Since the laboratory data and culture test by intra-articular joint puncture did not show any obvious abnormal values (Table 1 ), infection was denied. We performed revision cemented THA using KT plate with removal of the stem tip failure. We first split the patellar tendon and exposed the entry site for the retrograde femoral nail at the distal intercondylar region of the femur (Fig. 2 a). We then removed the stem body and the stem tip retrogradely (Fig. 2 b, c). We call the series of the procedures as “Retrograde Removal Technique (RRT)”. Here is the detailed RRT Procedure: First, prepare an intramedullary reamer with a sleeve and a stainless steel rod. The diameter of the reamer is recommended to be equivalent to the minimum diameter of the femoral intramedullary canal. The length of the rod should be extended at least 10 cm beyond the skin at the knee from the stem tip, and the diameter should be 1–2 mm smaller than that of the intramedullary reamer. In this case, a humeral reamer with a sleeve was selected because the diameter of the femoral intramedullary canal was very narrow. Second, perform a medial parapatellar approach. Under fluoroscopic guidance, reaming is carried out using the intramedullary reamer until just below the remaining stem. A slightly curved stainless steel rod is then inserted to the same level and impacted with a hammer to dislodge the fractured stem from the cement mantle. Finally, the stem is proximally extracted using intramedullary forceps. We finally performed revision THA with KT plate (Fig. 3 ). In the primary THA at a different facility, C-Prominent stem at size 2 (LOT No. BH010200 A070), 26 mm diameter of femoral head with 10/12TAPER (LOT No.4H012603 A169), and the 40 mm diameter of shell (LOT No.BH214000 A240) were used (Teijin Nakashima Medical, Okayama, Japan). Note that the stem and the acetabular socket was made of Cobalt-Chrome (Co-Cr) alloy or an ultra-high molecular weight polyethylene, respectively. The Exeter Universal cemented stem and uncemented Trident hemispherical acetabular shell (Stryker Orthopedics, Mahwah, NJ, USA), and modern cementing techniques were used with posterior approach to the hip for this revision surgery under general anesthesia. The operation time was 5 hours and 51 minutes. The bleeding during surgery was 298 mL and 100 mL of self-blood transfusion collected by cell saver was performed. The pathological examination with surgical specimen excluded infection and metallosis of this failure. According to the analysis report (Teijin Nakashima Medical, Okayama, Japan), the fracture surface of the stem demonstrated a herringbone pattern, which is characteristic of the fracture surface of brittle materials, and the polyethylene wear debris and associated osteolysis were detected in the shell. Although approximately one year has passed after the revision surgery, the patient has had little symptoms, and the laboratory test results including CRP have been normal. As far as we know, this is the first kind of case with stem tip failure after THA with the RRT. Since there has been no complication after the revision THA, this RRT could be useful for other patients with this complication after THA. Table 1 Patient Characteristics at Baseline prior to Admission Characteristics Reference range Values ESR 60 min (mm) 1–7 25 WBC (×10 3 /µL) 3.3–8.6 7.7 Neuro (%) 42.6–58.9 70.5 Ly (%) 30.3–40.5 20.9 Mono (%) 3.3–6.2 5.8 Eosi (%) 0-4.5 2.3 RBC (×10 6 /µL) 4.35–5.55 4.52 Hb (g/dL) 13.7–16.8 12.9 Ht (%) 40.7–50.1 39.8 MCV (fL) 83.6–98.2 88.1 MCHC (g/dL) 31.7–35.3 32.4 PLT (×10 3 /µL) 158–348 258 D-dimer (µg/mL) 0–1.00 1.16 Total protein(g/dL) 6.6–8.1 7.4 Albumin (g/dL) 4.1–5.1 3.9 T-Bil (mg/dL) 0.40–1.50 0.73 BUN (mg/dL) 8.0–20.0 17.0 Serum Creatinin (mg/dL) 0.65–1.07 0.61 eGFR (mL/min/1.73m 2 ) 75 Na(mmol/L) 138–145 142 K (mmol/L) 3.6–4.8 4.2 Cl (mmol/L) 101–108 106 Calcium (mg/dL) 8.8–10.1 9.5 Corrected Calcium (mg/dL) 8.7–10.3 9.8 TC (mg/dL) 142–219 242 AST (U/L) 13–30 18 ALT (U/L) 10–42 18 Alkaline Phosphatase(U/L) IFCC 38–113 76 LD (U/L) IFCC 124–222 210 HbA1c (%) 4.9-6.0 5.8 CRP (mg/dL) 0.00-0.14 0.43 The mechanism by which this C-prominent stem fracture occurs has been reported by Kimura et al ( 4 ). The authors conclude that the causes of this fracture was that firstly, polyethylene wear debris and associated osteolysis, which led to a loss of support appearing in the proximal part of the stem, secondly, the continuous internal stress concentration at a point just proximal to the fixed part, and thirdly, firmly fixation of the distal part of Co–Cr alloy stem. This case showed a similar phenomenon to the above. Also, plain radiographs and computed tomography (CT) had shown the cortical hypertrophy around the failure region of the left femur. Consequently, stress might have spread further and concentrated throughout the entire femur prior to the revision surgery. In other words, the stem fractured fatigue-wise due to repeated local loading applied to the distal part of the stem after the initial surgery. We herein introduce “RRT” for the patients with stem tip fracture after THA. There have been several reports that extended trochanteric osteotomy (ETO) is required for the removal of broken stems ( 5 ). They have proposed that ETO should be long enough to disrupt regions of bone ingrowth and interdigitation into the distal splines and clothespin. However, there are several merits of RRT as follows, compared to ETO. First, stem can be removed without damaging the cortical bone. Second, full weight-bearing is possible from the early postoperative period. Third, there is no need for a long implant. On the other hand, there are the following weak points on RRT. First, there has been no report on it, thus, the evidence is lack. Second, it is necessary to open the knee joint for manipulation, which causes damage to the articular cartilage. Conclusion This is the first kind of report to describe retrograde removal technique (RRT) for the stem tip fracture and cemented revision THA for the cup loosening after primary THA. Since any Orthopaedic surgeon can perform this surgical procedure with several merits compared to the ETO, it is recommended to perform RRT in the patients with stem fracture after THA. This study has several limitations. First, this study showed only one case with RRT. Second, there was no comparative data between ETO and RRT. Future studies are needed to confirm our new technique. Declarations * Ethics approval and consent to participate: The consent to participate was obtained from this patient. * Consent for publication: The Written Informed consent for publication was obtained from this patient for publication of a case report or identifying information/images. * Availability of data and material: Not applicable * Funding : This study did not receive any specific grants from public, commercial, or nonprofit funding agencies. * Competing interests: The authors declare no conflicts of interest. * Authors' contributions: TM conceptualized this study. YN and TM directed this study. YN wrote the main text. HK and TM prepared the materials and data. YN, NT, and TM gave advice for this study. All authors read and revised the manuscript. * Acknowledgement : Not applicable Author Contribution Y.N. wrote the main manuscript text.T.M. conceputualized this project. H.K., Y.N., and T.M. prepared figures and table. All authors reviewed the manuscript. References Forster KE, Will A, Torrington AM, Moores AP, Thomson D, Arthurs G, et al. Complications and owner assessment of canine total hip replacement: a multicenter internet based survey. Vet Surg. (2012) 41:545 50. doi: 10.1111/j.1532-950X.2012.01015.x. Chao EY. Fracture of the femoral component after total hip-replacement: an analysis of 58 cases. J Bone Joint Surg Am. (1981) 63:1078 94. doi: 10.2106/00004623-198163070-00005. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141:17–27.. Kimura M, Ando K, Yamada H. A mechanical review of postoperative stem fractures of cemented total hip arthroplasty implants without femoral fracture. Fujita Medical Journal 2018;4 (4):83-87. Lucero CM, Luco JB, Garcia-Mansilla A, Slullitel PA, Zanotti G, Comba F, Buttaro MA. Successful hip revision surgery following refracture of a modern femoral stem using a cortical window osteotomy technique: A case report and review of literature. World J Methodol. 2023;13(5):502-509. doi: 10.5662/wjm.v13.i5.502. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 05 May, 2025 Editor assigned by journal 29 Apr, 2025 Editor invited by journal 09 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 08 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6357627","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":453122576,"identity":"7a8c8166-05fe-4173-8a61-4127926d3507","order_by":0,"name":"Kohei Hashimoto","email":"","orcid":"","institution":"Aichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kohei","middleName":"","lastName":"Hashimoto","suffix":""},{"id":453122577,"identity":"126d776f-c44b-4d6f-abb5-ff4ff7f904a7","order_by":1,"name":"Yukio Nakamura","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAp0lEQVRIiWNgGAWjYJCCAxIVDAx8DAwJROtgPGBxhoGBjRQtzAcq28BaiAQGN3IPHLg5z04OqOXZA+K0nDmXcHDmtmRjoJZ0A+K0HO8xOCy5jTkR6LY0CeK0HOYxOPx3Tj0pWoC2HJBsOEyCFskzZwwOSBw7bszGTKxf+G7kGH+QqKmW42fvSXtAlBaFAzAWM08aUToY5BvgTPZjxGkZBaNgFIyCEQcAGosuZ1s65vwAAAAASUVORK5CYII=","orcid":"","institution":"Aichi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yukio","middleName":"","lastName":"Nakamura","suffix":""},{"id":453122578,"identity":"19e6f4f8-52ea-4b14-a700-e33f117870fd","order_by":2,"name":"Nobunori Takahashi","email":"","orcid":"","institution":"Aichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nobunori","middleName":"","lastName":"Takahashi","suffix":""},{"id":453122579,"identity":"be8c2a4e-79ef-4a61-a209-580217ff5d18","order_by":3,"name":"Takkan Morishima","email":"","orcid":"","institution":"Aichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Takkan","middleName":"","lastName":"Morishima","suffix":""}],"badges":[],"createdAt":"2025-04-02 05:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6357627/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6357627/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82352971,"identity":"1c75d303-6c7a-4772-8178-31c93e7cfc2a","added_by":"auto","created_at":"2025-05-09 11:04:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2133413,"visible":true,"origin":"","legend":"\u003cp\u003ePlain radiograph just after primary total hip replacement in the left hip at a different facility (a) and during the initial visit at our facility (b).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6357627/v1/0548ec560bb31d9c8de56d16.png"},{"id":82352972,"identity":"9393cf92-778d-4f60-a9ac-b1885f5b4043","added_by":"auto","created_at":"2025-05-09 11:04:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1070849,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical procedure (a) and videos (b) during surgery\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6357627/v1/16b690901e435d1c993f3ef3.png"},{"id":82355023,"identity":"1754bde1-520a-49fc-a048-2b3f5b2db199","added_by":"auto","created_at":"2025-05-09 11:12:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":848013,"visible":true,"origin":"","legend":"\u003cp\u003ePlain radiograph just after cemented revision total hip replacement in the left hip\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6357627/v1/c43739471980a9f4978dd76d.png"},{"id":82355024,"identity":"d88e2931-8401-4722-bc59-c58042a06781","added_by":"auto","created_at":"2025-05-09 11:12:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4670895,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6357627/v1/f966dd9a-8141-49a7-ad86-8b532c3167fc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Retrograde Removal Technique for Stem Tip Fracture After Total Hip Arthroplasty: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal hip arthroplasty (THA) is a highly effective surgical intervention for end-stage hip joint disorders. While common complications, such as infection, dislocation, and prosthetic loosening, are well-documented, very rare complication remains underreported. The reported rate of complications related to the use of THA techniques varies from 3% up to even 56% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStem fracture is a very rare and devastating complication. The femoral stem fracture has been reported as a result of implant\u0026rsquo;s design, metallurgical composition, quality of cement mantle, and surgical technique. The estimated occurrence is approximately 0.23\u0026ndash;0.27% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, there have been a few reports on the operative techniques in the stem fracture patients with THA.\u003c/p\u003e \u003cp\u003eThis study showed a case with stem tip fracture and cup loosening, potentially due to the polyethylene wear debris and associated osteolysis after primary THA at a different hospital. We retrogradely removed the tip successfully without any trouble, and then performed cemented revision THA as usual.\u003c/p\u003e"},{"header":"Case Description","content":"\u003cp\u003eThis study presents a case of stem tip fracture without any obvious trauma observed postoperatively in a patient undergoing THA. In this case, left hip and left thigh pain in a 63-year-old woman had started with a T-cane walking in 2022 at a different facility, and the symptoms had gradually worsened thereafter. She had had cemented THA at the hospital 8 years ago. According to the hip plain radiograph and the patient\u0026rsquo;s symptoms at that time, the primary cemented THA seemed to be successful (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUpon the initial visit to our facility in May 2024 with a referral letter, plain radiograph of the left hip revealed a stem tip failure with the stem loosening at proximal femur site and the cemented cup loosening. Radiolucencies were observed in the region surrounding the stem proximal to the stem fracture. Radiolucency of the bone distal to the fracture site was observed just near the fracture (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Since the laboratory data and culture test by intra-articular joint puncture did not show any obvious abnormal values (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), infection was denied. We performed revision cemented THA using KT plate with removal of the stem tip failure. We first split the patellar tendon and exposed the entry site for the retrograde femoral nail at the distal intercondylar region of the femur (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). We then removed the stem body and the stem tip retrogradely (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, c). We call the series of the procedures as \u0026ldquo;Retrograde Removal Technique (RRT)\u0026rdquo;. Here is the detailed RRT Procedure: First, prepare an intramedullary reamer with a sleeve and a stainless steel rod. The diameter of the reamer is recommended to be equivalent to the minimum diameter of the femoral intramedullary canal. The length of the rod should be extended at least 10 cm beyond the skin at the knee from the stem tip, and the diameter should be 1\u0026ndash;2 mm smaller than that of the intramedullary reamer. In this case, a humeral reamer with a sleeve was selected because the diameter of the femoral intramedullary canal was very narrow. Second, perform a medial parapatellar approach. Under fluoroscopic guidance, reaming is carried out using the intramedullary reamer until just below the remaining stem. A slightly curved stainless steel rod is then inserted to the same level and impacted with a hammer to dislodge the fractured stem from the cement mantle. Finally, the stem is proximally extracted using intramedullary forceps. We finally performed revision THA with KT plate (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the primary THA at a different facility, C-Prominent stem at size 2 (LOT No. BH010200 A070), 26 mm diameter of femoral head with 10/12TAPER (LOT No.4H012603 A169), and the 40 mm diameter of shell (LOT No.BH214000 A240) were used (Teijin Nakashima Medical, Okayama, Japan). Note that the stem and the acetabular socket was made of Cobalt-Chrome (Co-Cr) alloy or an ultra-high molecular weight polyethylene, respectively. The Exeter Universal cemented stem and uncemented Trident hemispherical acetabular shell (Stryker Orthopedics, Mahwah, NJ, USA), and modern cementing techniques were used with posterior approach to the hip for this revision surgery under general anesthesia. The operation time was 5 hours and 51 minutes. The bleeding during surgery was 298 mL and 100 mL of self-blood transfusion collected by cell saver was performed. The pathological examination with surgical specimen excluded infection and metallosis of this failure. According to the analysis report (Teijin Nakashima Medical, Okayama, Japan), the fracture surface of the stem demonstrated a herringbone pattern, which is characteristic of the fracture surface of brittle materials, and the polyethylene wear debris and associated osteolysis were detected in the shell. Although approximately one year has passed after the revision surgery, the patient has had little symptoms, and the laboratory test results including CRP have been normal. As far as we know, this is the first kind of case with stem tip failure after THA with the RRT. Since there has been no complication after the revision THA, this RRT could be useful for other patients with this complication after THA.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics at Baseline prior to Admission\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValues\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR 60 min (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3\u0026ndash;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuro (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.6\u0026ndash;58.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.3\u0026ndash;40.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMono (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3\u0026ndash;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEosi (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0-4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC (\u0026times;10\u003csup\u003e6\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.35\u0026ndash;5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7\u0026ndash;16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHt (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.7\u0026ndash;50.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCV (fL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.6\u0026ndash;98.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCHC (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.7\u0026ndash;35.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT (\u0026times;10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158\u0026ndash;348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD-dimer (\u0026micro;g/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal protein(g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.6\u0026ndash;8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u0026ndash;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-Bil (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40\u0026ndash;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBUN (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0\u0026ndash;20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Creatinin (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR (mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNa(mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u0026ndash;145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u0026ndash;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCl (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u0026ndash;108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.8\u0026ndash;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrected Calcium (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.7\u0026ndash;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTC (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u0026ndash;219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlkaline Phosphatase(U/L) IFCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u0026ndash;113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLD (U/L) IFCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124\u0026ndash;222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.9-6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mechanism by which this C-prominent stem fracture occurs has been reported by Kimura et al (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The authors conclude that the causes of this fracture was that firstly, polyethylene wear debris and associated osteolysis, which led to a loss of support appearing in the proximal part of the stem, secondly, the continuous internal stress concentration at a point just proximal to the fixed part, and thirdly, firmly fixation of the distal part of Co\u0026ndash;Cr alloy stem. This case showed a similar phenomenon to the above. Also, plain radiographs and computed tomography (CT) had shown the cortical hypertrophy around the failure region of the left femur. Consequently, stress might have spread further and concentrated throughout the entire femur prior to the revision surgery. In other words, the stem fractured fatigue-wise due to repeated local loading applied to the distal part of the stem after the initial surgery. We herein introduce \u0026ldquo;RRT\u0026rdquo; for the patients with stem tip fracture after THA. There have been several reports that extended trochanteric osteotomy (ETO) is required for the removal of broken stems (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). They have proposed that ETO should be long enough to disrupt regions of bone ingrowth and interdigitation into the distal splines and clothespin. However, there are several merits of RRT as follows, compared to ETO. First, stem can be removed without damaging the cortical bone. Second, full weight-bearing is possible from the early postoperative period. Third, there is no need for a long implant. On the other hand, there are the following weak points on RRT. First, there has been no report on it, thus, the evidence is lack. Second, it is necessary to open the knee joint for manipulation, which causes damage to the articular cartilage.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first kind of report to describe retrograde removal technique (RRT) for the stem tip fracture and cemented revision THA for the cup loosening after primary THA. Since any Orthopaedic surgeon can perform this surgical procedure with several merits compared to the ETO, it is recommended to perform RRT in the patients with stem fracture after THA.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this study showed only one case with RRT. Second, there was no comparative data between ETO and RRT. Future studies are needed to confirm our new technique.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e* Ethics approval and consent to participate:\u003c/strong\u003e The consent to participate was obtained from this patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* Consent for publication:\u003c/strong\u003e The Written Informed consent for publication was obtained from this patient for publication of a case report or identifying information/images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* Availability of data and material:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e*\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e: This study did not receive any specific grants from public, commercial, or nonprofit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* Competing interests:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e* Authors\u0026apos; contributions:\u003c/strong\u003e TM conceptualized this study. YN and TM directed this study. YN wrote the main text. HK and TM prepared the materials and data. YN, NT, and TM gave advice for this study. All authors read and revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e* \u003cstrong\u003eAcknowledgement\u003c/strong\u003e: Not applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.N. wrote the main manuscript text.T.M. conceputualized this project. H.K., Y.N., and T.M. prepared figures and table. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eForster KE, Will A, Torrington AM, Moores AP, Thomson D, Arthurs G, et al. Complications and owner assessment of canine total hip replacement: a multicenter internet based survey. Vet Surg. (2012) 41:545 50. doi: 10.1111/j.1532-950X.2012.01015.x.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChao EY. Fracture of the femoral component after total hip-replacement: an analysis of 58 cases. J Bone Joint Surg Am. (1981) 63:1078 94. doi: 10.2106/00004623-198163070-00005.\u003c/li\u003e\n \u003cli\u003eGruen TA, McNeice GM, Amstutz HC. \u0026ldquo;Modes of failure\u0026rdquo; of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141:17\u0026ndash;27..\u003c/li\u003e\n \u003cli\u003eKimura M, Ando K, Yamada H. A mechanical review of postoperative stem fractures of cemented total hip arthroplasty implants without femoral fracture. Fujita Medical Journal 2018;4 (4):83-87.\u003c/li\u003e\n \u003cli\u003eLucero CM, Luco JB, Garcia-Mansilla A, Slullitel PA, Zanotti G, Comba F, Buttaro MA. Successful hip revision surgery following refracture of a modern femoral stem using a cortical window osteotomy technique: A case report and review of literature. World J Methodol. 2023;13(5):502-509. doi: 10.5662/wjm.v13.i5.502.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Retrograde removal technique, Stem tip fracture, Total hip arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-6357627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6357627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe authors report a rare case of stem tip fracture after primary total hip arthroplasty (THA), where the patients underwent the fracture tip removal with revision cemented THA. 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