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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


In revision surgery of a neglected loose cemented stem, especially if long-standing infection is present, the bone may become extremely thin and fragile. A fracture during implant removal, therefore, occurs readily and the bone may simply disintegrate so that it cannot be reconstructed to produce intrinsic stability. In such cases, rather than try to put together a house of cards, the bail and nail technique may be used.

I first described this in 1992. A large bore intramedullary nail is inserted into what is left of the femur and the bone fragments proximally or cerclage wires are around the nail. The patient is left with a Girdlestone. Most patients cannot weight-bear on a Girdlestone for about two months. After that time, they are encouraged to do so as load bearing speeds healing and bone regeneration.

Generally, within six to nine months, the femur is reconstituted and a revision can be carried out. This is a simple operation as the medullary canal is already open and the regenerated bone is often of surprising good quality. It may even be possible to use a primary stem as opposed to a long revision stem, but this probably should not be done under nine months.

The presence of an IM nail and cerclage wires does not prevent the elimination of infection. As our brothers, the trauma surgeons, will attest the treatment of an infected non-union of the femur is an intramedullary nail.

This technique is seldom required. The author has used it in eight cases in the last 30 years. It is, however, extremely valuable in bailing out of an impossible revision, especially if strut allografts or modular long stems are not immediately available.