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Orthopedics & Rheumatology

Case Report Volume 14 Issue 2

Broken prosthetic distal inter-locking modular femur stem: a case report of rare implant type failure

Akshay Lekhi,1 Kuntal Patel,2 Deepak Herlekar2

1Hip and Knee MCh Fellow- NHS(UK), MBBS, MS, DipSICOT, IOA Fellow
2Consultant Hip and Knee, FRCS, Royal Lancaster Infirmary, NHS, UK

Correspondence: Dr Akshay Lekhi, MBBS, MS Orth, DipSICOT, IOA fellow (Arthroscopy), Hip and Knee fellow (Argentina), Senior Fellow, Trauma and Orthopaedics, NHS, UK

Received: December 17, 2021 | Published: March 14, 2022

Citation: Lekhi A, Patel K, Herlekar D. Broken prosthetic distal inter-locking modular femur stem: a case report of rare implant type failure. MOJ Orthop Rheumatol. 2022;14(2):35-36. DOI: 10.15406/mojor.2022.14.00574

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A 79-year old female presented with broken REEFTM stem (Depuy) femur prosthesis. She had three hip surgeries for trauma, followed by primary hip replacement (15 years before presenting) and later fifth surgery (seven years before presenting) for periprosthetic subtrochanteric femur fracture with a Depuy REEFTM stem system. The non-union at left femur subtrochanteric region fracture landed in this implant failure. The complex medical comorbidities and multiple hip surgeries made this a high-risk scenario. Patient recuperated satisfactorily but passed away 2 years post-operatively with urosepsis. Conclusion is tha no prosthetic stem can be completely immune to failure.


While broken femur stem prosthesis in total hip replacement, have been reported since long time, REEFTM stem1 is a modular revision femoral prosthesis with one reported case of fatigue fracture.2 Search was done using Google scholar, EMBASE, PubMed central and Cochrane database by keywords “Fracture, REEF, Femur, Stem.” Prosthetic femur stem failure with a fracture rate quoted to 0.30 % in a recent case control analysis for coated uncemented stems (2020).3 REEFTM stem is suited with type IIIa, IIIb and type IV bone loss in proximal femur as per Paprosky classification.1,4 It provides metaphyeseal -diaphyseal engagement and distal locking support in the femur shaft. Factors contributing to the failure of prosthetic femur stems - lack of proximal cement bonding to the prosthesis (risk for fatigue fracture), Varus positioning, inadequate proximal bone stock, fracture non-unions and lack of calcar support in femur.1,2,5–9 The evidence suggests possible preservation of viable bone stock during revision hip arthroplasty.10

Case report

This was a 79-year old wheelchair bound lady who presented after a fall off her wheelchair with broken left femur REEFTM stem in-situ (done 7 years before the fall) with a non-union of closed subtrochanteric fracture in left femur. There was no distal neurovascular deficit in the affected leg. She had five surgical procedures on the same hip before she presented to our hospital. She lived alone at home with care givers.

Surgical challenges – multiple previous surgeries, lost tissue planes and loss of anatomical bony architecture, weak bone stock. Medical challenges were comorbidities like Diabetes mellitus, previous history of deep vein thrombosis, peripheral vascular disease, spinal stenosis, rheumatoid arthritis, right above knee amputation.


  1. Radiograph- sufficient to arrive at the diagnosis in this case (Figure 1)
  2. A CT (computed tomography) scan with 3D reconstruction -for surgical planning
  3. Routine blood tests (Full blood count, blood group liver function and renal function tests), chest radiograph, electrocardiogram, echocardiogram and arranging 4 units of cross matched blood were done as part of the detailed pre-anaesthetic work up and consent including the patient as well as the next of kin. This also involved discussion regarding “Do Not Resuscitate” decision that was appropriately taken.

Figure 1 Pre-operative (above) and post-operative (below) images.


Detailed consent involving risk to life and discussion with family members was done as an essential part of surgical pre-operative planning. The patient underwent a complex hip arthroplasty revision via previous scar and posterior-lateral approach to the hip using a RECLAIMTM Stem system (Depuy) along with plate (as added strut support) and cable fixation. This prosthesis recommended in severe metaphyseal bone loss (Paprosky III and IV) where fixation is needed at or beyond the diaphysis alone.11 The proximal part of prosthesis was carefully with use of thin Mooreland’s osteotomes. The distal part at isthmus was difficult to extract whilst preserving the bone stock and hence a bone window was created with narrow blade saw that was later restored and supported with the strict (plate) and cables. It showed good healing over 1 year follow up. As a part of pre-operative planning, proximal femur replacement prosthesis and instrument set were kept on stand-by in case of excess bone damage or poor quality of bone to withhold the RECLAIMTM stem.

Follow up

  1. Superficial wound infection post-surgery- managed with intravenous and oral antibiotics successfully over 6 weeks
  2. Satisfactory post-operative radiographs- fracture union seen (Figure 1)
  3. Followed up to 1 and half year post operatively
  4. Could stand with a walking frame with assistance
  5. Right above knee amputation for peripheral vascular disease 1 year after this hip surgery; passed away of urosepsis at 81 years.


The patient was discharged with an ongoing healing wound and no further complications. She was able to stand herself with support and had started using a wheeled walker frame. The distal most end of her wound was appreciated to be healed well, on her first clinic follow up at 6 weeks from discharge. She had peripheral vascular disease that worsened affecting her contralateral leg and hence planned for amputation. This limited her mobility to a great extend and made her practically wheelchair bound.

The biomechanical analysis of each individual hip is important and essential criteria both pre-operatively as well post-operatively. A CT scan often helps in planning in relation to the bone loss that is pre-existing in a revision arthroplasty of implant failure. It is observed that most case reports utilize the on-site methods available and detailed retrieval method of a planned case of revision hip for failed stem is often not available.12,13

The common factors observed for a failing femoral stem are excess neck offset, extralong head and both where applied. Other significant risk factors were male sex, high body mass index, low neck segments and straight component design.3 Due to the limitation of word limit the detailed related literature discussion is currently not possible here, however we plan to continue our retrospective analysis aim to publish a detailed series of failed stems in the near future. We acknowledge the limitations as in any case report like selection bias, surgeon related factors and bias, reporting bias and lack of generalisability.

Learning outcomes

  1. Prosthetic femur stems are not immune to failure
  2. Salvage situation must be kept in mind while planning complex revision hip arthroplasty
  3. Comorbidities pose challenges in pre-surgery optimisation and rehabilitation
  4. A diaphyseal loading revision hip arthroplasty system was a bailout option in this particular case
  5. Mortality risk increases after hip fracture (four percent yearly increase14)

Statement of consent

The patient was duly informed and aware that the case report may be published while hiding the identity.



Conflicts of interest

The author declares no conflicts of interest.


  1. Johnson & Johnson Medical Limited. REEF Distally Interlocked Modular Femoral Reconstruction Prosthesis. United Kingdom, Depuy Synthes, 2021.
  2. Philippot R, Delangle F, Verdot FX, et al. Femoral deficiency reconstruction using a hydroxyapatite-coated locked modular stem. A series of 43 total hip revisions. Orthop Traumatol Surg Res. 2009;95(2):119–126.
  3. DR Krueger, KP Guenther, M C Deml, et al. Mechanical failure of 113 uncemented modular revision femoral components. risk factors for fracture and failure with a case control comparison analysis. The Bone & Joint Journal. 2020;102(5)573–579.
  4. Chun YS, Juh HS, Cho YJ, et al. Fracture of Fully-coated Femoral Stem after Primary Total Hip Arthroplasty for Nonunion of Intertrochanteric Fracture: A Case Report. Hip Pelvis. 2015;27(3):179–182.
  5. Andriacchi TP, Galante JO, Belytschko TB, et al. A stress analysis of the femoral stem in total hip prostheses. J Bone Joint Surg Am. 1976;58(5):618–624
  6. Wroblewski BM. Fractured stem in total hip replacement. A clinical review of 120 cases. Acta Orthop Scand. 1982;53:279–284.
  7. Chao EY, Coventry MB. Fracture of the femoral component after total hip replacement. An analysis of fifty-eight cases. J Bone Joint Surg Am. 1981;63(7):1078–1094.
  8. Rostoker W, Chao EY, Galante JO. Defects in failed stems of hip prostheses. J Biomed Mater Res. 1978;12:635–651.
  9. Woolson ST, Milbauer JP, Bobyn JD, et al. Fatigue fracture of a forged cobalt-chromium-molybdenum femoral component inserted with cement. A report of ten cases. J Bone Joint Surg Am. 1997;79(12):1842–1848.
  10. Sadoghi P, Pawelka W, Liebensteiner MC, et al. The incidence of implant fractures after total hip arthroplasty. Int Orthop. 2014;38:39–46.
  11. Paprosky WG, Aribindi R: Hip replacement: Treatment of femoral bone loss using distal bypass fixation. Instr Course Lect. 2000;49:119–130.
  12. Johnson & Johnson Medical Limited. Femoral Revision Algorithm - CORAIL PINNACLE. United Kingdom, Depuy Synthes, 2021.
  13. Sukopp M, Taylor D, Forst R, et al. Femoral Stem Fracture in Hip Revision Arthroplasty: A Systematic Literature Review of the Real-World Evidence. Z Orthop Unfall.
  14. Paksima N, Koval KJ, Aharanoff G, et al. Predictors of mortality after hip fracture: a 10-year prospective study. Bull NYU Hosp Jt Dis. 2008;66(2):111–117.
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