Fracture of the Femoral Broach Locking Mechanism and Surgical Technique to Retrieve the Broach

Abstract

The current case series reports on 4 cases of intraoperative fracture of the femoral broach locking mechanism during total hip arthroplasty and subsequent entrapment of the broach. Three of the cases were performed via the direct anterior approach and 1 was performed with the posterolateral approach. Two femoral broach locking mechanisms fractured with the use of a power broaching device and 2 occurred when using the calcar planar. The authors also discuss a minimally invasive technique to remove the broach. While intraoperative fracture of the femoral broach locking mechanism is not a common complication, surgeons should be aware of the potential causes of these complications as well as strategies and techniques to retrieve the broach should they encounter this issue.

Introduction

Intraoperative fracture of the femoral broach locking mechanism and subsequent entrapment of the broach is a rare complication that can occur during total hip arthroplasty (THA). Repetitive use of the femoral broaches can lead to material fatigue of the “locking mechanism” of the broach thereby increasing the risk of fracture, especially when there is eccentric transmission of force through the broach. Recently, Brzezinski et al described this unique complication during DAA THA using manual broaching (MB) [1]. Their work cites several sources which suggest that broach impaction in a DAA THA requires increased energy and frequency of impaction thereby increasing the risk of fracture at the broach locking mechanism.

In addition to surgical approach, the application of other surgical tools, such as a powered broaching (PB) device or calcar planer, on the femoral broach locking mechanism may impart excessive and eccentric stresses that increase the risk of fracture. Recently, novel PB devices have been utilized to increase the consistency of in-line strikes to the broach handle compared to MB. These devices have been shown to reduce operating room time and maximize femoral stem sizing [2,3]. Furthermore, when compared with MB, the use of PB devices in DAA THA have not demonstrated an increased risk of intraoperative bony fractures [4]. However, the stresses that are imparted on the femoral broach locking mechanism during PB remain unknown. To that end, we present 4 cases with the same complication of femoral broach locking mechanism fracture. Three of these cases were performed via DAA and one was performed via a posterolateral approach. Two of the femoral broach locking mechanisms fractured during the use of a PB device and the other two occurred during the use of a calcar planer. In addition, we describe an alternative minimally invasive technique for broach removal.

All patients involved in the case report have given written informed consent for publication of their deidentified medical record data.

Case histories

Between January and February 2024, 4 patients underwent THA performed by 4 surgeons at 2 institutions. All surgeons are fellowship trained specialists in hip and knee arthroplasty. The surgical teams involved in these cases were comprised of the attending surgeon and physician assistants or surgical assists. The attending surgeon performed all critical portions of the procedure including broaching. All patients underwent appropriate preoperative medical optimization and followed a standardized perioperative protocol. Patients received spinal anesthesia with sedation or general anesthesia, were administered 1 gram of tranexamic acid prior to incision, and received perioperative antibiotic prophylaxis. The standard surgical approach and equipment for each surgeon was used for these cases. Three of the patients underwent DAA THA on a Hana table (Mizuho OSI, Tokyo, Japan). One patient underwent THA via a posterolateral approach on a regular table. Standard cementless implants consisting of a titanium acetabular shell (Legend; Ortho Development Corporation, Draper, UT, USA or Trinity; Corin, Tampa, FL, USA), a highly cross-linked polyethylene liner (Legend; Ortho Development Corporation, Draper, UT, USA) or a ceramic liner (Biolox; CeramTec AG, Lauf, Germany), and a triple tapered hydroxyapatite-coated femoral stem (Actis; DePuy Synthes, Warsaw, IN, USA or Corail; DePuy Synthes; Warsaw, IN, USA) with a ceramic head (Biolox; CeramTec AG, Lauf, Germany) were utilized. A PB device (Kincise; DePuy Synthes; Warsaw, IN, USA) was used in 2 cases for femoral broaching. Postoperatively, all patients were weight bearing as tolerated and were started on aspirin for 4 weeks for deep vein thrombosis prophylaxis. The patients were discharged home after clearing gait training on an oral pain regimen. The patients were followed-up per standard postoperative protocol.

Case 1

A 59-year-old female (body mass index 24.8 kg/m²) with a history of anemia, anxiety, depression, and Hashimoto’s thyroiditis presented with a chief complaint of chronic left hip pain that was refractory to non-surgical treatment modalities. Radiographs demonstrated advanced left hip osteoarthritis (Fig. 1). The procedure was performed following the aforementioned anterior THA protocol.

Figure 1.

Case 1: 59-year-old female with (a) preoperative radiographs demonstrating severe osteoarthritis of the left hip and (b) postoperative radiographs demonstrating no hardware complications.

During femoral broaching, a size 5 broach was inserted using the PB device. Of note, preoperative templating was performed for this case, and a size 5 femoral component was the templated size. A calcar planar was then placed over the trunnion and when the planar was activated a portion of the locking mechanism on the broach broke off making it impossible to reattach the broach handle (Fig. 2). The fractured fragment was identified and removed from the surgical site. Using a straight osteotome the bone around the broach was carefully loosed up to facilitate extraction. After multiple other attempts to remove the broach finally a vise-grip with screw-on slap hammer was attached to the remaining fractured locking mechanism of the broach and the broach was removed (Fig. 3). The remainder of the case proceeded without any further complications. The hip was reduced and found to have restored offset and length. Postoperatively, the patient required a transfusion of one unit of packed red blood cells for a hemoglobin drop from 10.3 to 7.2g/dL. Otherwise, there were no complications, and she was discharged home on postoperative day 1.

Figure 2.

Case 2: (a) Incarcerated broach with fractured trunnion. (b) Extracted broach with fractured trunnion.

Figure 3.

Case 2: (a) Vise-grip attached to fractured trunnion of broach. (b) Back-slap hammer attached to vise-grip for extraction.

At 4 weeks postoperatively, she was doing well without any signs of implant migration or loosening (Fig. 1). The follow-up at 12 months demonstrated excellent results with no complications such as periprosthetic joint infection or loosening.

Case 2

A 70-year-old male (body mass index 28.8 kg/m²) with a history of hypothyroidism and hyperlipidemia who presented with a chief complaint of chronic right hip pain that was refractory to non-surgical treatment modalities. Radiographs demonstrated advanced right hip osteoarthritis (Fig. 4). The procedure was performed following the aforementioned anterior THA protocol.

Figure 4.

Case 2: 70-year-old male with (a) preoperative radiographs demonstrating severe osteoarthritis of the right hip and (b) postoperative radiographs demonstrating no hardware complications.

During femoral broach extraction using the PB device, the locking mechanism of a size 5 broach fractured at its narrowest point where it interlocked with the broach handle. Of note, preoperative templating was performed for this case, and a size 6 femoral component was the templated size. The fractured fragment was identified and removed from the surgical wound. The PB device and the MB handles were no longer able to connect to the broach to facilitate extraction. After loosening the broach using quarter inch osteotome a vise-grip with screw-on slap hammer was attached to the remaining stubby end of the locking mechanism of the broach and the broach was removed. The remainder of the case proceeded without any further complications. The hip was reduced and found to have adequate leg length and offset. Postoperatively, there were no complications, and the patient was discharged home on postoperative day 1.

At 4 weeks postoperatively, he was doing well without any signs of implant migration or loosening (Fig. 4). The follow-up at 12 months demonstrated excellent results with no complications such as periprosthetic joint infection or loosening.

Case 3

A 57-year-old-male (body mass index 29.3 kg/m²) with no significant past medical history who presented with a chief complain of chronic right hip pain that was refractory to nonsurgical treatment modalities. Radiographs demonstrated advanced right hip osteoarthritis (Fig. 5). The procedure was performed following the aforementioned anterior THA protocol.

Figure 5.

A 57-year-old male with (a) preoperative radiographs demonstrating severe osteoarthritis of the right hip and (b) postoperative radiographs demonstrating no hardware complications.

A 56-mm cementless cup (Trinity; Corin, Tampa, FL, USA) with a corresponding ceramic liner (Biolox; CeramTec AG, Lauf, Germany) was inserted into the acetabulum without any issues. Of note, the use of a ceramic-on-ceramic bearing surface is standard care for this surgeon. A standard femoral preparation followed with manual progressive broaching using compaction broaches up to a size 11 (Corail; DePuy Synthes; Warsaw, IN, USA). Of note, preoperative templating was performed for this case, and a size 11 femoral component was the templated size. A small battery-powered calcar planar was then used to mill down proximal bone during which the tip of the broach fractured. The broach could not be extracted with the broach handle because the remaining trunnion was too short. A straight osteotome was inserted on the anterior and posterior aspect of the broach to create a limited 5-mm trough which allowed a vise-grip to grab onto the trunnion. Atraumatic extraction was then completed by backslapping the vise-grip with a standard mallet. The case was then completed without any complication.

Postoperatively, he was made full weight bearing and was discharged on postoperative day 2. The follow-up at 12 months demonstrated excellent results, he had returned to work without restriction, and radiographs did not show any bony abnormalities (Fig. 5).

Case 4

A 48-year-old male (body mass index 28.4 kg/m²) with no significant past medical history who presented with a chief complain of chronic right hip pain that was refractory to nonsurgical treatment modalities. Radiographs demonstrated advanced right hip osteoarthritis (Fig. 6). The procedure was performed following the aforementioned posterior THA protocol.

Figure 6.

Case 4: A 48-year-old male with (a) preoperative radiographs demonstrating severe osteoarthritis of the right hip and (b) postoperative radiographs demonstrating no hardware complications.

A 56-mm cementless cup (Trinity; Corin, Tampa, FL, USA) with a corresponding ceramic liner (Biolox; CeramTec AG, Lauf, Germany) was inserted into the acetabulum without any issues. Of note, the use of a ceramic-on-ceramic bearing surface is standard care for this surgeon. A standard femoral preparation followed with manual progressive broaching using compaction broaches up to a size 13 (Corail; DePuy Synthes; Warsaw, IN, USA). Of note, preoperative templating was performed for this case, and a size 13 femoral component was the templated size. A small battery-powered calcar planar was then used to mill down proximal bone during which the tip of the broach fractured. The broach could not be extracted with the broach handle because the remaining trunnion was too short. A straight osteotome was inserted on the anterior and posterior aspect of the broach to create a limited 5-mm trough which allowed a vise-grip to grab onto the trunnion. Atraumatic extraction was then completed by backslapping the vise-grip with a standard mallet. The case was then completed without any complication.

Postoperatively, he was made full weight bearing and was discharged on postoperative day 2. The follow-up at 12 months demonstrated excellent results, he had returned to work without restriction, and radiographs did not show any bony abnormalities (Fig. 6).

Discussion

In this case series, we describe a previously reported complication of femoral broaching utilizing a PB device or a calcar planer as opposed to MB. The primary advantages of a PB device include consistent delivery of a set amount of force for broach insertion and extraction as well as improved ergonomics for the surgeon. Previous studies have demonstrated that MB in DAA requires an increased amount of force for broach insertion and extraction [5]. Furthermore, different broach handle designs can alter the force transmission during broaching resulting in increased rotational stress on the proximal femur and increased the risk of intraoperative fracture. The PB device aims to reduce the variability of off-center strikes to the broach handle. Additionally, compared to an MB technique, the use of PB devices can decrease energy expenditure during broaching by 50% and time spent broaching by 40% [6]. Strait et al evaluated whether utilization of a PB device increases the risk intraoperative fractures compared to MB and found no difference in the incidence of intraoperative and 90-day periprosthetic femur fractures [4].

Unfortunately, the impact of increased and altered force transmission in DAA THA on broach locking mechanisms is not well-understood. Brzezinski et al hypothesized DAA THA may increase the risk of broach fracture due to increased stress at the locking mechanism [1]. Whether or not the use of a PB device or a calcar planer further increases the risk of fracture of the locking mechanism is also not well-understood. Although the amount of energy delivered with each strike is the same in PB, the high frequency of force delivery over a prolonged period of time may impart a different stress at the locking mechanism compared to MB. Similarly, the use of a calcar planer may impart an excessive and eccentric stress on the femoral broach locking mechanism, especially if the surgeon attempts to ream off-axis in order to plane down any excess bone on the calcar. Future biomechanical studies evaluating the impact of a PB device and/or a calcar planer on the broach locking mechanism are clearly warranted in order to avoid this complication.

Another contributing factor to failure of the broach locking mechanism could be metal fatigue. Broaches undergo multiple cycles of high-energy forces which can result in material fatigue and eventually failure at their weakest point. For the Actis stem (Depuy Synthes, Warsaw, IN, USA), broaches start from size 0 and increase up to size 12 whereas the Corail stem (Depuy Synthes, Warsaw, IN, USA) broaches start from size 6 and increase up to size 20. Within our series, only the middle-sized broaches fractured; specifically, 2 cases involved size 5 Actis stem broaches and 2 cases involved size 11 and size 13 Corail stem broaches. While the smallest broaches are the most used, we hypothesize that the middle-sized broaches are more likely to suffer material fatigue and fracture because it is at these sizes that the increased force required to impact the broach combines with the increased frequency of their use compared to the larger broaches [2]. While compaction-style broaches have been shown to better densify bone during femoral preparation, [7] they also require greater implantation forces to achieve the same friction coefficient as sharp broaches, [8] and thus require more force during preparation which is a likely contributor to broach locking mechanism fracture in this case report.

The surgical technique guide for one of the stems presented recommends slight varus impaction to optimize both axial and rotation stability for this stem design [9]. Impaction into varus leads to a tensile load on the cutout, concave portion of the broach locking mechanism and a compression load on the straight medial aspect. This intended, nonaxial force, in combination with an offset broach handle design, is likely responsible for some component of the locking mechanism fatigue. Furthermore, significant use of the broach is likely to worsen the fit between the broach neck and broach handle due to material fatigue, which would increase the tensile and compression forces described above, thus adding to the risk of broach locking mechanism fatigue and fracture. Similar compaction, triple-taper stem designs that recommend varus impaction during broaching and stem insertion should be tested and monitored for broach locking mechanism fatigue.

Interestingly, Brzezinski et al found that the broaches that failed were in service for 4-years which is similar to our findings since the broaches described in our study were in service for approximately 3 to 4 years [1]. Whether or not this means that the mid-sized broaches from this manufacturer require servicing at the 4-year mark (approximately 1000-1500 use cases) is not well understood but definitely warrants further investigation. Brzezinski et al used all first-generation broaches, in our study we used 2nd-generation broaches [1]. This suggests that the diameter of the mated portion of locking mechanism may not be the only factor that contributes to fracture and that perhaps the locking design should be adjusted to increase longevity. In an alternative approach to solve the issue new broaches now have a small back up locking mechanism for an extraction tool (Fig. 7). Surgeons are advised to check their broaches to make sure they have this modification to facilitate removal of a broach after fracture of the locking mechanism.

Figure 7.

(a) New extraction handle for broaches which utilizes a slot on the broach to facilitate removal. (b) Comparison of new and old broach handles demonstrating new hook design. (c) Demonstration of extraction handle and broach connected via hook mechanism.

Brzezinski et al describe a novel technique of broach extraction involving the creation of an anteromedial cortical window followed by retrograde extraction of the broach with an osteotome [1]. We describe an alternative technique that does not require a cortical window but instead utilizes a vise-grip and slap hammer. Using this technique, we were able to successfully extract all 2 broken broaches. However, we recognize that the technique described by Brzezinski may be necessary if the described technique fails to extract the broach. Thus, we recommend a stepwise approach starting with the vise-grip, proceeding to a cortical window if the vise-grip fails to extract the stem, and as a last resort being ready to perform an extended trochanteric osteotomy. It is important to note that the company made changes to the broaches that now facilitate extraction using an extraction slap hammer, in case the broach locking mechanism fails.

Conclusions

Intraoperative fracture of the femoral broach locking mechanism is a complication that can occur during THA which presents a unique technical challenge for the orthopedic surgeon. Surgical approach as well as utilization of other surgical tools with the femoral broach may increase the risk of fracture. Thus, it will be important to be aware of associated complications as well as the surgical technique to address them.

Conflicts of interest

Elliot Sappey-Marinier reports receiving other financial or material support from Medacta, Serf, and Symbios. Tarik Ait Si Selmi is an unpaid consultant for Corin U.S.A; reports having stock or stock options in Deemea and Ganymed Surgical; and reports receiving IP royalties from DePuy, A Johnson & Johnson Company and Symbios SA. Friedrich Boettner reports being a paid consultant for OrthoDevelopment; reports having stock or stock options in AccuPredict Inc.; reports receiving royalties from OrthoDevelopment; and is a part of editorial or governing board for OrthoForum GmbH.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2025.101642.

Informed patient consent

The author(s) confirm that written informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series).

CRediT authorship contribution statement

Peter P. Hsiue: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Jeffrey A. O’Donnell: Writing – review & editing, Writing – original draft, Visualization, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Ryan Cheng: Writing – review & editing, Writing – original draft, Validation, Resources, Project administration, Methodology, Investigation, Conceptualization. Elliot Sappey-Marinier: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Data curation, Conceptualization. Tarik Ait Si Selmi: Writing – review & editing, Writing – original draft, Visualization, Resources, Project administration, Methodology, Investigation, Conceptualization. Friedrich Boettner: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization.