Hip Pain After a Femoral Fracture: It Is Not Always Related to the Implant

n Feature Article

Brian J. White, MD; Tara K. Hawkes, BS; Mackenzie M. Herzog, MPH

in some patients after appropriate healing abstract of the femoral shaft fracture.3 The origin of the continued pain is not always clear. The source of continued hip pain following fixation of traumatic femoral In some cases, implant removal may be shaft fracture is not always clear. Intra-articular hip pathology is often over- recommended; however, this is not always looked when evaluating the etiology of residual pain. The purpose of this successful.3 Although the source of resid- study was to describe cases of intra-articular hip pathology following trau- ual symptoms can be multifactorial, the matic femoral shaft fracture. This was a retrospective case series of patients possibility of intra-articular hip pathol- presenting to a private practice orthopedic clinic from 2012 to 2015. Three ogy is often overlooked. Given the high patients presented with symptomatic intra-articular hip pathology follow- energy associated with these injuries, it is ing traumatic ipsilateral femoral shaft fracture. Patients who underwent possible that the patient can sustain both hip arthroscopy with allograft labral reconstruction were identified retro- a femoral shaft fracture and a subluxation spectively. Validated, subjective outcome scores administered included of the hip joint.4,5 Subluxation of the hip the Modified Harris Hip Score (MHHS), Lower Extremity Functional Scale joint can cause intra-articular injuries, in- (LEFS), visual analog scale (VAS) for pain, and VAS scale for patient satis- cluding injuries to the labrum and/or carti- faction. Three patients were identified with residual, disabling groin pain lage, and these pathologies can cause late, after femoral shaft fracture fixation following a traumatic motor vehicle ac- persistent hip pain and disability. The pur- cident. All 3 patients were found to have a symptomatic ipsilateral labral pose of this study was to describe cases tear. In 2 of the patients, an indentation on the lateral femoral head was of intra-articular hip pathology following appreciated, which was hypothesized to be caused by a subluxation event. traumatic femoral shaft fracture. All 3 patients were treated with arthroscopic hip surgery. At final follow-up, all 3 patients showed significant improvement in MHHS, VAS pain scores, The authors are from Western Orthopaedics (BJW, TKH), Denver, Colorado; and the Profes- level of satisfaction, and LEFS. Residual pain following ipsilateral femoral sional Research Institute for Sports Medicine, shaft fracture is not always related to implant. Intra-articular hip pathology LLC (MMH), Chapel Hill, North Carolina. should be considered in patients with lingering hip pain. [Orthopedics. Ms Hawkes and Ms Herzog have no relevant 201x; xx(x):exxx-exxx.] financial relationships to disclose. Dr White is a paid consultant for Smith & Nephew, Biomet, and ConMed Linvatec. Correspondence should be addressed to: igh-energy motor vehicle acci- achieve early mobilization. Femoral shaft Brian J. White, MD, Western Orthopaedics, 1830 dents often result in polytraumatic fractures are not uncommon in these types Franklin St, Ste 450, Denver, CO 80218-1217 ([email protected]). injuries.1,2 Injuries are prioritized of traumatic mechanisms,1,2 and operative H Received: January 28, 2016; Accepted: June based on threat to life, with the additional fixation is often necessary to stabilize the 13, 2016. orthopedic goal of skeletal stabilization to fracture.2 Residual hip pain can be present doi:

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Materials and Methods with appropriate skeletal stabilization and also significant bruising and inflamma- A retrospective chart review was per- healed by 11 months postoperatively. The tion in the region of the iliopsoas tendon. formed to identify patients who under- patient had persistent left hip and groin Arthroscopically, the femoral neck was went hip arthroscopy following ipsilat- pain. The intramedullary nail in the left reshaped, removing excess bone to cre- eral femoral shaft fracture between 2012 femoral shaft fracture was removed, but ate a more normal concavity. The result- and 2015. Three patients with persistent pain persisted. At the time of consultation, ing alpha angle was to 43°. The labrum groin pain following fixation of an ipsilat- the patient reported groin pain, significant was not suitable for repair because it was eral femoral shaft fracture were identified. pain following any activity, and painful chronically torn, hypertrophic, and degen- Preoperative diagnosis was made based locking and catching within the hip joint. erative. As such, after appropriate prepa- on clinical examination findings, radio- Prior to this injury he was a police officer, ration of the acetabular rim, the labrum graphs and magnetic resonance imaging and he was unable to return to work after was reconstructed with a 7-cm frozen (MRI), and positive diagnostic injection. the injury. fascia lata allograft (AlloSource, Centen- All patients completed subjective, self- On physical examination, he had left nial, Colorado) and fixed with 5 anchors. reported questionnaires to assess pain and hip full extension, flexion to 130°, internal A microfracture procedure was performed function both pre- and postoperatively per rotation of 10°, and external rotation of on the grade 4 lesion of the acetabulum. standard of care at the authors’ institution. 75° with pain at the end ranges of motion. The iliopsoas tendon was also released ar- Questionnaires included the Modified Anterior impingement testing was posi- throscopically at the myotendinous junc- Harris Hip Score (MHHS),6 the Lower tive with significant, reproducible pain. tion to create a functional lengthening. Extremity Functional Scale (LEFS),7 and The patient scored 53 points on the preop- Dynamic testing once the hip was reduced visual analog scale (VAS) for average pain erative MHHS and 47 points on the pre- showed the impingement was appropri- at rest, average pain with daily activities, operative LEFS. The patient rated his hip ately treated. The anterior portion of the and average pain with athletic activities. a 6 at rest, 3 with daily activity, and 3 with capsulotomy was then closed. The patient Overall subjective satisfaction with the athletic activity on the VAS pain scale. underwent a supervised physical therapy procedure was also assessed using a VAS Anteroposterior (AP) pelvis and cross-ta- program for approximately 6 months. score for satisfaction from 1 to 10, where ble lateral radiographs demonstrated cam- Seven months postoperatively, the pa- 1 was extremely dissatisfied and 10 was type FAI and some calcification within the tient rated his level of satisfaction with his extremely satisfied. gluteus medius. A well-preserved lateral hip at a 10. He reported a pain level of 1 at Objective assessment was performed joint space was appreciated with no evi- rest, 2 with daily activity, and 2 with ath- using a standardized data collection tool dence of osteoarthritis. The femoral shaft letic activity. The patient scored a 94 on that is also used as standard of care at the fracture was healed and aligned. The al- the MHHS and 71 on the LEFS, resulting authors’ institution. Surgical data were pha angle measured 69°, and the center- in a 30-point improvement in the MHHS collected, including assessment of the edge (CE) angle measured 31°. Review of and 24-point improvement in the LEFS. cartilage, labral tissue, femoroacetabular MRI arthrogram suggested an acetabular In addition, the patient rejoined the police impingement (FAI), and capsule. Details labral tear. A diagnostic injection of 2 cc force and is currently training cadets at the regarding the surgical procedures per- of 0.25% marcaine and 4 cc of 1% lido- police academy. formed, including graft length and num- caine was performed. This eliminated the ber of anchors used for allograft labral patient’s hip pain, leading to high suspi- Patient 2 reconstruction, were also systematically cion of intra-articular hip pathology. The A 34-year-old man presented with recorded. patient was offered hip arthroscopy to continued left hip pain 9 months after diagnose and treat intra-articular hip pa- crashing his motorcycle. The crash re- Results thology. sulted in a left grade 3 open distal femo- Patient 1 During hip arthroscopy, the acetabu- ral fracture, left closed clavicle fracture, A 42-year-old man presented for eval- lar labrum was found to be extensively and left open proximal tibial fracture. The uation and treatment of continued left hip torn and significantly degenerative. There fractures were treated with open reduction pain 4.5 years after a high-speed pedestri- was an Outerbridge grade 4 cartilage le- and internal fixation (ORIF). At 6 months an vs motor vehicle accident. He sustained sion 5×15 mm in size on the edge of the following fixation, the femur showed in- a Gustilo grade 3 open left femoral shaft acetabulum. In the peripheral compart- complete union. The patient underwent fracture, bilateral tibial plateau fractures, ment there was significant wear over the plate and screw removal with revision right ankle fracture, and left proximal hu- anterior aspect of the neck and cam mor- to retrograde intramedullary nailing and meral fracture. All fractures were treated phology to the proximal femur. There was bone grafting. The fracture ultimately

healed, and the patient was able to return to work as a laboratory technologist; however, he continued to experience left hip and groin pain, which became especially painful while working. The patient used a prescription narcotic to treat hip pain and eventually developed a dependency on the drug. At the time of his visit, the patient reported groin pain while sitting, driving, walking, twisting, and squatting and also described moments of the hip joint feeling out of place. Figure 2: Preoperative anteroposterior radiograph of On physical examination, the patient Figure 1: Intraoperative photograph of Patient 2 Patient 3 showing bilateral femoral nails, coxa pro- had normal left hip flexion and exten- showing an indentation on the anterior portion of funda, pincer-type femoroacetabular impingement, the lateral femoral head. This intraoperative finding sion, 80° external rotation, and 5° internal and no evidence of arthritis or avascular necrosis. supports the injury mechanism of a posterior sub- rotation. Anterior impingement test was luxation that perched on the posterior wall of the positive with significant pain. The pa- acetabulum and created this indentation. tient scored 29 points on the MHHS and 14 points on the LEFS. On the VAS pain structed with an 8.5-cm graft fixed with scale, pain level was 6 at rest, 8 with daily 6 anchors. activity, and 10 with athletic activity. An- Two years postoperatively, the patient teroposterior and cross-table lateral radio- rated his level of satisfaction with his hip graphs revealed a healed and aligned fe- at a 10. The patient reported a pain level mur with a retrograde nail in place. There of 3 at rest, 4 with daily activity, and 4 was combination cam- and pincer-type with athletic activity. The patient scored FAI with a loose os acetabuli fragment. 74 points on the MHHS and 68 points on The lateral joint space was well preserved, the LEFS, for an overall improvement of Figure 3: Preoperative magnetic resonance image and there was no evidence of osteoarthri- 45 points in the MHHS and 54 points in of Patient 2 showing an acetabular labral tear. tis. The alpha angle measured 65°, and the the LEFS. CE angle measured 43°. Magnetic reso- impingement maneuver was positive for nance imaging suggested a labral tear. A Patient 3 both hips, with more significant pain rep- diagnostic injection took away the groin A 22-year-old woman presented with licated on the left side. The patient scored pain, suggesting intra-articular hip pathol- bilateral groin pain 2.5 years after a mo- 54 points on the MHHS and 48 points on ogy as the source of continued pain. The tor vehicle accident. She sustained bilat- the LEFS. On the VAS pain scale, she patient was offered hip arthroscopy. eral femoral fractures, which were treated scored a 2 at rest, 4 with daily activities, Arthroscopy showed normal cartilage with antegrade intramedullary nails. The and 6 with athletic activities. on the femoral head. The labrum was fractures were fixed, and the patient un- Anteroposterior and cross-table lateral extensively torn and degenerative. There derwent physical therapy. The patient was radiographs showed combined cam- and was a large os acetabuli fragment measur- able to return to activities of daily living; pincer-type FAI (Figure 2). The lateral ing approximately 1 cm and a significant however, she continued to experience joint space measured 3.5 mm bilaterally. cam deformity on the proximal femoral deep groin pain. At the time of consulta- The alpha angle measured 65°, and the CE neck. In addition, and consistent with his tion, the patient reported deep bilateral angle measured 36°. Magnetic resonance injury mechanism, there was an indenta- groin pain (left greater than right). Groin imaging showed bilateral labral tears (Fig- tion on the anterior femoral head just me- pain was experienced with long periods ure 3). A diagnostic injection was per- dial to the head-neck junction (Figure 1). of sitting, twisting, and squatting and oc- formed on the left hip, which eliminated Arthroscopically, the femoral neck was casionally with sleep. The patient also re- deep groin pain, suggesting intra-articular reshaped, and the os fragment and the ported painful anterior popping. hip pathology as the source of persistent labrum were resected. The labrum was On physical examination, she had 125° pain. Hip arthroscopy was offered. removed because it was too degenerative forward flexion, 15° internal rotation, and Arthroscopy showed normal cartilage for repair. The labrum was then recon- 70° external rotation bilaterally. Anterior on the femoral head. The cartilage on the

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tients underwent implant removal due to implant-related pain, but only 11 (50%) experienced a decrease in pain. These results suggest that consideration should be given to soft tissue and intra-articular pathology of the adjacent joints in situations where pain does not resolve following implant removal. A comprehensive assessment provides crucial information for intra-articular hip pathology. Historically, sharp and dull groin pain, as well as hip pain experienced Figure 4: Arthroscopic view in traction from the an- Figure 5: Arthroscopic view in traction of Patient 3 with extended standing, sitting, or walk- terolateral portal of Patient 3 showing a torn, shred- showing an 8.5-cm labral reconstruction with an IT ing, are commonly reported by patients ded labrum in the center of the picture with the Band (AlloSource, Centennial, Colorado) allograft. with an acetabular labral tear.13 Provoca- femoral head on the left and the cup on the right. tive testing can further help with the diag- ation caused the intra-articular pathology nosis. A slight modification of the anterior acetabulum was compressed in the ante- in these cases. A similar occurrence has impingement test where the patient is in rior superior quadrant and focally everted. also been recognized in the knee, where a supine position with the affected hip There was an indentation on the lateral several studies have documented ligamen- flexed to 90° and the hip adducted across femoral head opposite of this. The labrum tous knee damage in conjunction with the midline is useful for assessment of was significantly torn anteriorly, and, femoral fracture.8,9 labral tears.14 The hip is then internally given its chronic eversion and poor qual- A consideration for intra-articular rotated and moved from hip extension of ity, it was not felt to be repairable (Figure hip pathology was recommended several 80° to hip flexion of 130° in an attempt 4). The labrum was reconstructed with years ago by Watson el al10 in their report to grind the anterior aspect of the femoral an 8.5-cm allograft fixed with 7 anchors of a patient with residual pain following neck against the labral tear and the ante- (Figure 5). a fixated femoral shaft fracture. That pa- rior cup. Decreased, guarded motion and At 8 months after her hip arthroscopy, tient was also found to have an acetabular anterior pain are indicative of labral pa- the patient reported her level of satisfac- labral tear. The addition of the 3 patients thology. tion as a 10. Her VAS pain scores im- reported in the current study strengthens Radiographs of the hip, namely the proved to 1 at rest, 2 with activity, and 4 the conclusion that intra-articular hip pa- AP pelvis and cross-table lateral views, with sport. She scored 96 points on the thology should be considered in cases of are also useful to begin the evaluation of MHHS and 70 points on the LEFS, for an residual hip pain following femoral shaft the joint.13 Assessment of the joint space improvement of 42 points in the MHHS fracture. is helpful for diagnosing the degree of and 32 points in the LEFS. She was so Continued hip pain following ORIF of cartilage wear. Radiographs also allow pleased with her result that she had the a femoral shaft fracture is most common- for critical evaluation of the shape of the other hip treated arthroscopically, with ly treated with removal of the implant.3,11 acetabulum and the femoral head-neck similar findings and treatment. Implant removal successfully alleviates junction. Femoroacetabular impingement pain in many cases, but studies have also is common, occurring in more than 90% Discussion documented cases in which pain was not of cases with labral pathology.15 Magnetic The cases presented support consid- relieved. Dodenhoff et al3 reported the in- resonance imaging provides highly sensi- eration of intra-articular hip pathology in cidence of residual femoral pain in 80 pa- tive and accurate resolution of the labrum patients with persistent hip and groin pain tients who were treated for traumatic fem- and associated tissue, making it an effec- after high-energy femoral shaft fracture. oral fracture with a Grosse-Kempf nail. tive tool for identifying the location and High-energy trauma can subluxate or dis- Seventeen patients had the nail removed magnitude of a labral tear.3 A final con- locate adjacent joints, creating significant due to pain, and of these, 6 (35%) patients firmation of the hip joint as the source of intra-articular trauma. The indentation continued to experience pain. Similarly, pain can be obtained with a diagnostic observed on the femoral head of 2 of the Brown et al12 observed the incidence of injection.16 Residual hip pain following presented patients supports this phenom- late pain and implant removal after ORIF femoral shaft fracture can be multifacto- enon. It is hypothesized that the sublux- in 126 ankle fractures. Twenty-two pa- rial. If the residual hip pain and disability

are severe, an intra-articular injection of 2. Bucholz RW, Jones A. Fractures of the shaft 9. Moore TM, Patzakis MJ, Harvey JP Jr. Ipsi- of the femur. J Bone Joint Surg Am. 1991; lateral diaphyseal femur fractures and knee lidocaine and marcaine can objectively 73(10):1561-1566. ligament injuries. Clin Orthop Relat Res. quantify how much hip pain is truly origi- 3. Dodenhoff RM, Dainton JN, Hutchins PM. 1988; 232:182-189. nating from intra-articular hip pathology. Proximal thigh pain after femoral nailing: 10. Watson D, Walcott-Sapp S, Westrich G. causes and treatment. J Bone Joint Surg Br. Symptomatic labral tear post femoral shaft 1997; 79(5):738-741. fracture: case report. J Orthop Trauma. 2007; Conclusion 4. Milenkovic S, Mitkovic M, Saveski J, et al. 21(10):731-733. The intra-articular hip joint should be Avascular necrosis of the femoral head in 11. Toms AD, Morgan-Jones RL, Spencer-Jones considered as a source of lingering hip the patients with posterior wall acetabular R. Intramedullary femoral nailing: removing pain in a patient with polytrauma after fractures associated with dislocations of the the nail improves subjective outcome. Injury. hip [in Serbian]. Acta Chir Iugosl. 2013; 2002; 33(3):247-249. ipsilateral femoral shaft fracture. The 60(2):65-69. 12. Brown OL, Dirschl DR, Obremskey WT. In- possibility of an unrecognized hip sub- 5. Giannoudis PV, Kontakis G, Christoforakis cidence of hardware-related pain and its ef- luxation at the time of injury could create Z, Akula M, Tosounidis T, Koutras C. Man- fect on functional outcomes after open reduc- agement, complications and clinical results tion and internal fixation of ankle fractures.J a tear of the acetabular labrum and other of femoral head fractures. Injury. 2009; Orthop Trauma. 2001; 15(4):271-274. intra-articular pathology. The presented 40(12):1245-1251. 13. Beaulé PE, O’Neill M, Rakhra K. Acetabu- cases demonstrate patients with residual, 6. Byrd JW, Jones KS. Prospective analysis of lar labral tears. J Bone Joint Surg Am. 2009; severe, disabling groin pain following hip arthroscopy with 2-year follow-up. Ar- 91(3):701-710. throscopy. 2000; 16(6):578-587. fracture fixation. Increased awareness of 14. Lewis CL, Sahrmann SA. Acetabular labral 7. Binkley JM, Stratford PW, Lott SA, Riddle DL. tears. Phys Ther. 2006; 86(1):110-121. this diagnosis can lead to a faster recov- The Lower Extremity Functional Scale (LEFS): 15. Tanzer M, Noiseux N. Osseous abnormali- ery process and help patients attain a full scale development, measurement properties, ties and early osteoarthritis: the role of hip recovery from a devastating injury. and clinical application. North American Or- impingement. Clin Orthop Relat Res. 2004; thopaedic Rehabilitation Research Network. 429:170-177. Phys Ther. 1999; 79(4):371-383. References 16. Pateder DB, Hungerford MW. Use of fluo- 8. Emami Meybodi MK, Ladani MJ, Emami roscopically guided intra-articular hip in- 1. Kwong Y, Chong M, Hassan A, Kelly R. Meybodi T, et al. Concomitant ligamen- jection in differentiating the pain source in Severity of injuries associated with femoral tous and meniscal knee injuries in femoral concomitant hip and lumbar spine arthri- J Orthop Traumatol. fractures as a result of motor vehicle col- shaft fracture. 2014; tis. Am J Orthop (Belle Mead NJ). 2007; lisions. Arch Orthop Trauma Surg. 2006; 15(1):35-39. 36(11):591-593. 126(7):454-457.

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