n Feature Article Hip Pain After a Femoral Fracture: It Is Not Always Related to the Implant 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: MONTH/MONTH 20XX | Volume XX • Number X 1 n Feature Article 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 2 COPYRIGHT ©