VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

“Groin Pain” and Anatomic Considerations of the Hip: A Missed Periprosthetic Fracture in a 78-year-old Female Robert B. Zeller, OMS-III, Ryan C. Zitzke, MD, Tom Lindsey, MD. Prisma Health – Tuomey, Sumter, SC. VCOM – Carolinas Campus

Abstract # CBR-24

Supporting Data

Periprosthetic Fractures of the Hip


Approach to the Complex Hip. A hip fracture will classically present with “shortening and external rotation of the hip”, rather than someone who can stand and whose hip was stable and cleared one day ago [6] . Patients with a previous alteration in adjacent bones, joints, and other nearby soft tissue structures – whether acutely or with chronic pain – further complicate all musculoskeletal complaints [7] – [11] . The patient here, for example, should be expected to feel significant post-operative soreness, and the use of opioids for pain control after a joint replacement will certainly mask some of the symptoms of a fracture; her complaints were then likely unconsciously given less recognition by both her and during the initial clinical evaluation [12] . In a more chronic nature, the kinematic changes of the “antalgic gait” are also known to cause worsening joint derangements elsewhere over time [13] . This patient’s history of otherwise unmentioned plantar fasciitis, sacroiliitis, femoroacetabular impingement, and other biopsychosocial concerns are therefore also worthy of recognition for new complaints involving the lower extremities [10],[11],[14],[15] . It is then important to understand much of the patient’s whole story to incorporate, and not displace, any new complaints being evaluated. Approach to the PFF. Returning to the fracture observed, typically, a PFF is known to occur either intra-operatively, or after enough time has passed to allow prosthesis subsidence [5], [16] – [18] . In fact, pain after THR is increasingly common, and the American Academy of Orthopaedic Surgeons (AAOS) have developed an approach to such a complaint, which has been discussed in detail [19] . The increase in presence is attributed to how common the procedure has become, as well as increasing life expectancy in our vast geriatric population [4],[20] . Recognition and treatment are currently focused on the Vancouver classification, which has expanded into the Unified Classification System for Periprosthetic Fractures (UCS-PF) ( Table 1 ) [3],[5] . Despite these classifications, atypical fracture patterns, as identified in our patient, should always be considered with the addition of a new prothesis or other stress risers [16],[17] . Hip Neurovasculature and Pain Referral Patterns. While it may be easy to assume musculoskeletal evaluations are all about ordering imaging and crossing fingers, it is worth acknowledging the evolutionary complexity with which we bipeds have grown into. The neurovascular supply to the bipedal hip is complex [21] – [24] . A commonly mistaken error in recognition of hip joint etiology is in the patient describing a “groin pain”. In our understanding of the local anatomy, pain which is deep- to the inguinal ligament’s intersection with the Illiopsoas should not be surprising for true hip joint pathology. This is due to the obturator nerve supply to the anteromedial thigh, groin, and deep inguinal structures [24] . Despite this, pain experienced in the hip is not limited to the obturator nerve. Other hip joint nerve supply includes the femoral, sciatic, and superior gluteal nerves [23],[24] . In addition, referral patterns from primary spinal or knee injury are worth noting [7],[13],[25],[26] . These referral patterns are what makes physical exam skills so crucial if presentation is equivocal or uncommon. Bone Quality. The final considerations in a peri-prosthetic, or any hip fractures, are that of pathologic bones. Osteoporotic bone is always at the forefront in the elderly patient, which encourages a discussion toward maximizing treatment aimed at comorbidities [2],[27] . Other pathologic bone types should also be considered, as Konala et al. have previously noted a chronic hip pain, in a similarly aged and gender matched post-operative THR patient, whose pain persisted long after expected resolution of pain [28] . Consideration of bone quality should be considered in patients who have persistent pain or injuries after joint replacement.

Incidence [1] – [5] • Most commonly occur intraoperatively • Include 3.5% of primary uncemented hip replacements and 0.4% of cemented hip replacements • Postoperative periprosthetic hip fractures are rare (0.1%) • Most commonly occur at the stem tip • Preoperative templating assists in decreased risk of fracture • Early postoperative fractures more likely cementless in first 6 months • Stress risers are usually the cause • Late postoperative fractures are often cemented and occur at 5+ years Risk Factors [1] – [5] • Poor bone quality • Cementless Prosthesis • Compromised bone stock

Fracture Location

Recommended Treatment

A G Greater Trochanter

Treatment aimed at osteolysis <2cm: non-operative with partial weight bearing >2cm: ORIF with trochanteric claw to address abductor function loss

A L Lesser Trochanter

Non-operative treatment is typical

B1 Around/below stem with a well-fixed stem B2 Around/below stem with loose stem + good bone stock B3 Around/below stem with poor quality of bone for fixation

ORIF using cerclage cables, locking plates

Revision of femoral component to a long porous-coated cementless stem +/- acetabular component as needed Revision of femoral component with proximal femoral allograft or proximal femoral replacement

C Fracture well below prosthesis

ORIF with plate

Table 1 . Table of Vancouver Classifications . This is a table showing the different classifications and the recommended treatment for each group. (see Figure 1)

• Revision procedure requirement Postoperative Classification [1] – [5] • Vancouver Classification Table 1, Figure 1 • Considerations:




• Stability • Location • Surrounding bone quality

Figure 1. Vancouver Classification Anatomy . A visual representation of classifications. Image adapted from Hwang & Kim, 2011. (see Table 1)

Case Description

Figure 2. Successful THR and subsequent Injury . Initial THR proved successful (Image A). Image B shows the x- rays obtained 1 week after the fall, with Image C being home health’s image obtained that led to calling the orthopaedic surgeon.

Initial Presentation. A 78-year-old female is brought to the Emergency Department via Emergency Medical Services for evaluation after a ground level assisted fall. She is 1 day status post total hip replacement (THR) with normal post-operative x-rays ( Figure 2A ), but her only new symptoms include a mild groin pain. She remains able to ambulate with assistance from a walker but called 911 out of fear of structural damages. Patient is currently using opioids for pain control post-operatively. No obvious deformity visible at the hip joint. Incision remains clean, dry, and intact. One Week Later. Patient seen by home health (HH) and physical therapy (PT) for exercises. Her pain had worsened over the prior 7 days; in the last 24 hours, her pain levels have been 8/10 at their lowest. PT notes that her ability to stand from a seated position had become continually worse. HH called the operating surgeon with concerns about a hematoma at the anterior thigh, with the patient returning for repeat x-rays of the hip ( Figure 2B/C ). Patient was then admitted to hospital and scheduled for a revision THR the following day. Vascular surgery was consulted for the hematoma who recommended a Computerized Tomographic Angiography (CTA)( Figure 3 ). CTA with 3D reconstruction was obtained and shows a class B1 Vancouver Periprosthetic Femur Fracture (PFF). Unusual for PFF patterns, there was extension throughout the intertrochanteric region with a displaced Greater Trochanteric fragment. The distal portion of the proximal femur fragment had been pulled cephalad to disrupt the muscular branches of the Deep Femoral Artery. The distal vascular supply, fortunately, remained intact. Treatment. Treatment involved initial blood transfusion to replete patient’s hemoglobin of 6.9g/dL to minimize risk of complications. Intraoperatively, the fracture was reduced, with component revision, and stabilized using cerclage wires a claw plate at the Greater Trochanter ( Figure 4 ).

Figure 3. CTA with 3D Reconstruction . Further imaging showed the hematoma forming due to vascular injury involving the muscular branches of the deep femoral artery

Figure 4. Revision THR Outcome . Post-operative x rays obtained after the revision showed successful anatomic reduction of the fracture with stable components.


Purpose & Acknowledgements

A special thank you to our patient, her family, VCOM, and the many providers at Prisma involved in this patient’s care – especially Drs. Ryan C. Zitzke, Kurt T. Stroebel, Michael Naylor, and Daniel Carney.


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