Management of Lateral Thigh Pain following Cephalomedullary Nail: A Technical Note

Michael Rosen,Connor Kasik,Michael Swords

doi:10.51894/001c.12931

Michael Rosen, Connor Kasik + Show 1 more

Open Access

https://doi.org/10.51894/001c.12931

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Abstract

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

Highlights

Usage of proximal femoral fixation devices, such as cephalomedullary nails (CMN) and sliding hip screws (SHS), for peritrochanteric femoral fractures continue to rise, increasing from a rate of 3% in 1999 to 67% in 2006.1 The additional prevalence of these implants leads to an increased incidence of the associated complications, with little attention often paid to persistent pain after successful fracture union.[2]
In the literature to date, persistent pain after radiographic union has been commonly treated with hardware removal; lateral hip pain being the most common complication after CMN.[3]
The difference between CMN and SHS may be attributed to the larger size diameter of the proximal locking device (PLD) for the CMN. These results demonstrate the importance of implant retention, especially in those with CMN

Summary

Introduction

Usage of proximal femoral fixation devices, such as cephalomedullary nails (CMN) and sliding hip screws (SHS), for peritrochanteric femoral fractures continue to rise, increasing from a rate of 3% in 1999 to 67% in 2006.1 The additional prevalence of these implants leads to an increased incidence of the associated complications, with little attention often paid to persistent pain after successful fracture union.[2] Over 40% of patients report pain after nail placement,[2] one of the most common being lateral hip pain over the greater trochanter.[3,4]. Symptomatic lateral hip pain may develop as the fracture compresses on the proximal locking device (PLD), creating increased hardware prominence. Options to address this evolving postoperative problem may include conservative treatment with local steroid injection at the site of maximal tenderness, physical therapy or invasive options including isolated PLD removal or complete hardware explantation. Several reports can be found in the literature describing associated femoral neck fractures following removal of hardware.[5,6,7]

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