1. Robert B. Zeller OMS-IV – Edward Via College of Osteopathic Medicine – Carolinas
2. Ryan C. Zitzke MD – Prisma Health
3. Tom Lindsey DO – Edward Via College of Osteopathic Medicine – Carolinas

Introduction
A Periprosthetic Femur Fracture can occur at any point during or after a total hip replacement (THR) procedure. These fractures occur around the prosthetic implant using the Vancouver-expanded United Classification System (UCS) – based on the implant’s stability and the fracture’s location.

Case
The present case report describes a patient who developed a periprosthetic hip fracture one day after undergoing a THR and only complained of “groin pain.” Initial evaluation of the patient did not identify the fracture due to low clinical suspicion by the patient’s clinical presentation and the prior procedure serving as a distraction for considerations of pain and function. Over the next week, her pain worsened, and she developed a large hematoma in the anterior thigh. Upon being made aware of her condition by Home Health, the Orthopedic Surgeon admitted her directly for a revision THR and osteosynthesis.

Discussion
The patient ultimately achieved good functional outcomes, but this case reminds us of factors that often slip through the cracks when seeking medical optimization before surgery. It also highlights the importance of close monitoring for early signs of complications in select post-operative patients with otherwise benign-appearing presentations, utilizing a potentially fatal case. Finally, it opens a discussion on areas of consideration for a formal clearance process to be discussed in future papers.

Keywords: Periprosthetic Femur Fracture, Pre-operative clearance, risk mitigation, Hip pain, Groin pain

Introduction
A periprosthetic femur fracture is a severe complication that can occur after replacing a hip. As the name suggests, these fractures occur around the prosthetic implant and may happen intraoperatively or post-operatively, with an incidence ranging from 0.1% to 18% of cases across the literature (1,2). The time to post-operative complications occur an average of eight years and seven months after the hip replacement, most often attributed to subsidence or pathologic bone quality; however, increasing scientific and medical advancements allow for uncovering risk factors that seem to occur regularly (3,4). Pain after THR is increasingly common, and the AAOS have developed an approach to such a complaint, which they have discussed in detail previously (5). The incidence of periprosthetic hip fractures is increasing, but this should not be surprising as the number of THRs performed also continues to rise, and life expectancy due to medical advances continues to grow (6–9).

Immediate recognition of a periprosthetic fracture can be difficult when masked within a complex hip. While the toolbox of an orthopedic surgeon is undoubtedly famed for its uniqueness in the OR, its most crucial tools include the skills utilized for a good history and physical exam. A lack of knowledge here may lead to early, unnecessary imaging and missed diagnoses for patients with vague musculoskeletal complaints (10). These skills are information in any general practitioner’s setting, as an estimated 25% of presentations are musculoskeletal, despite musculoskeletal disease making up only 2% of the U.S. medical school curriculum, with variation in educational emphasis among allopathic and osteopathic education (11–13). The symptoms of this fracture are also highly variable, which complicates initial clinical recognition due to a typical description of only minor trauma and the ambulatory status of some patients with stable stems (6).

Imaging typically begins with an x-ray using standard orthogonal views, per hospital protocols, with further direction based on radiologist guidance, orthopedic request, or otherwise directed by Appropriate Use Criteria (14). This process is helpful for screening, but it relies heavily on x-ray technicians for image quality, radiologists for timely readings with little information about the patient, and patient presentation being in line with expected appearances. The reality of these factors is where missed fractures come in, with extremity fractures being the second most frequently missed diagnosis, after breast cancer, among radiology readings (15). The level of radiographically occult hip fractures is also surprisingly reported at 4-9% in patients presenting after trauma. In periprosthetic fractures specifically, bias from the satisfaction of search (SOS) error is highly likely 16. The distracting presence of a new prosthesis and staples may easily lead to the evaluation of the incorrect area of concern (16).

The Vancouver Classification is used for management and has expanded into the Unified Classification System for Periprosthetic Fractures (UCS-PF) (Table 1) (2,6). Definitive treatment options for periprosthetic femur fractures typically include surgical revision, osteosynthesis, or both. The expanded classification considers the fracture location and stability, the surrounding bone quality, and the patient’s overall health and functional status for surgery (17,18). Shared decision-making and unique patient considerations guide treatment specifics due to a lack of evidence suggesting a single standard treatment option.

A periprosthetic femur fracture can lead to increased morbidity, permanent disability, prolonged recovery, damaged rapport, and a heightened risk for worsened complications over many years, which are no longer avoidable, including the exceptional risk of additional fractures being three times greater (3,19–22). These are undoubtedly unavoidable in all patients, but there is no current standard for addressing cumulative risk and risk factors outside the more apparent medical risk factors. In this case report, we describe a patient with a periprosthetic hip fracture who was only one day out from a THR, whose periprosthetic femur fracture was missed on initial evaluation, leading to a delay in treatment. While her outcome was successful, imaging suggests that she was considerably lucky, given the displacement of the proximal femur segment, which bordered the major arteries of the thigh.

Case Presentation
A 78-year-old female with a history of bilateral sacroiliitis and right femoroacetabular impingement (FAI) was referred to the office by pain management for further evaluation and treatment of longstanding right hip pain. Her only other medical history involved a previous surgery for plantar fasciitis, anti-inflammatory-limiting gastritis, and anxiety. The referring physician notified her of osteoarthritis (OA) in this hip, which had now begun to limit her activities of daily living. She was confirmed to be a good candidate for surgery, given the limitations and functional disability from her hip OA, and she was scheduled for the procedure shortly after. Intraoperative and postoperative images were obtained (Figure 1A), and her procedure and recovery were unremarkable before being discharged with a routine anticipated recovery.

The following day, she was at home and sustained a low-energy mechanical fall, which was assisted to the floor by furniture. The patient called 911 due to fear of the consequences of being home alone. In the emergency department (ED), she complained of only mild pain in the anterior groin, around the inguinal ligament. However, she was also using opioids for pain control post-operatively, as anticipated. She denied any other new musculoskeletal pain, weakness, or focal neurologic deficits. A physical exam revealed an elderly female who was anxious but ambulatory with assistance from a walker. The hip was diffusely tender post-operatively, but the incision site and overlying bandages were clean, dry, and intact. She was discharged with an “inguinal strain” diagnosis and sent home with her daughter and son-in-law to avoid further concerns about falls while alone during her recovery.

Over the next week, her baseline pain levels continued to worsen at baseline as reported by physical therapy (PT) and home health. PT notes also indicate increasing difficulty in standing from a seated position. On post-op day eight, home health (HH) noted her pain levels as 8/10 at their lowest. The patient was unable to find rest in any positions. When evaluating the hip further, HH noted a massive hematoma in the anterior thigh, causing concern (Figure 1C). She promptly called the office to show an image of the hematoma. Upon receiving the call, the operating surgeon was notified of the prior ED visit and reviewed the images obtained.

The Orthopedic Surgeon admitted the patient directly to the hospital, where additional X-rays were obtained (Figure 1B). The fracture pattern identified was atypical for expected Vancouver fracture patterns, involving the intertrochanteric region with subtrochanteric extension (Figure 2). The proximal femoral segment’s location, with presence of a hematoma, led to the decision to consult vascular surgery who recommended a computer tomographic angiogram (CTA), with runoff and 3D reconstruction, to rule out vascular injury or emergent surgical indications (Figures 2,3). These images showed the proximal fragment bordering the deep femoral artery, superficial femoral artery, and lateral circumflex femoral artery with blunt dissection of the tissues between them. Fortunately, the arteries were all in contact with the outer cortex of the femur, which prevented any damage to the artery walls.

Treatment began with an initial blood transfusion to replete the patient’s hemoglobin of 6.9 g/dL before her procedure. She was then cleared for an urgent revision of THR and osteosynthesis, with treatment as a Vancouver B1 fracture. The Hardinge approach was utilized to avoid the fracture fragments during exposure. The consulted Vascular Surgeon was also readily available to assist with arterial bleeding. Intraoperatively, there was no obvious evidence of subsidence or loosening, and the fragments were large enough to get a read on. Reduction required careful considerations to avoiding any translational or rotational movement, knowing that the proximal segment was abutting the major arteries of the thigh. Hardware for stability involved utilizing six Smith and Nephew 2.0 cables, with a Zimmer claw plate to support an Arcos modular femoral revision system (Figure 5). The remainder of the procedure was completed without any complications. She was discharged to the inpatient rehabilitation unit the following day, where she quickly recovered, and she has since been pleased with her hip. Her progress since this incident has been successful, with only slight hip abduction weakness as a reminder.

Discussion
In this case report, we have discussed many errors which led to a delay in recognition and treatment. This is due to the multiple factors being applied in line with the “Swiss Cheese Model”, which has shed light on the need for a more thorough evaluation of patients needing joint replacements, or other orthopedic procedures, to reveal patient risks for all involved in the patient’s care.

The following patient factors addressed would have been helpful to consider pre-operatively, to call our patient “optimized for surgery” instead of only “medically optimized.” These identifications are essential for all providers involved in care, as they are typically recognized prior to the procedure by the surgeon, but this is not shared information when things do not go as planned. We chose to group these based on an approach rooted in osteopathic philosophy, which was then modified to incorporate allopathic teachings, for the inclusion of our peers (Table 2). The factors are also loosely applied, which is deliberate, as the focus of these groups serves as a guideline of overlapping considerations and not a set of strict rules.

Circulatory & Respiratory – General Medical Considerations
Our first patient factors for discussion utilize the Circulatory & Respiratory Model. We applied this model from an approach that discusses typical general medical applications, which, as the name suggests, would make sense for vital organ considerations. The lack of applied factors is most important in the patient examined, as their physical health would seem unremarkable when considering their health record. In this case, the primary risks include a sedentary lifestyle and obesity (BMI = 30.2 kg/m2), which often go together (23–25). The level of either is overall benign relative to the typical THR patient, but inclusion is essential to encourage a more thorough assessment (26,27). From an orthopedic standpoint, these would increase the risk of fragility fractures, and from a surgical standpoint, increased inflammation and decreased cardiovascular capacity. The lack of patient history leaves room for complacency in the usual “medical clearance,” typically answered by determining metabolic equivalents. Some providers prefer formalized scoring of cardiovascular capacity, which may also be considered for select patients and procedures to include here (28). For other patients, or those who may be questionable, both “prehabilitation” and cardiovascular assessment is an option which can be provided by physical therapists (24,29,30).

Biomechanical – Functional Considerations
We will also continue the discussion of a sedentary lifestyle and obesity for our Biomechanical considerations involving the body’s posture, structure, and functional capacity. This model revolves around optimal movement, combined with symmetric and adequate strength, necessary components of proper joint mechanics (31–34). Further application of the Biomechanical Model for consideration relates to movement over our lifetime. The kinematic changes of an antalgic gait are known to cause worsening joint derangements elsewhere over time (35). These patients often develop compensatory changes as they shift their body weight, changing the body’s evolutionarily optimized gait mechanics. Over the years, an increased contralateral stance phase causes worsened joint derangements, with cyclical ipsilateral muscle weakening. This cycle repeats as the primary joint-related pain wanders to other weight-bearing joints, increasing biomechanical stress applied. This concern is where our patient’s history of plantar fasciitis with fasciotomy, sacroiliitis, and femoroacetabular impingement is worthy of recognition for any new complaints involving the lower extremities (36). We have dubbed these patients with multiple prior joint concerns as having a chronic antalgic gait to allow a simplified communication for management – physical therapy – in a similar way as previously discussed, involving biomechanical assessments and necessary prehabilitation (37).

Neurologic – “Pain-to-Brain” Considerations
The neurovascular supply and anatomical implications for our hips are also complex, and the consideration for neurologic etiologies and referred pain is always ruled out for orthopedic patients, which leads to our Neurologic Model discussion. The primary nerves of consideration at the hip include the obturator nerve, with rarer involvement of the femoral and superior gluteal nerves (38–41). Recognition of anatomy is one of the more critical concerns in neurovascular considerations post-operatively or following traumatic injury. This allows a simple stratification of patients in assessing the case urgency. Fortunately, the risk for permanent damage in a THR is low but not dissimilar to rates of periprosthetic femur fracture at 0.6 to 3.7%, with an unsurprisingly higher risk of injury during revision THR at 7.6% (42). For the patient listed here, recognizing pain distribution is particularly important for her evaluation, as the fracture site should lead to pain anticipated in the thigh (Figure 1,2) (43). In addition, assessing this patient is difficult due to expected soreness and inflammation on postoperative day 1, which will misguide the evaluation of anything surrounding the incision site (44). Pain management using opioids also alters the patient’s sensory capability, as well as being concerned about involvement in her fall (45).

Biopsychosocial – “Brain-to-Pain” & Circumstantial Considerations
We will draw upon the Biopsychosocial Model to continue our discussion of orthopedic post-operative pain modulation. There is no longer a surprise that supratentorial involvement plays a significant role in negatively impacted pain and joint replacement outcomes as a physical extension of mental suffering (46–49). For the patient that needs reassurance that their experience is not unique or concerning, it is also no surprise that social support serves the same purpose, with data to support improved outcomes from the presence of someone to alleviate a distressed state of health(50,51). This patient population may often be seen with anxiety, but the behaviors, which are often managed by reassurance, involve pain catastrophizing. The modulation mechanism is simply the age-old mind-over-matter: they mind, and the pain matters. We hypothesize that this patient’s Generalized Anxiety diagnosis played a significant role in the perceived “groin pain,” despite the fracture’s location, which would be expected to lead to thigh pain. This is further shown in the ED notes, which showed that the patient called 911 due to concern for her implant’s integrity. The final Biopsychosocial consideration involves the provider’s perception of the patient with respect to potential pain catastrophizing at that moment, which leaves room for misinterpretation, as it is difficult to properly assess a patient in an anxious or distressed state (52,53).

Metabolic – Biochemical & Endocrine Considerations
Bone quality is an obvious consideration in any fracture, which fits nicely in discussing the Metabolic Model of Treatment. Osteoporotic bone is always at the forefront in the elderly patient, with seemingly endless discussion in the literature on fragility fractures, their risks, and approaches to management (54,55). Bone quality is also a consideration in fracture patterns, such as intertrochanteric fractures, with a similar pattern (56). While this fracture is in a unique classification, the fracture pattern encourages discussion of her bone quality. During our retrospective review of outside electronic health records, we identified our patient to have osteopenia, diagnosed three years prior, which still needed to be identified in the patient’s co-management process when seeking surgical clearance. Additional Metabolic Model discussion involves other endocrine-related processes, such as hyperparathyroidism, diabetes, nutritional deficiencies, and the many intricate, complex physiologic processes which regulate our body’s balanced and optimized state.

Complications are an inevitable part of medicine, and it is a surgeon’s responsibility to weigh the risks and benefits of a procedure relative to each specific patient to allow the patient to make fully informed decisions in their care and to minimize the risks of a negative outcome. The weight of this is a heavy burden for surgeons, who must be able to identify risks from each area of a patient’s life, as addressed above, sometimes with very limited time to consider these factors before an urgent or emergent procedure. This reality can wear down a vital component of healthcare delivery as surgeons begin their careers knowing that they enjoy surgery and the results of improving someone’s life; however, they must carefully weigh these considerations and deny a patient the opportunity for a procedure due to questionable levels of risk, or concern for patients taking legal action, despite appropriate actions, but improper documentation and errors in communication. In the future, we will further review this case and develop a risk-stratifying model to incorporate into assessing patients and addressing risks. This vision is expected to highlight patients that would benefit from a procedure in question with respect to the associated risks. For the patient, it should serve to fully identify risks and protective factors to modify their risks for the procedure, in a more thorough & informed consent process, with a formal method to notify patients and other providers of reasons for poor candidacy pre- and post-operatively. We hope this may allow sharing of the burden inherent to the shared decision-making process and allow a surgeon to operate in confidence, knowing that there is no imbalance in knowledge of risk-benefit analysis and that they have done everything in their power to help a patient. It may also more easily identify these at-risk patients and stratify their risk level for other healthcare professionals to remain alert for complications addressed pre-operatively.

Conclusion
In recent years, increasing focus has shed light on the many previously thought “non-medical” components of patient risk which affected this patient. With increasing numbers of joint replacement procedures performed, data continuously reveals new risks associated with specific populations, including those unique risk factors beyond the clinical assessment. In this paper, we evaluated a patient utilizing a philosophy rooted in osteopathic education that aligns with all physicians’ education.

Patients often present atypically for periprosthetic fractures and should be considered with a low threshold for additional workup. In the case presented, it is easy for the orthopedic surgeon to note these fractures retrospectively. Radiologists, emergency medicine physicians, and other generalists, however, should not carry the expectation of specialist-level education on the individual risk factors associated with patient procedures during their assessment of patients. The distraction of a normal-appearing hip joint implant on imaging, the anxiety experienced by the patient, and acknowledgment of the anxious affect by the provider have significant implications for earlier identification of patients at risk for early complications to increase the threshold of concern for post-operative patients.

This paper is a prime example of the need for specialized expertise to guide risk stratification in patients’ peri- and post-operative management without requiring consultations for every seemingly benign presentation while providing adequate coverage to allow for secondary and tertiary prevention strategies. It sheds new light on potential considerations for pre-operative risk identification among patients. This is meant to open discussion for a formal method that would share a surgeon’s awareness of questionable surgical candidates that may undoubtedly benefit from a procedure but at an increased risk. Presently, there are no specific methods for the early detection of these patients across specialties. Future papers by our group will further evaluate this paper for a broader assessment of the orthopedic patient and discuss the implementation of a novel model for orthopedic surgeons to identify and mitigate risks in their patients.

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5 | Figure 6

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