What are the next steps for an older adult patient with a history of trauma or osteoporosis, who continues to experience pain 5 months after trochanteric (intramedullary) nailing?

Evaluation and Management of Persistent Pain After Trochanteric Nailing

Obtain immediate radiographs to assess for hardware complications (cut-out, malposition, or fracture nonunion), as these are the most common causes of persistent pain at 5 months and may require conversion to total hip arthroplasty. 1

Initial Diagnostic Workup

Imaging Assessment:

• Order AP and lateral hip radiographs to evaluate for:

  • Lag screw cut-out (migration through the femoral head into the joint) - the most common implant-related complication requiring revision 1
  • Fracture nonunion or malunion 1
  • Hardware prominence or malposition 1
  • Distal femoral fracture at the interlocking bolt site 1

• Consider advanced imaging if radiographs are inconclusive:

  • MRI to evaluate for greater trochanteric pain syndrome (trochanteric bursitis, abductor tendon pathology) 2
  • CT scan for detailed assessment of fracture healing and hardware position 1

Clinical Examination:

• Assess for point tenderness over the greater trochanter (suggests hardware irritation or greater trochanteric pain syndrome) 2
• Evaluate gait pattern and weight-bearing tolerance 3
  • Pain with weight-bearing suggests hardware failure or nonunion 1
• Test hip range of motion and strength, particularly abductor function 2

Management Based on Findings

If Hardware Complications Identified:

Lag Screw Cut-Out (Most Common):

• Convert to total hip arthroplasty - this is the definitive treatment for cut-out with 16 of 19 patients requiring this conversion 1
• Be aware that conversion surgery has higher complication rates than primary arthroplasty:
  • Trochanter major refixation is technically challenging 1
  • Risk of intra- or postoperative dislocations (may require anti-dislocation rings) 1
  • Cement extrusion can occur 1

Fracture Nonunion:

• Convert to total hip arthroplasty if nonunion is established (5 patients required this in one series) 1
• Alternative: Re-osteosynthesis with long cephalomedullary nail if bone stock adequate 1

Distal Femoral Fracture at Bolt Site:

• Requires plate osteosynthesis or conversion to long cephalomedullary nail 1

If No Hardware Complications:

Greater Trochanteric Pain Syndrome:

• This is a common cause of lateral hip pain that can occur after hardware placement 2

• Initial conservative management:

  • Physical therapy focusing on hip abductor strengthening 2
  • Regular acetaminophen (paracetamol) every 6 hours 3
  • Avoid NSAIDs in elderly patients due to acute kidney injury and gastrointestinal complications; if used, co-prescribe proton pump inhibitor 4
  • Corticosteroid injection into trochanteric bursa (provides 2.7-fold chance of recovery) 5

• Opioid use should be cautious:

  • Elderly patients are vulnerable to accumulation, over-sedation, and respiratory depression 4
  • Avoid in renal dysfunction 3
  • Never prescribe codeine - causes constipation, emesis, and postoperative cognitive dysfunction 3

Hardware Irritation Without Failure:

• Trochanteric pain necessitating hardware removal occurred in 30 patients in one series 1
• Critical warning: 4 patients sustained femoral neck fractures after nail removal, so removal should be performed cautiously and only when absolutely necessary 1
• Consider removal only after fracture is fully healed (typically >12 months) 1

Osteoporosis Evaluation and Treatment

Mandatory Assessment:

• Every patient over 50 with a fragility fracture requires systematic evaluation for subsequent fracture risk 4
• Order outpatient DEXA scan 3
• Refer to bone health clinic or endocrinology for osteoporosis management 3

Pharmacologic Treatment:

• Initiate bisphosphonates or denosumab as first-line therapy to prevent subsequent fractures 6
• Ensure adequate calcium and vitamin D supplementation 4
• Denosumab should never be interrupted without switching to another therapy, as rapid bone loss occurs 6

Red Flags Requiring Urgent Intervention

• Progressive pain with weight-bearing suggests impending hardware failure 1
• New onset of groin pain may indicate lag screw cut-out 1
• Inability to bear weight suggests nonunion or hardware failure 1

Prognosis

• Trochanteric pain can be chronic: 36% of patients still have symptoms at 1 year, and 29% at 5 years 5
• Patients with osteoarthritis in lower limbs have 4.8-fold risk of persistent symptoms 5
• Most complications after cephalomedullary nailing can be prevented with proper surgical technique, but some are inevitable and require conversion surgery 1