**OP NOTE, MRI’s and Bone scan interpretations are below narrative**
PC is a 61 year old female who has had chronic hip pain and surgery from 2016 which involved a femur fracture that required three screws and a subsequent IT band stretch. She was eventually found to have erosion tears and hip alignment problems. In December, 2022 she has total left hip arthroplasty and open gluteus medius tendon repair with orthopedic. According to notes, no complications with the procedure and was sent to rehab for 2 weeks and then discharged home.
December 23, 2022 first recheck at the office reports increasing left hip pain especially during physical therapy. The office note says that this pain is most likely due to nerve irritation and no radiology is ordered.
Next follow up is January 31st. Still complaining of left hip pain with continuing therapy and minimal improvement with range of motion. Pain is described as burning and sharp and 9 out of 10. She was given additional medications and instructions to continue physical therapy. No radiology ordered.
Next visit is March 21st. Still using walker and minimal improvement in range of motion. Still having pain in hip at this time. Still sharp and burning you know the scale of 9 out of 10. They diagnosed her with complex regional pain syndrome and would be sent to pain management. Surgeon states that the patient may decrease her physical therapy but may continue walking. Also instructed to use quad cane.
Next follow up is April 21st. Still having excruciating pain MRI and bone density scan ordered by pain management physician. MRI reports post-operative changes with no evidence of muscle or tendon tears. No fluid collection. Generally unremarkable. She is given IM injection of steroid and lidocaine. This gives temporary relief.
Next follow-up is May 23rd. Still no relief with constant pain. Many notes concerning range of motion problems. This particular note sates that the pain may be related to prolonged period of symptoms prior to surgical intervention and a possible functional leg length discrepancy of 2mm? This is based on pain and symptoms, 2nd opinion MD sees PC on June 16th and states that the left leg pain possibly due to tightness of the IT band, infection of the hip, inflammation. Also notes that still tender to touch at surgical site and difficulty with range of motion. Is now referred to hip specialist.
August the 2023 PC goes to hip specialist, informs her that the new MRI shows significant gluteal tendon tearing, hip displacement and 1cm lengthening which is completely opposite of the MRI interpretation. Possible misread? There's belief that the soft tissue is scarred and has nerve damage. There's also clear psoas tendonitis so he gives a guided psoas injection with temporary relief. Noted to have internally rotated toe/foot progression angle, flexion contracture.
Note reads as follows: “Multiple etiologies of pain. I do believe she is having some degree of pain from a injury lateral femoral cutaneous nerve. Nothing that | can help surgically there. Clearly has been lengthening. She does have a screw is quite prominent within the and iliopsoas muscle. This may be creating some of her anterior discomfort. Removal may be beneficial but require arthrotomy dislocation removal of polyethylene with revision arthroplasty. Limb length inequality will remain unchanged as shortening limb would be ill-advised. I do think she would benefit from trochanteric surgeries appears on MRI she has had failure of repair of her abductors. This obvious would raise the question as to how it access the hip given she has had prior anterior surgery which would not allow access to the gluteals time of screw removal at the hip. Patient is going to Mull these issues over. I think she will come to surgery which would be beneficial though not totally retic gait her symptoms.”
December 2023 there's discussion to have additional procedure to remove screw and do revision. December 2023 PC returns to specialist for plan of action. This involves reviewing MRI that there's a “failure of the repair of her abductors”. PC continues to be in retractable pain and the surgeon notates once again that his assessment is an injury from the lateral femoral cutaneous nerve and that there is a screw within the iliopsoas muscle.
February of 2024, PC has revision surgery. We are still waiting for records and imaging from that particular procedure.
We are looking for an orthopedic surgeon who is well versed in hip replacements and follow-up treatments. Our concern is that there was a significant delay in addressing the PCS pain and potential nerve damage. We're concerned that the MRIs may be inconsistent. Also obviously, a concern for length discrepancy post procedure. Actual imaging for this particular client is still in process, so if there is a positive opinion we are still awaiting that radiology.
**As a reminder, the original operative note, subsequent MRIs and bone scan interpretations are below.**
Appreciate your time and opinions on this matter.
MRI 4/10/23:
Findings:
Osseous Hips: The patient is status post left total hip arthroplasty with extensive susceptibility artifact associated with femoral and acetabular prostheses. There is normal marrow signal within the adjacent acetabulum and proximal.left femoral shaft. There is no evidence of fracture or marrow replacing process. No large joint effusion is seen about the left hip. Limited evaluation of the right hip shows no evidence of fracture or AVN. Visualized Osseous Pelvis: The signal intensity within the remainder of the visualized osseous pelvis is unremarkable with no occult bony pathology noted.
Soft Tissues: The proximal thigh muscles appear unremarkable. The hamstring tendons are intact. Postoperative change is seen along the lateral soft tissues of the left hip consistent with granulation tissue and scar formation. No organized or drainable fluid collection or trochanteric bursal collection is identified. There is no gluteal muscle tear or atrophy noted.
Visualized Pelvis: No soft tissue masses or abnormalities of the visualized pelvis. There is no periarticular pseudotumor seen about the left hip.
IMPRESSION:
1. MRI of the left hip demonstrates postoperative change with prior total left hip arthroplasty.
2. There is no evidence of muscle or tendon tear involving the gluteal and proximal thigh muscles. Postoperative granulation tissue and scar are seen within the lateral soft tissues about the hip. There is no organized or drainable fluid collection.
3. No soft tissue mass or pseudotumor is noted.
MRI 11/2/22 (Pre-OP)
Susceptibility artifact from left hip fixation results in heterogeneous fat suppression and geometric distortion of the left hip. On nonfat suppressed images, no demonstrable evidence of significant arthrosis can be identified. Mild capsular stripping at the lateral slip of rectus is Present. The lesser tuberosity comes in close proximity to the ischial tuberosity with deformation and atrophy of the quadratus femoris, on axial images 14 through 20 of series 10, consistent with ischiofemoral impingement. The iliopsoas is unremarkable. The gluteal tendons are unremarkable.
IMPRESSION:
1. Left hip fixation resulting in significant artifact.
2. Findings consistent with significant ischiofemoral impingement on the left, as described.
Bone scan 4/4/23:
FINDINGS: Very mild increased flow and blood pool a\!tivity is seen along the fell proximal fomur. Finding is compatible with mild inflammation. Delaye images reveal increased tracer uptake at the left hip greater trochanter. 111is pattern can be seen normally this far out from surgery. Normal activity is seen in the pelvis. Whole body Images arc otherwise unremarkable.
IMPRESSION:
I. Mild activity a Ions ihe ieft proximal lemur is compatible with very mild inflammation. The pattern of uptake can be seen normally this far out from surgery. Exam is otherwise unremarkable.
Original OP Note:
Indications for Procedure:
61-year-old female patient with a history of a femoral neck fracture that was treated with cannulated screws. She had subsequent valgus collapse but uneventful healing. She had hip impingement symptoms that were treated with hip arthroscopy and debridement. Though she had significant relief for about 2 years she continues to have impingement pain and is developed arthritic changes in the hip. She is also developed a tear of the abductor tendon on the left. I had a long discussion with her regarding her problem and after she demonstrated a clear understanding of the risks benefits and possible complications of the procedures as listed above versus further conservative management she wished to proce~d with surgery.
Details of Procedure:
The correct patient was identified in the preoperative area and left hip
marked with a marking pen. The patient was brought to the operating
room and spinal anesthesia was used with sedation. The patient was
positioned on the Hana table. Fluoroscopic images were taken of the
pelvis and of the left hip. The hip was cleaned with ChloraPrep and
then draped in a sterile fashion. Prior to incision a timeout was
performed and the entire operating room team to ensure the correct
patient procedure and laterality. Preoperative antibiotics were given
prior to incision and tranexamic acid was administered intravenously.
A direct anterior approach was used. A longitudinal skin incision along
the distal and lateral to the anterior superior iliac spine was made.
Hemostasis was achieved and fascia over the tensor fascia lata muscle
belly was identified. This was incised and lifted off the muscle belly. The interval between the T FL and the sartorius was utilized. The
ascending branches of the lateral femoral circumflex artery were
identified and then coagulated with electrocautery. Retractors were
placed around the capsule of the femoral neck superiorly and inferiorly.
The indirect head of the rectus was reflected from the joint capsule.
A capsulotomy was performed.
Next the hip was internally rotated and iliotibial band opened to allow
exposure of the screw heads from the cannulated screws. Electrocautery
was then used to identify these and they were easily removed from the
femur. Prominent bone was then debrided with a rongeur. This was left
open to allow later repair of the abductor tendon. Retractors were then placed intra-articularly to expose the femoral
neck. The femoral neck was cut according to the preoperative template
and a napkin ring was removed the femoral head was removed with a
corkscrew. The acetabulum was exposed debrided and reamed to achieve a
1 mm press-fit. The acetabular component was impacted under
fluoroscopic and navigation system guidance using fluoroscopy to confirm
optimal component orientation. The implant was confirmed to be securely
press-fit. A neutral liner was then placed.
Attention was turned towards the femoral exposure. The femoral hook
lift was placed around the vastus ridge laterally. The leg was
maximally externally rotated with no traction on the leg. Inferior
capsular release along the medial calcar was performed, a Mueller
retractor was placed over the medial calcar. A small curved Hohmann
retractor was placed lateral to the greater trochanter. The posterior
capsule was incised with electrocautery. The leg was then slowly
extended, abducted while lifting the femur upward with a bone hook
ensuring that the femur was not caught up on the acetabulum. Sufficient
posterior release was performed to adequately expose the femur for
preparation. The canal was assessed with a box osteotome followed by a
T-handle probe and it was confirmed that no perforation was occurring.
Sequential broaches were then used to achieve axial and rotational
stability. The trial neck and head segment was placed and the hip was
reduced. Fluoroscopic image overly techniques as well as hip navigation
systems were used to evaluate the femoral component position fill hip
length and hip offset. Adjustments were made to ensure the anatomic
reconstruction of the hip joint was achieved. The hip was then
dislocated and the trial components removed. The femur was irrigated
and the real implants were impacted carefully. Maximal internal
rotation and external rotation were then performed with no evidence of
impingement. The pericapsular tissue was inspected for bleeding and
coagulated with electrocautery. Final fluoroscopic images were obtained
in the operating room and confirmed implant position. Next we then moved back to the opening in the iliotibial band to expose
the abductor tendon which was clearly torn. Fluoroscopic guidance was
used to place 2 suture anchors at the proximal aspect of the tendon
footprint. These were then shuttled into each opposite anchor creating
excellent medial compression and tendon repair. The remainder of the
opening was closed with a #2 FiberWire. The iliotibial band was then
closed with a #1 Vicryl suture.
The wound was then thoroughly irrigated with dilute Betadine solution
followed by saline. Periarticular injection cocktail was used in the muscles around the hip. The wound was closed in a layered fashion. The
skin was closed with subcuticular absorbable sutures, surgical adhesive
and sterile dressing was applied.
The drapes were removed and the patient was then taken to the recovery
room.
Files:
No questions yet!
Do you believe there might have been medical error?
It's difficult to tell with such limited and subjective information, frankly, but it does seem as though there were issues in terms of timeliness of recognition of the complication, and technically of prominent screw placement.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, difficult to tell for certain, but there was a prominent screw likely causing psoas symptoms. The delay in time to diagnosis of the gluteal rupture could also have caused further injury and deterioration in the patient's condition. Lateral femoral cutaneous nerve injury is a known possible complication and not a medical error.
What makes you a good expert for this case?
I am a board certified orthopedic surgeon with experience in total hip and revision hip arthroplasty.
How often do you encounter cases similar to this one in your practice?
Not that frequently, but complications like this are not all that rare.
Do you believe there might have been medical error?
Some degree of lengthening is very common following total hip arthroplasty. A leg length difference can be determined with physical exam and full length lower extremity x-rays. Limb lengthening cannot be assessed with hip MRI. It is possible to have lateral femoral cutaneous nerve irritation with surgery and this typically does not result in significant disability. It is unclear to me what screw remains in place based on the operative report as she had a total hip arthroplasty and there was no indication that any acetabular screws were placed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, some degree of lengthening is common after total hip arthroplasty and this can put some stretch on the LFCN. I would be much more concerned if there was a sciatic nerve injury/palsy and this does not appear to be the case. There was no indication of failure of the abductor (gluteal) muscle repair based on posteroperative MRI from April 2023.
What makes you a good expert for this case?
I am a board certified orthopedic surgeon who has been practicing for 9 years. I specialize in lower extremity surgery and have treated patients following total hip arthroplasty.
How often do you encounter cases similar to this one in your practice?
I frequently see patients who have experienced some degree of lengthening following total hip arthroplasty.
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