EP5.6 When Nail Entry Becomes the Problem: Gluteal Cuff Repair for Persistent Pain After Cephalomedullary Nailing with Structural Augmentation

Abstract Background Persistent lateral hip pain following cephalomedullary nailing (CMN) is often attributed to hardware prominence; however, iatrogenic injury to the hip abductor mechanism at the nail entry site is an underrecognized contributor. Disruption of the gluteus medius and minimus may result in persistent pain and dysfunction despite fracture healing and conservative management. The purpose of this case series is to describe patients with refractory lateral hip pain after CMN and present a surgical technique emphasizing gluteal cuff repair as the primary treatment for persistent post-operative hip pain after CMN, with adjunct fibular strut allograft augmentation to address structural defects following hardware removal. Technique/Methods Three patients presented with persistent lateral hip pain following healed proximal femur fractures treated with CMN or intramedullary fixation. All failed conservative management, including physical therapy, oral medications, and corticosteroid injections. Clinical evaluation demonstrated focal greater trochanter tenderness, pain with hip motion, and weakness with abduction. Imaging displayed hardware prominence at the proximal nail entry site and minimal prominence at the lateral insertion of the interlock screw. All patients underwent hardware removal, trochanteric bursectomy, and direct inspection of the abductor mechanism. In each case, gluteus medius and/or minimus defects were identified at the nail entry site and repaired using a double-row suture anchor construct. Proximal femoral defects were addressed with fibular strut allograft and calcium phosphate augmentation. Results At 10-week follow-up, all patients demonstrated significant improvement in pain and function, with one reporting near-complete resolution. All discontinued pain medications and were ambulating independently without assistive devices. Physical examination revealed improved hip abductor strength and resolution of greater trochanter tenderness. Radiographs confirmed stable graft position without evidence of femoral neck collapse, graft migration, or hardware-related complications. Conclusion CMN insertion may compromise the hip abductor mechanism and represents an under-recognized source of persistent postoperative lateral hip pain. Addressing abductor pathology with anatomic repair is critical for symptom resolution. When combined with structural augmentation to mitigate femoral neck weakness following hardware removal, this technique provides a comprehensive and reproducible strategy to restore both soft tissue function and structural integrity.