To Prehabilitate or Not to Prehabilitate, That is the Question

Case Diagnosis: Acetabular, sacral, and pubic insufficiency fractures secondary to radiation osteonecrosis.

Case Description or Program Description: 78 year old female with history of anal squamous cell carcinoma complicated by radiation osteonecrosis presented with worsening left groin pain. Imaging revealed insufficiency fractures of the left acetabulum, pubic root and sacrum. Treated conservatively with weight-bearing precautions; follow-up imaging revealed new left femoral head fracture. Sent to emergency department and subsequently underwent percutaneous pinning of left obturator ring and ORIF left acetabulum.

Setting: Acute Hospital/Rehabilitation Hospital

Assessment/Results: Patient sent to rehabilitation hospital to "prehabilitate" before undergoing total hip arthroplasty. However, during her stay she began having increased pain in the left anterior groin, preventing her from bearing weight on the left side and ultimately inhibiting therapy progression. New imaging showed slightly worsening of her acetabular fractures and patient taken urgently to operating room for total hip arthroplasty. Returned to rehabilitation hospital and successfully completed rehabilitation course, discharging back to independent living.

Discussion (relevance): "Prehabilitation" has become popular when preparing patients for various surgical or chemotherapy treatments. Although this can help patients gain strength to accommodate for the future deficits they may experience following treatment, occasionally it could delay the treatment patients may require. As in this case, during therapy the patient began putting more weight onto her hip joints causing her fractures to worsen to the point of unbearable pain. When thinking of candidates for prehabilitation, the severity of illness/injury should always be taken into account.

Conclusions: The concept of prehabilitation can be effective in certain populations, however it should never delay care. A rapid degeneration in function that begins to limit therapies may be a sign that a more urgent intervention is needed than what was originally thought. With that, always be an advocate for your patients and know when further workup is indicated, especially during their (sometimes long) IPR stay.