Orthopedics

Unexplained Pain After THR: What Should I Do?

John M. Cuckler, MD

  • Orthopedics. 2010;33(9)
  • Posted September 1, 2010

Abstract

Early causes of hip pain within the first year of total hip replacement (THR) include failure of fixation, infection, instability, other sources of pain (eg, lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft tissue irritation. Metal-on-metal THRs may present with pain due to hypersensitivity within the first 1 to 3 years after arthroplasty. Late causes of pain include loosening, wear reactions, or mechanical dysfunction such as subluxation associated with wear of the articular couple. Late hematogenous infection is often sudden in onset, but may be subtle. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Evaluation of the painful hip should start with a careful history: is the current pain similar or different to the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. Careful comparison of serial radiographs is necessary to identify loosening. Serologic tests should include a sedimentation rate and C-reactive protein; if both are elevated, aspiration of the joint under radiograph control for culture is indicated. In the absence of abnormalities in the studies described above, serial Technetium bone scans performed every 6 to 12 months may suggest loosening if progressive increases in uptake are observed about a component. Malposition of the acetabular component may be associated with psoas tendon impingement (symptomatic with active flexion of the hip) and may be confirmed by computed tomography scan or a psoas tenosynogram. Hypersensitivity of metal-on-metal THRs should be suspected in the presence of early (subtle) osteolysis, and the presence of predominantly mononuclear cells on the sterile aspirate. Perseverance and patience are encouraged in the pursuit of an accurate diagnosis, and objective analysis of the data is necessary. Do not operate without sufficient cause.

Despite the reliable and consistent results of total hip replacement (THR), some patients present with pain following the procedure that will require a careful and disciplined evaluation in an effort to resolve the issue. This article presents a suggested approach to the painful THR both in the early postoperative period, and after a period of successful arthroplasty function.

Early causes of hip pain within the first year of THR include failure of fixation, infection, instability, other sources of pain (lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft-tissue irritation.1 Metal-on-metal THRs may present with pain due to hypersensitivity 1 to 3 years following arthroplasty.

Evaluation of the painful hip should start with a careful history. Is the current pain similar to or different from the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. If the pain following THR is the same as it was prepoperatively, the hip may not have been the source. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Key questions to be answered when obtaining the history include: (1) Was the preoperative pain clearly related to hip use or motion? (2) Did the preoperative pain severity correlate with the severity of the preoperative radiograph pathology?

Careful comparison of serial radiographs is necessary to identify loosening. The patient should be asked to bring all radiographs (pre- and postoperative) to the first visit if the patient is seeking a second opinion. Serologic tests should be obtained at the time of the initial evaluation and should include erythrocyte sedimentation rate (ESR) and C-reactive…

Abstract

Early causes of hip pain within the first year of total hip replacement (THR) include failure of fixation, infection, instability, other sources of pain (eg, lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft tissue irritation. Metal-on-metal THRs may present with pain due to hypersensitivity within the first 1 to 3 years after arthroplasty. Late causes of pain include loosening, wear reactions, or mechanical dysfunction such as subluxation associated with wear of the articular couple. Late hematogenous infection is often sudden in onset, but may be subtle. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Evaluation of the painful hip should start with a careful history: is the current pain similar or different to the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. Careful comparison of serial radiographs is necessary to identify loosening. Serologic tests should include a sedimentation rate and C-reactive protein; if both are elevated, aspiration of the joint under radiograph control for culture is indicated. In the absence of abnormalities in the studies described above, serial Technetium bone scans performed every 6 to 12 months may suggest loosening if progressive increases in uptake are observed about a component. Malposition of the acetabular component may be associated with psoas tendon impingement (symptomatic with active flexion of the hip) and may be confirmed by computed tomography scan or a psoas tenosynogram. Hypersensitivity of metal-on-metal THRs should be suspected in the presence of early (subtle) osteolysis, and the presence of predominantly mononuclear cells on the sterile aspirate. Perseverance and patience are encouraged in the pursuit of an accurate diagnosis, and objective analysis of the data is necessary. Do not operate without sufficient cause.

Despite the reliable and consistent results of total hip replacement (THR), some patients present with pain following the procedure that will require a careful and disciplined evaluation in an effort to resolve the issue. This article presents a suggested approach to the painful THR both in the early postoperative period, and after a period of successful arthroplasty function.

Early THR Pain

Early causes of hip pain within the first year of THR include failure of fixation, infection, instability, other sources of pain (lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft-tissue irritation.1 Metal-on-metal THRs may present with pain due to hypersensitivity 1 to 3 years following arthroplasty.

Evaluation of the painful hip should start with a careful history. Is the current pain similar to or different from the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. If the pain following THR is the same as it was prepoperatively, the hip may not have been the source. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Key questions to be answered when obtaining the history include: (1) Was the preoperative pain clearly related to hip use or motion? (2) Did the preoperative pain severity correlate with the severity of the preoperative radiograph pathology?

Careful comparison of serial radiographs is necessary to identify loosening. The patient should be asked to bring all radiographs (pre- and postoperative) to the first visit if the patient is seeking a second opinion. Serologic tests should be obtained at the time of the initial evaluation and should include erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). If both are elevated, aspiration of the joint under radiographic control for culture is indicated.2 A sedimentation rate >31 mm/sec and a CRP >20 mg/L have a 98% sensitivity.3 The CRP should return to near normal levels within 3 weeks of the index procedure, while the ESR will remain elevated approximately 3 months following THR.4 It is important to remember that although joint aspiration for diagnosis of infection has a 96% to 100% specificity, the sensitivity is only between 67% and 83%.5,6

Malposition of the acetabular component may be associated with psoas tendon impingement (symptomatic with active flexion of the hip) and may be confirmed by computerized axial tomography scan or a psoas tenosynogram7 (Figures 1, 2). Impingement of the prosthetic femoral neck against either the anatomic or prosthetic acetabular rim may be associated with groin or buttock pain.8 Hypersensitivity to metal-on-metal THRs and the presence of predominantly mononuclear cells on the sterile aspirate9 should be suspected in the presence of early (subtle) osteolysis. Hypersensitivity following metal-on-metal THR may present as groin pain, or effusions or soft tissue masses that can be identified with ultrasound or MRI examination of the joint.10

Figure 1: Severe groin pain on active flexion of the hip Figure 2: Radiographs of the same hip after revision
Figure 1: Preoperative radiograph of a patient with severe groin pain on active flexion of the hip. Note the vertical and retroverted socket, which resulted in impingement of the psoas tendon on the anterior rim of the acetabular prosthesis. Figure 2: Radiograph of the same hip after revision. The properly positioned acetabular component resulted in complete relief of the preoperative complaints.

Mild activity-related thigh pain following both cemented and cementless THR is not uncommon, and in the absence of loosening or infection, will usually resolve over several months to years. Severe thigh pain will require more extensive evaluation, and will often be associated with loosening.11

In the absence of abnormalities in the studies described above, serial Technetium bone scans performed every 6 to 12 months may suggest loosening if progressive increases in uptake are observed about a component.12 If the initial evaluation is negative, the patient should be counseled that a definitive diagnosis may require up to 2 years, and that careful follow-up and re-evaluation approximately every 6 months will be necessary.

Late Onset Pain Following THR

Late causes of pain (>1 year) include loosening, wear reactions, or mechanical dysfunction such as subluxation associated with wear of the articular couple. Careful review of prior serial radiographs with the most recent studies should allow diagnosis of loosening. Late hematogenous infection is often sudden in onset, but may be subtle, especially in the presence of low-virulence organisms. All cases of late onset pain should receive screening with an ESR and CRP. If either study is abnormal, aspiration of the joint under fluoroscopic control is indicated, both for culture and cell count. A cell count of >3000 PMNs per cc in association with elevated ESR and CRP is highly suggestive of infection.13 In addition, fluid should be analyzed for cell count and differential. If the patient has a metal-on-metal articular couple, the predominant presence of monocytes in the culture-negative aspirate may suggest the existence of a hypersensitivity reaction; subtle, small areas of osteolysis in the proximal femur or about the periphery of the acetabular component are usually present on radiograph examination.

Perseverance and patience are encouraged in the pursuit of an accurate diagnosis, and objective analysis of the data is necessary. Do not operate without identification of an objective.

References

  1. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009; 91(1):128-133.
  2. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009; 361(8):787-794.
  3. Ghanem E, Antoci V Jr, Pulido L, Joshi A, Hozack W, Parvizi J. The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and C-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. Int J Infect Dis. 2009; 13(6):e444-e449.
  4. Bilgen O, Atici T, Durak K, Karaeminogullari O, Bilgen MS. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001; 29(1):7-12.
  5. Levitsky KA, Hozack WJ, Balderston RA, et al. Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty. 1991; 6(3):237-244.
  6. Somme D, Ziza JM, Desplaces N, et al. Contribution of routine joint aspiration to the diagnosis of infection before hip revision surgery. Joint Bone Spine. 2003; 70(6):489-495.
  7. Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009; 17(6):337-344.
  8. Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg Am. 2007; 89(8):1832-1842.
  9. Willert HG, Buchhorn GH, Fayyazi A, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005; 87(1):28-36.
  10. Nikolaou V, Bergeron SG, Huk OL, Zukor DJ, Antoniou J. Evaluation of persistent pain after hip resurfacing. Bull NYU Hosp Jt Dis. 2009; 67(2):168-172.
  11. Brown TE, Larson B, Shen F, Moskal JT. Thigh pain after cementless total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg. 2002; 10(6):385-392.
  12. Callaghan JJ, Van Nostrand D, Dysart SH, Savory CG, Hopkins WJ. Prospective serial technetium diphosphonate and indium-111 white blood cell labeled imaging in primary uncemented total hip arthroplasty. Iowa Orthop J. 1996; (16):104-112.
  13. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008; 90(9):1869-1875.

Author

Dr Cuckler is from Alabama Spine and Joint Center, P.C., Birmingham, Alabama.

Dr Cuckler receives royalties from and is a consultant for Biomet, Inc. No funds are received relevant to the topic of this article.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: John M. Cuckler, MD, Alabama Spine and Joint Center, P.C., 513 Brookwood Rd, Ste 375, Birmingham, AL 35209 (jcuckler@charter.net).

doi: 10.3928/01477447-20100722-28

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