REVISION PEARLS: What Causes Hip Pain after Total Hip Arthroplasty?
Editor’s Note: ICJR’s annual Revision Hip & Knee Course is one of the most popular continuing medical education activities we host. Due to the COVID-19 pandemic, however, the course – which would have started on Thursday, June 18 – had to be canceled this year. Although the course will not be held, this week we’ll be highlighting some of the highest-rated sessions from past meetings and offering a special discount for you to attend the course in 2021.
Evaluating a patient who presents with a painful hip following total hip arthroplasty (THA) calls for a broad differential diagnosis and an understanding that THA failure is multifactorial and may require several visits, testing, and consultation with colleagues to arrive at the right diagnosis.
And, said Tad M. Mabry, MD, at ICJR’s annual Revision Hip & Knee Course, the surgeon needs to keep in mind that not every patient with a painful THA needs another procedure: If the cause of the pain is unclear, reoperation is not likely to result in meaningful improvement in pain and function.
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During his presentation, Dr. Mabry reviewed the common and not-so-common intrinsic and extrinsic failure modes for THA:
- Implant loosening
- Bearing surface issues
- Abductor issues
- Leg length discrepancy
- Heterotopic ossification
- Iliopsoas impingement
- Stem tip pain
- Neurologic, from the lumbar spine or peripheral nerves
- Referred pain from the sacroiliac joint
- Vascular disease
- Stress fracture
- Visceral pain
Dr. Mabry, from Mayo Clinic in Rochester, Minnesota, recommends a systematic approach to evaluating the painful hip after THA:
History: This includes details of the index procedure and the current history, including:
- Pain and functional limitations
- Exacerbating and alleviating factors
- Recent or ongoing antibiotic exposure
Physical examination: Along with evaluating general/psych issues, the spine, and the neurovascular system, the surgeon should evaluate:
- The patient’s gait
- Leg length
- Range of motion
- Provocative maneuvers that cause pain with resistance, pain at the extremes of motion, and/or nerve tension
Imaging: Dr. Mabry said that at Mayo Clinic, the standard radiographs for a painful THA are:
- Anteroposterior (AP) pelvis
- AP proximal femur (including the entire implant)
- Oblique proximal femur
- Lateral hip
Dr. Mabry will add Judet and false profile views if he’s concerned about pelvic dissociation.
He also said that advanced imaging – including ultrasound, CT scan, MRI, and bone scan – can be helpful in some instances, but in general, plain radiographs combined with the history and physical examination will be adequate for making a diagnosis.
Infection evaluation: All painful hips are assumed to be infected until proven otherwise, Dr. Mabry said. Labs that help him rule out infection include the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP). Patients must have a 2- to 3-week antibiotic holiday before testing to improve the accuracy of these labs, he said.
Dr. Mabry will consider hip aspiration if the ESR or CRP level is elevated or if these levels are normal but he suspects infection based on the following:
- The patient has had multiple prior surgeries.
- The patient had undergone postoperative reoperation following THA.
- The patient had prolonged wound drainage or antibiotic use.
- The patient has been in constant pain or has experienced an abrupt change in pain without an identifiable mechanical cause
- The patient has known risk factors for infection.
Metal evaluation (in patients with a metal implant)
Click the image above and learn more from Dr. Mabry about evaluating patients who present with hip pain after THA.
Disclosures: Dr. Mabry has no disclosures relevant to this presentation.