Painful Hip Arthroplasty: What Should We Find? Diagnostic Approach and Results

Abstract

Introduction: Identifying the source of pain is paramount for determining appropriate treatment and ensuring successful outcome in terms of management and relief of pain. The difficulty is that each surgeon has his or her own way of seeing the problem, and there is no consensus for the evaluation of these patients. The study hypothesis was that it is possible to find the cause of the pain in most cases. Patients and methods: All patients consulting for unexplained painful hip arthroplasty were included and followed a decision tree to assess the cause of the pain. The primary endpoint was the final diagnosis. Secondary endpoints were subgroup comparison between main causes and assessment of risk factors. Results: Two hundred one hips of 194 patients were included as unexplained painful hip arthroplasty 6 months postoperatively. Final diagnoses comprised periarticular pain in 53 cases (26.4%): 40 cases of trochanteric bursitis, 5 of iliopsoas tendinitis, 5 of abductor deficiency, 1 of ischial tuberosity tendinitis, and 2 of heterotopic ossification; projected pain in 49 (24.4%): 45 cases of back pain with or without neuropathy, 3 of knee osteoarthritis, and 1 of metabolic neuropathy; wear in 40 (19.9%), in the polyethylene liner; loosening in 20 (10.0%): loosening of the femoral component in 8 and that of the cup in 12; material problems in 17 (8.5%): trunnionosis in 13 and metallosis in metal-on-metal implants in 4; no diagnosis in 7 hips (3.5%); infection in 6 (3.0%), all chronic; instability without real dislocation in 3 (1.5%); misplacement in 3 (1.5%), all for leg-length discrepancy; fracture in 2 (1.0%): 1 of greater trochanter and 1 of ilio-ischiopubic ramus; complex regional pain syndrome in 1 (0.5%). Discussion: To our knowledge, this is the first study on the causes of painful hip arthroplasty in clinical practice, whether leading to revision or not. A systematic approach, including physical examination, radiographic assessment and laboratory studies, is needed to find the cause of the pain. It is important to understand the pain so that it can be treated appropriately. Revision surgery can sometimes helpdbut the worst thing is to make the patient worse.

Painful Total Hip Arthroplasty: A Systematic Review and Proposal for an Algorithmic Management Approach

“…Periprosthetic myofascial etiology groups specific diagnosis such as iliopsoas tendinitis/tendinopathy due to tendon impingement, ischial tuberosity tendinitis, and bursitis. Similarly, to Erivan et al (16), our results showed that periarticular pain is poorly described in literature and the best described myofascial etiology is iliopsoas impingement, probably due to its potential surgical treatment.…”

A Case of Iliopsoas Bursitis With Compressive Femoral Nerve Palsy Treated With Iliopsoas Tendon Release

“…The anatomical location and proximity of the iliopsoas bursa to the femoral neurovascular bundle (femoral nerve, femoral artery, and femoral vein) is well documented in the literature [ 11 , [15] , [16] , [17] ]. It is because of this anatomic proximity that neurovascular compromise can occur by mass effect with bursal distention [ 3 ].…”

“…Although iliopsoas pathology is a well-established cause of groin pain after THA, it is much less commonly associated with a mass, femoral nerve palsy, or vascular compression [ [3] , [4] , [5] , [6] ]. Cases of iliopsoas bursitis with mass effect on neurovascular structures following THA can be complex to diagnose and effectively treat.…”

Technical Considerations and Avoiding Complications in Total Hip Arthroplasty

“…In those with refractory symptoms, revision total hip arthroplasty of the acetabulum or a psoas tendon release has been described. 2 Trochanteric impingement and trochanteric pain are common concerns in the postoperative period after THA. Trochanteric impingement occurs when the trochanter impinges on the acetabulum during a physiologic range of motion.…”

“…1 Although complications are uncommon, when they occur, they cause notable morbidity to the patient. 2 Common etiologies for failure include dislocation, infection, aseptic loosening, periprosthetic fracture, trunnion damage, and persistent pain. 3 Early recognition of the potential intraoperative pitfalls and understanding how to avoid them help improve the final result.…”