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Radiographs of the left thigh of a 65-year-old man who has new-onset pain in that area. He had total hip replacement surgery 2 years earlier.
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Slide
Radiographs of the left thigh of a 65-year-old man who has new-onset pain in that area. He had total hip replacement surgery 2 years earlier.
After undergoing total hip replacement surgery 2 years earlier, a 65-year-old man comes to the office complaining of left thigh pain. He is a postal worker and has noticed the thigh pain over the last few months when he is walking with a heavy bag. He denies pain at rest or having fevers, chills, or sweats. He felt the surgery was very successful and states that this is the first time he has had pain. On examination, the patient has no pain with either passive or active range of motion of the hip. He has no pain with hip flexion against resistance or tenderness to palpation over the greater trochanter.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Identifying the cause of new-onset hip pain in people who have undergone total hip replacement can be very difficult. The majority (90%) of those who undergo total hip replacement have excellent pain control and improved activity levels.1,2Pain that never improves...
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Identifying the cause of new-onset hip pain in people who have undergone total hip replacement can be very difficult. The majority (90%) of those who undergo total hip replacement have excellent pain control and improved activity levels.1,2
Pain that never improves after surgery is likely a complication of the surgery itself, such as infection, instability, fracture, or poor implant alignment. Persistent pain can also be a sign of other pathology that may have been missed, including lumbar or sacroiliac joint disease. Pain at rest that increases while walking is common if there is loosening of the prosthetic components. Activity-related pain and pain with resisted hip flexion are signs of tendinitis or bursitis of the hip. Pain on palpation over the greater trochanter most likely indicates trochanteric bursitis. Pain at night or at rest is common with infection and tumors. Groin pain is more indicative of problems with the acetabular component, whereas thigh pain is more indicative of problems with the femoral stem.1,2
Aseptic loosening is the most common cause of pain after total hip replacement surgery and should be suspected in this patient. Radiographic results in these patients may be normal or may show radiolucent lines and/or shifting of the prosthetic components with aseptic loosening. The first step in the workup of hip pain is generally to order laboratory testing, including erythrocyte sedimentation rate and C-reactive protein level (inflammatory markers) to rule out infection. If the inflammatory markers are elevated and the suspicion for hip infection is high, joint aspiration should be performed. A bone scan can be ordered once infection is ruled out. A bone scan can pick up areas of increased bone activity that may suggest prosthetic loosening. Results of bone scan should be interpreted carefully, however, because increased uptake on bone scan can be seen for up to 2 years after total hip replacement in patients with no hip pain.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Duffy, PJ, Masri BA, Garbuz DS, Duncan CP. Evaluation of patients with pain following total hip replacement. J Bone Joint Surg. 2005;87:2566-2575.
- Robbins GM, Masri BA, Garbuz DS, Duncan CP. Evaluation of pain in patients with apparently solidly fixed total hip arthroplasty components. J Am Acad Orthop Surg. 2002;10:86-94.
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