Not all painful hips require revision, investigator says

Issue: September 2010

If a surgeon is unable to identify the cause of a painful hip following total hip arthroplasty, “please do not operate on it, particularly if it is not your case to begin with,” noted David S. Hungerford, MD, a professor of orthopedic surgery at Johns Hopkins University, at the 11th Annual Current Concepts in Joint Replacement (CCJR) Spring Meeting in Las Vegas. “Because if you put a scar on it, it willbe your case from then on.”

When evaluating a painful hip, “establishing the right diagnosis is crucial,” Hungerford said. “There is almost no indication for an exploratory operation to ascertain the source of pain. It needs to be done prior to surgery. Frankly, if the surgeon is unable to locate the source of pain, he should wait.”

Infection is one source of pain, although fairly uncommon. “About half of all infections occur in the immediate postoperative period, while a few infections occur late that may be due to seeding of the prosthesis, which can occur at any time,” Hungerford told Orthopedics Today. The seeding can be from a distant source, such as an abscessed tooth. In about 90% of cases, a two-stage revision will cure the infection.

Possible sources

If the source of pain is a loose prosthesis, “it is generally radiographically evident, either in radiolucency around the prosthesis or a prosthesis that has changed position,” Hungerford said. “If you have good bone stock, reoperation can be very successful. The success rate will be parallel to the quality of the bone that remains.”

In the case of a painful hip that is obviously not loose or infected, non-hip sources should be evaluated. Impingement is often associated with a jumbo cup, a large head or a resurfacing device. “Iliopsoas impingement on the anterior aspect of a proud acetabular component can be a source of significant groin pain,” Hungerford said. Impingement with a resurfacing device will likely need to be converted to a standard total hip replacement (THR), whereas a jumbo cup may require a psoas tendon release.

Abductor muscle dysfunction is also a potential source of discomfort and pain, “especially with the direct lateral approach, whereby the adductor muscles can become detached from the trochanter,” Hungerford said. “But almost any approach is associated with a certain incidence of trochanteric bursitis.” The bursitis generally demonstrates point tenderness at the trochanter, and most patients respond to steroid injections.

Comorbidity-related pain

Lumbar disease and vascular conditions may be two other sources of pain. A vast number of patients with hip disease also have a degenerative lumbar spine disease. “Many of these patients have had spine surgery,” said Hungerford, who recommends a complete evaluation by both a spine specialist as well as a joint surgeon, which may necessitate a discectomy, a decompression or a lumbar spine infusion to relieve pain. Two other legitimate causes for reoperation may be heterotopic ossification and progressive osteolysis, as well as severe wear.

In metal-on-metal (MOM) hips, aseptic lymphocyte dominated vasculitis associated lesion (ALVAL) “is the new kid on the block, and I think we are going to, unfortunately, be hearing a lot more about it,” Hungerford said. “I believe it is around to stay and needs to be suspected in all cases of painful MOM arthroplasty, whether it is a painful resurfacing or a painful MOM THR.”

When creating an algorithm for revision, “you need to recognize that not all revisions are equal,” Hungerford said. Unlike primary hip replacement, “where the degree of difficulty is fairly narrow, in revision that range is huge.” This range can vary from an extremely simple revision in a loose prosthesis with slight bone loss to a prosthesis with significant bone loss and osteolysis.

“I have even seen cases where a revision could not be done. There was not enough bone to hang a new prosthesis on,” Hungerford said. – by Bob Kronemyer

Reference:

Hungerford DS. The painful hip: diagnosis & deliverance? Paper 83. Presented at the 11th Annual Current Concepts in Joint Replacement Spring Meeting. May 23-26. Las Vegas.

David S. Hungerford, MD, can be reached at 10715 Pot Spring Road, Cockeysville, MD 21030; 443-444-4732; e-mail: daveheide1@verizon.net.

Dr. Hungerford shares with the readership sage advice on evaluating the patient with a painful total hip arthroplasty. While it is often easy to find subtle radiographic abnormalities that “might not be quite perfect” (particularly when the X-ray is not your own!), embarking upon revision surgery without a clear cause of pain is frequently associated with less than satisfying results for both the patient and the surgeon. An algorithmic approach to evaluation including a screen for infection with an erythrocyte sedimentation rate and a C-reactive protein followed by a search for intrinsic causes of pain (those directly related to the hip joint) and finally extrinsic causes of pain such as the lumbar spine is imperative.

In cases where the cause of pain is unclear, as Dr. Hungerford suggests consulting a colleague can be extremely helpful in either confirming the diagnosis or reassuring the patient that an indication for re-operation is not present. In his closing remarks, he reminds us that there is a large spectrum of complexity in the setting of revision total hip arthroplasty and there are both cases that might be outside of one’s comfort zone and those patients that simply are beyond further reasonable attempts at reconstructive efforts.

– Craig J. Della Valle, MD
Associate Professor of Orthopaedic Surgery
Rush University Medical Center