PAIN IN THE TOTAL HIP AREA
August 24, 2008
Contents: Source of pain in the total hip Pain from tissues around the total hip Occasional pain Pain in a soundly healed total hip is actually not unusual. Pain that is not lasting and is not too severe occurs also in patients with well functioning total hip joints. Pain in the total hip produced by the first steps you take after longer sitting is by no means uncommon in a well healed total hip. Such pain subsides with further walking Studies showed that the percentage of pain-free patients increases up to 2 years after the operation, then the percentage of pain-free patients decreases steadily. For more information about this type of pain see also the chapter Life with a total hip. Some patients also experience "clicking" and other sensations from their total hip, although these sensations are not causing any pain or other discomfort. There are many tentative explanations of these sensations, such as a tendon moving across the new joint , etc; these sensations, difficult to reproduce at medical examination often occur in well functioning total hips. If the X-ray is normal then there is no reason to continue with further examinations of such otherwise well functioning total hip. Pain that increases in severity, is lasting, and is troubling the patient Such pain must always trigger a closer examination. Actually almost all complications of total hip replacement cause pain in the replaced hip joint area, in the groin and/or in the thigh. The main complications that are accompanied by severe and increased pain in the total hip area are What causes the pain in the total hip area: You should realize that pain in the total hip area may have three sources: The source of pain may be the failed total hip joint itself (e.g. loosening, infection) The source of pain may be the changes in the structures and tissues around the total hip joint (e.g. ossifications within the muscles, fatigue fracture of the pelvis, trochanter inflammation, nerve damage) The source of pain may be elsewhere - Pain in the total hip area has nothing to do with the total hip prosthesis (e.g. spine disease, vascular disease) Pain: When and where When investigating the source of pain in your total hip it is important to know when the pain started in which area you feel the pain (if you can localize the pain at all) When did the pain start: Pain that never ceased in spite of the operation: The patient never experienced pain relief from the total hip surgery. Then the hip disease (if there was such) probably has not been the cause of the patient’s troubles. The pain originating from spinal disease (spinal disc damage, spinal stenosis) may be confused with the pain caused by hip disease. In rare instances the patient has had the disease of the spine and the hip diseases, both causing troubles. After the total hip operation the spine is still causing troubles.. In rare cases the hip has been the real cause of pain but the pain continues due to gross technical error at operation or early postoperative infection of the total hip. Pain that developed suddenly only weeks after the surgery may be caused by acute postoperative infection, dislocation of the total hip prosthesis Pain that developed successively only weeks after the surgery may herald development of ectopic ossifications around the total hip, but also development of infection Pain that developed successively after a longer pain- free interval suggests loosening or late infection of the total hip Pain that developed suddenly after a longer pain free interval suggests fracture of the skeleton around the total hip (accident?) loosening because of osteolys that was silent before (osteolys&fracture) stress fracture of the skeleton (pelvis fracture, e.g. so called ramus pubis fracture damage of the total hip prosthesis (fatigue fracture of the shaft, fracture of the inliner), hematogenous (blood borne) late infection dislocation of the total hip Progressively worse pain with no relief at night or at rest is suspect of infection or nerve damage ossifications extremely rare malignant disease (cancer) The site and the radiation of the pain: Click on the icon for a full size picture Pain in the groin and in the root of the thigh is often found in loosening of the cup component Deep boring pain in the whole thigh is often associated with loosening of the femoral component or infection. Spontaneous pain in the thigh is observed in ectopic ossifications and in (young) patients with cementless total hip shafts. Pain purely over the trochanter area suggests inflammation in the soft tissues there, or irritation from wire circles left there after operation. The patients cannot rest or sleep on the affected side Pain arising in the lumbar spine (e. g entrapment of lumbar nerve roots) may mimic very closely pain in the hip area. Pain in the buttock, with irradiation to the back of the thigh is more likely to have its origin in the lumbar spine than in the hip. Pain in the buttock occurs also with vascular disease of the abdominal aorta. This pain has "claudicatio character": The pain increases with physical activity (walking) until it is unbearable and diminishes when the patient stops the activity. Other complaints associated with pain: Pain aggravated by walking - is often caused by a loose total hip prosthesis. Occurrence of sudden limping associated with pain always heralds serious failure of the total hip. Pain character of some important THR complications Loosening of the total hip Loosening of the total hip causes pain in the replaced hip that occurs during motion. Patients perceive the pain in the hip joint area if the cup is loose, and in the hip and thigh area when both cup and shaft components are loose. Patients with only loose shaft component perceive the pain mainly in the shaft area. (Khan 1998) The X-ray pictures show typical radiolucent lines in cases of more advanced loosening. In less advanced cases, the comparison of successive X-ray pictures may show that the total hip components changed their position. In some patients with limited areas of osteolysis, the osteolysis focus may lie "behind" a metal backed cup component or metallic shaft component. In these cases the osteolytic focus will be effectively shadowed by the metallic components and it will not appear on conventional X-ray pictures. Special X-ray projections are necessary in these cases. The laboratory tests show normal values. For more information visit also the chapter If your hip joint fails and Loosening of total hip joints Infection of the total hip Early infection causes severe pain, edema, and redness in the operation wound. The late infection causes increasingly more and more deep pain in the total hip area. The pain is not dependent on the patient's activity. The operation wound may show openings (sinuses) that secret gray or yellow fluid. On the other hand, the operation wound may be parfectly well healed. Laboratory tests show signs of unspecific inflammation, elevated ESR and elevated CRP. (For information about these tests visit the chapter Diagnosis of the hip disease). ESR is, however, really elevated in only about 90% of all patients with infected total hips. Patients with long antibiotic treatment may still have low or borderline ESR values (< 20 mm for men, < 28 mm for women). CRP is elevated in all patients with total hip infections. For more information visit also the chapters Treatment of total hip infections and Total hip infection. Other causes of pain in the total hip joint itself Thigh pain in cementless total hip pain from a cementless femur component is quite frequent during the first two postoperative years, although the X-ray shows well healed shaft of the total hip prosthesis. The pain if felt in the thigh, it may be worse during or after much activity / motion. There is no known treatment for this type of pain. In some patients this pain successively diminishes and disappears completely, in other patients the pain lasts unchanged. In some studies cementless prostheses with apatite coating proved to produce only slight thigh pain. Repeated dislocation / subluxation of the ball component - the pain is sudden and the leg is stiff in one position. The patient usually knows the cause of the pain (the dislocation). Some patients also learned some tricks how to get the hip joint back in the place themselves. Dislocated hip must be reduced, usually in narcosis See the chapter Dislocation of the TH /Dislocation Worn out or dislodged polyethylene liner inside the artificial socket produces pain. Pain in the hip may occur at once, but in other patients the pain develops successively. Some patients experience painful clunks. X-ray examination usually discloses that the femoral ball lies asymmetrically in the cup. See also Dislocation of the TH / Dislocated liner Fatigue fracture through the shaft of the femoral component of the total hip prosthesis. This is nowadays a rare complication since the producers of total joints developed new strong metal alloys. It has been observed more often in heavy people. The fatigue fracture through the metallic stem of the prosthesis may be barely seen on special X-ray examinations. Patients often complain of pain in the thigh that increases with activity Management of the pain in the total hip area There are two extreme cases of pain in the total hip area: in one extreme case, the patient has severe pain in the total hip area but nothing on the X-ray pictures in the other extreme case, the patient is without pain, but on an (accidentally?) taken X-ray picture of his/ her total hip, there are signs of osteolysis around the prosthesis. You should keep these extreme cases in mind when you discuss the management of your painful hip with your surgeon. The initial management of the painful hip should include X-ray pictures of the total hip, whole pelvis and thigh, and lumbar spine laboratory exam: ESR and C reactive protein (CRP) If after this examination the cause of hip pain is still uncertain the surgeon usually installs a regime of limited weight bearing and repeats the examinations after 6 weeks. Some complications manifest themselves during this periods on repeated X-rays, such as ossifications in the muscles, stress fractures in the skeleton, etc. In the meantime, the surgeon may contemplate on some special x-ray examinations (CT). The CT examination with special technique will reveal hidden osteolysis areas. (The osteolysis in itself causes no pain, only when the total hip component starts moving -becomes unstable because of the osteolysis - the pain starts) If after this period of limited weight bearing the pain continues and the X-ray pictures show no changes and the lab exam (ESR and CRP) are still negative the surgeon then usually orders bone scan. The surgeon may also order a MRI examination to assess the state of the femoral component of the prosthesis and the soft tissues around it, (the cup is not depicted so reliably with this method). If the bone scan or the MRI shows signs of loosening, the surgeon decides on the treatment - revision operation. Before the revision operation, some surgeons perform puncture of the total hip. The puncture has two goals: First; to produce a sample of joint fluid for bacteriological examination Second: to carry out so called arthrography. (Arthrography: the surgeon injects a radioopaque (contrast) dye into the total joint. If the components are loose, the dye will come into the loose space between the prosthesis and the skeleton. On X-ray pictures the surgeon will see that the contrast dye forced its way between the skeleton and the prosthesis.) Pain originating in the tissues around the total hip Fracture through the skeleton Fracture through the skeleton around the total hip prosthesis causes pain. These fractures may appear during surgery after forceful impacting / blowing the cementless total hip into the skeleton. The fracture line may be hair thin and not always apparent on ordinary X-ray pictures, during revision operation of a loose total hip. The skeleton around the total hip prosthesis is thin and may fracture during the operation. Usually the surgeon has discovered and managed the fracture already during the operation. In loose total hips the skeleton is thin and the fracture may be produced by only minimal trauma, such as a forceful step and stumbling. See more in the chapter Loosening of total hip joints Impingement of soft tissues between neck and cup of the hip prosthesis. Specifically, a muscle called iliopsoas may be entrapped between the overhanging cup component and the neck of the femoral component. These patients usually develop pain weeks or months after the operation. The pain is located in the groin, the pain is aggravated when the patient bends (flexes) the hip against resistance. Typically, the pain occurs when the patient is getting in or out of a car. Close inspection of X-ray pictures may give suspicion of this complication if the surgeon sees an abnormally tilted cup component, protruding screws, or large cement lumps in place. Infiltration of the painful muscle with local anesthetics (pain relieving solutions) will bring relief and confirm the diagnosis. Note: the injection into the joint must be done on the operation theatre under sterile precautions! For more information visit also Other complications of total hip surgery Non-union of the trochanter that was detached during the operation. The non-union may be connected with weak force in the abductor muscles (the muscles pushing the leg from the midline). With severe pain and muscle weakens the surgeon might recommend an operation to reattach the trochanter. Pain from the wire cerclage (loop) inserted in the trochanter to reattach it to the thigh bone. The operation method with detachment of the trochanter is used very often in revision operations of a failed total hip and this form of pain is observed in about 6 % of all patients with revision operations of a failed total hip. Removal of the metallic cerclage usually also relieves the pain See also the chapter Total hip operation Inflammation ( bursitis) of the bursa in the trochanter area (bursa is a sac filled with liquid and placed between tendons and bone). These inflamed sacs are painful for touch or direct pressure. Impingement of the nerves (sciatic, femoral, obturator nerve) crossing the new hip joint by screws, cement masses, scars. The pain is deep, intense, lasting. Sometimes there is also a muscle weakness and the skin is insensible for touch. The patients feel painful tingling in the extremities. Comprehensive neurologic examination, close inspection of X-rays, and the character of the pain usually disclose the cause of this pain. For more information see also the chapter Other complications of total hip surgery / nerve damage. Formation of ( heterotopic) bone in soft tissues causes pain and sometimes also mild inflammation in the tissues around the hip joint. Initially, the ossifications are not apparent on X-ray pictures. For more information see also the chapter Other complications of total hip surgery / heterotopic ossifications. Stress fracture of the pelvis (so called ramus pubis fracture) may occur in patients with weak (osteoporotic) pelvic skeleton. The pain is centered in the groin area. The fracture line may be difficult to discover on X-ray pictures initially. Repeat X-ray examination after 6 weeks, if there is a stress fracture it will be now clearly seen. Pain from outside, yet perceived in the hip area: If the hip joint was not the source of the pain, total hip operation could not relieve the symptoms - of course. But it still happens that patients have their hips replaced although the hip was not the source of pain in the leg.. These patients have typically never experienced pain relief from the total hip operation. Their pain just continued unchanged in spite of the total hip replacement. There are two conditions that produce intense pain that may be confused with pain from the hip joint. Lumbar spine disease (low back) When is the lumbar spine the source of pain? Before the total joint surgery The presence of a limp, groin pain, and / or limited internal rotation of the hip predicts that the pain is originating primarily from the hip joint disease, as opposed to originating from the spine. The spine suffers when the hip joint is diseased; the stiff diseased hip joint transfers the loads to the lumbar spine that wears out. These patients may have pain radiating in the buttock and thigh that may be confused with hip pain, especially if the X-ray pictures also show small changes in the hip joint. Patients with pain radiating in the leg should always be examined with X-ray pictures of the lumbar spine and possibly other examinations of the lumbar spine (MRI) to exclude lumbar spine disease as a cause of the pain before one decides on total hip operation. Pain caused by hip joint disease does not radiate below the knee joint area. Patients with pain caused by the damaged hip joint usually have painfully limited movements in the hip joint. More seldom, however, both causes of leg pain, osteoarthritis of the hip and lumbar spine disease, may be coexistent in one patient. In rare cases, both diseases may be treated by operation. The surgeon then faces the difficult decision which of them, the hip or the spine, should be operated on first. Pain in the back and leg after spinal anesthesia Some patients who have had spinal anesthesia perceive weeks and even months after surgery back pain, sometimes irradiating into the leg. The reason for this pain are not clear. The pain usually subsides successively. Vascular disease of the abdominal aorta (aneurysm) that may cause severe pain in the buttock musculature. This pain is typically of "claudicatio" character i.e. the pain occurs after some walking distance and disappears when the patient stops walking. References: Grant P et al, Acta Orthop Scand 2001; 72: 537-40 Khan Orthopedics 1998;21: 123-6 NEXT to Loosening total hip joints
Time after Total Hip Surgery
% patients pain-free
6 months
85 %
2 years
95 %
10 years
75 %
CAUSE OF PAIN
% of all patients with increasing hip pain had this complication
Loosening of the total hip
67 %
Infection of the total hip
22 %
Pain from spine / abdomen
5 %
Other causes
6 %
Patients with a limp were seven times more likely to have their leg pain originating from the hip disorder than from the spine disorder alone. Similarly, patients with groin pain and limited internal rotation of the hips were 14 times more likely to have their leg pain originating from the hip disorder than from the spine disorder alone.
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