Evaluation of persistent pain after hip resurfacing.
Abstract: Evaluation and treatment of pain following hip resurfacing arthroplasty can be challenging, even for the most experienced arthroplasty surgeon. As in any total hip replacement, there are a number of investigative tools at the disposal of orthopaedic surgeons to elicit the underlying causes of pain for diagnosis and treatment. A detailed history and physical examination are the most important first steps in the differential diagnosis of the intrinsic and extrinsic etiologies of hip pain. Serial radiographs from the time of surgery also should be reviewed and compared for changes indicative of loosening, migration, and osteolysis, in combination or alone. Diagnostic injections with local anesthetic agents additionally can be performed to localize the origin of pain. Bone scintigraphy, hip joint aspiration, and laboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), should be requested routinely to exclude an occult infection. The use of ultrasound (US), magnetic resonance imaging (MRI), and even hip arthroscopy has been suggested as potential diagnostic tools when metal sensitivity is suspected. Relative to cause, femoral neckfractures and the possibility of metal hypersensitivity as sources of persistent groin pain should always be considered in metal-on-metal hip resurfacing. Additionally, iliopsoas tendinopathy and anterior impingement of the femoral neck are well-recognized causes of pain and should be included in the differential diagnosis. Surface arthroplasty is becoming an acceptable alternative to standard total hip replacement in young patients. It is increasingly essential to recognize the different causes of pain following resurfacing in order to make an accurate diagnosis and initiate timely, appropriate treatment.
Subject: Orthopedic surgery (Health aspects)
C-reactive protein (Health aspects)
Surgeons (Health aspects)
Pain (Care and treatment)
Pain (Health aspects)
Authors: Nikolaou, Vassilios S.
Bergeron, Stephane G.
Huk, Olga L.
Zukor, David J.
Antoniou, John
Pub Date: 04/01/2009
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: April, 2009 Source Volume: 67 Source Issue: 2
Accession Number: 247449431
Full Text: Total hip arthroplasty (THA) has been shown to be a cost-effective procedure, providing symptomatic relief and high satisfaction rates. (1,2) Modern metal-on-metal (MOM) hip resurfacing is an increasingly popular treatment approach and represents approximately 10% of all arthroplasties performed in countries where the procedure has been available for almost a decade. (3) Hip resurfacing allows for more femoral bone preservation and is believed by many surgeons to offer lower dislocation rates, greater range of motion, increased activity levels, and ease of revision. (4,5) Nevertheless, hip resurfacing remains a technically difficult procedure, requiring precision and proper implant alignment to avoid complications and prevent early failure. Patients occasionally complain of postoperative hip pain. Determining the cause or causes of pain after resurfacing is often clinically challenging. The following evaluation of different etiologies of persistent pain after hip resurfacing suggests potential diagnostic and therapeutic modalities for the management of early and late postoperative pain.

Evaluation of the Painful hip in Resurfacing Arthroplasty

Initial Evaluation

As in all total hip replacements, a number of investigative tools are available to elicit the underlying causes of pain. In the differential diagnosis of the intrinsic and extrinsic etiologies of hip pain, the most important first steps are a detailed history and physical examination. Several questions will help narrow the differential diagnosis, such as what was the onset and timing of the pain, was there a pain-free interval after surgery, and determining whether the nature of the postoperative pain is different from that experienced preoperatively. Importantly, a thorough physical examination can identify common causes of local and referred pain, such as an inguinal hernia, trochanteric bursitis, peripheral vascular disease, and radicular lumbar pain.

Serial radiographs from the time of surgery should be reviewed and compared for changes indicative of loosening, migration, or osteolysis. Diagnostic injections with local anesthetic agents also can be performed to localize the origin of the pain. (6) There is little evidence to support the use of bone scintigraphy with Technetium-99 methylene diphosphonate ([sup.99]Tc MDP) alone over serial radiographs in the diagnosis of infection or loosening.7 Although gallium citrate ([sup.67]Ga) scanning has shown improved sensitivity and specificity compared to [sup.99]Tc MDP, Indium 111 -labeled ([sup.111]In) leukocyte scans are the preferred method to evaluate patients with pain after resurfacings. (8-10) Hip joint aspiration (11,12) and laboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), should be requested routinely to exclude an occult infection. (13) Other special examinations, such as magnetic resonance imaging (MRI) with metal artifact reduction sequences (MARS) (14) or interventional procedures using hip arthroscopy, (15) should also be considered to identify fluid collections, muscle inflammation, bone marrow edema, synovial abnormalities, damaged components, or implant loosening.

Potential Etiologies of Pain

Femoral Neck Fractures

Fracture of the femoral neck is one of the most common causes of early failure following hip resurfacing and can be a source of postoperative pain. The incidence of fractures with newer generation surface arthroplasties has been reported to be approximately 4%. (16)

There are a number of risk factors associated with the occurrence of femoral neck fractures. It is thought that females are almost twice as likely to sustain a fracture as males, this being possibly related to the lower bone density of females. (17) Obesity also has been correlated with a higher likelihood of femoral neck fractures, resulting from poor exposure during surgery, intraoperative notching, and varus orientation of the femoral component. (16,18) Surgical technique is also of upmost importance to minimize the risk of neck fractures from varus positioning of the component, (19) notching of the superolateral neck, incomplete seating, and improper impaction of the femoral implant. (17,20)

Acute femoral neck fractures following resurfacing are usually obvious, leading patients to seek urgent medical attention (Fig. 1). However, some fractures are occasionally preceded by a painful phase prior to fracturing. (18) Occult fractures can also be a cause of persistent postoperative pain, and physicians should be able to recognize the potential risk factors and treat patients accordingly with either protected weight bearing (21) or revision to THA.


Loosening of Components

Aseptic loosening of the femoral or acetabular components in resurfacing can be potential sources of pain. (22,23) In a series of 400 hybrid surface arthroplasties, there were seven revisions reported that were due to femoral component loosening. (22) The investigators recognized that female gender, large femoral head cysts, and small component size were major contributing factors to femoral stem loosening. Femoral radiolucencies, however, were symptomatic in only one patient from this series.

Concerns of component wear are minimal in modern metal-on-metal surface arthroplasty. (24) Other factors, such as cementing technique, may play a more important role in femoral component loosening. Hip resurfacing studies have shown extensive variability in the desired amount and distribution of cement. (25,26) Insufficient cement penetration (22) or thermal necrosis due to cement penetration (25) also have been shown to result in component loosening.

Acetabular component loosening has recently been recognized as a potential cause of early and late postoperative pain. In one multicenter study, it was responsible for 71% of revisions in a series of 200 patients who underwent metal-on-metal resurfacing. (23) Male patients and those with a greater body mass index (BMI) were more likely to develop loosening of the acetabular component. Revision surgery of only one of the components or conversion to a standard total hip replacement is usually recommended in the circumstances of a loose implant.

Metal Hypersensitivity

Metal hypersensitivity in patients undergoing hip arthroplasty with metal-on-metal bearings is well recognized and initially was described shortly after these implants were introduced. (27) However, recent reports have associated metal hypersensitivity with joint effusions, enlarged bursa, rapidly progressive osteolysis, and persistent groin pain in patients who underwent modern resurfacing. (28) The histological appearance of tissue surrounding failed metal-on-metal implants reveals an infiltrate of various immunologic cells, numerous endothelial venules, large fibrin exudate, and necrosis. (29) The term aseptic lymphocytic vasculitis-associated lesions (ALVAL) has been used to describe these features. (29)

The exact prevalence of these hypersensitivity reactions is unknown, partly due to the shortage of reliable investigative tools to confirm the diagnosis. (30) In a series of 1300 MOM resurfacings, 12 hips were found to have pseudotumors from hypersensitivity reactions. (31) The initial presentation of patients with pseudotumors included groin pain, spontaneous dislocation, neurologic symptoms, and a palpable mass. The investigators raised the suspicion of preoperative metal sensitization, given that all the pseudotumors occurred in females. In a separate series of 1500 patients, four patients with groin pain underwent exploratory surgery, confirming the diagnosis of a metal sensitivity reaction. (28) These patients presented with typical features and equivocal test results suggestive of possible metal sensitivity.

Surgeons should be aware of the possibility of metal sensitivity in patients with groin pain that is otherwise unexplained. In the event that a hypersensitivity reaction is confirmed on histological examination, revision arthroplasty with removal of the implant responsible for generating the metal ions usually provides symptomatic relief. (28)

Iliopsoas Tendinopathy

Iliopsoas tendinopathy has been recognized as a cause of anterior groin pain following THA. (32-35) The iliopsoas bursa is located between the tendon and the hip joint capsule, and iliopsoas tendinitis often leads to inflammation of the bursa because of their anatomic proximity. (36) Iliopsoas tendinopathy is found in approximately 5% of patients with painful THA. (32) Groin pain is often aggravated by activities and is typically characterized by painful active hip flexion and passive extension. Deep palpation may elicit tenderness over the site of inflammation. Local injection under radiological guidance can be diagnostic. (37)

The iliopsoas tendon usually impinges over an anterior prominence of the acetabular component. Large prominences can occur subsequent to component malpositioning, oversized implants, or cement extrusion. Femoral neck osteophytes and loss of anterior implant-neck offset after hip resurfacing can also contribute to tendon irritation as the iliopsoas tendon travels over the neck to its insertion. These factors can be aggravated in surface arthroplasty, since larger acetabular components are usually required and exposure is limited. Nevertheless, the exact cause of iliopsoas tendonitis often remains inconclusive. (37)

Conservative therapy should be attempted first, with activity modification, physiotherapy, and adequate analgesia provided by nonsteroidal antiinflammatory drugs (NSAIDs). Local injection into the iliopsoas tendon under radiological guidance has been used as a diagnostic and occasionally therapeutic modality by providing temporary or sustained pain relief. (33,35,37-39) Additionally, botulinum toxin infiltration has demonstrated satisfactory results for the treatment of iliopsoas tendinitis after THA. (35) Failure of nonoperative treatment usually requires surgical exploration with tendon release, (34,38) removal of osteophytes and extruded cement, or revision of a malpositioned acetabular component. (36,40)

Hip Impingement

Painful impingement between the acetabular rim and a stemmed femoral implant after THA has been well described. (41) Impingement may be a cause of persistent groin pain after hip resurfacing (42) and can be elicited during the physical examination using a provocative impingement test that combines hip flexion, adduction, and internal rotation. (43) There are a number of factors that can result in impingement, including anterior protrusion of the femoral neck, bony deformity of the proximal femur, and component malalignment. The head-neck diameter ratio is considerably reduced in surface arthroplasty compared to standard THA, given that the femoral neck is retained. Various types of femoral head and neck abnormalities, such as the pistol grip, have been associated with femoroacetabular impingement (FAI) and early osteoarthritis. (44,45) The asphericity of the femoral head and flattening of the head-neck junction typical of the pistol grip deformity will further contribute to prosthetic impingement because of the loss of anterior femoral headneck offset ratio. (46) Retroversion of the acetabular component or posterior translation and anterior angulation of the femoral implant also will cause the femoral neck to abut the acetabular rim, resulting in persistent pain postoperatively during hip flexion (Fig. 2).

Complete radiographic evaluation of orthogonal views is essential to identify anatomic abnormalities preoperatively and to exclude impingement postoperatively. The femoral head-neck offset ratio can be estimated from a cross-table lateral radiograph and a value less than or equal to 0.15 has been found to be consistent with FAI. (46) Recognition of bony deformities prior to resurfacing and adequate correction at the time of surgery are the mainstay in the prevention of impingement and postoperative pain. Restoration of the head-neck offset can be achieved by slightly translating the femoral component anteriorly with posterior alignment. (47) Excessive translation is limited by the amount of host bone and the thickness of the cement mantle required for fixation of the femoral implant. Orienting the acetabular component in sufficient anteversion may prevent impingement within the patient's functional range. Over-sizing the femoral component entails a larger acetabular cup and unnecessary removal of bone stock around the acetabulum. Removal of femoral neck osteophytes (22) and neck osteoplasty (42) have been recommended to avoid postoperative impingement, although the former should be performed cautiously since it has been associated with femoral neck fractures. (47)



As the indications for hip resurfacing continue to expand and the survival rates remain encouraging, more surgeons will be performing this procedure for young and active patients with osteoarthritis. Determining the source of hip pain following surface arthroplasty is challenging, and it is imperative to avoid the technical pitfalls that can result in postoperative pain and failure. Early recognition of other common causes of groin pain will also facilitate the initiation of appropriate treatment.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.


(1.) Mancuso CA, Salvati EA, Johanson NA, et al. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty. Jun 1997;12(4):387-96.

(2.) Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. Mar 20 1996;275(11):858-65.

(3.) Buergi ML, Walter WL. Hip resurfacing arthroplasty: the Australian experience. J Arthroplasty. Oct 2007;22(7 Suppl 3):61-5.

(4.) Shimmin A, Beaule PE, Campbell P. Metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg Am. Mar 2008;90(3):637-54.

(5.) Quesada MJ, Marker DR, Mont MA. Metal-on-metal hip resurfacing: advantages and disadvantages. J Arthroplasty. Oct 2008;23(7 Suppl):69-73.

(6.) Braunstein EM, Cardinal E, Buckwalter KA, Capello W. Bupivicaine arthrography of the post-arthroplasty hip. Skeletal Radiol. Oct 1995;24(7):519-21.

(7.) Lieberman JR, Huo MH, Schneider R, et al. Evaluation of painful hip arthroplasties. Are technetium bone scans necessary? J Bone Joint Surg Br. May 1993;75(3):475-8.

(8.) Merkel KD, Brown ML, Dewanjee MK, Fitzgerald RH, Jr. Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis. A prospective study. J Bone Joint Surg Am. Mar 1985;67(3):465-76.

(9.) Palestro CJ, Kim CK, Swyer AJ, et al. Total-hip arthroplasty: periprosthetic indium-111-labeled leukocyte activity and complementary technetium-99m-sulfur colloid imaging in suspected infection. J Nucl Med. Dec 1990;31(12):1950-5.

(10.) Mulamba L, Ferrant A, Leners N, et al. Indium-111 leucocyte scanning in the evaluation of painful hip arthroplasty. Acta Orthop Scand. Oct 1983;54(5):695-7.

(11.) Levitsky KA, Hozack WJ, Balderston RA, et al. Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty. Sep 1991;6(3):237-44.

(12.) Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. May 1999;81(5):672-83.

(13.) Sanzen L, Carlsson AS. The diagnostic value of C-reactive protein in infected total hip arthroplasties. J Bone Joint Surg Br. Aug 1989;71(4):638-41.

(14.) Toms AP, Marshall TJ, Cahir J, et al. MRI of early symptomatic metal-on-metal total hip arthroplasty: a retrospective review of radiological findings in 20 hips. Clin Radiol. Jan 2008;63(1):49-58.

(15.) Khanduja V, Villar RN. The role of arthroscopy in resurfacing arthroplasty of the hip. Arthroscopy. Jan 2008;24(1):122. e121-3.

(16.) Marker DR, Seyler TM, Jinnah RH, et al. Femoral neck fractures after metal-on-metal total hip resurfacing: a prospective cohort study. J Arthroplasty. Oct 2007;22(7 Suppl 3):66-71.

(17.) Shimmin AJ, Bare J, Back DL. Complications associated with hip resurfacing arthroplasty. Orthop Clin North Am. Apr 2005;36(2):187-93, ix.

(18.) Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. J Bone Joint Surg Br. Apr 2005;87(4):463-4.

(19.) Vail TP, Glisson RR, Dominguez DE, et al. Position of hip resurfacing component affects strain and resistance to fracture in the femoral neck. J Bone Joint Surg Am. Sep 2008;90(9):1951-60.

(20.) Campbell P, Beaule PE, Ebramzadeh E, et al. The John Charnley Award: a study of implant failure in metal-on-metal surface arthroplasties. Clin Orthop Relat Res. Dec 2006;(453):35-46.

(21.) Cossey AJ, Back DL, Shimmin A, et al. The nonoperative management of periprosthetic fractures associated with the Birmingham hip resurfacing procedure. J Arthroplasty. Apr 2005;20(3):358-61

(22.) Amstutz HC, Beaule PE, Dorey FJ, et al. Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study. J Bone Joint Surg Am. Jan 2004;86(1):28-39.

(23.) Kim PR, Beaule PE, Laflamme GY, Dunbar M. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty. Sep 2008;23(6 Suppl 1):44-9.

(24.) Amstutz HC, Le Duff MJ. Background of metal-on-metal resurfacing. Proc Inst Mech Eng [H]. Feb 2006;220(2):85-94.

(25.) Morlock MM, Bishop N, Ruther W, et al. Biomechanical, morphological, and histological analysis of early failures in hip resurfacing arthroplasty. Proc Inst Mech Eng [H]. Feb 2006;220(2):333-44.

(26.) Beaule PE, Matar WY, Poitras P, et al. 2008 Otto Aufranc Award: component design and technique affect cement penetration in hip resurfacing. Clin Orthop Relat Res. Jan 2009;467(1):84-93.

(27.) Benson MK, Goodwin PG, Brostoff J. Metal sensitivity in patients with joint replacement arthroplasties. Br Med J. Nov 15 1975;4(5993):374-5.

(28.) Campbell P, Shimmin A, Walter L, Solomon M. Metal sensitivity as a cause of groin pain in metal-on-metal hip resurfacing. J Arthroplasty. Oct 2008;23(7):1080-5.

(29.) Willert HG, Buchhorn GH, Fayyazi A, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. Jan 2005;87(1):28-36.

(30.) Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. Mar 2001;83(3):428-36.

(31.) Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. Jul 2008;90(7):847-51.

(32.) Ala Eddine T, Remy F, Chantelot C, et al. [Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and conservative treatment in 9 cases]. Rev Chir Orthop Reparatrice Appar Mot. Dec 2001;87(8):815-9. [French]

(33.) Trousdale RT, Cabanela ME, Berry DJ. Anterior iliopsoas impingement after total hip arthroplasty. J Arthroplasty. Aug 1995;10(4):546-9.

(34.) Della Valle CJ, Rafii M, Jaffe WL. Iliopsoas tendinitis after total hip arthroplasty. J Arthroplasty. Oct 2001;16(7):923-6.

(35.) Fish DE, Chang WS. Treatment of iliopsoas tendinitis after a left total hip arthroplasty with botulinum toxin type A. Pain Physician. Jul 2007;10(4):565-71.

(36.) Johnston CA, Wiley JP, Lindsay DM, Wiseman DA. Iliopsoas bursitis and tendinitis. A review. Sports Med. Apr 1998;25(4):271-83.

(37.) O'Sullivan M, Tai CC, Richards S, Skyrme AD, Walter WL, Walter WK. Iliopsoas tendonitis a complication after total hip arthroplasty. J Arthroplasty. Feb 2007;22(2):166-70.

(38.) Heaton K, Dorr LD. Surgical release of iliopsoas tendon for groin pain after total hip arthroplasty. J Arthroplasty. Sep 2002;17(6):779-81.

(39.) Wank R, Miller TT, Shapiro JF. Sonographically guided injection of anesthetic for iliopsoas tendinopathy after total hip arthroplasty. J Clin Ultrasound. Sep 2004;32(7):354-7.

(40.) Noble PC, Box GG, Kamaric E, Fink MJ, Alexander JW, Tullos HS. The effect of aging on the shape of the proximal femur. Clin Orthop Relat Res. Jul 1995(316):31-44.

(41.) Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg Am. Aug 2007;89(8):1832-42.

(42.) Lavigne M, Rama KR, Roy A, Vendittoli PA. Painful impingement of the hip joint after total hip resurfacing: a report of two cases. J Arthroplasty. 2008 Oct;23(7):1074-9; Epub 2008 Jan 24.

(43.) Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome. A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br. May 1991;73(3):423-9.

(44.) Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res. Dec 1986;(213):20-33.

(45.) Ito K, Minka MA 2nd, Leunig M, et al. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. Mar 2001;83(2):171-6.

(46.) Beaule PE, Harvey N, Zaragoza E, et al. The femoral head/ neck offset and hip resurfacing. J Bone Joint Surg Br. Jan 2007;89(1):9-15.

(47.) Amstutz HC, Campbell PA, Le Duff MJ. Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am. Sep 2004;86-A(9):1874-7.

Vassilios S. Nikolaou, M.D. Ph.D., Stephane G. Bergeron, M.D., Olga L. Huk, M.D., M.Sc., David J. Zukor, M.D., and John Antoniou, M.D., Ph.D.

Vassilios S. Nikolaou, M.D. Ph.D., Olga L. Huk, M.D., M.Sc., David J. Zukor, M.D., and John Antoniou, M.D., Ph.D., are from the Division of Orthopaedic Surgery, McGill University, and the Lady Davis Institute for Medical Research, SMBD Jewish General Hospital, Montreal, Quebec, Canada. Stephane G. Bergeron, M.D., is from the Division of Orthopaedic Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada. Correspondence: John Antoniou, M.D., Ph.D., Lady Davis Institute for Medical Research, SMBD Jewish General Hospital, 3755 Chemin de la Cote Ste-Catherine, Montreal, Quebec H3T 1E2 Canada; janton@orl.mcgill.ca.
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