Thigh Pain After Total Hip Arthroplasty

1
Thigh Pain After Total Hip Arthroplasty

• Sepein Chiang, D.O.
• Garden City Hospital

2
Introduction

• Disabling hip pain is the primary indication for
  total hip arthroplasty
• THA is very successful
• Occasionally, there is persistent hip/thigh pain
  despite well-fixed and well-positioned components

3
Introduction

• Pain or point tenderness of the thigh at the
  distal tip of the femoral prosthesis
• Severity ranges from start-up pain to
  debilitating pain that limits ambulation
• Most are not limited in their activity and take
  NO pain medications

4
Introduction

• Usually spontaneously resolves within the first 1
  to 2 years postoperatively
• Persistent pain often responds to activity
  modification, NSAIDs or analgesics

5
Introduction

• For some, significant cause for dissatisfaction
• Severe pain has been reported in 1.4 to 4 of
  THAs
• Severe pain that does not respond to conservative
  measures may require revision surgery

6
Causes

• Rule out loose stem, infection, stress fracture
  and spinal/neurologic problems
• History physical exam
• Radiographs
• Bone scans
• Lab tests- CBC, ESR, CRP, joint aspiration

7
Causes prosthesis factors

• Mismatch in modulus of elasticity
• Cobalt chrome vs titanium
• Stem size
• Cemented vs cementless
• Proximal vs extensive porous coating
• Bony vs fibrous ingrowth
• Length of follow-up

8
Bony Ingrowth

• No radiopaque lines
• No subsidence
• Mild cortical hypertrophy
• Mild proximal stress shielding

9
Probable Stable Fibrous Ingrowth

• Parallel radiopaque lines up to 1 mm without
  progressive migration

10
Unstable Cementless Stem

• Divergent radiopaque lines
• Progressive subsidence or migration
• Bony pedestal

11
Causes technique factors

• Poor stem sizing with instability and
  micromotion, and radiographic bony pedestal and
  progressive bead shedding
• Stem malposition with stress transfer

12
Causes patient factors

• Age
• Sex
• Activity level
• Bone quality

13
Type of Stem Fixation

• Barrack and Paprosky, The Journal of
  Arthroplasty, August 2000
• Age, sex, activity level, length of follow-up,
  stem size, bone type (Dorr index) and type of
  femoral stem fixation
• 2 surgeons at 2 university hospitals
• 320 patients, 2 4 years post-op (mean 3 years)

14
Barrack and Paprosky

• Matched pair analysis between proximally coated
  (Replica, DePuy) and fully coated stems (Prodigy,
  DePuy)
• Matched pair analysis between cemented stems
  (Endurance, DePuy) and fully coated stems

15
Barrack and Paprosky

• Type of fixation was the only parameter that
  correlated to thigh pain
• Overall pain in 42 proximally coated, 19 fully
  coated and 16 cemented
• Matched prox vs fully coated 4220
• Matched fully coated vs cemented 1816
• No difference in severity

16
Type of Stem Fixation

• Engh, JBJS 1997
• 26 incidence of thigh pain in the proximally
  coated AML
• 17 with the extensively coated AML

17
Cemented vs Noncemented

• DLima, Oishi, Petersilge, Colwell and Walker
  CORR 1998
• 200 consecutive primary THAs
• Thigh pain in 3 cemented, 40 noncemented
• In 25 matched pairs, thigh pain in 2 (8)
  cemented, 8 (32) noncemented

18
Bony vs Fibrous Ingrowth

• Engh, et al
• British Editorial Society of Bone and Joint
  Surgery, January 1987
• 307 patients at 2 years follow-up
• No correlation between thigh pain and age, sex or
  disease process
• Thigh pain in 11 good bone, 26 poor bone quality

19
Engh, et al

• 3X lower incidence of thigh pain with bony vs
  fibrous ingrowth
• Bony ingrowth in 93 of press fit vs 69 with no
  press fit
• Thigh pain in 9 press fit vs 23 with no press
  fit

20
Stem Instability

• Campbell, Rorabeck, Bourne, Nott
• 110 patients, 2 year follow-up
• PCA (porous coated anatomic, Howmedica)
• Thigh pain correlated with subsidence greater
  than 2 mm, distal periosteal reaction and
  progressive bead shedding
• Suggests stem instability with distal stress
  transfer

21
Treatment

• Activity modification
• Non-weightbearing 6 weeks
• NSAIDs
• Analgesics
• Cortical strut grafting
• Revision surgery

22
Cortical Strut Grafting

• Domb, Hostin, Mont Hungerford
• Cortical strut grafting of the lateral femur
  without revision of the femoral component
• Struts spanned the distal tip 3 inches proximally
  and distally

23
Cortical Strut Grafting

• 6 of 7 gained relief with 5 excellent and 1 good
  HSS score
• Increases the rigidity of the host bone to
  decrease the modulus mismatch of the prosthesis
  and host bone
• Denervation of the bone
• Originally described by Hedley and Firestone in
  11 of 12 patients

24
Conclusions

• Thigh pain following THAs can range from mild
  start-up pain to debilitating pain requiring
  revision surgery
• Severe thigh pain is relatively uncommon, 1.4 to
  4
• Instability, micromotion and modulus mismatch
  most common causes