HIP ARTHROPLASTY
Painful total hip
arthroplasty
Jurek RT Pietrzak
Matthew J Donaldson
Babar Kayani
Fares S Haddad
Abstract
Total hip arthroplasty (THA) is a common surgical procedure that im-
proves patients’ quality of life and function with great and reproducible
success. However, long-term pain is experienced in 7e23% of pa-
tients. This article discusses potential predisposing factors, their aeti-
ology and the subsequent evaluation of persisting pain after THA. A
thorough, structured approach to clinical history and examination al-
lied with knowledge of potential differential diagnoses will help focus
subsequent investigations to determine the cause. Diagnosis allows
the provision of the most appropriate nonoperative or operative treat-
ment course.
Keywords Assessment; diagnosis; evaluation; pain; total hip
replacement
Introduction
Total hip arthroplasty (THA) is one of the successful surgical
procedures in modern medicine. There are almost 2.55 million
people living with a THA in the USA alone. THA favourably
impacts the vast majority of patients’ general health, quality of
life and functioning while being a cost-effective surgical pro-
cedure. Hip pain is one of the most important indications for
THA. THA can allow enduring improvement in physical function
for over 25 years and is generally unaffected by mild pain.1
Jurek RT Pietrzak MBBCh (Wits) FC Orth (SA), Senior Clinical Fellow in
Orthopaedics, Department of Trauma and Orthopaedics, University
College London Hospital (UCLH), UK. Conflicts of interest: none
declared.
Matthew J Donaldson BSc (Adv) MBBS (Syd), Orthopaedic Research
Fellow, UCLH, Department of Trauma and Orthopaedics, University
College London Hospital (UCLH), UK. Conflicts of interest: none
declared.
Babar Kayani BSc (Hons) MRCS MBBS Senior Orthopaedic Research
Fellow, UCLH, Department of Trauma and Orthopaedics, University
College London Hospital (UCLH), UK. Conflicts of interest: none
declared.
Fares S Haddad BSc MD(Res) MCh (Orth) FRCS (Orth) FFSEM, Consultant
Orthopaedic Surgeon, University College London Hospitals, Hon.
Professor, Division of Surgery, University College London, Clinical
Research Lead, UCLH Orthopaedics, Divisional Clinical Director of
Surgery UCH, Director, Institute of Sport, Exercise and Health,
UCLH, Department of Trauma and Orthopaedics, University College
London Hospital (UCLH), UK. Conflicts of interest: none declared.
ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Pietrzak Jurek RT., et al., Painful total hip arthroplasty, Orthopaedics and Trauma (2017), https://doi.org/
10.1016/j.mporth.2017.11.008
Despite the reported levels of improvement, between 3.3%
and 16.8% of patients are not completely satisfied with their
outcome post-THA, with the incidence of chronic pain reported
as varying between 7% and 23%.2 This can be due to functional
limitation or activity related pain, where walking and climbing
stairs remain uncomfortable for patients. Britton et al.3 charac-
terized the pattern of pain following THA in 2000 patients,
demonstrating that pain improved considerably during the first
6 months, followed by a modest amelioration of pain over the
following 2 years and in some cases up to 4 years. However,
a subset of patients seem to not have any improvement in pain
beyond 12 months post-THA.
The end stage for progressive THA pain is revision surgery.
Sadoghi et al.4 used world-wide registry data to identify that the
common causes for THA revision are aseptic loosening (55.2%),
instability (11.8 %) and septic loosening (7.5%) while 3.5%
were done for ‘pain without other cause’. It is therefore
important to understand the variability, natural history and
appropriate timing of investigations and treatment of ‘the painful
THA’. This is especially the case in those patients with new onset
or suddenly worsening pain.
Predictors of pain after THA
Certain patient groups may be more susceptible to dissatisfaction
and pain after THA. It is therefore important to identify those pa-
tients who require extended counselling prior to THA and attempt
risk reduction where possible. Local registry data may assist in
identifying commonly encountered co-variables of reported THA
pain. The Swedish hip registry (approximately 35,000 cases)
identifies that although satisfaction with THA is almost 90%, the
presence of pain in several joints, advanced age and male gender
were predictive of poorer outcomes. Other considerations should
include education, comorbidities and mental health.
Whilst complaints of pain from multiple sites prior to THA has
been shown to predict poorer outcomes, the impact of age and
gender is controversial. A prospective double blind randomized
study that showed that there was no correlation of pain with age.
Age may be a greater predictor of the degree of functional
improvement than the extent of pain relief. Gender appeared to
make no difference to the likelihood of pain after THA, although
in the same study, Singh et al.5 noted that females more often
reported extended NSAID and opioid use.
A greater improvement in pain has been noted in patients
with a higher level of education. MacWilliam et al.6 described
how a statistically significant (p < 0.01) change in pain score for
each additional co-morbidity was evident in patients with a low
level of education. Patient expectations also affect post-
operative outcomes. A strong understanding and belief that
THA will result in pain relief results in a greater likelihood of
improvement in the pain component of the WOMAC score. The
amount of time spent waiting for surgery is not significantly
associated with persistent hip pain post-THA.7
Depression and diabetes are both associated with greater
probability of post-THA pain. Adequate control and counselling
should be considered in these patient groups. Moderate to severe
pain was significantly related to depression in a retrospective
review of 5707 THAs at 2 years’ follow-up, but not in 3289
THAs at 5 years.5 Diabetes is a risk factor for persistent pain
1 Ó 2017 Elsevier Ltd. All rights reserved.
 HIP ARTHROPLASTY

1e2 years after primary THA. This may be as a result of a chronic extra-capsular. Sources of intrinsic pain include mechanical
systemic pro-inflammatory state, or due to glucose control and loosening, infection, modulus mismatch, impingement caused by
diabetes-related complications, such as neuropathy. soft tissue or bone and pain as a consequence of synovitis orig-
In a review of 42,233 patients on the Swedish Hip Arthro- inating from polyethylene debris, metal hypersensitivity or
plasty Register, Rolfson showed that more patents had a lower allergy.
incidence of pain with the posterior hip approach versus the It is essential that periprosthetic joint infection (PJI) is a
direct lateral approach (78% vs 74%) at 1 year, This correlation foremost consideration in any differential diagnosis for painful
persisted to 6 years follow-up.8 Pain during the immediate post- THA. The rate of PJI may be up to 3% in primary THA. The high
operative period may impact on pain intensity profiles 6 weeks index of suspicion for PJI is paramount as subsequent manage-
later but does not seem to influence the persistence of pain at 6 ment of septic failure is vastly different from aseptic causes.
months. Diagnosis is based on the findings of raised inflammatory
markers, positive cultures from hip aspiration and suggestive
Causes of painful THA radiographic findings such as endosteal scalloping and periosteal
reaction.
A systematic approach is imperative to determine the underlying
Pain may be caused by aseptic loosening of implants. In
cause of pain after THA. This ultimately determines the most
general, a loose femoral component classically provokes thigh
appropriate course of nonoperative, pharmacological or surgical
pain. Loose acetabular components commonly result in groin
management. The causes of a painful THA can be divided into
pain or can induce isolated buttock pain. This pain is usually
intrinsic (involving the prosthetic implants and hip joint) and
more distal than mechanical pain derived from the lumbar spine.
extrinsic pathologies. The causes are listed in Table 1 with a
Aseptic loosening may be diagnosed radiographically by
complementary flow diagram, Figure 1, included as a summary
observing progressive implant movement or radiolucencies at the
of recommendations and for reference.
bone interfaces. Fibrous ingrowth and resultant implant micro-
Intrinsic causes motion may render THA painful despite the appearance of
An intrinsic cause of pain is derived from the hip joint itself. radiographically well-fixed components.
Intrinsic causes may be further categorized as intra-capsular or The rate of postoperative periprosthetic femoral fractures
varies from 0.1% to 5.4% as shown by Berry et al.,9 where the
incidence of periprosthetic fractures was reported to be 0.3% in
Causes of pain following total hip arthroplasty 20,859 primary cemented THAs and 5.4% in 3121 uncemented
Intrinsic Infection
THAs. Data from the Swedish National Hip registry show the
Aseptic loosening
average time from implantation to fracture was approximately
Instability
7.4 years in a primary THA and 3.9 years in revision THA.
Pain at stem tip
Studies using data from the Mayo Clinic and the Swedish registry
C Modulus mismatch
showed that 94% and 70% of patients respectively had stem
Synovitis loosening before fracturing.10 Insufficiency fractures of the pubic
C Polyethylene debris rami may exist after THA which can also result in pain.
C Metal hypersensitivity A difference between the modulus of elasticity of the bone and
C Crystalline arthropathy the implant exists and is a rare cause of pain, ordinarily in the
Extrinsic Local Impingement thigh. This pain is generated as a result of the stress transfer
C Bone (GT/pelvis) mismatch between the implant and the host bone. Stem geom-
C Soft tissue etry, size composition and porous coating can influence this
Bursitis phenomenon. The prevalence of thigh pain has been linked to
Tendonitis increased size of femoral stem.
Heterotopic ossification Impingement of the components may culminate in pain from
Stress fracture instability or soft tissue irritation. Subluxation or dislocation as a
Remote Spine consequence of hip instability causes capsular distension and
C Facet arthritis/spondylosis soft tissue trauma, inducing pain. The capsule may be impinged
C Radiculopathy or compressed between the neck and cup or between the greater
C Stenosis trochanter and ilium. This is influenced by component design,
Neuropathy/nerve entrapment alignment and abductor tension and function. Sources of insta-
C Femoral, obturator, sciatic bility and or impingement such as areas of cement, osteophytes
C Lateral femoral cutaneous or component malalignment may be delineated by computed
Vascular claudication tomography (CT) scan.
Hernia Iliopsoas tendinitis may result from inadequate acetabular
C Abdominal anteversion or disproportionate antero-inferior overhang. This
C Vastus lateralis/fascia lata groin pain is provoked by active and resisted hip flexion. It may
Tumour limit a patient’s ability to easily climb stairs, get into and out of
GT, greater trochanter. vehicles or put on trousers as a consequence of painful hip
flexion. Image-guided infiltration of local anaesthetic may be
Table 1 diagnostic and therapeutic.

ORTHOPAEDICS AND TRAUMA --:- 2 Ó 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Pietrzak Jurek RT., et al., Painful total hip arthroplasty, Orthopaedics and Trauma (2017), https://doi.org/
10.1016/j.mporth.2017.11.008
 HIP ARTHROPLASTY
Figure 1 Flow diagram for painful THA. CSP, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; USS, ultrasound
scan.
Extrinsic causes
Extrinsic sources of pain are as a result of pathologies outside the
hip joint and can be further categorized into local or remote
causes. Local extrinsic causes relate to the hip joint but do not
involve the THA prosthesis. Remote extrinsic sources occur
when pain radiates to the hip area.
Local extrinsic pain includes lateral hip pain due trochanteric
bursitis, abductor tear or fatigue, suture irritation or retained/
broken wires. Inadequate closure of the fascia lata may result in
the herniation of vastus lateralis, recognizable by direct deep
palpation, which may manifest as lateral hip pain. Pain may also
be referred from the genito-urinary tract, inguinal hernia or other
muscle hernias. Partial or complete avulsion of the abductor
musculature, especially with anterolateral surgical approaches, is
a postoperative complication which may reflect as pain, weak-
ness or both.
Heterotopic ossification (HO) may occur after THA. It is
controversial whether the presence of HO without impingement
causes pain. However, the presence of voluminous amounts of
HO may definitively limit range of motion and cause significant
impingement which may be severely disabling. Approximately
8% of THA patients experience mostly activity-related HO pain,
however, the radiographic prevalence may be as much as 90%.
Lumbosacral pathology frequently exists at the same time as a
hip complaint. Spinal stenosis, disc herniation, spondylosis,
spondylolisthesis and radiculopathy may mimic hip pain. Dis-
tinguishing the true source of pre-operative pain may be difficult.
Clinical evaluation may aggravate both intrinsic hip pathology
and sacro-iliac and lumbar disease. One suggested method is hip
anaesthetic arthrograms.
ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Pietrzak Jurek RT., et al., Painful total hip arthroplasty, Orthopaedics and Trauma (2017), https://doi.org/
10.1016/j.mporth.2017.11.008
Inadvertent nerve injury at the time of surgery may result in
pain, particularly the femoral, sciatic or lateral femoral cutaneous
nerves. Arterial insufficiency may present as hip or buttock pain
in those with vascular disease. There are case reports of groin
and buttock pain due to gluteal or iliac artery stenosis. Vascular
referral for investigation should be considered as angioplasty
may relieve perceived THA pain.
Rare sources of pain include primary bone tumours, soft tis-
sue tumours or metastatic lesions in the vicinity of THA pros-
theses. Visuri et al.11 highlighted the infrequency of this
pathology by showing that only 31 soft tissue sarcomas and 10
bone sarcomas reported in the literature between 1974 and 2003
were associated with THA. Malignant fibrous histiocytoma is the
most common associated malignant tumour. Missing this pa-
thology is both easy, as radiographs may be crowded with
hardware and osteolytic defects, and ultimately devastating.
Unfortunately, identifying the root of painful symptoms in
THA may prove impossible. The term ‘painful prosthesis’ has
been used to describe the idiopathic origin of pain when no
specific cause can be detected. Treatment strategies may include
revision surgery with unpredictable clinical outcomes especially
pertaining to pain relief.
History
As described above a long list of potential causes of pain after
THA exist. It is therefore imperative that a comprehensive and
exhaustive history and subsequent clinical examination allow
focused investigation. Determination of the nature, onset, site,
frequency, relieving and exacerbating factors of pain are
essential.
3 Ó 2017 Elsevier Ltd. All rights reserved.
 HIP ARTHROPLASTY
Should the presumed hip pain remain unchanged following
arthroplasty surgery, careful consideration must be given to the
accuracy of the initial diagnosis for which THA was performed.
Other causes of pain should be pursued with renewed vigour.
However, a change in the type of pain makes a surgical cause
more plausible. Constant, unremitting pain may indicate infec-
tion, fracture, or impingement. Late-onset pain may suggest
aseptic loosening, low-grade infection, osteolysis or instability.
‘Start-up’ pain, or pain on initiation of movement may be a sign
of prosthetic loosening.
Determination of the exact site of pain may suggest cause.
Pain over the greater trochanter may be caused by trochanteric
wires, bursitis or non-union. Groin pain may signal acetabular
component concerns, inguinal hernia or iliopsoas irritation. The
origin of deep gluteal pain may be from the lower back, sacro-
iliac joint, proximal hamstring tendinopathy or neurogenic
problem, but could also be from acetabular loosening. Loosening
at the tip of the femoral stem may cause pain in the back of the
thigh.
A history of persistent wound ooze, delayed wound healing,
haematoma formation or a protracted in-patient hospital stay
may hint at PJI.
Every effort should be made to get access to the patient’s
previous hospital records especially operation details such as
surgical approach, provision and timing of prophylactic antibi-
otics, untoward perioperative events, blood transfusion etc.
Examination
The first part of the clinical examination is evaluation of the
patient’s gait and determining whether it is an antalgic, Tren-
delenburg (as a result of abductor deficiency) or short limb gait.
True and apparent limb length discrepancy must be measured
and any pelvic obliquity and scoliosis be identified. Progressive
leg shortening may indicate loosening with subsequent subsi-
dence of the prostheses. Skin inspection is obligatory for identi-
fication of scars, sinuses or inflammation around the hip. Deep
palpation of tenderness is necessary to identify, for instance,
underlying neuromas or trochanteric bursitis.
Examination of range of movement may provide diagnostic
clues. Impingement or loosening may manifest as pain at ex-
tremes of movement, while pain throughout the range may
indicate an infective or inflammatory process. The Stinchfield
test is a valuable test that distinguishes between intra-articular
and extra-articular hip pathology. This is a pain elicited by an
increase in hip joint reactive force with resisted active flexion of
the hip.
Investigations
Blood tests
Blood tests in painful THA are essential to exclude an infective
process. Routine blood investigations include full blood count
(FBC), erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP). Leucocyte count alone is non-contributory in diagnosing
infection and is only raised in 15% of cases of confirmed PJI.
Spangehl et al.12 highlighted its limited use in PJI by reporting
that an elevated leucocyte count has a sensitivity of 20%, spec-
ificity of 96%, a positive predictive value of 54% and a negative
predictive value of 84%.
ORTHOPAEDICS AND TRAUMA --:-
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10.1016/j.mporth.2017.11.008
ESR is a non-specific marker of inflammation. It falls to less
than 20 mm/hour after about 6 months in uncomplicated
THA. A PJI is highly suspicious should the ESR be notably
higher, a mean greater than 60 mm/hour. The CRP returns to a
normal value more rapidly than the ESR. It peaks at day 2 and is
usually normal after 3 weeks. Therefore, an increase in CRP may
be suggestive of an infection. Spangehl et al.12 showed that the
combination of a normal ESR and CRP had a specificity of 100%
for excluding the diagnosis of PJI in patients with a painful THA.
The evaluation of serum interleukin (IL)-6 may play a role in
the diagnosis of infection. Hoell et al.13 showed that serum IL-6
of 13 pg/ml or higher has a positive-predictive value of 90.9%
for indicating infection. A serum IL-6 of 8 pg/ml or higher may
indicate an absence of infection.
Radiography
Plain radiographs are a requisite starting point for any analysis of
a painful THA. They provide indispensable information
regarding component position, limb length inequality, femoral
offset and appraisal of all prosthetic interfaces.
Serial radiographs are the most effective method of detecting
component loosening. Therefore, in addition to obtaining pre-
operative imaging, initial post-operative radiographs are impor-
tant as they provide a reference point for any future comparison.
Radiographs should be taken in a consistent manner with regard
to positioning, penetration and rotation to allow for the most
advantageous comparison.
The patient may be more vulnerable to particular failure
modes such as metallosis in metal-on-metal THA or failed seating
of ceramic liner in the metal acetabular socket as a result of
component mal-positioning. Radiographs must be studied to
determine the type of implant and bearing surface coupling
should operative notes not be available.
Radiographic criteria to assess loosening of both cemented
and uncemented femoral stems exist. As previously mentioned,
sequential review of serial radiographs adds most value. The
Harris classification may be used for cemented femoral implants.
In a review of 171 cemented THAs the likelihood of loosening
was defined as ‘possible’, ‘probable’ or ‘definite’ based on
defined radiographic criteria14. The presence of a radiolucent
line of 50e100% of the cement-bone interface on at least one
view is interpreted as ‘possibly loose’ while the radiolucency
found in 100% of the interface is referred to as ‘probably loose’.
Migration or cement mantle fracture is indicative of a ‘definitely
loose’ component. Subsequent studies have, however, disputed
the validity of these criteria.
In cemented femoral components, radiographic signs that
may hint at loosening described by Engh et al.15 include migra-
tion, reactive lines, pedestal formation, calcar hypertrophy, bead
loss and the absence of clear areas of osseointegration (‘spot
welds’).
DeLee and Charnley16 three-zone radiological analysis should
be utilised to describe loosening of cemented and uncemented
acetabular components. The more progressive and extensive the
lucent radiologic lines are the more likely implant loosening is
present. Lucency in all three zones is associated with a high
incidence of loosening (>90%) and requirement for revision sur-
gery. Periosteal reaction, scalloping of the bone or rapidly pro-
gressive osteolysis are concerning for radiologic sequelae of PJI.
4 Ó 2017 Elsevier Ltd. All rights reserved.
 HIP ARTHROPLASTY
Nuclear imaging
The use of nuclear imaging using radioisotope tracers may assist
with the diagnosis of loosening or infection in the painful THA.
The binding of the radioisotope in technetium-99 methylene
diphosphate bone scans to calcium hydroxyapatite in metaboli-
cally active bone with increased blood flow is sensitive, but lacks
specificity for infection or loosening. Lucid interpretation is
essential as increased uptake is seen in other conditions such as
fracture, osteolysis and malignancy. It can also persist in the
acetabulum, greater trochanter and prosthetic tip even in
asymptomatic, uncomplicated THA up to 2 years post-
operatively.17
Special tracers have been developed to differentiate between
metabolic and mechanical pathology more reliably. Indium-111
binds preferentially to leukocytes. It has therefore been re-
ported as having a greater sensitivity (86%e92%) and specificity
(73%e100%) in diagnosing PJI. Oswald,18 however, showed
that there may be an increased uptake of technetium and
indium-111 in uncomplicated, asymptomatic THAs by porous-
coated implants up to 2 years after implantation. The uptake in
cemented stems, however, peaks at 12 months.
Improved accuracy in detecting infection may be achieved
with the addition of a technetium colloid scan for which uptake
in infection is different to that of a labelled-leucocyte tracer. This
combination allows a sensitivity and specificity of diagnosing
infection of greater than 90%.
The use of fluorodeoxyglucose positron emission tomography
(FDG-PET) scans has shown promise especially in discriminating
between septic and aseptic causes of loosening. It is not, how-
ever, widely available.
Magnetic resonance imaging (MRI)
MRI allows improved visualization of the surrounding soft tis-
sues compared to other imaging modalities. It may better define
the abductor attachment, inflammatory reaction to debris such as
pseudotumours, neurovascular structures, extravasated cement
or heterotopic bone.
Its use in the immediate surrounding peri-articular soft tissues
may be limited by metal artifact. Subsequently, Olsen et al.19
described the first integrated approach to a metal-suppression
sequence. Metal artifact reduction sequence (MARS) solves the
trouble with the artifact obscuring the periprosthetic tissues.
MARS MRI is a highly sensitive modality for the detection of
small pseudotumors and assessment of hip muscle atrophy.
Ultrasound may also be of benefit. Ultrasound may also pro-
vide detailed imaging of solid or cystic extra-articular lesions. It
may assist in the detection of muscle atrophy, joint effusion,
gluteal tendon avulsion and iliopsoas or trochanteric bursitis.
Siddiqui et al.20 found in a prospective cohort study comparing
MARS MRI and ultrasound that ultrasound was superior for
detection of joint effusion and tendinous pathologies but inferior
for pseudotumours and muscle atrophy.
Computed tomography (CT)
CT scans can be used to analyse loosening in cementless femoral
stems that appear stable on plain radiographs. CT scans are also
of value in determining not only the presence, but the extent of
peri-prosthetic fractures, bone loss within the acetabulum and
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10.1016/j.mporth.2017.11.008
femur, suspected impingement, evaluation of bone density due
to stress shielding, detection of liner wear and metallosis.
Metal artifact may hinder accurate CT analysis. Metal artifacts
can be minimized by technical manipulation of the scanning
process, using appropriate reconstruction algorithms and section
thickness. CT scans optimized to reduce metal artifact can allow
improved evaluation of the implant hardware, component fixa-
tion and the host bone and soft tissues.
Robinson et al.21 showed that CT was better than MARS MRI
in determining osteolysis. CT, however, was unable to detect
many pseudotumors and was considered an unsuitable substitute
should MARS MRI not be available. Ultrasonography should then
rather be considered.
Hip aspiration
The American Academy of Orthopaedic Surgeons Clinical Prac-
tice Guidelines proposed that hip aspiration for both white cell
count and differential and microscopy, culture and sensitivity be
done should if either (or both) ESR and CRP be elevated. Aerobic
and anaerobic culture and culture in agar based broth media
should be undertaken on fluid aspirated fluid from the hip. A PJI
is possible should the hip aspiration produce a positive cell count
and culture. The hip may need to be re-aspirated should results
be indefinite. Hip aspirate culture alone yields a variable sensi-
tivity of 50%e86%. Della Valle et al.22 reported that a greater
specificity, sensitivity and positive predictive value for recog-
nizing infection exists in patients with a serum ESR over
30 mm/hour, a CRP greater than 10 mg/dl and a synovial fluid
aspirate of more than 3000 white blood cells per ml.
Simultaneous injection of local anaesthetic injection and hip
aspiration may be of great diagnostic value. This approach may
help distinguish intrinsic from extrinsic sources of pain. Craw-
ford et al.23 reported that this technique provided a prompt,
reliable diagnosis with minimal morbidity and a sensitivity of up
to 96%.
New investigations
Serum and synovial biomarkers are more specific methods for
confirming PJI. These include serum biomarkers such as pro-
calcitonin, IL-6 tumor necrosis factor (TNF)-a and synovial fluid
biomarkers which include cytokines such as IL-1b, IL-6, IL-8 and
vascular endothelial growth factor. Another example, a defensin
is a synovial biomarker released from neutrophils in the presence
of bacteria. These may eventually surpass ESR and CRP serology
(especially since these are elevated in multiple inflammatory
conditions) and microbiological analysis of histology and culture.
An a defensin level of greater than 5.2 mg/ml has been reported
to have a sensitivity and specificity of 97% and 96%
respectively.24
Metallosis
Metallosis is a devastating source of painful THA that is of great
interest currently. Deviation from a thorough, uniform work-up
for painful THA must be avoided even in the presence of an
implant with high revision rates or increased metal ion levels.
There must be a high index of suspicion in THA with metal-on-
metal (MoM) bearing surface couplings and hip resurfacing
procedures. Metal-on-metal THAs may present with pain due to
5 Ó 2017 Elsevier Ltd. All rights reserved.
 HIP ARTHROPLASTY
hypersensitivity 1e3 years following arthroplasty. However, it
may also arise as a result of corrosion at the head-neck or
modular neck-stem junctions irrespective of the bearing surface.
Groin pain may be present in association with a palpable groin
mass.
The clinical use of metal ion levels in the evaluation and
diagnosis of painful THA with MoM bearing surface couplings is
evolving. The Medicines and Healthcare products Regulatory
Agency updated its recommendations regarding MoM THA in
June 2017. It reported that no agreed threshold value for whole
blood metal levels exists that either predicts outcome or man-
dates revision. They advised that any decision to revise must be
based on patient factors, blood metal levels, imaging findings
and implant type and position. The current recommendations
from the British MHRA25 advised that serum levels of either or
both chromium and cobalt levels in whole blood greater than 7
ppb necessitates closer evaluation and imaging. Cobalt levels in
cases with corrosion of modular junctions tend to be greater than
chromium levels. Metal ion levels are sometimes incongruous
with the degree of adverse local tissue reaction.
The use of MARS MRI is a useful adjunct in quantifying the
extent of soft tissue involvement. MARS MRI scans or ultrasound
scans are more valuable in evaluating MoM THA than isolated
blood metal levels alone. There is an important diagnostic and
subsequent planning role for ultrasound evaluation of patients
with MoM implants. Pain may also be accompanied by systemic
symptoms which may include fatigue, cardiomyopathy, polycy-
thaemia, neurological signs and hypothyroidism.
Summary
Any patient with a painful THA must be approached in an
organized and methodical manner. A comprehensive history and
thorough physical examination is essential. If this is combined
with an intricate knowledge of the potential differential di-
agnoses, it will determine the subsequent selection of appro-
priate special investigations allowing an eventual accurate
diagnosis in most cases. Any surgery without satisfying these
steps in attaining the correct diagnosis first may result in sub-
optimal outcomes. A
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ORTHOPAEDICS AND TRAUMA --:-
Please cite this article in press as: Pietrzak Jurek RT., et al., Painful total hip arthroplasty, Orthopaedics and Trauma (2017), https://doi.org/
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ORTHOPAEDICS AND TRAUMA --:- 7 Ó 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Pietrzak Jurek RT., et al., Painful total hip arthroplasty, Orthopaedics and Trauma (2017), https://doi.org/
10.1016/j.mporth.2017.11.008