The Painful Hip and Hip Revisions

In this episode of PodMD, Orthopaedic Surgeon Dr Paul Thornton-Bott will be discussing the topic of the painful hip and hip revisions, inlcluding what a hip revision is, causes of a painful hip, management and more.

• Transcript
  Please note this is a machine generated transcription and may contain some errors.
  *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

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  Today I’d like to welcome to the PodMd studio Orthopaedic Surgeon, Dr Paul Thornton-Bott

  Dr Thornton-Bott is an orthopaedic surgeon. His specialty/ special interest involves arthroplasty of the Hip and Knee, arthroplasty revisions, computer navigated, and robot assisted surgery and a focus on trauma; fractures and neck of femur outcome.

  Today, we’ll be discussing the topic of Hip revisions.

  *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
  If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

  Paul, thanks for talking with us on Pod MD today.

  Paul: Thank you for having me

  Question 1
  The topic of today’s discussion is the painful hip and hip revisions. Paul, can you describe for our listeners what a hip revision is?

  Paul: An excellent question, and it’s got a very high satisfaction rate,with modern techniques in the implants and the bearing surfaces totally replaced and should last many years, I expect my hip replacements to last the life of most of my patients, at least up to 25 years and sometimes longer,patients can sometimes have problems with the hip replacements. And I, I classify these issues as short, medium and long term.

  Question 2
  Tell me more about the classifications?

  Paul: So, the most common cause in a patient presenting with a painful hip replacement is failure of the hip 15 or more years after the initial surgery. This is long-term natural fader of joint replacement. commonly hip replacements are a metal ball on a plastic pocket or bearing, and the plastics put it on a 15 years ago, where else to a greater extent than the modern bearings that we’re using today, unfortunately is the plastic. Where’s the date re from this process causes damage to the bone surrounding the hip replacements. And this is called osteolysis. Now this can cause loosening of the implants as this happens, the patient is likely to develop pain often in the groin. And if the socket or the acetabular component becomes loose or pain in the top of the thigh as the femoral STEM.

  Question 3
  Can you go a little more into detail?

  Paul: Well, the most common cause in a patient presenting with a painful hip replacement is the failure of the hip 15 or more years after the initial surgery. And this is long-term natural failure of the joint replacement, but commonly hip replacements are a metal ball or a plastic socket or bearing. And the plastic put in over 15 years, years ago were out to a greater extent than the modern bearings we’re using. Now as the plastic, where’s the debut from this process causes damage to the bone surrounding the hip replacement. And this is called osteolysis. This process causes loosening of the implants. And as this happens, the patients are likely to develop pain often in the groin. If the socket or the acetabular component becomes loose or pain in the thigh, as the femoral STEM becomes loose, these patients will present to their GP with a classic start-up pain, where they first develop pain when waiting up in the morning. And this tends to settle slowly as the loose implants, then settle in or for a few steps. Many implants are cemented into the bone, certainly into the femur. And after many years of cement yourself can start to fail again, causing pain on mobilization.

  Question 4
  So, what is midterm failure and what can GPS expect to see?

  Paul: Well, patients present in between one- and 10-years following surgery, pain in the joint will often present with a sudden onset of pain and this made, and they may describe some sort of injury or a fall of the, which the pains come on and this could be due to subluxation of the joint where it is partially dislocated or a fracture. And it’s important in these patients to exclude a friendship around the implant. Now pain can be muscular in nature, such as audio, so it’s problems or Bluetooth problems such as trucking by scientists. Sometimes a hip replacement can loosen early and miss. This can be because of poor materials or often poor component position at the time as surgery. Another cause of midterm pain is infection, which thankfully Sean can be rare, but gradual onset of pain in the joint associated with swelling possible warmth or redness at the joint. it needs to be investigated thoroughly if a patient presents with fever, malaise, or lethargy, this may indicate sepsis and these more urgent management.

  Question 5
  What about early issues with a painful joint ?

  Paul: A patient who presents in the first year or less following the joint replacement are the ones often present the most challenges. It can be often difficult to work out more than this is a case where causes include loose components that had never really settled in or grown in instability, muscular pain, but scientists, scar pain. And again,occasionally we get infection.

  Question 6
  So, Paul, how do our GPs investigate, what is causing the pain?

  Paul: So we’re showing with the history and a good examination you can narrow in other courses that pain or for hip replacement is relatively rare. And it’s always important to identify alternative sources of pain and exclude pelvic abdominal neurological sources now it is very important to assess the lumbar spine as this can very commonly mimic hip pain. And the joint itself is fine. The GP should always examine the greatest kind of signs of preciseness as this is the cause of pain that can occur at any time during the life of joint replacement, rotating, the hip inflection can identify instability and growing pain on a straight leg raise may indicate earlier. So as scientists, an x-ray of the hip is important. First investigation for discovering evidence of loosening and poor implant position that may indicate early fight. Well, we’ve looked at the position of the board in the socket.

  If the head is not in the middle of the socket, then this could indicate where of the plastic liner or even fracture of a ceramic hip joint. This is a more complex condition looking around the implants themselves, both in the femur in this and the pelvis. You can sometimes see gaps and they should always be treated with suspicion. And these signs of loosening the best with a CT or a bone scan, any muscular types of pain can be investigated with ultrasounds such as [inaudible] scientists. If there is suspicion of infection, then urgent pathology is recommended. So, labs should be done. An ultrasound looking for joint effusion is also very useful. Now it’s important in these cases that the patient’s referred back to the originating surgeon quickly. However, don’t think don’t hesitate to seek another opinion to get a fast response patient. Don’t always remember the details of the surgeon who could be operating in the first place or the surgeon who did the operation may long, may no longer be practicing plain. X-rays also, are you always useful to what NFI fractures around a joint replacement and these are known as Perry Presidio.

  Question 7
  How does the GP manage the painful hip replacement and when do they refer to the orthopaedic surgeon?

  Paul: Something as simple as a trochanteric bursitis and iliopsoas bursitis can be managed by the GP with analgesia, physiotherapy and steroid injections that aren’t settled. Please refer to any indication of loosening or where should be referred routinely. But if there’s a fracture, then this should be referred to bed. Importantly, an undisplaced fracture or periprosthetic fracture can often be treated easily with a fixation. Whereas if the fracture displaces, and this is,usually requires a full revision of the hip.

  Now, if this GP suspects infection then labs full, full blood count, CRP and ESR are vital. And it also sounds like a scan looking for fluid is helpful. Please refer the patient urgently to the originating surgeon, if you or another surgeon, if not, and if any signs of sepsis, you really need to refer to ed. Now, importantly, unless the patient is done well, do not give antibiotics or the joints going to need aspirating. The why to let the offending organism, and this should be done before anybody to give them aspiration of the joint is best done in a sterile setting. So, I’d speak to the orthopaedic surgeon or his team about this. The orthopaedic surgeon is always going to be grateful if you’ve organized simple investigation, such as x-ray or design labs, et cetera, the more specialist examination, which is bone scans, MRI or CT are indicating specific circumstances and are best left

  Question 8
  What about pain in the first few weeks or literally straight after a hip replacement – how long s that expected to last?

  Paul: Sure. It’s amazing how comfortable hip patients can be off the surgery. And they’ve often been more comfortable than pril despite the surgical pain, as this will often be outweighed by the loss of the arthritic pain as a rule of thumb pain rate persists beyond three weeks. And the majority of patients will be pain-free by six weeks at the very latest pain should gradually decrease. So, any patient presenting with increasing pain needs to be investigated, please always check for wound infections. And if this is suspected, I’d recommend discussing with the region. I think surgeons, prior to prescribing any antibiotics, some other surgeons I do, um, prefer to see the patients themselves, an early infection of a joint place then can be treated far more easily with a simple wash out of the joint. If the patient presents a late sort of six weeks or so after several courses by the politics, you’ve often missed the boat and they’re likely to require a two-stage revision.

  Concluding Question
  Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on a hip revision

  Paul: She will totally replace it with an ancient operation. And the vast majority of patients with pain-free for many years, GPS was always considered a source of pain other than the joint. So firstly, late presentation than pain is likely due to natural where the hit and needs to be expected 15 years, a simple x-ray and referred to the orthopaedic surgeon. And she has no clue that most causes can be identified with an x-ray ultrasound and muscular cause it can be managed by allied health and simple pain-relieving measures. Well, let’s call it. The other causes of pain should be referred, and fractures should always be referred urgently. And finally, infection is vanishingly rare in hip replacement surgery, but the GP was always having it in the back of their minds when presented with a painful hip replacement, the simple labs and referral to the surgeon are essential. And always remember if the patient didn’t go well, they should go straight to ED

  Thanks for your time and the insights you’ve provided.

  Paul: You are welcome, thanks you for having me