Painful Total Hip Replacement Research Articles

Dithiotreitol pre-treatment of synovial fluid samples improves microbiological counts in peri-prosthetic joint infection

PurposeSynovial fluid cultures of periprosthetic joint infections (PJI) may be limited by bacteria living in the fluids as biofilm-aggregates. The antibiofilm pre-treatment of synovial fluids with dithiotreitol (DTT) could improve bacterial counts and microbiological early stage diagnosis in patients with suspected PJI.MethodsSynovial fluids collected from 57 subjects, affected by painful total hip or knee replacement, were divided into two aliquots, one pre-treated with DTT and one with normal saline. All samples were plated for microbial counts. Sensitivity of cultural examination and bacterial counts of pre-treated and control samples were then calculated and statistically compared.ResultsDithiothreitol pre-treatment led to a higher number of positive samples, compared to controls (27 vs 19), leading to a statistically significant increase in the sensitivity of the microbiological count examination from 54.3 to 77.1% and in colony-forming units count from 1884 ± 2.129 CFU/mL with saline pre-treatment to 20.442 ± 19.270 with DTT pre-treatment (P = 0.02).ConclusionsTo our knowledge, this is the first report showing the ability of a chemical antibiofilm pre-treatment to increase the sensitivity of microbiological examination in the synovial fluid of patients with peri-prosthetic joint infection. If confirmed by larger studies, this finding may have a significant impact on routine microbiological procedures applied to synovial fluids and brings further support to the key role of bacteria living in biofilm-formed aggregates in joint infections.

Trochanteric impingement: is it a source of pain after THR?

While uncommon, trochanteric-pelvic impingement may lead to significant lateral hip pain. We defined “impingement distance” as the radiographic distance from the medial aspect of the greater trochanter and the corresponding lateral edge of the acetabular bone or component and compared this to the contralateral normal hip. We present two painful total hip replacement (THR) cases, each featuring a patient with severe lateral hip pain when walking and sitting. Both patients had diminished femoral offset and trochanteric-pelvic clearance, compared to the contralateral normal hip. The impingement distance was increased an average of 10 mm with the exchange to a longer femoral head. Both patients had immediate and complete pain relief with operative treatment to increase the impingement distance.

Total hip replacement: between normal rehabilitation and complication

Total hip replacement is a common and succesful treatment of the osteoarthritis of the hip. According to the demographical trends in Switzerland in the coming decades, there will be a significant increase in the demand for total hip replacement surgery. The 20-year survival of a total hip prosthesis is approximately 85%. New prosthesis designs aim to improve the hip biomechanics, sacrifice less bone stock and facilitate "minimal-invasive"' approaches to the hip joint. Severe complications in total hip replacement comprise dislocation, aseptic loosening, infection, periprosthetic fracture and limping. The painful total hip replacement requires thourough and systematic work up of extrinsic and intrinsic causes. A referral to the orthopaedic specialist should be considered early.

The painful total hip replacement

Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 Americans each year. Patient satisfaction with THR is very high, with improvements in general health, quality of life, and function while at the same time very cost effective. Although the majority of patients have a high degree of satisfaction with their THR, 27% experience some discomfort, and up to 6% experience severe chronic pain. Although it can be difficult to diagnose the cause of the pain in these patients, this clinical issue should be approached systematically and thoroughly. A detailed history and clinical examination can often provide the correct diagnosis and guide the appropriate selection of investigations, which will then serve to confirm the clinical diagnosis made.

Metal allergy in patients with total hip replacement: A review

Metal-on-metal prostheses are increasingly and widely used in total hip arthroplasty, and offer particular benefit to patients with osteoarthritis. Adverse effects related to the release of metal ions (such as cytotoxicity, genotoxicity, carcinogenicity and metal allergy) are common, however. The aims of this review article were to explore the relationship between corrosion products and implant-related hypersensitivity, define normal and toxic metal ion concentrations, and differentiate between allergy and infection in painful total hip replacement. The simultaneous presence of corrosion products and hypersensitivity-related tissue reactions indicates a relationship between the development of corrosion and implant-related hypersensitivity. There are no clear boundaries between normal and toxic metal ion concentrations. Several methods exist for the differential diagnosis of metal allergy and infection, including ultrasound-guided aspiration, patch testing and arthroscopic biopsy. More research is required to elucidate fully the relationship between metal articulations and allergy, and to determine the concentrations of metal ions that lead to harmful effects.

Magnetic resonance imaging of painful total hip replacement: detection and characterisation of periprosthetic fluid collection and interobserver reproducibility

The purpose of our study was to demonstrate the diagnostic value of magnetic resonance imaging (MRI) when measuring and characterising periprosthetic fluid collections in patients with painful hip prosthesis and to provide an estimation of interobserver reproducibility. Nineteen patients (mean age 59±13 years) with painful total hip replacement and clinical suspicion of infection underwent MRI. Images were reviewed blindly by two musculoskeletal radiologists with different levels of experience who evaluated the presence/absence of soft tissue oedema or fluid collection (when present, three-plane maximal diameters were measured; involvement of skin/subcutaneous/deep tissues or prosthesis were estimated; fluid was classified as serous/purulent/haematic according to signal behaviour). Interobserver agreement was calculated (Cohen's ). A total of 26 MRI studies were carried out (three patients underwent two and two patients underwent three MRI examinations). Both readers detected soft tissue oedema (13/26, 50%) or fluid collection (21/26, 81%) and characterised the fluid as serous (9/21, 43%), purulent (8/21, 38%) or haematic (4/21, 19%). The collection involved skin/subcutaneous tissues (16/21, 76%), deep soft tissues (19/21, 91%) or the implant (12/21, 57%). For all evaluations, interobserver agreement was complete (=1). No significant differences were found between the measurements of the collections (p>0.258). MRI is highly reproducible in detection, localisation, quantification, and characterisation of fluid collections when the presence of implant infection is clinically suspected.

Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4 years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosis.

(i) Evaluation of a painful total hip replacement

Total hip replacement is a common and effective operation with a high success rate. This article discusses the aetiology and evaluation of persisting pain after total hip replacement. A thorough history and physical examination and appropriate investigation can determine the cause of the painful total hip replacement in most patients, allowing appropriate treatment.

Das Obturator-externus-Impingement nach Hüftprothesenimplantation

A patient with a painful total hip replacement that is not obviously loose presents a diagnostic challenge. One of the rare causes is psoas impingement syndrome. Because there are several periarticular muscles, further muscle impingements are possible. We report on a case of painful obturator externus muscle impingement on the acetabular cup. On magnetic resonance imaging, a pathologic contact between the obturator externus muscle and the caudal rim of the cup was seen. A positive injection confirmed the pathologic contact.

The Painful Total Hip Replacement

Total hip replacement is one of the most common and successful orthopaedic procedures. However, evaluation and treatment of the painful total hip replacement is one of the most difficult challenges for the arthroplasty surgeon. The differential diagnosis includes causes that are intrinsic and extrinsic to the hip. A thorough history and physical examination provide the basis for a focused, efficient workup of the painful total hip replacement. The temporal onset, duration, severity, site, and character of the pain all provide important clues in determining the cause of the painful total hip replacement. The physical examination should focus on tests and maneuvers that reproduce the patient's symptoms. Laboratory tests and radiographic evaluation are used selectively as indicated by the history and physical examination findings. With a careful and thorough evaluation, the cause of the painful total hip replacement can be determined in most patients, and the appropriate treatment can be initiated.

ASSESSMENT OF THE SYMPTOMATIC TOTAL HIP

This new information has recently been incorporated into a series of algorithms for evaluating painful cemented and cementless total hip replacements. As the interpretation of many tests varies significantly between cemented and cementless components, the approach to these two situations differs accordingly. Careful review of sequential plain radiographs remains a mainstay of initial evaluation. The sedimentation rate is also a cost effective method of adding useful information. Based on this assessment, cemented and cementless components can be classified as loose, well fixed, or having lysis without being loose. Subsequent evaluation should incorporate new information regarding the effectiveness, limitations, and cost of various diagnostic tests available for the evaluation of the painful total hip replacement.

Radiological evaluation of painful total hip replacement.

Ninety-four cases of clinically failed, cemented, total hip prostheses requiring surgery were reviewed to determine the accuracy of preoperative plain radiography, culture of aspirated fluid, arthrography, and bone scanning. When radiopaque cement had been used to embed the prosthesis, plain radiography was highly accurate in detecting a loose femoral component, less so in detecting a loose acetabular component. Culture of aspirated fluid was accurate in diagnosing infection. A positive arthrogram identified loosening with good accuracy; however, a negative arthrogram did not reliably exclude loosening. 99mTc bone scans frequently differentiated loosening from loosening with infection. The suggested sequence of diagnostic tests is plain radiography followed by bone scanning. If the bone scan shows diffuse augmented uptake, culture of aspirated fluid followed by arthrography is indicated.

Gallium-67 scanning in the painful total hip replacement

Pain following total hip replacement is a significant clinical and diagnostic problem. Technetium scanning has proved a sensitive indicator of infection or loosening but does not differentiate between them. This study assessed the value of gallium-67 to aid this differentiation. Thirty patients underwent revision surgery. Fourteen were proven to be infected and 13 had positive gallium scans as also did two patients without infection. The implications of these false interpretations are discussed. Increased gallium activity was correlated with the patterns of the 99mTc scans and arthrographic appearances. It is concluded that gallium-67 scanning is a valuable adjunct to the assessment of the painful hip replacement when infection is suspected.

Sequential use of technetium 99m MDP and gallium 67 citrate imaging in the evaluation of painful total hip replacement

Fourteen patients with 20 total hip joint replacements were studied for 14 painful prosthetic hips. Clinical examination, plain film radiographs and 99Tcm-MDP bone scans failed to differentiate between infection and mechanical loosening of a prosthesis. Sequential use of 99Tcm-MDP and 67Ga-citrate bone scans were performed in an attempt to discover underlying infectious process. Increased focal uptake of both radiopharmaceuticals over the same hip indicated an infectious process responsible for prosthetic loosening. There were no false positive gallium examinations. Sequential use of 99Tcm-phosphate compounds and 67Ga-citrate is recommended for differentiation between mechanical loosening of a prosthesis and loosening of a prosthesis secondary to an infectious process.