What causes long-term hip pain after hip replacement?
Ross Hauser, MD and Danielle Matias, PA-C
As we will see in the research below, looking for a cause of long-term pain after hip replacement can be challenging. When an MRI or X-ray does not show a bone fracture, a hardware fracture or hardware deficiency, or obvious soft-tissue damage, a person can go from doctor to doctor, test to test, and still not get the diagnosis of what is causing his/her post-hip replacement pain. In some cases, the hip replacement can make the same side leg or other side leg appear longer, or cause other problems. In some people, we hear about chronic hip dislocations. We often get emails that sound like this:
Problems with leg length
I had a total right hip replacement. Now my left-side pelvis is lower than the right side. My left leg is more than one inch longer than the right. Daily constant pain left side in my groin area near my pelvis.
Problems with leg length and spinal stenosis
I had a hip replacement two years ago. I immediately told my doctor my leg was too long. Every doctor visit thereafter I told my doctors my leg is too long. The doctors minimized my complaints and told me it would be better in 6 months. What happened next was the sudden onset of excruciating pain and dysfunction. I am now being told to have neurosurgery.
I had one excruciating episode of muscle spasm that was treated in the emergency room with muscle relaxers and analgesics. I got back to about 50% of feeling normal. Another episode followed. This time in the emergency room I got a dexamethasone injection, prednisone tapering, and oxycodone to manage my pain. The urgent care orthopedics X-ray revealed lumbar scoliosis which was not present a year ago. Extremely high left side pelvis. I am now scheduled for imminent surgery.
I had a right hip replacement that has since dislocated five times. I then had revision surgery. Major groin pain ever since. I have difficulty going upstairs and need to help my leg into the car. I feel an impingement but don’t know how to identify it or fix it.
When someone comes in with hip pain following hip replacement and hardware issues have been ruled out, there is an expectation that soft tissue damage may be a culprit. We will explore this explanation below. But first, let’s examine possible reasons for pain after hip replacement.
Part 1: Pain and painkillers cause pain after hip replacement
In this section, we will explore the pre-surgery use of opioids and sleep problems as a cause of pain after hip replacement.
A February 2023 paper (1) from Swedish, Finnish, Danish, and Norwegian university researchers examined problematic opioid use or abuse among osteoarthritis patients with chronic postoperative pain after joint (including hip) replacement. The researchers found 13.7% of patients with osteoarthritis and a hip/knee joint replacement were classified as problematic users and they had more symptoms and conditions with higher pre-surgery doses of opioids than a control group they were compared to.
Here is a November 2020 study published in The Journal of Arthroplasty (2).
- Patients awaiting total joint arthroplasty (replacement) have high rates of opioid use, and many continue to use opioid medications long-term after surgery.
- The strongest risk factor for chronic postoperative opioid use was preoperative opioid use.
Recently many people who finally had a hip replacement had to wait for a very long-time to get it as we suffered through the global health crisis. During this time many people had to resort to prolonged opioid usage. It should be pointed out that this study was a three-year outcome. Even before the Covid-19 health crisis people were using opioids before surgery and this study shows that opioid use after surgery continued at a high rate.
Sleeping problems – A cause of prolonged pain after hip replacement
Among the many factors that prolonged pain can induce besides reliance on opioids, is pain’s impact on sleep. An August 2021 study published in the European Journal of Pain (3) examined the impact of sleep disturbance on acute post-surgical pain. Here researchers from Skåne University Hospital and Lund University in Sweden combined with efforts from Johns Hopkins University School of Medicine and the University of California, Los Angeles (UCLA) looked at patients who had poor sleep habits. They write: “Poor sleep quality and impaired sleep continuity are associated with heightened pain sensitivity, but previous work has not evaluated whether preoperative sleep problems impact long-term postoperative pain outcomes. Here, we show that sleep difficulties prior to total hip arthroplasty adversely predict postoperative pain control 6 months after surgery.”
Part 2: The problem diagnosis
“The situation complicates when history, clinical examination, and plain radiography fail to locate the exact origin of hip pain. In a few cases, patients were revised without having found the cause of pain.”
Let’s take an over decades-long introductory journey to unknown or more understand as “confusing to understand” pain following hip replacement.
In 2011, doctors writing in the journal Clinical Cases in Mineral and bone metabolism (4) offered this assessment of the mystery of pain following hip replacement: “The occurrence of pain following a technically satisfactory arthroplasty is of concern for both the orthopaedic surgeon and the patient. It’s one of the most difficult challenges for the surgeon to evaluate and treat. The difficulties in managing painful (hip replacement) are due to the heterogeneous (could be caused by many things) nature of the disease. Pain related to the surgery itself can be associated with the implant, bone alterations, and soft tissue or nerve injuries. The situation complicates when history, clinical examination, and plain radiography fail to locate the exact origin of hip pain. In a few cases, patients were revised without having found the cause of pain.”
In other words, a second surgery was suggested even though it was not clear if it could help.
A similar article was published in 2019 in The Journal of Arthroplasty (5). This study, according to the authors at the time, was “the first study on the causes of painful hip arthroplasty in clinical practice, whether leading to revision or not.” What did the doctors of this 2019 study suggest?
“Identifying the source of pain is paramount for determining appropriate treatment and ensuring successful outcomes in terms of management and relief of pain. The difficulty is that each surgeon has his or her own way of seeing the problem, and there is no consensus for the evaluation of these patients. The study hypothesis was that it is possible to find the cause of the pain in most cases.”
In other words, depending on your surgeon, the heterogeneous (could be caused by many things) problem is compounded, and there may not be a clear path to understanding what is causing the pain. This study suggests a way to find the cause.
The researchers examined the records of 194 patients, seven of whom had both hips replaced, who had unexplained painful hip arthroplasty 6 months postoperatively. These were the diagnosis of the 201 hip replacements:
- Periarticular (Not coming from in the joint but around the joint ) in 53 cases (26.4%):
- 40 cases of trochanteric bursitis
- 5 cases of iliopsoas tendinitis
- 5 of abductor (muscle) deficiency,
- 1 of ischial tuberosity tendinitis,
- and 2 of heterotopic ossification (boney overgrowth);
Please see our article: Hip pain and hip instability | What happens if hip muscles are weak?
Pain coming not from the hip was seen in 49 patients (24.4%):
- 45 cases of back pain with or without neuropathy,
- 3 of knee osteoarthritis, and
- 1 of metabolic neuropathy (neuropathy);
Please see our articles: Hip-spine syndrome before and after failed hip replacement and lumbar spinal fusion complication;
Pain from the implant
- Implant wear was seen in 40 patients (19.9%), in the polyethylene liner;
- Loosening in 20 (10.0%):
- loosening of the femoral component in 8 and
- loosening of the cup in 12 patients.
- Problems with the implant material in 17 patients (8.5%):
- Trunnionosis (wear of the area where the head attaches to the neck of the hip bone) in 13.
- Metallosis in metal-on-metal implants in 4;
- No diagnosis in 7 hips (3.5%);
- Infection in 6 hips (3.0%),
- All chronic; instability without real dislocation in 3 (1.5%);
- (Implant) misplacement in 3 (1.5%), all for leg-length discrepancy;
- Fracture in 2 (1.0%): 1 of greater trochanter and 1 of ilio-ischiopubic ramus;
- Complex regional pain syndrome in 1 (0.5%).
The researchers here conclude with a warning about rushing patients to surgery without knowing the cause of pain: “Revision surgery can sometimes help-but the worst thing is to make the patient worse.”
Part 3: Did hip replacement patients really experience great improvements or did the doctors think the patients did and reported it as such?
For many people, hip replacement was a great success. In other instances, the doctors thought that the surgery was a great success. The patients themselves were not so sure.
This is a point of contention in the medical industry. First, people do get good results with hip replacements, especially those with significant osteoarthritis-caused deformities. But how good were the results for everybody? Researchers writing in the Public Library of Science health journal PLusOne (6) wrote that because there are many hip replacement component types and many techniques for surgical installation of these products, there is concern that medical research on the long-term effectiveness of the varying techniques is inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates. In other words, doctors may have interpreted patient results as being much better than they actually were to support the use of a specific implant or specific technique.
These findings were supported by other researchers including a 2018 study published in the journal BMC Medical Research Methodology (7) which also found problems of accuracy in reporting patient success in hip replacement and suggested to doctors that results of the research that patients were happy with their hip replacements may not be as good as is being reported.
In a February 2020 study in the journal BioMed Central Musculoskeletal Disorders, (8) doctors reported that there may be under-reporting of adverse side effects in hip replacement. This is what these doctors said:
“Dislocation, periprosthetic fracture, and infection are serious complications of total hip replacement and which negatively impact on patients’ outcomes including satisfaction, quality of life, mental health and function. The accuracy with which patients report adverse events after surgery varies. The impact of patient self-reporting of adverse effects on patient-reported outcome measures (PROMs) after total hip replacement is yet to be investigated.”
Do people who have adverse effects that cannot be confirmed through medical testing really have adverse effects?
The doctors of this study then sought to determine the effect of confirmed and perceived adverse effects on patient-reported outcome measures after primary total hip replacement.
Here are the learning points of this research:
- Forty-one adverse effects were reported in a group of 417 patients (234 females), with 30 adverse effects reported by 3 months after surgery.
- Eleven (27 reported) infections, two (six reported) periprosthetic fractures, and two (eight reported) dislocations were confirmed.
- Those in the no adverse effects group reported significantly better outcomes than the reported adverse effects group.
- Patients who report adverse effects have worse outcomes than those who do not, regardless of whether the adverse effects can be confirmed by standard medical record review methods.
- The observed negative trends suggest that patient perception of adverse effects may influence the patient outcome in a similar way to those with confirmed adverse effects.
What are we to make of this? Do people who have adverse effects that cannot be confirmed through medical testing really have adverse effects? In our experience they do. Because it cannot be confirmed, does that mean it is not reported as an adverse effect? The bottom line here is that people are reporting adverse effects, are they being taken seriously?
The surgical causes of hip replacement failures
An April 2023 study in The Journal of Arthroplasty (13) comes from researchers at the Alpert Medical School of Brown University. In this paper, doctors examined the effect of spinopelvic fixation (the spine and pelvis are fused together) in addition to lumbar spinal fusion on dislocation/instability and revision in patients undergoing primary total hip replacement. The researchers say that this examination had not been reported previously.
The patients of this study were 30 years and older and had either a:
- total hip replacement only,
- total hip replacement with prior single-level lumbar spine fusion,
- total hip replacement with prior 2-5 level lumbar spine fusion, or
- total hip replacement with prior lumbar spine fusion with spinopelvic fixation.
At 2 years following surgery:
- 7.8% of total hip replacement patients with prior spinopelvic fixation had a dislocation event or instability,
- 4.7% of total hip replacement patients with prior 2-5 level lumbar spine fusion had a dislocation event or instability,
- 4.2% of total hip replacement patients with prior single-level lumbar spine fusion had a dislocation event or instability, and
- 2.2% of total hip replacement patients undergoing only total hip replacement had a dislocation event or instability.
The research concludes: “Conclusion: At 2 years, spinopelvic fixation in total hip replacement patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without lumbar spine fusion, and an over 2-fold increase in total hip replacement revision risk compared to those with lumbar spine fusion without spinopelvic fixation.”
Induced Recurrent Instability After Total Hip Arthroplasty.
To put the prosthetic device into your hip, muscles, tendons, and ligaments have to be moved out of the way, stretched, and cut. Part of the hip replacement procedure is soft tissue reconstruction. In some people, this soft tissue repair can become undone or pulled out. This is the cause of acute pain after hip replacement. In others, this repair does not hold that well and your hip becomes unstable and painful. Many people also had degenerative wear and tear in the tendon attachments to the muscles prior to surgery. If this wear and tear was not addressed prior to surgery, even though the hip is new, pain can come from the worn-out tendons and from the worn-out ligaments.
As mentioned earlier, many people do well with hip replacement surgery. Some people do not. For some people the answer to fixing their failed hip replacement procedure, as we have just seen, is addressing problem ligaments, tendons and weakened muscles.
Surgeons writing in the Journal of Bone and Joint Surgery Reviews (9) discuss these problems:
“(Surgical) intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic (taking tissue from somewhere else) augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (replacement).”
- Direct repair of the abductor mechanism at the greater trochanter can be used in patients who present with hip instability for less than 15 months following hip replacement
- Augmentation of soft tissue with acellular dermal allografts (from a cadaver) can be considered for patients with abductor avulsion (muscles and tendons that have pulled off the bone) that require posterior capsular reconstruction.
- You can use the Achilles tendon and the heel bone from a cadaver for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and who have tissue inadequacy in the posterior wall of the hip joint.
- The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus.
- Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, a large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks.
- Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components.
That is putting back a lot of stuff.
Research: iliofemoral and ischiofemoral ligament reconstruction techniques following hip replacement may help salvage a bad hip replacement
Here is an understanding of the idea, “you don’t know what you got until you don’t got it.”
In December 2020, surgeons writing in the medical journal Orthopaedics and Traumatology, Surgery and Research (10) discussed the problems of chronically dislocating hip replacements. Again, we do want to stress that many people have very successful hip replacement procedures, and some people have very successful hip preplacement repair or revision surgeries. These are typically not the people we see at our center. We see people looking for help with hip replacement procedures that have not fared well for them.
In this paper, the surgeons discuss the problems of recurrent dislocations of the patient’s total hip arthroplasty (replacement). For many people, this problem, as they note, can be repaired by going into the hip again and replacing the socket hardware or the cup with a “dual-mobility and constrained cup.” This hardware can limit the range of motion to prevent recurrent dislocations or your replacement from popping out of place. But, this hardware replacement may also fail in the case of hip abductor mechanism loss.
Hip abductor mechanism sacrifice and loss
We are going to quickly discuss hip abductor mechanism loss. While this is in regard to hip replacement fixes, we are going to show just how important the hip ligaments are in building our opinion that treating the hip ligaments, non-surgically can reduce or eliminate the need for hip replacement in selected patients with hip osteoarthritis.
The hip abductor mechanism is your ability to lift your leg to the side. If you have hip abductor mechanism problems following a hip replacement, you will have pain on the outer side of the hip and limp a bit. In more severe cases, the muscles left in the hip after the surgery will atrophy, or worse, you will have muscle necrosis. The muscle is dying.
In the study above the surgeon researchers announced:
“For such complex situations, we developed an original artificial iliofemoral and ischiofemoral ligament reconstruction technique . . . The technique was implemented in 2 patients showing recurrent dislocation after total hip replacement, associating total femur replacement, and cemented constrained liner in a metal reinforcement ring. (Patient had a lot of problems following the initial hip replacement). In 1 of the 2 cases, the abductor mechanism had been entirely sacrificed. This simple and accessible salvage technique prevented the recurrence of dislocation at 12 months follow-up in these complex cases, previously subject to several episodes per year.”
They had to go back in and put the ligaments back
The good news here is that these surgeons have a way of helping with complex hip replacement problems. In their paper, hip replacement dislocations occurred several times a year. What should be understood is that the fix these complex problems, they had to go back in and put the ligaments back. In this case, artificial ligaments.
The ligaments need to be saved to prevent hip pain after hip replacement
In pain following hip replacement, since the prime suspect bone-on-bone was alleviated by the hip replacement what could be causing the patient’s continued pain? Doctors at Washington University in St. Louis School of Medicine suggest that it must be the hip ligaments. They write: “Surgical management for hip disorders should preserve the soft tissue constraints (ligaments) in the hip when possible to maintain normal hip biomechanics.”(11)
For many people, hip instability is a possible cause of hip pain following a hip replacement.
In February 2023, researchers at the Warren Alpert Medical School of Brown University wrote in the journal Biology (12). The researchers suggest that the results of their study support the primary hypothesis that patients with an associated diagnosis of sarcopenia, within the two years before undergoing primary hip replacement experience increased rates of postoperative complications, including implant dislocations, falls, fragility fractures, and urinary tract infections, compared with patients NOT diagnosed with sarcopenia. Furthermore, these patients were more likely to require hospital readmission.
Other points of note from this research:
- Results demonstrated that patients with sarcopenia are approximately 100% more likely to experience a dislocation.
- Patients with sarcopenia may have inadequate peri-implant soft tissue, which may place them at significant risk of dislocation.
- Prior studies have shown reduced soft tissue tension (ligament and tendon laxity may be included with muscle mass) which are approximately four times lower than patients who exhibited no dislocations.
- Muscles in reduced soft tissue tension in hip replacement include hip musculature, such as the iliopsoas, hamstring, gluteal muscles, and quadriceps.
Some people will have, years later following a hip replacement, a perfectly stable hip, and no pain. On the other hand, those who are left with pain and clicking after hip replacement surgeries likely have unresolved hip instability that is continuing to cause symptoms.
In general, the younger and more physically active someone is, the faster the hip replacement will wear down. These two are correlated, as younger people are typically more active. Additionally, younger people that undergo a hip replacement have longer to live, meaning they likely will put ‘more miles’ on their replacement parts. Physical activity, especially high-impact exercise, will more quickly wear away a joint replacement. The continuous, repetitive motion of the replacement parts can cause microscopic particulate debris to break off, thus causing the body to mount an immune response to these foreign particles. The debris may include plastic, cement, ceramic, or metal depending on the type of hip replacement performed. Immune reactions to these particulates can further cause the destruction of surrounding bone and loosening of the replacement, which would necessitate a need for hip replacement revision.
We have seen many patients in the over three decades of care we have been providing. Sometimes we have a great success story. Such as an 82-year-old patient who came to us using a cane. He first started using the cane ten years prior following a total hip replacement. After years of continued hip pain after surgery, his orthopedic surgeons wanted to do a revision hip replacement. Something this patient did not want. After only two Prolotherapy visits, involving injections to the surrounding ligaments and tendons, he was able to walk without a cane.
Prolotherapy is a regenerative treatment that can successfully treat pain after hip replacement by way of repairing the ligaments and tendons stretched or cut during the hip replacement procedure.
Summary and contact us. Can we help you?
We hope you found this article informative and that it helped answer many of the questions you may have your pain. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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