Groin pain following hip resurfacing: a case-control study

Residual Symptoms and Function in Young, Active Hip Arthroplasty Patients: Comparable to Normative Controls?

BACKGROUND

Whether patient-reported symptoms and function after total hip and surface replacement arthroplasty in young, active patients compare favorably to those without known hip pathology has not been investigated.

METHODS

A retrospective, multicenter study was designed in which 5 centers contributed patients aged <60 years with a presymptomatic University of California at Los Angeles score ≥6 undergoing hip arthroplasty. Data were collected by an independent, third-party survey center that administered a questionnaire assessing patient satisfaction and function. A "control" population with no prior hip interventions or hip pathology limiting their activity, that met the age and activity criteria, was identified for comparison using multivariate regression analyses.

RESULTS

Eight-hundred six hip arthroplasties (682 total hip arthroplasty, 124 surface replacement arthroplasty) and 158 controls were included. A greater percentage of hip arthroplasty patients were male and aged >50 years which was controlled during multivariate regression analyses. Control patients reported the presence of a limp (15%), stiffness (11%), and pain in the hip (8%), but to a lesser degree than hip arthroplasty patients. Control patients were less likely to report pain in the hip (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.7, P = .006), stiffness in the hip (OR = 0.5, 95% CI = 0.3-0.8, P = .02), and a limp (OR = 0.5, 95% CI = 0.3-0.8, P < .001) vs patients undergoing hip arthroplasty.

CONCLUSION

When interviewed by an independent third party, a substantial portion of control patients did note the presence of hip symptoms, but to a lesser degree than young, active patients undergoing hip arthroplasty.

Incidence and Location of Pain in Young, Active Patients Following Hip Arthroplasty

Persistent pain following hip arthroplasty remains a concern, especially in young, active patients. Four hundred twenty patients less than 60 years of age with a pre-symptomatic UCLA score ≥ 6 (196 total hip arthroplasty [THA]; 224 surface replacement arthroplasty [SRA]) completed a pain-drawing questionnaire investigating the location, severity, and frequency of pain around the hip. At a mean of 2.9 years of follow-up, 40% reported pain in at least one location around the hip. There was no difference in the incidence of groin pain between SRA and THA patients (32% vs. 29%, P=0.6), but THA patients had a greater incidence of anterior (25% vs. 8%, P<0.001) and lateral (20% vs. 10%, P=0.01) thigh pain. A high percentage of young, active patients experience persistent pain following hip arthroplasty.

Radiographic parameters associated with pain following total hip and surface arthroplasty

Pain following total hip arthroplasty (THA) and surface arthroplasty (SRA) remains a significant source of patient dissatisfaction. Two hundred twenty-four SRA and 196 THA patients completed a pain drawing questionnaire and postoperative radiographic measurements of component positioning were performed. In the SRA cohort, 11 of 21 patients (52%) with acetabular uncoverage of ≥5 mm versus 43 of 147 (29%) with acetabular uncoverage of ≤4.9 mm reported groin pain (P=.03). In the THA cohort, an increased distal-third canal fill ratio and a lower canal calcar ratio trended towards a higher incidence of thigh pain (P=.10 and .06), while a decreased mid-third canal fill ratio was associated with increased severity of thigh pain (P=.04). This study identifies associations between radiographic findings and pain following THA and SRA.

A case series of 35 hip revisions for adverse reactions to metal debris following Cormet hip resurfacing

The primary aim of this study was to analyse our painful metal-on-metal (MoM) hip resurfacing revisions with evidence of 'adverse reactions to metal debris' (ARMD). In our series of 35 revisions the median whole blood Cobalt levels were 58 nmols/l (range 12-1407 nmols/l), and whole blood Chromium levels were 73 nmols/l (range 2-353 nmols/l). Thirty-four of our 35 patients had abnormal imaging on Ultrasound scanning (USS). The mean histological Campbell grading of ARMD was 4, and ranged from 0-9. The mean Oxford Hip Score (OHS) increased from 19 pre-revision (range 4-46) to 33 post-revision surgery (range 23-47).We found no correlation between the preoperative metal ion levels, and the severity of the disease or the outcome.Pain following hip resurfacing may arise from a number of causes and when groin pain arises in conjunction with abnormal cross sectional imaging we have offered our patients revision surgery regardless of raised metal ions or grossly abnormal imaging, with good results.

Do survival rate and serum ion concentrations 10 years after metal-on-metal hip resurfacing provide evidence for continued use?

BACKGROUND

Owing to concerns attributable to problems associated with metal-on-metal bearing surfaces, current evidence for the use of hip resurfacing is unclear. Survival rates reported from registries and individual studies are controversial and the limited long-term studies do not conclusively allow one to judge whether hip resurfacing is still a reasonable alternative to conventional THA.

QUESTIONS/PURPOSES

We asked whether the long-term survival rate of hip resurfacing is comparable to that of conventional THA and certain factors can be identified that influence serum ion concentration 10 years postoperatively. We specifically assessed (1) the 10-year survivorship in the whole cohort and in male and female patients, (2) serum concentrations of metal ions in patients with hip resurfacing who had not undergone revision surgery, and (3) potential influencing factors on the serum ion concentration.

METHODS

We retrospectively reviewed our first 95 patients who had 100 hip resurfacings performed from 1998 to 2001. The median age of the patients at surgery was 52 years (range, 28-69 years); 49% were men. We assessed the survival rate (revision for any reason as the end point), radiographic changes, and serum ion concentrations for cobalt, chromium, and molybdenum. The correlations between serum ion concentration and patient-related factors (age, sex, BMI, activity) and implant-related factors (implant size, cup inclination, stem-shaft angle) were investigated. The minimum followup was 9.3 years (mean, 10 years; range, 9.3-10.5 years).

RESULTS

The 10-year survivorship was 88% for the total cohort. The overall survival rate was greater in men (93%) than in women (84%). Median serum ion levels were 1.9 μg/L for chromium, 1.3 μg/L for cobalt, and 1.6 μg/L for molybdenum. Radiolucent lines around acetabular implants were observed in 4% and femoral neck thinning in 5%.

CONCLUSIONS

Although our overall failure rate was greater than anticipated, the relatively low serum ion levels and no revisions for pseudotumors in young male patients up to 10 years postoperatively provide some evidence of the suitability of hip resurfacing in this subgroup.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.