Painful hip prosthesis (revision)
The symptoms of a painful hip prosthesis can occur shortly after the operation or at a later stage. For most patients, pain is the main symptom. This can occur at rest, during exercise or during movement. The pain can come on suddenly or become more severe over time. The type of pain can also vary greatly: from burning, pulling, stabbing, electrifying to dull.
A revision of the hip joint means that, depending on the cause and pain, the artificial hip joint may have to be operated on again, for example to remove scar tissue, reattach a piece of bone or tendon or remove and replace part or all of the artificial joint.
What are the reasons for a painful hip prosthesis?
The causes of a painful hip prosthesis are very varied and can be due to the operation, the hip prosthesis or the patient themselves: falls, infections, loosening of the hip prosthesis, overuse or excessive expectations. For example, a fall can cause the bone in the thigh or pelvis in which the artificial hip joint is anchored to break. This can even cause the artificial hip joint to loosen. Other causes of hip joint loosening (stem and/or socket) can be an infection, an increase in osteoporosis or severe abrasion (metal or plastic) with ingrowth of scar tissue as well as an allergy. In the event of loosening, patients report a dull pain that is dependent on weight-bearing and movement, as well as gait instability, which increases over time.
Other causes of pain and discomfort around the artificial hip joint include pinching scar tissue, too much or too little tension on the hip muscles, suboptimal position of the acetabulum or hip socket, bursitis, tendonitis, torn muscle fibres, inflammation of the hip joint, etc.tendonitis, torn muscle fibres, bony avulsion or detachment of important stabilising tendon attachments on the hip muscles, formation of bone spurs, abrasion of the plastic insert of the socket (inlay), etc.
If the hip pain increases and does not get better despite resting for a certain period of time, it should be examined in detail by a specialist.
How are the causes of the pain clarified?
If a patient with a painful hip prosthesis comes for an assessment, thorough questioning and examination are very important. The following questions should be clarified:
- How: How can the pain be triggered? Is it a particular movement that triggers the pain? Is it present at rest or only during exertion?
- When: How long has the pain been present? When was the artificial hip joint inserted? Is a prosthesis passport available? Are there any known allergies to metal (nickel) or cement?
- Where: Where can the pain be localised? On the side of the hip joint or inside?
- What: What is the nature of the pain: burning, pulling, dull, stabbing, pulsating or electrifying? What has brought relief so far?
The affected hip joint is also examined for redness, overheating and swelling. The mobility of the hip joint is then tested. Can pain be provoked by certain movements, or does a tendon snap? Are there certain painful pressure points? The hip muscle strength and gait pattern are then tested.
Normal x-rays of the hip joint are then taken. If it is not clear at this point what the cause is, further specialised examinations may be ordered: SPECT/CT (combination of scintigraphy and computer tomography to visualise the current bone activity anatomically), CT (layer-by-layer imaging of the bone), ultrasound and allergy investigations.
How can a painful hip prosthesis be repaired?
Depending on the cause, different therapies are recommended. These start with conservative measures such as physiotherapy and anti-inflammatory medication.
If these are ineffective or have already been exhausted, surgery is recommended to correct the problem. Depending on the diagnosis, a joint-preserving operation, a partial replacement or a complete replacement of the prosthesis may be considered.
Joint-preserving surgery
- Removal of painful scarring or free joint bodies
- Fixation of torn tendons or broken bones
- Rinsing the joint and taking tissue samples for a microbiological examination to rule out an infection
Partial replacement of the artificial joint
- Replacement of the femoral head to either increase or reduce muscle tension
- Replacement of the cup insert (inlay) to restore a stable joint
New artificial hip joint
In certain cases it is necessary to replace the hip stem and the acetabulum or even the entire hip prosthesis. Depending on the problem, either the same prosthesis model can be selected again. Otherwise, a so-called revision prosthesis is used, which is larger and longer.
For osteoporosis or muscle weakness
If the bone quality is too weak (advanced osteoporosis), the bone loss is too great or there are muscle weaknesses, the hip joint can be replaced with a Double Mobility femoral head to stabilise the joint. In the case of brittle bone and advanced osteoporosis, the hip components are cemented into the bone sooner, which allows the joint to be loaded more quickly. However, if an allergy (metal, cement) has been proven, the new artificial hip joint should be replaced with a cementless hip prosthesis, as the hip stems and the acetabulum are made of titanium and a ceramic-on-ceramic pairing can be used.
For infections
In the event of a chronic infection, the artificial hip joint must be removed and/or replaced with a cement spacer. This is followed by targeted antibiotic therapy, which lasts six to nine weeks depending on the germ. In such cases, we work together with an experienced infectiologist who determines the individual antibiotic therapy. If the inflammation values are within the normal range two weeks after discontinuation of the antibiotics and the hip joint is clinically free of irritation, a new artificial hip joint can be implanted.
In most cases, the same minimally invasive methods are used for revision operations as for the initial operation. If this is not possible for individual reasons, the conventional surgical method is used. This means that the hip joint must be exposed through an approx. 15 centimetre incision from the side with splitting of the corresponding hip muscles. The type of operation and its procedure are explained in the preliminary consultation. As the exact conditions in the joint only become fully visible during the operation, it may be necessary to deviate from the regular surgical procedure discussed during the operation.
What does the follow-up treatment look like?
The follow-up treatment for revisions can vary greatly and depends on what exactly had to be done. If a new artificial hip joint has been inserted, the same requirements apply in principle as for a primary hip prosthesis, except that the hospital stay and rehabilitation period are longer. This means that walking sticks with partial weight bearing and thrombosis prophylaxis are required for at least six weeks.
Frequently asked questions
Can an artificial hip hurt?
Yes, if it no longer functions as it should. The pain can be load- and movement-dependent. This is especially true if the anchoring of the artificial hip joint is loose. Pain can also be caused by infections, trapped scar tissue, ossification, excessive tension on the muscles, allergies and abrasion as well as bone fractures due to a fall. A painful hip prosthesis must be examined and clarified by a specialist.
How does a defective hip prosthesis make itself felt?
A defective artificial hip prosthesis causes similar symptoms to those you are already familiar with from an arthritic hip joint, namely: pain, restricted movement and gait instability. In addition, the artificial hip joint can dislocate due to a blow or movement, resulting in immediate pain, inability to move and shortening of the leg. This is always an emergency and must be clarified immediately.
Loosening of the anchoring of the artificial hip joint is characterised by pain depending on the load and movement. The abrasion of the cup insert (made of polyethylene (plastic) or metal) leads to deposits in the mucous membrane and in the bone, which in turn leads to inflammation of the mucous membrane and, in the longer term, to loosening of the artificial joint and even cyst formation in the bone, resulting in an increased risk of fracture. In addition, the artificial head is less well guided in the cup insert, which can lead to gait instability and an increased risk of dislocation. This process is very slow and can only become noticeable after years.
If you have an artificial hip joint and new pain has arisen that has not subsided significantly after three to four days despite rest, you should definitely have your artificial hip joint checked by a specialist.
When does an artificial hip joint need to be replaced?
An artificial hip joint must be replaced if the pain associated with weight-bearing or movement increases significantly, resulting in a further reduction in quality of life. This pain is caused by a slow loosening of the anchoring of the artificial hip joint in the bone. This can be triggered by infections, chronic overloading (sport, obesity), an increase in osteoporosis, allergies and abrasion or wear and tear of the artificial hip joint (made of plastic or metal, depending on what was used). A fall with a corresponding fracture of the femur or pelvis can also lead to acute loosening of the hip prosthesis.
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PD Dr Andreas L. Oberholzer is a recognised expert in hip complaints and has extensive experience in the field of artificial hip joints.
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PD Dr Andreas L. Oberholzer
FMH specialist in orthopaedics and trauma surgery. Areas of specialisation: Knee, hip and foot surgery.