I had a total hip replacement and my hip hurts!

It’s not common for me to hear a lot of complaints about pain after hip replacement surgery because a total hip replacement is one of the best surgeries a patient can undergo to get relief from a painful arthritic joint. 95% of the time, patient’s have wonderful outcomes, but sometimes, problems arise after a total hip replacement, and that’s where my joint reconstruction experience can help (and why I hear about pain after hip replacement).

A lot of hip replacements are being done, and they are increasing exponentially as the population ages, especially the baby boomers.

We also have better implants now and are doing them in younger and younger patients because the prostheses are going to last longer. With more hip replacements being done, we are expecting a rise in revision procedures too, it is predicted to go up 137% in the next two decades, which will have a significant impact on healthcare.

Before I delve into hip pain possibilities after total hip replacement, let’s look at the causes of hip pain prior to surgery. Possibly, some if not all the pain a patient has before surgery is not a result of arthritis of the hip.

Common things that cause “hip pain” and can confound a diagnosis:

• Low back pain from arthritis or sciatica, especially if the pain radiates down past the knee. This can be seen up to 30% of the time and should be evaluated as a possibility by the hip surgeon before surgery.
• Bursitis and inflammation or tendonitis. Point tenderness or pain with laying on the side of the painful hip could be a sign of trochanteric bursitis. It is very common in patients and usually resolves with a cortisone injection.
• Tendonitis around the hip muscles or subtle tears. Sometimes, inflammation around these tendons irritates the local nerves around the hip and can cause radiation or pain in the groin, thigh, and buttock. These can also usually be addressed with physical therapy, cortisone injections and anti-inflammatories. Most of the time, these soft tissue conditions resolve completely over time.

Advanced imaging can help rule out things like stress fractures, labral tears, cartilage tears, and tendon tears or other conditions causing hip pain like a pinched nerve in the back. Usually after a physical exam and basic x-rays of the hip to rule out hip bone abnormalities or obvious arthritis most physicians can identify the cause of hip pain, but it still can be elusive and will need close follow up.

4 complaints about pain after hip replacement

1. “I was diagnosed with hip pain from arthritis and I had a hip replacement, and now I have pain or the pain never went away.”

Onset of pain: Was the pain immediate after surgery and never got better or was there a period of time where it was fine and then suddenly or insidiously did pain develop over time?

If the pain was immediate and never got better, where is it located? Is it groin pain, thigh pain, or both?

Immediate pain that never resolved could be the sign of a subtle fracture around the implant that developed during the surgery and was never discovered, or could be a result of acute inflammation of the tendons around the hip–especially if the hip feels weak or painful in the groin with resisted flexion activities like going up the stairs or getting out of a car or chair.

If it hurts on the side while laying on it, it could be trochanteric bursitis. Tendonitis and bursitis after hip replacement is common especially in the acute healing phase. These conditions usually resolve with pain medication, anti-inflammatories, physical therapy, and in some cases, cortisone injections.

The key for these conditions is improvement. Rate of improvement will differ patient to patient, but it’s important to observe some improvement. If it never improves, we have to worry about things like subtle infection (very rare), fracture, possibly loose implants that never allowed the bone to grow into the implant after surgery due to too much micro motion, especially if the patient was highly active too quickly.

Sometimes blood tests, and advanced imaging may be helpful but it is difficult to find a cause early on after a surgery because the results can be inconclusive. The prudent (though difficult) action is to watch and wait over a period of time to see if the symptoms resolve with conservative management.

If the hip was normal and pain free after surgery and healed but later developed pain in the groin, thigh, or both areas, our tests can then identify a cause because the acute healing phase is over.

Sometimes, it’s an obvious cause such as a dislocation or a fracture around the implant from a trauma or fall, but late hip pain could be from other causes: recurring tendonitis, bursitis and low back pain, or a pinched nerve need to be ruled out by the physician before any imaging or testing is performed.

2. “I have groin pain when I put weight on the leg but it is pain free or not bad at rest. It is worse when getting up from a chair.”

This could be a sign that the acetabular cup component is loose. Bone scans and advanced imaging can usually identify a loose cup if the patient is over a year out from initial surgery.

3. “I have thigh pain with putting weight on the leg and twisting, it is ok at rest.”

Like the previous statement, this can be a sign that the femoral component is loose. Again, bone scans and advanced imaging and x-rays can usually identify this as a cause.

4. “I have groin and/or thigh pain at rest, and it is worse at night. I feel weak, and lethargic. The pain is constant, achy and sometimes burning or throbbing.”

This is more concerning because it could indicate a joint infection or bodily reaction to metal or plastic debris. Blood work and aspirations of the joint are helpful to rule these conditions out as long as the patient is not on antibiotics for some other reason. Advanced imaging like MRI and bone scans can also be helpful. Recent dental work, an immune system depressing virus, or certain medications can make this problem much worse because the immune system may not be functioning, as it should.

Overall, hip replacements are very successful and help most patients. The risk of complications like dislocation and infection are about 1-2% for total hip replacements, and not all complications require revision surgery. Some will heal with time while others may just need conservative treatment.

Studies show the most common causes for hip revision after a total hip replacement are instability (recurrent dislocation), aseptic loosening of the implants from wear, and infection.

A recent article found the number one cause for hip revisions was from aseptic loosening in 45% of their recorded hip revision cases (over 1100 hip revisions), followed by wear (16%), instability (16%), infection (10%), and fracture.

They are also seeing a rise in revisions of metal on metal hip replacements secondary to metal debris causing local tissue reactions and destruction of the hip tissues.

It is important to see your total joint surgeon if you are experiencing any pain after replacement. It’s also important to understand why your hip might hurt.

I hope you’re in the majority of people who have wonderful outcomes from hip replacement. It improves tens of thousands of lives each year. If you do have complications, there are concrete solutions to the issues that may occur.