To treat the patient, one must understand what has brought the patient in for evaluation. In failed total hip arthroplasty, the most common presenting complaints are pain, instability, infection, periprosthetic fracture, and metal-related adverse local tissue reaction, with or without pain.

For the painful total hip arthroplasty, it is important to obtain a history of the pain as this may suggest a diagnosis. In particular, it is important to understand the temporal onset, severity, site, character, and location of the pain. There have been a number of excellent articles describing the evaluation of a painful total hip arthroplasty (2,3). It is helpful to review these articles when faced with a diagnostic challenge. Pain can be either intrinsic to the hip or extrinsic. A list of intrinsic and extrinsic causes of hip pain is listed in Table 21-1. It is obviously important to avoid revising a total hip arthroplasty for pain that is extrinsic to the hip.

It is important to understand the temporal onset of pain. Persistent pain since surgery, new onset of pain following a pain-free interval, severe activity-related pain relieved by rest, or constant pain, including pain at rest and pain at night, all suggest different possible diagnoses (Table 21-2).

The location of pain is also helpful in suggesting a diagnosis. It is important to identify whether the pain is primarily in the groin or deep buttock, in the thigh, or over the greater trochanter. It is also important to distinguish hip pain from other sorts of pain such as low back pain and radiating pain from the buttock to the knee and below. Table 21-3 summarizes some of the possible diagnoses that are associated with various locations of pain about the hip.

Instability and dislocation are also common reasons for patients to present for revision total hip arthroplasty. A careful history of the dislocations, how many, when they occurred, what the patient was doing at the time of dislocation, and how they were treated is important to understand. Generally speaking, if a patient has dislocated three times or more and has failed reasonable attempts at maintaining stability such as education, home evaluation, and bracing, many surgeons will be inclined to reoperate. If the implants are grossly malpositioned, most will reoperate sooner.

Deep infection is unfortunately also a common presenting complaint. It is important to understand the history of the symptoms, particularly the temporal onset in relation to the index surgery and any prior history of infection, either in the hip or elsewhere in the body. Fitzgerald (4) originally described three different types of periprosthetic infection, the acute fulminating infection that occurs shortly after surgery, the delayed infection that is likely related to the initial surgery but presents late due to a less virulent organism, and the late hematogenous infection that is an acute infection occurring in a previously uninfected total joint arthroplasty. Diagnosis of deep infection, particularly the delayed infection, can be challenging. The AAOS published a very helpful clinical practice guideline in 2010 on the diagnosis of periprosthetic infection (5). More recent work on synovial fluid biomarkers for infection holds the promise of very highly sensitive and specific tests for deep periprosthetic infection (6).

Periprosthetic fracture can occur in the setting of acute trauma or can happen subacutely, usually in the setting of osteolysis. Obviously in the trauma setting, the patient presents to the emergency department with a history of trauma. A patient may present to clinic, however, with a history of a sudden increase in pain, but no history of significant trauma. This may represent an osteolysis-related periprosthetic insufficiency fracture. In either case, plain radiographs are usually sufficient to confirm the diagnosis, though CT may be needed in more subtle cases, particularly those relating to osteolysis.

Though corrosion and metal reaction can happen in any total hip arthroplasty, metal-related adverse local tissue reaction should be on the differential diagnosis of anyone with a metal on metal bearing, a total hip arthroplasty with a cobalt-chrome head, or a total hip arthroplasty with a modular femoral neck. Metal-related adverse local tissue reaction, however, must be treated as a diagnosis of exclusion. Other intrinsic and extrinsic causes of hip pain must be ruled out before metal reaction is diagnosed as the cause of the patient’s problems.

Metal-related adverse local tissue reactions may or may not be painful. Even without pain, substantially elevated metal ion levels or progressive local tissue reaction as seen in metal artifact suppression MRI can be an indication for surgery. The American Academy of Orthopaedic Surgeons has recently published an information statement on current concerns with metal on metal hip arthroplasty, which includes guidelines on the evaluation and management of patients with metal on metal total hip arthroplasty (7).

Plain radiographs are critical to evaluating a problematic total hip arthroplasty. If possible, try to obtain old x-rays of the hip in question for comparison to current films. Standard radiographs should include the low AP pelvis, which provides a view of the entire femoral component, the frog lateral of the hip, and the cross-table lateral of the hip. Each view provides important information.

On the AP pelvis, look at the acetabular component first. Note the type of fixation used for the acetabular component and try to identify the model of the acetabular component based on its radiographic appearance. Evaluate the acetabular component abduction angle and get a sense of the acetabular anteversion (to be confirmed later on the cross-table lateral). Figure 21-1 shows the presenting radiograph of a patient who had undergone a metal on metal total hip arthroplasty and developed metal-related soft adverse local tissue reaction and hip instability due to an overabducted acetabular component. Look at the location of the hip center and note whether it is proximal or distal and medial or lateral compared to normal hip anatomy. Look at the quality of the bone supporting the acetabulum and look for osteolytic defects. If there is substantial osteolysis and the implant has migrated, the patient may have had a periprosthetic insufficiency fracture of the bone supporting the acetabular component. If concerned about pelvic discontinuity,
order Judet views of the pelvis and a lateral view of the pelvis or a false-profile view of the hip, as these last views often provide a view of the posterior column without interference from the hip hardware (8,9). The lateral view of the pelvis done in the standing position can also give a sense of the natural pelvic tilt for that particular patient. Look for radiographic signs of loosening, including migration and radiolucent lines, and look for signs of fixation such as spot welds on an uncemented component. Figures 21-2 and 21-3 show dramatic examples of cemented and
uncemented acetabular component migration. Figure 21-4 shows a more subtle case of acetabular component loosening associated with osteolysis and bead shedding.

Look at the femoral component on the low AP pelvis. Note the type of fixation used and try to identify the model of the femoral component. Evaluate the position of the femoral component in relation to the femur. This involves evaluating the center of the femoral head in relation to the tip of
the trochanter. Locate the collar, or the proximal extent of the porous coating in a collarless implant, and note its relation to the calcar and lesser trochanter of the femur. Look at the quality of the bone supporting the femoral component, and look for osteolysis or a periprosthetic fracture—particularly in the area of the greater trochanter. Then, look for radiographic signs of loosening (Tables 21-5

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