The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue Supplement 2

Scientific Articles | May 04, 2011

Residual Groin Pain at a Minimum of Two Years After Metal-on-Metal THA with a Twenty-eight-Millimeter Femoral Head, THA with a Large-Diameter Femoral Head, and Hip Resurfacing

Martin Lavigne, MD, MSc, FRSC(C)¹; Jean-Michel Laffosse, MD, PhD²; Muthu Ganapathi, MD, MSc¹; Julien Girard, MD, MSc³; Pascal Vendittoli, MD, MSc, FRCS(C)¹

¹ Department of Orthopedic Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, 5415, boulevard de l'Assomption, Montréal, QC H1T 2M4, Canada. E-mail address for M. Lavigne: lavigma2@hotmail.com
² Institut Locomoteur, Service de Chirurgie Orthopédique, Centre Hospitalier Universitaire de Toulouse-Rangueil, 1, avenue Jean Poulhès TSA 50032, 31059 Toulouse CEDEX 9, France
³ Sport and Medicine Department, Orthopaedic Department, Roger Salengro Hospital, Centre Hospitalier Régional Universitaire de Lille, 2, avenue Oscar Lambret, 59037 Lille CEDEX, France

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopedic Surgery, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada

J Bone Joint Surg Am, 2011 May 04;93(Supplement 2):93-98. doi: 10.2106/JBJS.J.01711

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Abstract

Background:

Groin pain may persist in up to 4.3% of patients after total hip arthroplasty and up to 18% of patients one year after hip resurfacing. The incidence of this problem after total hip arthroplasty with a large-diameter femoral head is unknown.

Methods:

We analyzed the natural history of groin pain and its clinical consequences during the first two years after three types of hip arthroplasty. Data were collected prospectively on 279 patients. Eighty-five patients had a polyethylene sandwich metal-on-metal total hip arthroplasty with a 28-mm-diameter femoral head, 105 had hip resurfacing, and eighty-nine had a total hip arthroplasty with a large-diameter femoral head component with three other cup designs (forty-nine in this group had the same monoblock acetabular cup design as those who had hip resurfacing).

Results:

At the twenty-four-month follow-up evaluation, seventy-seven patients (28%) reported at least one painful area around the hip and thirty-four patients (12.2%) had pain at more than one location. At three months, the incidence of groin discomfort was significantly increased in those who had hip resurfacing (30.5%) and in those who had total hip arthroplasty with a large-diameter femoral head (30%) compared with those who had total hip arthroplasty with a 28-mm femoral head (18.3%). This incidence decreased at two years (14.9%, 16.9%, and 12.9%, respectively). At twenty-four months postoperatively, eleven (four who had hip resurfacing, six who had total hip arthroplasty with the large-diameter head, and one who had total hip arthroplasty with the 28-mm head) of forty-one patients who had groin pain had not reported groin pain at previous follow-up evaluations. Of the forty-one patients reporting groin pain at the time of the last follow-up, twenty-three patients (56%) did not seek further evaluation or treatment, nine had revision surgery (22%), and the remaining nine patients thought the pain was substantial enough to warrant further evaluation and treatment.

Conclusions:

When the exact source of groin pain cannot be found after total hip arthroplasty, careful follow-up should be done as local reactions to metal-on-metal implants and component loosening may take time to become apparent clinically or on imaging studies.

Level of Evidence:

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

As many as 35% of patients may have some pain after total hip arthroplasty^1-4. The causes of hip pain are numerous^4-9, and groin pain may persist in up to 4.3% of patients after total hip arthroplasty¹⁰. Recent studies have shown that groin pain may also occur in as many as 18% of patients one year after hip resurfacing^11,12. Persistent pain after hip resurfacing is a source of patient dissatisfaction. Pain may limit the return to work and negatively impact clinical function and the ability to return to sports^12,13. However, with the absence of a standardized definition of the location, severity, and type of pain and the lack of studies on homogeneous groups of patients managed with hip resurfacing and total hip arthroplasty, it is difficult to make valid comparisons between the types of arthroplasty and groin pain. Current studies of groin pain have a short follow-up period without information about its natural history. As for metal-on-metal total hip arthroplasty with a large-diameter head, little is known about the incidence of residual groin pain, although clinical experience suggests it may be as much of a problem as in hip resurfacing¹¹.

In this prospective study, we aimed to determine (1) the incidence of pain in the groin area at several follow-up periods during the first two years after surgery and (2) the impact of groin pain on the Western Ontario and McMaster Universities Osteoarthritis Index¹⁴ (WOMAC) and University of California at Los Angeles (UCLA) activity¹⁵ scores in three homogeneous groups of patients who had metal-on-metal total hip arthroplasty with a 28-mm head, total hip arthroplasty with a large-diameter head, or hip resurfacing.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Data were collected prospectively on 279 patients who were scheduled for hip arthroplasty at two hospitals where the same three experienced hip surgeons performed surgery between March 2005 and May 2008. All patients gave written consent for inclusion in the study. The study was approved by the institutional ethics committee. No significant difference regarding patient characteristics was found among the three study groups (Table I). The study groups consisted of 105 patients who had hip resurfacing (cemented DUROM femoral and uncemented DUROM acetabular components [Zimmer, Warsaw, Indiana]), eighty-five patients who had total hip arthroplasty with a 28-mm-diameter femoral head component (CLS femoral stem, 28-mm Metasul femoral head with polyethylene sandwich metal liner, and cementless Allofit acetabular cup [Zimmer]), and eighty-nine patients who had total hip arthroplasty with large-diameter femoral head components from different manufacturers. Forty-nine patients who had total hip arthroplasty with a large-diameter head had the same monoblock DUROM acetabular component as the hip-resurfacing group, with a CLS femoral stem with DUROM femoral head (Zimmer). Nineteen patients were managed with the Taperloc femoral stem with M2a-Magnum femoral head and acetabular components (Biomet, Warsaw, Indiana); ten patients, with the Trilock femoral stem with ASR XL femoral head and acetabular components (DePuy, Warsaw, Indiana); and eleven patients, with the ANTHOLOGY femoral stem and Birmingham Hip Resurfacing (BHR) femoral head and acetabular components (Smith & Nephew, London, United Kingdom). With the patient in the lateral decubitus position, a posterior surgical approach was used. Circumferential capsulotomy was performed routinely in patients having hip resurfacing and selectively, at the surgeon's discretion when extending the hip past neutral was difficult, in patients having total hip arthroplasty with the 28-mm head or the large-diameter head. The surgical procedure for hip resurfacing has been previously described¹⁶. The choice of femoral component size for hip resurfacing depended on a balance between restoration of the head-neck-diameter ratio and acetabular bone conservation^16,17. An effort was made to restore normal offset of the anterior femoral neck by removing anterior neck osteophytes, translating the femoral component anteriorly, or performing a careful femoral neck osteoplasty when necessary. For total hip arthroplasties with a 28-mm head and those with a large-diameter head, the surgical procedure proposed by the manufacturer was followed. In all three groups, restoration of the leg length, femoral offset, and hip center of rotation in the involved leg was based on the uninvolved leg. The target for acetabular component position was 45° of abduction and 20° of anteversion in all cases. Femoral anteversion of 10° to 20° was the goal. Postoperative physical therapy included progressive full weight-bearing from the first postoperative day and the same strengthening and stretching exercises in all groups. No flexion of >90° and no combined adduction and internal rotation were allowed in the group having total hip arthroplasty with a 28-mm head for six weeks postoperatively, whereas only flexion was limited to 90° for two to four weeks in the groups that had hip resurfacing and total hip arthroplasty with a large-diameter head to allow healing of the capsule and short hip rotator muscles, without other motion restrictions.

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TABLE I Details on the Patients in the Three Study Groups

	Hip Resurfacing	Total Hip Arthroplasty with 28-mm Head	Total Hip Arthroplasty with Large-Diameter Head	P Value
No. of patients	105	85	89
Male patients*	61 (58.1)	56 (65.9)	49 (55.1)	0.318
Diagnosis of osteoarthritis*	87 (83)	63 (74)	69 (77.5)	0.637
Age†(yr)	49.7 ± 8.4 (23-64)	51 ± 8.8 (22-65)	51.2 ± 8.9 (29-69)	0.414
Body-mass index†	27.1 ± 5.0 (17.6-44.9)	28.1 ± 5.9 (19.7-39.1)	27.3 ± 4.9 (19.6-36.6)	0.181
Preop. WOMAC score†(points)	52.4 ± 15.1 (12-84)	56.6 ± 18.1 (11-96)	53.3 ± 17.3 (6-84)	0.254
Acetabular component size†(mm)	54.6 ± 3.9 (46-64)	55 ± 3.6 (48-64)	54.1 ± 4.0 (46-66)	0.288
Follow-up‡(mo)	25 (20-28)	26 (21-28)	24 (20-26)	0.308

*The values are given as the number of patients, with the percentage in parentheses.
†The values are given as the mean and the standard deviation, with the range in parentheses. WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.
‡The values are given as the mean, with the range in parentheses.

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TABLE I Details on the Patients in the Three Study Groups

	Hip Resurfacing	Total Hip Arthroplasty with 28-mm Head	Total Hip Arthroplasty with Large-Diameter Head	P Value
No. of patients	105	85	89
Male patients*	61 (58.1)	56 (65.9)	49 (55.1)	0.318
Diagnosis of osteoarthritis*	87 (83)	63 (74)	69 (77.5)	0.637
Age†(yr)	49.7 ± 8.4 (23-64)	51 ± 8.8 (22-65)	51.2 ± 8.9 (29-69)	0.414
Body-mass index†	27.1 ± 5.0 (17.6-44.9)	28.1 ± 5.9 (19.7-39.1)	27.3 ± 4.9 (19.6-36.6)	0.181
Preop. WOMAC score†(points)	52.4 ± 15.1 (12-84)	56.6 ± 18.1 (11-96)	53.3 ± 17.3 (6-84)	0.254
Acetabular component size†(mm)	54.6 ± 3.9 (46-64)	55 ± 3.6 (48-64)	54.1 ± 4.0 (46-66)	0.288
Follow-up‡(mo)	25 (20-28)	26 (21-28)	24 (20-26)	0.308

The presence or absence of groin pain was recorded preoperatively and at three months, six months, one year (ten to fourteen months), and two years (twenty-two to twenty-eight months) after surgery by the same research assistant in person or by a telephone interview. At the twenty-four-month follow-up visit, patients were also asked about the presence of pain at other locations around the hip and the need for medications for hip pain. To be considered as pain, the symptoms needed to be present daily or substantial enough to modify activities of daily living. Pain locations were defined. The groin indicated the area extending from the inner thigh to the anterior border of the greater trochanter and from the anterior superior iliac spine to the level of the base of the greater trochanter. The thigh was the circumferential area distal to the base of the greater trochanter. The greater trochanter area was bordered by the anterior and posterior aspects of the greater trochanter and from the base of the greater trochanter to the lateral aspect of the iliac crest. The buttock area extended from the posterior aspect of the greater trochanter to the sacroiliac joint to the posterior aspect of the iliac crest, and the back area included the sacroiliac joint and the ipsilateral paravertebral area. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (a scale from 0 to 100, with the lowest score of 0 reflecting the best functional outcome)¹⁴ was completed preoperatively and at twenty-four months postoperatively, and the UCLA activity scale¹⁵ (a scale from 0 to 10, with the highest score of 10 reflecting the highest activity level) was completed at twenty-four months postoperatively. The one investigation for the patients with persistent groin pain at the time of the last follow-up included anteroposterior pelvic radiographs and lateral femoral radiographs at the immediate postoperative and last follow-up evaluations for all patients, and bone scan, ultrasound examination, magnetic resonance imaging (MRI), blood work-up, serum metal ion levels, or computed tomography (CT) scans were performed on a selective basis.

Statistical Analysis

Demographic data on the three study groups were compared with use of chi-square tests (sex and diagnosis) or one-way analysis of variance (ANOVA) (age at time of surgery, preoperative body-mass index, WOMAC score, and length of follow-up). For acetabular cup size, a Kruskal-Wallis test was used since data were not normally distributed. The incidence of groin pain with each type of arthroplasty at different follow-up times, the incidence of pain at different locations around the hip, and the need for medications at twenty-four months were compared with chi-square tests. One-way ANOVA was used to compare the mean UCLA scores, whereas a Mann-Whitney test was performed for the WOMAC score since data were not normally distributed. Post hoc comparisons between types of implants were used when a test showed a significant difference. The significance level was set at p < 0.05.

Results

Introduction | Materials and Methods | Results | Discussion | References

At the time of the twenty-four-month follow-up, seventy-seven patients (28%) reported at least one painful area around the hip and thirty-four patients (12.2%) had pain at more than one location. The groin area was more frequently the location of pain (14.9%) compared with the buttock (7.2%; p = 0.007), back (8.0%; p = 0.003), and thigh (3.8%; p < 0.001), but its incidence of pain was not significantly different from the incidence of pain around the greater trochanter (9.3%; p = 0.089). Pain medications were administered specifically for pain around the hip in forty-one patients (14.7%), with only nine patients (3.2%) managed with narcotics and 100 patients (35.8%) managed with anti-inflammatory medications.

The incidence of groin pain in the three study groups at each follow-up period is shown in Table II. There was no significant difference in the incidence of groin pain between the various types of total hip arthroplasty with a large-diameter head at all follow-up periods. In all groups, there was a significant decrease in groin pain between preoperative and all postoperative follow-up evaluations (p = 0.02). At three months postoperatively, the incidence of groin pain was greater in hip resurfacing patients (p = 0.035) and patients who had total hip arthroplasty with a large-diameter head (p = 0.045) compared with those who had arthroplasty with a 28-mm head. The incidence of groin pain in the hip-resurfacing group and the group that had total hip arthroplasty with a large-diameter head decreased with time of follow-up to become similar to that in the total hip arthroplasty group at the time of the last follow-up (p = 0.685). At twenty-four months postoperatively, forty-one patients had groin pain and eleven of them (four who had hip resurfacing, six who had arthroplasty with a large-diameter head, and one who had arthroplasty with a 28-mm head) had no groin pain at previous follow-ups. Twenty-three (56%) of the forty-one patients reporting groin pain had pain they considered mild (Table III). Nine (22%) of the forty-one patients had additional surgery; five patients were in the group that had hip resurfacing (one had grade-3 heterotopic ossification, one had femoral neck impingement on the acetabular cup, and three had femoral component loosening), two were in the group that had total hip arthroplasty with a 28-mm head (deep infection in both), and two were in the group that had total hip arthroplasty with a large-diameter head. Of those last two, one had removal of a cable grip plating system with cerclage cable used for an intraoperative greater trochanteric fracture. In the other patient, a precise cause for pain was not found despite careful serial radiographic review, blood work-up, bone scintigraphy, and MRI of the hip. During revision to a metal-on-polyethylene total hip arthroplasty, no specific reason for the pain could be determined. Despite early improvement in function following the revision arthroplasty, pain recurred four months postoperatively, still without clear explanation. The patient was sent to the pain clinic.

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TABLE II Incidence of Groin Pain at Each Follow-up Period for Each Type of Hip Arthroplasty

	Follow-up Period*
Type of Arthroplasty	Preop.	3 Mo	6 Mo	1 Yr	2 Yr
Hip resurfacing	82/105 (78.1)	32/105 (30.5)†	17/96 (17.7)	15/99 (15.2)	15/101 (14.9)
Total hip arthroplasty with 28-mm head	55/83 (66.3)	15/82 (18.3)	11/78 (14.1)	13/85 (15.3)	11/85 (12.9)
Total hip arthroplasty with large-diameter head	56/84 (66.7)	21/70 (30.0)‡	9/72 (12.5)	12/89 (13.5)	15/89 (16.9)
All patients pooled	193/272 (70.2)	68/257 (26.5)	37/246 (15)	40/273 (14.7)	41/275 (14.9)
P value§	0.363	0.003	0.621	0.862	0.685

*The incidence is reported as a percentage (in parentheses) that is calculated as the number of patients reporting groin pain divided by the number of patients with available data at the corresponding follow-up period.
†The difference between the incidence of groin pain for the total hip arthroplasty with the 28-mm head and the hip resurfacing was significant (p = 0.035).
‡The difference between incidence of groin pain with the total hip arthroplasty with the 28-mm head and the total hip arthroplasty with the large-diameter head was significant (p = 0.045).
§Intergroup analysis of variance.

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TABLE II Incidence of Groin Pain at Each Follow-up Period for Each Type of Hip Arthroplasty

	Follow-up Period*
Type of Arthroplasty	Preop.	3 Mo	6 Mo	1 Yr	2 Yr
Hip resurfacing	82/105 (78.1)	32/105 (30.5)†	17/96 (17.7)	15/99 (15.2)	15/101 (14.9)
Total hip arthroplasty with 28-mm head	55/83 (66.3)	15/82 (18.3)	11/78 (14.1)	13/85 (15.3)	11/85 (12.9)
Total hip arthroplasty with large-diameter head	56/84 (66.7)	21/70 (30.0)‡	9/72 (12.5)	12/89 (13.5)	15/89 (16.9)
All patients pooled	193/272 (70.2)	68/257 (26.5)	37/246 (15)	40/273 (14.7)	41/275 (14.9)
P value§	0.363	0.003	0.621	0.862	0.685

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TABLE III Diagnoses Found to Explain Pain in Forty-one Patients with Residual Groin Pain at Twenty-four Months of Follow-up*

Diagnosis	Hip Resurfacing	Total Hip Arthroplasty with 28-mm Head	Total Hip Arthroplasty with Large-Diameter Head
No further investigation requested	8	6	9
Heterotopic ossification	1 (excision) and 1 (in association with psoas tendinopathy)	1 (located at rectus femoris origin relieved by cortisone injection)	0
Femoral neck impingement	1 (neck osteoplasty)	0	0
Femoral component loosening	3 (revision of femoral component)	0	0
Deep infection	0	1 (2-stage revision)	0
Painful trochanteric cable grip	0	0	1 (removal of cable grip)
Psoas tendinopathy	1 (substantially improved with cortisone injection)	1 (declined psoas release)	2 (substantially improved with cortisone injection)
Sacroiliac joint dysfunction	1 (improved)	0	0
Low back pain with L5-S1 facet arthrosis	0	0	1 (sent to pain clinic)
Unexplained pain	0	1 (sent to pain clinic and psychiatric evaluation)	2 (1 had unsuccessful cup revision and 1 was offered joint exploration)

*The values are given as the number of patients, with the treatment or result in parentheses. Some patients had more than one diagnosis.

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TABLE III Diagnoses Found to Explain Pain in Forty-one Patients with Residual Groin Pain at Twenty-four Months of Follow-up*

Diagnosis	Hip Resurfacing	Total Hip Arthroplasty with 28-mm Head	Total Hip Arthroplasty with Large-Diameter Head
No further investigation requested	8	6	9
Heterotopic ossification	1 (excision) and 1 (in association with psoas tendinopathy)	1 (located at rectus femoris origin relieved by cortisone injection)	0
Femoral neck impingement	1 (neck osteoplasty)	0	0
Femoral component loosening	3 (revision of femoral component)	0	0
Deep infection	0	1 (2-stage revision)	0
Painful trochanteric cable grip	0	0	1 (removal of cable grip)
Psoas tendinopathy	1 (substantially improved with cortisone injection)	1 (declined psoas release)	2 (substantially improved with cortisone injection)
Sacroiliac joint dysfunction	1 (improved)	0	0
Low back pain with L5-S1 facet arthrosis	0	0	1 (sent to pain clinic)
Unexplained pain	0	1 (sent to pain clinic and psychiatric evaluation)	2 (1 had unsuccessful cup revision and 1 was offered joint exploration)

*The values are given as the number of patients, with the treatment or result in parentheses. Some patients had more than one diagnosis.

The remaining nine patients reporting groin pain at the time of the last follow-up were evaluated further. Ultrasound evaluation confirmed clinically suspected psoas bursitis or tendinitis in three patients (two who had total hip arthroplasty with a large-diameter head and one who had hip resurfacing). Among those three patients, the patient with hip resurfacing also showed grade-3 heterotopic ossification, which could contribute to residual symptoms, and the ultrasound examination of the two patients who had total hip arthroplasty with a large-diameter head showed tenting of the tendon over the edge of the femoral head. One patient who had arthroplasty with a 28-mm head had psoas tendinopathy, confirmed by ultrasound, and declined further treatment. One hip-resurfacing patient, who had suspicious sacroiliac joint involvement on clinical examination and increased uptake of the sacroiliac joint on bone scintigraphy, received two injections of cortisone in the sacroiliac joint with good pain relief. One patient who had arthroplasty with a large-diameter head with marked low back pain worse than the groin pain was referred for treatment to the back pain clinic. Grade-2 heterotopic ossification of the rectus femoris tendon at the insertion on the anterior inferior iliac spine was relieved only partially with a cortisone injection in one patient (who had total hip arthroplasty with a 28-mm head). The cause of pain remained unknown in the other two patients despite an extensive evaluation. Of those two patients, one with a total hip replacement with a 28-mm head was offered consultation at a clinic that specialized in psychosomatic disease. The other patient who had a total hip replacement with a large-diameter head (ASR XL; DePuy) was offered revision of the acetabular component but had not had this surgery at the time of the latest evaluation. The chromium (2.57 µg/L) and cobalt (1.85 µg/L) ion levels in the whole blood of this patient were within an acceptable range. Hypersensitivity testing was not performed in any patient. Radiographic review of the nine patients showed none had cup malposition, a cover arc of <10 mm according to the criteria of De Haan et al.¹⁸, or radiographic signs of implant loosening.

At twenty-four months, the WOMAC score for all patients reporting groin pain irrespective of the type of arthroplasty was significantly greater than that for the patients free of groin pain (mean and standard deviation, 17.4 ± 15.3 points compared with 4.4 ± 6.1 points; p < 0.001). A trend (p = 0.082) was observed with a lower UCLA score for patients with groin pain (mean, 6.8 ± 2.0 points) compared with patients free from groin pain (mean, 7.3 ± 1.8 points). To assess the relative effect of groin pain, we compared the WOMAC and UCLA activity scores of patients reporting groin pain with those of patients free of groin pain within the arthroplasty groups. The WOMAC score was significantly greater for patients with groin pain compared with those free of groin pain in the group that had hip resurfacing (p < 0.001) and the group that had total hip arthroplasty with a large-diameter head (p < 0.001), whereas no difference in the WOMAC score was observed between patients with or without groin pain after total hip arthroplasty with a 28-mm head (p = 0.147). The UCLA score demonstrated a trend, with a lower score for patients with groin pain compared with patients without groin pain, only in the hip-resurfacing group (p = 0.072).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Several studies have investigated the incidence of pain after total hip arthroplasty^1,2,19,20, and many authors have detailed the strategies to deal with patients who have pain after total hip arthroplasty, especially those with groin pain^5,6,9,21,22. Specific causes of groin pain related to hip resurfacing include impingement of the native femoral neck on the acetabulum^23,24, femoral neck fractures, collapse of the femoral component, or a biological reaction to metal ions or particles^25-27. Recently, short-term studies have found groin pain to be more prevalent after hip resurfacing compared with that after total hip arthroplasty with a 28-mm head^11,12. Furthermore, groin pain after hip resurfacing was severe enough to affect clinical function measured by the WOMAC score¹² and reduce the level of sports activity^12,13. The current literature comparing hip resurfacing and total hip arthroplasty includes differences in patient demographic data, duration of follow-up, activity level, definitions of groin pain, patient expectations, and type of implant bearing surfaces. Our study showed a higher incidence of groin pain after hip resurfacing and total hip arthroplasty with a large-diameter head compared with that after total hip arthroplasty with a 28-mm head, but only at the three-month follow-up evaluation. Although the incidence of groin pain was similar in all groups two years after surgery, groin pain had a significant impact on clinical function only in patients who had hip resurfacing and those who had total hip arthroplasty with a large-diameter head.

This study has some limitations. The results obtained in this young patient population may not be generalized to a group of older, less active patients or to hip arthroplasties performed with other bearing surfaces. Although the definition and severity of groin pain was standardized and data collection was done by one research assistant, comparison of the results with those in the literature is difficult because of differences in methodology for data collection. The severity of groin pain was assessed indirectly by comparing WOMAC and UCLA scores in patients with and without pain. A visual analog scale would have provided a more objective evaluation of the severity of pain. Pain other than in the groin area may have an influence on the clinical scores, although this was not reported to be different among the groups.

At a minimum of six months of follow-up, Bin Nasser et al.¹² found residual groin pain in 18% of 116 patients with hip resurfacing, while Bartelt et al.¹¹ found an incidence of 18% among thirty-nine patients with hip resurfacing at the time of the twelve-month follow-up. This is similar to our findings with hip resurfacing at six months (17.7%) and twelve months (15.2%) of follow-up. The greater incidence of groin pain at three months after hip resurfacing compared with that after total hip arthroplasty with a 28-mm head may be due to soft-tissue dissection at surgery and to the larger native femoral neck after hip resurfacing pressing the healing capsule against the acetabulum during motion. In hip resurfacing and total hip arthroplasty with a large-diameter head, the larger femoral head may be rubbing against the synovium and capsule during the healing process, causing pain. This mechanism of pain has been described after bipolar hip arthroplasty²⁸ and hip arthroscopy²⁹, and may explain the appearance of de novo groin pain at twenty-four months in patients with hip resurfacing or total hip arthroplasty with a large-diameter head. The incidence of groin pain in the metal-on-metal total hip arthroplasty with a 28-mm head in this study (12.9%) was higher than the incidence reported after metal-on-polyethylene arthroplasty, which has been reported to range from 4.3% to 7%^10,11. This difference may be due to the young patients included in our study¹¹.

Although the incidence of groin pain is similar among the three types of arthroplasty at the time of the last follow-up, the effect of groin pain on clinical function seems greater after hip resurfacing and after total hip arthroplasty with a large-diameter head compared with that after total hip arthroplasty with a 28-mm head, with a significantly higher WOMAC score after hip resurfacing or total hip arthroplasty with a large-diameter head for patients with groin pain than for those without groin pain. There was a trend toward a lower UCLA score for patients with groin pain after hip resurfacing, an observation also reported by Bartelt et al.¹¹ and Bin Nasser et al.¹². There may be several reasons for the greater influence of groin pain on clinical function observed after hip resurfacing and total hip arthroplasty with a large-diameter head at two years postoperatively. As mentioned previously, the larger femoral head in hip resurfacing and in total hip arthroplasty with a large-diameter head may be rubbing against the capsule³⁰, or there may be entrapment of synovial folds between the articulating surfaces. Psoas tendinopathy, as was demonstrated by ultrasound examinations in two patients in this study who had total hip replacement with a large-diameter head, may be caused by the edge of the femoral head component. The cup design of the hip-resurfacing and total hip replacement with large-diameter-head systems is different from that of the total hip replacement with a 28-mm head. The thick monoblock cobalt-chromium cup design may cause pain by transmitting peak load differently to the periacetabular area than the thinner polyethylene sandwich design titanium cup. Other potential sources of pain after hip resurfacing include poor restoration of femoral offset and acetabular cup malposition^11,12,24.

Most (56%) of the forty-one patients with groin pain at the time of the last follow-up did not seek further treatment or investigation despite lower clinical scores. Groin pain led to reoperation in 22% of the patients, for whom a precise diagnosis was made in all but one patient with a total hip replacement with a large-diameter head who underwent acetabular component revision without resolution of pain. Psoas tendinopathy has been well described after total hip arthroplasty⁷ and appeared to be the reason for groin pain in four of nine patients seeking further investigation. Bin Nasser et al. found psoas pathology in five of twenty-one patients with groin pain after hip resurfacing¹². The sacroiliac joint and the lower back can also be a source of groin pain, as shown in this study and others⁸. Reactivity or hypersensitivity to metal ions or particles may cause persistent or developing groin pain. Contrary to the reports of Hart et al.³¹ and Bin Nasser et al.¹², we have not seen soft-tissue changes due to a reaction to metal ion or metal debris on MRI scans of our patients. These changes may become apparent with time in the three patients with undiagnosed groin pain. Acetabular component loosening may occur after hip resurfacing and after total hip arthroplasty with a large-diameter head without classic radiographic changes³², and this may also be discovered with longer follow-up. Finally, Pacault-Legendre et al.³ suggested psychiatric evaluation to rule out psychotic or depressive disorders in patients with chronic pain after total hip arthroplasty.

In conclusion, although patients commonly report persisting groin pain or discomfort after any type of hip arthroplasty, the pain was not severe enough in 56% of our patients to warrant further evaluation or treatment. Patients who have total hip arthroplasty with a 28-mm head, total hip arthroplasty with a large-diameter head, and hip resurfacing have similar rates of groin pain two years after surgery. There was a greater impact of groin pain on clinical function after metal-on-metal hip resurfacing and total hip arthroplasty with a large-diameter head compared with metal-on-metal total hip arthroplasty with a 28-mm head. Groin pain should be discussed preoperatively as a potential persisting symptom after hip arthroplasty, especially when larger femoral heads are used. When the exact source of groin pain cannot be found, careful follow-up should be done as local reactions to metal-on-metal implants and component loosening may take time to become apparent clinically or on imaging studies.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

head of femur ; hip joint ; metals ; pain ; hip replacement arthroplasty ; groin pain

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Martin Lavigne, Jean-Michel Laffosse, Muthu Ganapathi, Julien Girard, Pascal Vendittoli; Residual Groin Pain at a Minimum of Two Years After Metal-on-Metal THA with a Twenty-eight-Millimeter Femoral Head, THA with a Large-Diameter Femoral Head, and Hip Resurfacing. The Journal of Bone & Joint Surgery. 2011 May;93(Supplement_2):93-98.

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