Evaluation of Pain in Patients with Apparently Solidly Fixed Total Hip Arthroplasty Components

Evaluation of Pain in Patients With Apparently Solidly Fixed Total Hip Arthroplasty Components

Graham M. Robbins, MB, BS, FRCSOrth, Bassam A. Masri, MD, FRCSC, Donald S. Garbuz, MD, FRCSC, and Clive P. Duncan, MB, MSc, FRCSC

Abstract

The cause of pain in a patient with an apparently solidly fixed total hip arthro- third of patients who fail on the pain plasty can be difficult to elucidate. A detailed history, careful examination, and rating do not fail on overall Harris plain radiographs provide the most useful information, especially in excluding or Charnley scores.3 It has been sug- causes not primarily related to the hip. Determining whether the pain is related gested that a simple visual analog to the implant, to soft tissue, or to bone can require laboratory tests, radiograph- pain score may be more accurate in ic and fluoroscopic imaging, and contrast arthrography and local anesthetic assessing outcome because it corre- injections. Particularly when pain is caused by occult infection, erythrocyte lates highly with the Harris hip sedimentation rate, C-reactive protein level, hip aspiration, advanced radiologic score.4 Also, in patients with multi- imaging, and nuclear medicine scans can help determine the diagnosis. ple joint dysfunction, reference thus J Am Acad Orthop Surg 2002;10:86-94 can be made specifically to the joint of interest. A THA Outcome Evaluation Form prepared jointly by the Hip Society, the American Total hip arthroplasty (THA) is a corrected). Mancuso et al1 found Academy of Orthopaedic Surgeons, very successful procedure, achieving that 60% of patients expected pain and the Société Internationale excellent pain relief, improvement in relief and only 7% expected an de Chirurgie Orthopédique et de activity level, and patient satisfac- increase in nonessential activities. Traumatologie attempts to address tion in 90% of cases.1 However, in Those who expected psychological the deficiencies of previous scores some patients, discomfort persists or improvement—for example, to “feel by incorporating patient satisfaction. develops. Although the main cause normal again” and lose the “stigma” It also contains all the data necessary of failure of THA is aseptic loosen- of disability—were the most satis- for calculating the other standard ing, hip pain of other origin should fied (96%); those who wanted to hip scores. not be attributed to presumed loos- return to nonessential activities were ening. The diagnostic dilemma of least satisfied (75%). Burton et al2 the painful hip after a seemingly reported that only 55% of patients Dr. Robbins is Clinical and Research Fellow, well-fixed THA is becoming more had their expectations fully met by Division of Reconstructive Orthopaedics, common as more arthroplasties are THA. In addition, the extent of dis- University of British Columbia, Vancouver, performed. Therefore, practitioners ease and any comorbidities also can BC, Canada. Dr. Masri is Associate Professor who treat patients who have under- have a marked effect on functional and Head, Division of Reconstructive gone THA should appreciate the result and overall satisfaction—for Orthopaedics, University of British Columbia. Dr. Garbuz is Assistant Professor, Division of range of causes of hip pain and de- example, whether the primary con- Reconstructive Orthopaedics, University of velop a rational approach for inves- dition affects only the treated hip or British Columbia. Dr. Duncan is Professor tigation. both hips and whether other sys- and Chairman, Department of Orthopaedics, The level of postoperative patient temic disabilities exist. University of British Columbia. satisfaction depends partially on the The assessment of pain after THA patient’s expectations for the sur- is made more difficult because, Reprint requests: Dr. Masri, Third Floor, 910 West Tenth Avenue, Vancouver, BC V5Z 4E3, gery. It is necessary to ensure that although it is the primary reason for Canada. an unmet expectation is not at the a THA, pain is often underweighted root of the patient’s dissatisfaction by hip scores. Although the Harris Copyright 2002 by the American Academy of (eg, a persistent limp when a leg- hip score weights pain more heavily Orthopaedic Surgeons. length inequality has not been fully than does the Charnley score, one

86 Journal of the American Academy of Orthopaedic Surgeons Graham M. Robbins, MB, BS, FRCSOrth, et al

Pain after THA in which the components appear to be solidly Is initial diagnosis correct? Initial relief of No Review history and examination fixed can have many causes. A symptoms by THA number of investigative steps may (eg, lumbar spine, pelvis, knee) be required to elicit the underlying Yes cause (Fig. 1).

Radiologic evidence Both Aseptic Yes ESR and CRP of loosening negative loose THA History

Either or both No A precise, in-depth history and positive physical examination of the patient Review history, examination, and plain are the most important steps in Aspiration Negative Reaspiration radiographs; do local anesthetic, assessing the painful THA. Even impingement, and fluoroscopy studies most cases of deep sepsis may be Diagnosis made Infected Positive correctly diagnosed from the history loose THA and physical examination alone.5 The time of onset of pain is of Yes No key importance. If the patient has Both negative, Treat ESR and CRP had no pain-free interval after weak history appropriately surgery and if the nature of the pain is different from that experienced Either or both positive preoperatively, a cause related or strong history directly to the surgery is implied, Negative, Positive Aspiration such as an acute infection, a large weak history hematoma, poor implant fixation, impingement, instability, or frac- Negative, ture. Persistence of the preoperative strong history pain suggests that the original diag- Aseptic fixed THA Infected 99Tc MDP nosis for which the THA was done Negative (possible minor bone scan should be questioned because an- fixed THA loosening) other source is likely. The site of the pain may give some Positive insight into its source. Groin and buttock pain are usually indicative of 111In leukocyte Positive acetabular cup or capsular abnormal- scan ities, while thigh pain or referred knee pain are often related to the Negative or femoral component. Localized pain equivocal over the greater trochanter is sugges- Sulphur tive of bursitis, and pain radiating Positive Negative colloid scan below the knee is usually of radicular or peripheral nerve origin. So-called start-up pain may represent early Figure 1 Algorithm for the investigation of painful total hip arthroplasty. THA = total hip arthroplasty; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein level; loosening of one or both components. 99Tc MDP = technetium 99 methylene diphosphonate. Pain associated solely with activity may be related to an inflammatory condition, such as iliopsoas tendinitis or iliopectineal bursitis. End-of-stem In addition to the timing of the risk of deep prosthetic infection as a pain may be caused by a modulus onset and location of pain, a careful result of delayed wound healing mismatch between the implant stem history should be taken to identify or large hematoma formation. and the bone. Pain at night or at rest any precipitating events, such as Therefore, specific inquiry should be suggests infection or tumor but may trauma, systemic illness, or infection made about wound drainage, persis- also occur with aseptic loosening. elsewhere. There is an increased tent fever, prolonged antibiotic

Vol 10, No 2, March/April 2002 87 Pain After Total Hip Arthroplasty administration, or delayed hospital Instability or impingement may a subset of patients has symptoms discharge. General factors that be a more subtle cause of intermit- of hip disease that cannot be easily increase the risk of infection include tent pain in the hip; they may be distinguished from spinal disease. previous hip surgery or infection, elicited by a particular position or Such symptoms can be particularly ongoing infection (eg, venous stasis motion of the lower extremity corre- perplexing after hip replacement. ulcers), immunosuppression, or neo- sponding to the position or activity In such cases, a diagnostic block of plastic disease. Moeckel et al6 did not during which the patient has experi- the hip joint with local anesthetic find increased incidence of deep sepsis enced pain. A complete examina- may help delineate the source of of hip arthroplasty in patients with tion of the ipsilateral knee and the the pain. In some cases, local irrita- diabetes mellitus, a finding contrary spine should include range of motion of the sciatic nerve may cause to popular belief. In female patients, tion and assessment of nerves and thigh pain without spinal disease. a gynecologic history also should be tendons. When predicated, an ab- Pain also may be related to a obtained, particularly to elicit any dominal, pelvic, neurologic, or vas- metabolic condition, such as Paget’s relationship between the pain and cular assessment can be done to rule disease. This disease can be unilat- menses, which can occur with endo- out causes of referred pain from eral and affect the pelvis, lumbar metriosis and other conditions. an abdominal or pelvic mass, pe- spine, or femur. It may coexist with ripheral vascular disease, or spinal osteoarthritis of the hip but should stenosis. be apparent from plain radiographs Physical Examination and laboratory studies. Paget’s disease can produce pain in the postop- Although the patient may complain Differential Diagnosis of erative period but should respond primarily of pain in the hip, referred the Painful THA well to medical management. pain from conditions unrelated to Primary bone tumors and metas- the arthroplasty must be ruled out. Referred Pain tases in either the pelvis (Fig. 2), The skin should be examined for When surgery does not provide lumbar spine, or femur can give rise inflammation, a sinus (healed or relief of symptoms, hip pathology to symptoms suggestive of a painful open), wound drainage, and any may not have been the cause of the THA. Likewise, supra-acetabular, sources of remote infection that may symptoms for which the THA was femoral head, and femoral neck spread to the hip. Areas of altered done. Other conditions can mimic metastases can give rise to pain simi- sensation and localized tenderness degenerative arthritis of the hip by lar in nature to degenerative arthritis in a scar suggest a neuroma. Pal- producing hip and leg pain. of the hip. These metastases may pation may accurately localize an Spinal stenosis may produce not be evident on plain radiographs, area of tenderness or discomfort, buttock, hip, thigh, or even groin however, because they may be hid- such as that from trochanteric bursi- pain; however, the pain should not den by bone changes of arthritis. A tis or a stress fracture of the pubic be exacerbated by passive range detailed history of a previous malig- ramus or midfemur. The groin and of motion of the hip, and some nancy and risk factors may explain the iliac fossa should be carefully ex- neurologic findings should be dis- new symptoms or signs as well as amined for any fullness or masses, covered on physical examination. radiographic features of bone de- especially to eliminate the possibility Sometimes the symptoms of spinal struction. Night or rest pain is a par- of an inguinal hernia. stenosis develop only after surgery ticular feature of this diagnosis. If a The range of movement of the because of the patient’s increased diagnosis of neoplastic disease is hip should be carefully assessed level of activity; however, the pa- considered, then further investiga- and documented. Pain at the ex- tient should be able to distinguish tion includes tests for erythrocyte tremes of motion is indicative of this as a new pain, different from sedimentation rate, prostate-specific loosening, whereas pain present preoperative pain. Degenerative antigen, serum protein electropho- throughout the range suggests and inflammatory disorders of the resis, and urinary protein electro- inflammation or infection. Pain on lumbar spine and sacroiliac joints phoresis, as well as chest radiograph, resisted abduction may be seen with also may produce symptoms in the bone scan, mammography, and, trochanteric bursitis, gluteal calcific hip region. These conditions are potentially, computed tomography. tendinitis, or the early stages of het- usually apparent on taking a de- erotopic ossification. Pain with tailed history and examination and Local Pain resisted hip flexion or passive hip can be confirmed with radiographs, When referred causes of pain extension may be associated with computer tomography, or magnetic have been excluded, the pain is likely iliopsoas tendinitis. resonance imaging. Nevertheless, related to the hip itself.

88 Journal of the American Academy of Orthopaedic Surgeons Graham M. Robbins, MB, BS, FRCSOrth, et al

pain. Incorrect cup position and advanced polyethylene wear also may precipitate subluxation. Insufficient anteversion of large uncemented acetabular components that produces a prominent anterior lip can cause iliopsoas impingement. The impingement may respond to injection of corticosteroid or to arthroscopic tenotomy, but it may require cup revision and iliopsoas débridement.10 Similarly, large mar- ginal osteophytes or extruded cement can cause impingement pain. Deep sepsis remains a serious complication after THA. The types of wound sepsis have been classi- fied into three stages by Fitzgerald A B et al.11 Stage I represents an obvious florid postoperative infection, Figure 2 A, Normal anteroposterior radiograph of the pelvis 5 years after a right total hip arthroplasty. B, Two years later, the patient reported right groin pain and had a metastatic which may be difficult to distin- lesion to the pubic ramus from carcinoma of the lung. guish from a more superficial infection. Stage II is an indolent infection occurring 6 to 24 months after surgery, and stage III is the initial Implant-Related Pain bony hypertrophy. Pain from end occurrence of infection more than 2 Aseptic loosening is the main fill is usually less than that from years after surgery. Although the cause of pain after THA and must loosely fitting distal stems and is of implant may remain solidly fixed be considered even when the com- later onset. Whiteside,9 using a for a considerable period, progres- ponents appear to be firmly fixed. proximally porous-coated implant, sive loosening inevitably occurs in Although loosening is usually clear found that pain occurred in 3% of the presence of infection. from the typical features on plain patients with a tight distal fit and in radiographs (ie, progressively in- 53% of those with loose fit. Pain Soft-Tissue–Related Pain creasing lucent lines, cement frac- also can be produced by a large Trochanteric bursitis usually pre- ture, or component migration), loos- uncemented stem due to a modulus sents as localized tenderness over ening sometimes becomes apparent of elasticity mismatch with the sur- the greater trochanter and is re- only during further investigation. rounding bone. ported to occur in 17% of arthro- Thigh pain, a major concern with Joint instability can cause pain. plasties performed with a trochan- earlier uncemented arthroplasties, Dislocation of the arthroplasty is a teric osteotomy and in 3% with- has become much less of a clinical discrete event with an obvious histo- out.12 Trochanteric bursitis can be problem. Callaghan et al7 reported ry and can be clearly seen on ex- produced by prominent or broken an incidence of thigh pain of 18% at amination as well as on diagnostic wires from the reattachment of the 1 year, which remained unchanged radiographs. Subluxation is less osteotomy; however, the benefit of when the patients were rereviewed obvious; the patient may have dis- wire removal in such cases is vari- at longer follow-up. Engh and comfort only from soft-tissue stretch- able. A local anesthetic injection, Massin8 found an incidence of thigh ing, which can be associated with with or without corticosteroid, may pain of 8% in patients with bone a mechanical clunk. Subluxation be tried initially to predict the prob- ingrowth and of 35% with fibrous is often provoked by a particular able benefit of surgery. Similarly, ingrowth. They described two dif- movement or posture and is more symptoms can be produced by ferent types of thigh pain, one likely to occur in patients with de- prominent sutures used in the re- caused by a loosely fitting under- tachment of the abductor mechanism pair after other surgical approaches. sized distal stem with some relative or as a result of poor patient compli- Tendinitis may occur, and it usu- movement, the other by good end ance. Repeated episodes of subluxa- ally affects the abductor, adductor, or fill causing localized stresses and tion may give rise to a more constant iliopsoas muscles. There also might

Vol 10, No 2, March/April 2002 89 Pain After Total Hip Arthroplasty be pain from tight tissue tension, Bone Pain investigation is required. Useful which is evident by restricted range Intraoperative fractures of the modalities include serologic tests, of movement or by a fixed deformity. greater trochanter or shaft are usu- sophisticated radiologic investiga- Although detachment of the abduc- ally apparent at the time of surgery. tions, and nuclear medicine scans, tors is associated with abnormal gait Femoral stress fractures can occur in as well as microbiologic investiga- mechanics and weakness, detach- the late postoperative period, usually tions to rule out occult infection. ment itself is not uniformly agreed to at the stem tip, particularly when be a cause of hip pain. stems implanted in varus with the Blood Tests Nerve injuries occur in fewer stem tip are in contact with the lat- The white blood cell (WBC) count than 1% of hip arthroplasties, most eral cortex. In patients undergoing is usually not helpful and is rarely commonly in women.13 The injury revision surgery, a stress fracture elevated, even in obviously infected may be direct (eg, caused by an may develop at the site of shaft win- hips.16 Canner et al17 found an ab- instrument, cement, hematoma, or dows and perforations. Therefore, normal WBC count in only 15% of in- scar entrapment) or indirect, caused round or oval anterior windows are fected hips, and Spangehl et al5 found by tension on a nerve when leg preferable to lateral ones with cor- an elevated WBC count in only 20% length is markedly increased during ners. Eschenroeder and Krackow15 of patients with hip infection. arthroplasty. The sciatic, femoral, describe the late onset of a stress Because the erythrocyte sedimen- obturator, or lateral cutaneous fracture of the femoral shaft at the tation rate (ESR) is a nonspecific nerves of the thigh may be affected. site of extruded cement and recom- inflammatory marker, it is difficult Meralgia paresthetica, a condition mend bone grafting of these defects to interpret. A substantial number affecting the lateral femoral cuta- if they become symptomatic. Stress of patients also have connective tis- neous nerve of the thigh, typically is fractures of the pubis usually occur sue disorders and other conditions marked by a sensory deficit and a because of increased patient activity that can raise the ESR. After an un- trigger point, either medial to the after the arthroplasty, but this may complicated THA, the ESR usually anterosuperior iliac spine or any- be complicated by development of returns to normal by 6 months18 but where within an adjacent scar. The disuse osteoporosis before surgery. can remain elevated for longer than site can be localized with regional These insufficiency fractures may 1 year.19 Lachiewicz et al16 found anesthetic injection studies. Causal- not become apparent on radiographs the ESR markedly elevated (mean, gic pain occurs in approximately for several weeks after the onset of >80 mm/h) in 17 of 19 patients with one fourth of nerve injuries,13 and pain, when the healing response first infected THAs but also slightly while it usually affects the foot, it can be seen radiographically. increased (mean, 32 mm/h) in 58 of may be felt more proximally. Post- Whether nonunion of a trochan- 116 of the uninfected patients. operative hip and thigh pain caused teric osteotomy causes pain remains Sanzén and Carlsson20 found no by vascular complications is less fre- controversial. Although fixation of cases of aseptic loosening with an quent. Hematoma formation or markedly displaced nonunions has ESR >30 mm/h, and other authors injury to the femoral artery result- been reported to relieve pain, most have shown that a cutoff of 30 ing in an aneurysm can cause vas- authors have demonstrated no dis- mm/h has a diagnostic sensitivity of cular claudication. tinct correlation between pain and 60% to 94% and specificity of 65% to Herniation of the vastus lateralis the nonunion itself. Finally, while 85% for identifying infection5,18,21,22 muscle through a distal defect in the heterotopic bone has been reported (Table 1). fascia lata closure has been reported to cause discomfort in the early The C-reactive protein (CRP) is in 6 of 780 patients in the first 5 stages of its development, it is de- an acute-phase protein that rises months after surgery.14 All patients batable whether it causes any pain within hours of surgery. In uncom- presented with lateral thigh pain on once it has matured. plicated cases, the CRP level returns activity or standing; the pain was to normal by 3 months postopera- relieved by a thigh support stocking tively.19,23 Sanzén and Carlsson20 and, ultimately, by surgical closure Laboratory and found that no cases of aseptic loos- of the defect. The diagnosis is indi- Radiographic Evaluation ening had a CRP level >20 mg/L cated by the local tenderness and without another probable cause for palpable defect in the lower end of If the cause of persistent pain after a the elevation. the wound. Therefore, care should hip replacement is not obvious after Improved diagnostic accuracy be taken in closing the distal fascia a thorough history, physical exami- can be obtained by using both the lata, particularly where it extends nation, and plain radiographic eval- ESR and the CRP values. Of the beyond the skin incision. uation have been done, further infected hips in the study by Sanzén

90 Journal of the American Academy of Orthopaedic Surgeons Graham M. Robbins, MB, BS, FRCSOrth, et al

imaging the hip under fluoroscopy Table 1 may not only identify the presence Value of Elevated Erythrocyte Sedimentation Rate in Identifying Infection of the instability but also help the of a Total Hip Arthroplasty surgeon determine the potential cause. Fluoroscopy also can indi- No. No. Diagnostic Diagnostic cate the positions a patient should Study Prostheses Infected Sensitivity (%) Specificity (%) avoid to prevent impingement. Forster and Crawford18 100 33 94 73 Levitsky et al21 72 — 60-67 65 Contrast Arthrography and Magnuson et al22 98 50 73 73 Diagnostic Local Anesthetic Spangehl et al5 202 34 82 85 Injections Although the main use of contrast arthrography is to confirm nee- dle position during aspiration of the and Carlsson,20 18 of 25 had a CRP be carefully scrutinized for evidence hip joint to rule out occult infection, level >20 mg/L and 14 of 23 had an of asymmetrical wear and osteoly- it also can be used to examine the ESR >30 mm/h. Only 1 of 23 infect- sis. The typical features of loosen- extensions of the smooth-walled, ed hips, but all 33 uninfected hips, ing, such as progressively increas- small pseudocapsule that will have had a CRP level <20 mg/L and an ing lucent lines, cement fracture, formed around the hip joint by 4 to 5 ESR <30 mm/h. Similarly, Spangehl and component migration, are best months after surgery. Contrast ar- et al5 found that an upper-limit CRP appreciated on serial radiographs. thrography also is used to look for level of 10 mg/L gave a sensitivity of Endosteal scalloping and multi- abnormal bursae and occult implant 96% and a specificity of 92% and that lamellar periosteal new bone forma- loosening not readily visible on the all infected hips had at least either a tion in the femur are highly sugges- plain radiographs. Abscess cavities CRP level >10 mg/L or an ESR >30 tive of infection. are usually irregular, with synovial mm/h. They suggest that normal hypertrophy and a narrow commu- measurements of ESR and CRP level Fluoroscopy nication with the joint, while sterile exclude infection and that an eleva- When subluxation is suspected, bursal cavities are typically larger, tion of both the ESR and CRP level in- dicates an 84% probability of sepsis.

Plain Radiography The careful analysis of plain radiographs, including an anteroposterior view of the pelvis to show the proximal femur, a lateral view of the hip, and anteroposterior and lateral views of the femur, often reveals helpful features in diagnos- ing pain after total hip arthroplasty. Rapidly progressive osteolysis may be seen secondary to wear particles. Assessment of the component position might suggest instability, whereas prominence of an area of cement or an osteophyte can imply impingement. Although osteolysis second- R ary to polyethylene wear is often silent, with severe bone loss, pain may result from an impending pathologic fracture around the acetabular component, in the greater Figure 3 Anteroposterior radiograph showing severe femoral osteolysis. The right side trochanter, or even in the femoral was solidly fixed and the defect was bone grafted. The left side was revised for loosening. shaft (Fig. 3). Radiographs should

Vol 10, No 2, March/April 2002 91 Pain After Total Hip Arthroplasty smooth-walled extensions of the between 67% and 92% and a speci- pseudocapsule. Bursae were identi- ficity of between 94% and 97%.6,16,21 fied in 43% of patients with a painful Levitsky et al21 found aspiration to hip arthroplasty; approximately one be the single most useful test in half of these bursae were greater tro- identifying deep sepsis. As men- chanteric, one quarter were supra- tioned, Spangehl et al5 demonstrated acetabular, and one quarter were that if the ESR and the CRP level are located around the iliopsoas ten- both raised, the probability of sepsis don.24 Of those with no radiologic is 84%; this rate rises to 89% with a findings to suggest infection or loos- positive hip aspirate culture. ening, 12 of 27 (44%) responded to a local anesthetic injection, supporting Local Anesthetic Diagnostic a diagnosis of bursitis.25 To reduce Blocks the rate of false negatives in tests for Local anesthetic injection studies Figure 4 Technetium 99 methylene loosening, it is essential to inject suf- may be performed to try to localize diphosphonate bone scan demonstrating ficient contrast to fill the pseudocap- the site of origin of the pain. If increased uptake by an infected but firmly sule and obtain postambulatory trochanteric bursitis is thought to fixed total hip arthroplasty. radiographs. contribute to the pain, the bursa Arthrography can help rule out may be injected with either lido- occult loosening in a particularly caine alone, as a diagnostic test, or uncemented stem, tumors, reflex perplexing case, although this use of in combination with a corticoste- sympathetic dystrophy, and other arthrography is rare. Arthrography roid, as a therapeutic modality. In- metabolic conditions. In the un- appears to be no more accurate than jection of the hip joint with local complicated THA, uptake around plain radiography for excluding anesthetic may help distinguish the lesser trochanter and shaft is loosening of the femoral compo- between pain of articular origin and usually insignificant by 6 months, nent, but it is more sensitive than pain that may be referred to the hip but in 10% of cases, uptake may radiography (89% versus 37%, re- joint. Braunstein et al28 found that persist at the greater trochanter, spectively) and is more specific 10 of 11 painful THAs (91%) with an prosthesis tip, and acetabulum for (80% versus 63%, respectively) for identifiable intracapsular cause more than 2 years.29 The pattern of excluding loosening of the acetabu- obtained relief of pain within 20 uptake has not been found to con- lar component.26 Murray and Rod- minutes of an intra-articular bupiv- sistently reflect the presence or ab- rigo27 did arthrograms on 53 asymp- acaine injection. If there is no pain sence of infection and, despite initial tomatic hips; 23% appeared to be relief with the injection of local enthusiasm, more recent studies loose. Furthermore, 7 of 12 hips anesthetic into the joint, then extra- have shown no substantial benefit with positive arthrograms were articular causes of the pain should with 99Tc MDP over serial radio- later found not to be loose. In gen- be sought. graphs in the diagnosis of infection eral, arthrography overestimates or loosening.30 acetabular loosening and underesti- Gallium citrate (67Ga) is taken up mates femoral loosening. Digital Bone Scintigraphy by leukocytes and is therefore a bet- subtraction arthrography may pro- ter indicator of infection or inflam- vide a slight benefit over plain Technetium 99 methylene diphos- mation. It has been used in conjunc- arthrography.24 Nevertheless, ar- phonate (99Tc MDP) bone scintigra- tion with 99Tc MDP scintigraphy to thrography is rarely used alone to phy identifies areas of increased investigate musculoskeletal infec- investigate a hip replacement for bone activity through the preferen- tion.31 Sequential 99Tc MDP and loosening, except in the context of tial uptake of the diphosphonate by 67Ga scanning is a specific test (89%) aspiration biopsy.6 metabolically active bone (Fig. 4). for differentiating between infection 99Tc MDP scintigraphy requires the and aseptic loosening of orthopaedic Aspiration of the Hip Joint bone to have a good blood supply; prostheses but it has a poor rate of When the clinical suspicion of otherwise, false-negative results can sensitivity (57%) and accuracy of infection is high, with elevation of occur. In addition to loosening or only 75%.31 either the ESR or the CRP level, or infection, increased uptake may be Indium 111-labeled (111In) leuko- both, a hip joint aspiration is indi- seen with heterotopic bone forma- cyte scans are better than sequential cated. Hip aspiration has a reported tion, Paget’s disease, stress frac- 99Tc MDP and 67Ga scans for exclud- sensitivity in identifying infection of tures, modulus mismatch of a large ing infection. Merkel et al31 found

92 Journal of the American Academy of Orthopaedic Surgeons Graham M. Robbins, MB, BS, FRCSOrth, et al the sensitivity of 111In leukocyte To differentiate infection from gating causes of pain other than occult scans to be 86% (compared with 57% loosening more accurately, 111In infection. for sequential 99Tc MDP and 67Ga leukocyte scans have been com- Although in some instances ex- scans) and the specificity to be 100% bined with complementary 99Tc sul- ploration of a painful THA without a (compared with 89%). The accuracy fur colloid imaging. Osteomyelitis definite diagnosis has been of benefit of 111In leukocyte scans was 94%, stimulates leukocyte accumulation to the patient, if, after careful assess- compared with 75% for sequential but inhibits sulfur colloid. The 99Tc ment and consideration of the causes 99Tc MDP–67Ga, with no false-nega- sulfur colloid has similar uptake to there is still no working diagnosis, tives. Other studies have demon- 111In-labeled leukocytes in normal then exploratory surgery is unwise. strated a high sensitivity (range, 88% bone, but its uptake is inhibited by to 92%) and specificity (range, 73% infection. Palestro et al35 found that to 100%) with 111In leukocyte while the 111In leukocyte scan was Summary scans.22,32 The use of an 111In leuko- positive in 100% of infected hips in cyte scan is therefore preferable to their study, it also was positive in The investigation of pain in a the use of a 67Ga scan in the patient 77% of aseptic loosening hips. Com- patient with a THA that is not obvi- with a painful THA. plementary sulfur colloid scanning ously loose presents a diagnostic Oswald et al33 described the nor- improved the diagnostic accuracy to challenge. A precise history and mal findings in 99Tc MDP and 111In 98% (sensitivity, 100% and specifi- careful examination provide the leukocyte scanning of the unce- city, 97%). most helpful information, especially mented hip. At 24 months, the Because 99Tc MDP bone scintigra- in excluding causes unrelated to the porous-coated acetabulum still phy alone is of little benefit in the hip surgery. Pain related to the showed increased activity in 76% of investigation of the painful hip after surgery itself can be associated with 99Tc MDP and 37% of 111In leuko- THA, its routine use is not recom- the implant, soft-tissue or nerve cyte scans, but all were decreasing mended. In contrast, serial 99Tc injuries, herniation, or bone. All with time.33 At 24 months, the MDP–111In scanning may be of help potential causes of the pain should proximally porous-coated femoral when infection is suspected and other be investigated systematically, components continued to show tests are nondiagnostic. A finding that including laboratory and radio- uptake (primarily at the tip) in 72% the amount of uptake on the 111In- graphic evaluations. Exploratory of 99Tc MDP and 48% of 111In leuko- labeled scan is not as high as that on surgery without a definite diagnosis cyte scans.34 the 99Tc MDP scan can justify investi- should not be done.

References

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94 Journal of the American Academy of Orthopaedic Surgeons