Groin pain following hip resurfacing: a case-control study

We compared 47 patients with groin pain following hip resurfacing to a matched control group. Functional scores and plain radiographs were assessed along with measurement of whole blood cobalt and chromium by inductively coupled mass spectrometry. Symptomatic patients underwent ultrasound scan of the affected hip. Mean functional outcomes were poor in those with pain and good in the control group. Groin pain was associated with valgus stem positioning and lower neck:head ratio (relatively narrow neck) (p=0.03, p=0.04 respectively). We classified patients with groin pain into two groups: biological and mechanical. The biological group had soft tissue abnormalities on USS and higher levels of cobalt and chromium (p=0.04, p=0.05 respectively). The mechanical group had normal USS, lower metal ion levels and more retroverted femoral components (p=0.01).     

抗骨质疏松治疗对髋关节置换术后疼痛影响的临床研究

目的 探讨骨质疏松与置换术后疼痛是否互相影响及机制,为临床髋关节置换术后疼痛制定更有效、合理的治疗方案提供启示和理论支持.方法 30例髋关节置换术后疼痛伴有骨质疏松患者进行Singh指数测定,分为骨质疏松治疗组(治疗组)和消炎镇痛组(对照组),参照美国Harris髋关节功能评分标准评分进行对比分析.结果 治疗组治疗后的Harris评分明显高于对照组(P<0.01).结论 骨质疏松是髋关节置换术后产生疼痛的重要原因,髋关节置换术后疼痛进行系统地抗骨质疏松治疗应当引起临床的更加重视.     

Thigh pain after cementless total hip arthroplasty: evaluation and management

Data from short- and long-term follow-up studies indicate that thigh pain is a significant complication after apparently successful cementless total hip arthroplasty. In most cases, reported symptoms are mild to moderate, resolve spontaneously or do not progress, and require little or no therapeutic intervention. However, persistent thigh pain may be a source of dissatisfaction or may present as severe, disabling pain. Possible causes include bone-prosthesis micromotion, excessive stress transfer to the femur, periosteal irritation, or a mismatch in Young's modulus of elasticity that increases the structural rigidity of the prosthetic stem relative to the femur. Thorough diagnostic evaluation of thigh pain is essential to rule out prosthetic infection or loosening, stress fracture, or spinal pathology as the primary source. Treatment options in the aseptic, well-fixed femoral component include medical management, revision of the femoral component, or cortical strut grafting at the tip of the implant.     

Propacetamol versus ketorolac for treatment of acute postoperative pain after total hip or knee replacement

We assessed the analgesic efficacy of IV propacetamol and ketorolac in a double-blinded, placebo-controlled study involving patients undergoing total hip or knee replacement procedures. On the first morning after major joint replacement surgery, 164 patients experiencing moderate-to-severe pain were randomly assigned to receive an IV infusion of propacetamol (2 g), ketorolac (15 or 30 mg), or placebo (saline). Patient-controlled analgesia with morphine was made available as a "rescue" analgesic on patient's request during the 6-h postdosing evaluation period. The median time to onset of analgesia with propacetamol (8 [95% confidence interval 6,10] min) was shorter than ketorolac 15 mg (14 [7,16] min), and placebo (16 [8; not estimable] min) although the differences did not reach statistical significance. However, compared with ketorolac 30 mg, propacetamol had a shorter duration of analgesia (3.5 [2;5.4] vs 6 [3.3; not estimable] h). Analysis of pain intensity and pain relief scores demonstrated that propacetamol produced a significantly greater improvement in pain relief than saline from 45 min until 5 h after the injection. Propacetamol was not significantly different from ketorolac 15 mg and 30 mg with respect to the main analgesic efficacy variables during the 6-h assessment period. The most frequently reported adverse event with propacetamol was injection site pain (28% vs 19% for ketorolac 15 mg, 29% for ketorolac 30 mg, and 10% for placebo, respectively). In conclusion, propacetamol (2 g IV) possesses a similar analgesic efficacy to ketorolac (15 or 30 mg IV) after total hip or knee replacement surgery.     

髋关节置换术后持续疼痛影响因素的逻辑回归分析

目的探讨影响髋关节置换术后持续疼痛的危险因素。 方法选择2014年1月至2017年6月在增城区新塘医院和南方医院严格按照纳入和排除标准收集的髋关节置换术的814例患者作为研究对象。收集患者临床资料,观察临床资料与术后持续性疼痛的相关性,单因素分析采用卡方检验,多因素分析采用逻辑回归(logistic)分析。 结果单因素分析显示,吸烟不是影响髋关节置换术后持续性疼痛的因素(χ²＝0.814,P>0.05),性别、年龄、身体质量指数、饮酒、长期镇痛药物应用、置换类型、假体类型、手术时间、麻醉持续时间、髋关节活动时间、术后C反应蛋白(CRP)是影响髋关节置换术后持续性疼痛的因素(χ²＝11.826、14.705、12.344、4.184、15.279、10.140、9.837、8.862、16.019、12.864、23.485,P<0.05)。多因素logistic分析结果显示年龄<60岁、身体质量指数>28 kg/m²、髋关节活动时间≤2 d是影响髋关节置换术后持续疼痛的独立危险因素(waldχ²＝13.716、18.948、15.423,P<0.05)。 结论髋关节置换术后持续性疼痛是多因素综合作用的结果,临床工作中应考虑对这些因素进行针对性防控,以降低髋关节置换术后持续性疼痛的发生率。     

Diabetes is associated with persistent pain after hip and knee replacement

Background and purpose

In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity.

Patients and methods

The incidence of pain in the operated joint was surveyed 1–2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint.

Results

49 of the134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2–38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2–15).

Interpretation

Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1–2 years after primary hip or knee replacement.Many patients continue to experience pain after joint replacement. Persistent pain is defined as pain that develops after surgery and that has been present for over 3 months (International Association for the Study of Pain 1986) and its prevalence is underestimated (Visser 2006). According to Beswick et al. (2012), at least 5–21% of hip replacement recipients and 8–27% of knee replacement recipients suffer from persistent pain postoperatively.Persistent pain is generally thought to be of neuropathic origin and caused by perioperative nerve damage (Kehlet et al. 2006). However, neuropathic pain appears to be rare in joint replacement patients (Wylde et al. 2011). Instead, these patients often describe their pain in a way that indicates the presence of an inflammatory factor (Wylde et al. 2011). The degree of the inflammatory state is associated with the severity of preoperative pain in patients with osteoarthritis (Stürmer et al. 2004). In addition, the intensity and duration of preoperative pain correlates with persistent postoperative pain in knee replacement surgery (Lundblad et al. 2008, Puolakka et al. 2010). Other established risk factors for persistent pain include genetic factors, history of preoperative pain, depression, existence of other chronic pain sites, and psychosocial factors (Kehlet et al. 2006, Nikolajsen et al. 2006, Rolfson et al. 2009).Low-grade systemic inflammation is associated with the pathogenesis of diabetes, metabolic syndrome (MetS; a clustering of cardiovascular risk factors including abdominal obesity, hypertension, dyslipidemia, and impaired glucose metabolism (Alberti et al. 2009)), and obesity. All these conditions are common in joint replacement recipients (Meding et al. 2007, Gonzales Della Valle et al. 2012, Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee 2013). Diabetes is associated with poor postoperative outcomes, including reduced joint function (Robertson et al. 2012) and slower recovery in terms of pain and function (Jones et al. 2012). Obesity is associated with slower recovery, especially in knee patients (Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee 2013). It has been hypothesized that the systemic proinfammatory state in MetS negatively affects patients’ function and recovery after joint replacement (Gandhi et al. 2010). To our knowledge, the effect of disorders of glucose metabolism, MetS, and obesity on persistent pain after joint replacement has not been studied previously.We therefore determined whether glucose metabolism disorders, MetS, and obesity are associated with persistent pain in the operated joint 1–2 years after primary joint replacement.     

Nerve injury and limb lengthening after hip replacement: treatment by shortening

Nineteen patients had a severe neurologic deficit and persistent dysesthetic pain after total hip replacement. During surgery their limbs had been lengthened by 1.3 to 4.1 cm. Patients with other reasons for nerve injury such as hematoma, dislocation, or direct operative trauma were excluded. Also excluded were patients whose lengthening was part of the operative plan to address previous shortening. None of the patients had neurologic deficits or dysesthetic pain preoperatively. Patients were offered revision hip surgery to shorten the limb. Seventeen patients proceeded to surgery. Two acetabular revisions, five modular femoral head exchanges, and 10 femoral component revisions were done. The average shortening was 1.5 cm (range, 0.5-3.6 cm). The trochanter was advanced in four patients and a constrained acetabular liner was used in four patients. Nine hips were stable without additional measures. There were no complications and nine patients had an excellent result. This was defined as elimination of their dysesthetic pain. Two patients had partial improvement and six patients had no improvement. Seven of 11 patients with motor deficits had improvement in strength with three making a full recovery. When painful neurologic symptoms accompany limb lengthening after total hip replacement, revision surgery may be helpful, although patients should be informed the rate of success is far from uniform.     

Uncemented total hip replacement and thigh pain

Summary. We reviewed 145 consecutive patients who had total hip replacements using uncemented CLS Spotorno femoral stems which achieve primary fixation with bony ingrowth which occurs later mainly in the metaphyseal region. The mean age was 54.9 years and average follow up 7.8 years. The Merle d’Aubigne and Harris hip scores were used for evaluation, together with plain radiographs. Current medium term follow up showed a survival rate of 96.7% and a good functional score in more than 90%. Special attention was paid to postoperative thigh pain which occurred in only one patient. These results are encouraging, but a follow up of more than 10 years is required before comparable results to cemented stems can be claimed. Accepted: 11 July 1995     

髋臼骨折内固定术后的全髋关节置换

目的探讨髋臼骨折经内固定术后出现并发症而导致疗效不佳,行全髋关节置换(TH R)的方法和疗效。方法总结经切开复位内固定治疗的髋臼骨折患者11例,因术后27～63个月(平均46.5个月)内继发创伤性关节炎或股骨头坏死,继而行全髋关节置换术。其中合并髋臼骨缺损6例,进行颗粒性植骨2例,结构性加颗粒性植骨4例;异位骨化4例,均发生于K-L入路。采用后外侧入路9例,髂股延伸切口2例,其中6例为原手术切口。结果11例患者全部得到随访,随访1年6个月～7年3个月,平均3年5个月。出现感染1例,脱位1例,无菌松动1例。术后再次异位骨化2例,其中1例引起坐骨神经症状,再次行神经松解术。所有随访病例髋关节功能均有改善,H arris评分由术前平均47分,提高到术后88分。结论选择正确的手术入路,适当处理异位骨化组织和内固定物,重建髋臼骨缺损,是髋臼骨折经切开复位内固定术后,再行全髋关节置换成功的关键。     

Intravenous ketoprofen for pain relief after total hip or knee replacement

Background: There are few studies in which ketoprofen, a propionic acid derivate NSAID, has been tested as an intravenous postoperative analgesic. The aim of this double-blind, randomized, placebo-controlled work was to study the tolerability and efficacy of intravenous ketoprofen in seventy-six patients undergoing hip or knee total endoprothesis surgery using three different doses.
Methods: The patients received either ketoprofen 50 mg, 100 mg or 150 mg, or placebo as an initial intravenous loading, followed by an infusion containing 50 mg, 100 mg or 150 mg or placebo, respectively, over the following eleven and a half hours. The consumption of fentanyl was recorded and the patients assessed their pain intensity on a 10-cm visual analogue scale (VAS) at 0, 2, 4 and 12 hours. Possible side-effects were recorded at the same intervals.
Results: Patients receiving ketoprofen showed significantly lower total fentanyl consumption and significantly better pain relief at 12 hours was achieved by a 300 mg dose of ketoprofen than by placebo. Side-effects were minimal, with no differences between the groups.
Conclusion : A bolus of ketoprofen following continuous infusion of ketoprofen, coupled with a PCA-system, was an effective and safe approach for the relief of postoperative pain.     

Complex regional pain syndrome after hip replacement in a diabetic patient

Objective  

We present a case report of complex regional pain syndrome (CRPS) type I following total hip replacement in a patient with insulin-dependent diabetes mellitus.     

封闭式负压引流术治疗人工关节置换术后深部感染

目的探讨采用封闭式负压引流术(vacuum sealing drainage,VSD)结合病灶清创治疗人工髋、膝关节置换术后深部感染的方法和疗效。方法 2006年9月-2010年5月,收治13例人工关节置换术后深部感染患者。男5例,女8例;年龄56～78岁,平均62.5岁。置换术后7 d～1年2个月发生感染,中位时间14 d;发生感染至入院时间为8 d～4年6个月,中位时间21 d。均见脓性或脓血性分泌物,5例形成窦道,8例切口、引流口未愈合。分泌物引流口或窦道口皮肤缺损范围为5 mm×3 mm～36 mm×6 mm;分泌物引流通道或窦道深度为21～60 mm。11例取组织行病理检查,提示10例为急性或慢性化脓性感染急性发作,1例为结核。6例取分泌物培养,提示5例金黄色葡萄球菌阳性,1例为阴性。彻底清创后,10例行白天冲洗和晚上持续VSD治疗;3例仅持续VSD治疗。结果 1例人工全髋关节翻修术者VSD治疗时出血较多,停止负压吸引并加压包扎,第3天再次行VSD无大量出血。患者均获随访,随访时间1年～4年5个月,平均2年11个月。10例患者经VSD治疗后7～75 d感染控制,平均43 d;假体均保留,无感染复发,创面愈合良好,疼痛缓解,关节功能良好。1例因负压区疼痛过敏难以忍受拒绝VSD治疗,感染控制无效行大腿中上段截肢;1例感染结核疗效不明显,取出假体后采用骨水泥填塞临时膝关节融合治疗;1例VSD治愈后9个月感染再复发,取出假体旷置、VSD治疗3周,1年4个月未复发。结论 VSD结合病灶清创术使深部创面引流充分,可促进创面愈合,降低感染复发率,最大程度保留假体。     

人工全髋关节术后脱位的预防及治疗

术后髋关节脱位是人工全髋置换术(THR)后严重的并发症,如处理不善,常会引起严重的下肢功能障碍,导致关节手术失败.1994-2001年,我院共行THR手术436例,其中术后发生脱位有11例,加上外院转入5例,共16例,现报告如下.……     

Ketorolac, diclofenac and ketoprofen are equally efficacious for pain relief after total hip replacement surgery

We have compared the efficacy of ketorolac 30 mg i.v. followed by infusion at a rate of 90 mg/15.5 h, with that of diclofenac 75 mg followed by infusion of 75 mg/15.5 h or ketoprofen 100 mg followed by infusion of 100 mg/15.5 h, on postoperative pain in 85 patients after hip replacement surgery under spinal anaesthesia in a prospective, double-blind, randomized study. Supplementary analgesia was administered during the 16-h postoperative period with bolus doses of fentanyl delivered by a patient-controlled analgesia system. Mean total consumption of PCA-administered fentanyl was 890 (SD 400) micrograms in the ketorolac group, 920 (550) micrograms in the diclofenac group and 850 (350) micrograms in the ketoprofen group (ns). Median VAS scores were low over the entire study in each group and there was no significant difference between groups. No serious adverse events were recorded.      

无痛病房管理对全髋关节置换术后疼痛控制的效果评价

目的探讨无痛病房管理在全髋置换术后疼痛控制的效果。方法本组66例行全髋关节置换术的患者随机分为两组,实验组采用无痛病房管理,对照组采用传统的镇痛方法。记录术后第1、2、3天患者静息和被动活动视觉疼痛模拟评分（VAS）,术前和术后3个月Harris髋关节功能评分。结果术后第1、2天的静息和被动运动VAS评分均有统计学差异（P〈0．05）;术后第3天的静息VAS评分无统计学差异（P〉0．05）,被动运动VAS评分有统计学差异（P〈0．05）。术前与术后3个月的Harris髋关节功能评分无统计学差异（P〉0．05）。结论无痛病房管理能有效减轻全髋关节置换术后疼痛,对术后3个月髋关节功能无明显影响。     

The pain and function of the hip (PFH) scale: a patient-based instrument for measuring outcome after total hip replacement

The Pain and Function of the Hip (PFH) scale was developed following the recommendations of the Société International de Chirurgie Orthopedique et Traumatologie to assess the outcomes of total hip replacement (THR). This study evaluated metric properties of the PFH scale and its ability to measure clinical change (responsiveness) in consecutive patients undergoing THR. Patients were evaluated preoperatively and at 3 and at 12 months postoperatively. The PFH scale and the Nottingham Health Profile (NHP) were administered. Complete data were collected for 79 patients. Mean overall preoperative PFH score was 26.5 and mean overall PFH score 12 months postoperatively was 69.8 (P < .01). Correlation with the NHP was high (r = -0.64), and the magnitude of improvement (effect size) as assessed by the PFH scale was large (3.6 compared with 1.7 for the NHP). The PFH scale is simple and valid, and may complement routine clinical evaluation of hip replacement. Residual pain after hip replacement may have been previously underestimated.