BHS SURGICAL STANDARD
Investigation of the Painful Total Hip Replacement Background & Inclusion.
A small but significant proportion of patients have ongoing pain following Total Hip Arthroplasty. Despite routine clinical tests the diagnosis can remain unclear and challenging. This surgical standard includes all patients with persistent pain over 3 months following total hip replacement that have had infection and aseptic loosening ruled out with routine investigations including plain X-rays and CRP. For further guidance on the diagnosis of prosthetic joint infection and aseptic loosening please refer to the respective BHS Surgical Standards.
Diagnosis
1. A comprehensive history and examination is required to arrive at a diagnosis, considering the timing, character and location of the pain combined with gait, hip range of movement, strength and lumbar spine screening.
2. A comparison should be made of the pre-operative to post-operative pain, should it be unchanged then the initial diagnosis for which a THR was performed should be questioned and a referred cause of pain considered.
3. Component loosening or infection only accounts for approximately one third of cases in those with pain following total hip arthroplasty. The remaining are accounted for by a combination of other intrinsic, peri-articular or extrinsic referred causes of pain. Iliopsoas impingement (16-20%), referred pain (9-14%) and greater trochanteric pain syndrome (8-13%) are the most common causes. A table below summarises possible causes to consider 1-3.
References:
1. Yucuma D, Riquelme I, Avellanal M. Painful Total Hip Arthroplasty: A Systematic Review and Proposal for an Algorithmic Management Approach. Pain Physician. 2021;24(3):193-201.
2. Hulin K, Fearon A, Newman P. What are the diagnoses attributed to persistent hip pain after hip arthroplasty? A systematic review. J Clin Orthop Trauma. 2025 May 9:67:103036.
3. Quesada-Jimenez R, Kahana-Rojkind AH, Domb BG. Soft-Tissue Sources of Extra-articular Pain Following Total Hip Arthroplasty: A Comprehensive Review. J Am Acad Orthop Surg Glob Res Rev. 2025;9(9):e25.00226.
4. Expert Panel on Musculoskeletal Imaging, Weissman BN, Palestro CJ, et al. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol. 2023;20(11S):S413-S432.
5. Disantis A & Andrade AJ et al. The 2022 ISHA physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement. J Hip Preserv Surg. 2023 Jan 2;10(1):48-56.
6. Martin HD, Reddy M, Gómez-Hoyos J. Deep gluteal syndrome. J Hip Preserv Surg. 2015 Jul;2(2):99-107.
7. Hasija R, Kelly JJ, Shah NV, Newman JM, Chan JJ, Robinson J, Maheshwari AV. Nerve injuries associated with total hip arthroplasty. J Clin Orthop Trauma. 2018 Jan-Mar;9(1):81-86.
8. Complex regional pain syndrome in adults UK guidelines for diagnosis, referral and management in primary and secondary care 2018. Royal College of Physicians.