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Mid-thigh pain after anterior approach total hip replacement

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I had direct anterior approach total hip 3/21/12 and have never been able to ambulate without anterior mid-thigh pain. At first, it was worse the first few steps after sitting or standing, and now there is a severe limp. Post-op films do not reveal a problem, so I am having MRI tomorrow. If there is a implant/bone mismatch, will the MRI show this? What else is on the differential? The pain really feels as if it is in the bone, very deep, and I think due to my limp I have developed IT band issues. Since day one my lateral thigh has felt like it completely knots up with walking. Gets worse the more walking I do. I had cortisone earlier this week for trochanteric bursitis, with no relief. Wondering now about muscle/tendon or ligament damage during the surgery. Most of the symptoms are immediately post op and the OS has given me zero help, thinks it is muscle pain. Muslce pain would have resolved by now. The angle of the implant is varus, could that have an impact on the pain?
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First Helper User Profile Gaelic
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replied June 29th, 2012
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Dklewandow,

Mid thigh pain, especially at start up, is not uncommon. Especially with press fit total hip components (it also occurs in some cemented prostheses). This is do to micromotion of the femoral stem. As the stem becomes for solidly fixed in the femoral canal, the pain usually subsides. But, this can take several months (up to 9-12 months).

In press fit femoral stems, they have a coating on the outside, which is rough and has a lot of tiny nooks and crannies. As the bone heals from surgery, it grows into all of these tiny areas. This "in growth" makes the stem more stable.


However, you state that your pain is actually getting worse. Micromotion of the femoral stem usually gradually gets better.


As to other problems, the biggest that is always of concern, is an indolent infection. This may show up on MRI. Usually, a Technetium-99 bone scan is also used for assessing for an infection.

Sometimes, the micromotion will show up on plain flat film x-rays, as increased bone density at the tip of the stem. But, not always. And, it takes a while for the body to lay down the extra bone in reaction to the micromotion, so it may not show up for several months.

As to the varus position of the femoral stem, that can be a problem, but it depends upon how much varus it is in. In orthopedic residency, it is often stated that the 11th Commandment of Orthopedics, is "thou shalt not varus". Varus deformities and positions are not usually tolerated by the patient as well as a valgus is. Of course, neutral is usually sought, but there are many factors that go into placement of prostheses, so some have to be placed in a tad bit of varus or valgus. Again, it usually depends upon the amount of varus or valgus that the implant is in.


Hope you figure out what is causing you discomfort. It is a shame that an operation that is done for pain control, causes you problems.

Good luck.
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replied August 7th, 2012
I an experiencing this same type of pain in my right thigh. Right hip replacement was 9/2011 and left hip was 4/2012. Since LEFT hip was done, pain in right femur/thigh has escalated. I am also experiencing issues with IT band on rhigh side.
Wondering if you have found any additional information or resolution.
Thanks.
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replied August 7th, 2012
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acfern,

As with any problem, the cause has to be identified. If you have not spoken with your surgeon about the problem, that should be your first step. A thorough evaluation needs to be done, and maybe some studies.

Though some little aches and pain are to be expected, total joint replacements should not be causing significant discomfort.

Again, the underlying etiology has to be determined, because treatment depends upon what is causing the discomfort. There are a whole host of things that can cause problems around a total hip replacement, anything from an indolent infection to tight muscles to bursitis to micromotion of the stem and so on.


Good luck. Do hope that you and your surgeon figure out what is causing your problem.
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replied January 24th, 2013
hi i am having pain 2 yrs after a right hip replacement i get pain in my grion right side pain in my top of leg when i sneeze my leg feels heavy and spasms all the time muscle feels very hard in the thigh i get burning pain in differant places on my groin and leg but pain in the groin and burns is so bad makes me feel sick pain in buttock and lower back pain from the top of right leg down to behind my shin thigh is swelled a little and muscle at the top will not relax after been flexed have a lump at the top of muscle al the time i had a car accident in 2005 which caused the above but i was hoping replacment would have helped was good up to about 5 mths after op but then things started getting worst at first was like a dead leg feeling but just got worst from there but was told that it would pass

any help would be great
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replied January 24th, 2013
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redjamie,

It may not be the actual hip joint that was causing your problems, and as such, replacing the joint will not take care of the symptoms.

If you have not already been evaluated, you really need your spine evaluated, to make sure that you do not have any compressed nerves.

Good luck. Hope you find the reason for your continued problems.
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replied January 25th, 2013
hi Gaelic
thanks for reply did have a scan on my back was that there was just wear and tear but at times pain is unbearable in the groin and down side of my leg
and if i sneeze or slightly knock my leg it is very pain full feels like its burning and sharp at times
any ideas what it could be
physio thinks my pelvis is twisted and tilded and leg is being held incorrectly at an inward angle
any help would be great
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replied January 25th, 2013
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redjamie,

Unfortunately, without being able to examine you, it is difficult to determine exactly what is causing your problems.

As to the tilt in the pelvis, if the therapist can do come exercises (and they make you feel better), that's great. Unfortunately, that (and leg length descripancy) are always the problems that therapists come up with, since it is what they can treat. But, again, if the treatment your therapist is providing is working, go for it.


It is a bit concerning that you have continued to have the discomfort, even though the joint was replaced. If the majority of your pain was coming from a degenerative hip joint, then replacing it should have really reduced the amount of your pain.


If your pain did get better after the replacement, then you developed a different set of symptoms, then you do have to check and make sure there is not anything going on this the replacement, such as infection or loosening of the prosthesis.


But, there are so many things which can cause groin pain. They just have to be systemetically ruled out. Unfortuantely, it can take a lot of investigation and time.


Sorry, that I cannot be a more help. Hope that you find the cause of your problems.

Good luck.
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replied November 25th, 2012
Dklewando, wondering how you made out with your MRI. I had anterior THR 3/5/12 and still experiencing similar thigh pain and groin pain. Had 2 cortisone shots in outer thigh, 2 ultrasound guided injections in iliopsoas tendon, blood tests to rule out infection and CT scan to rule out loosening. Been doing PT 3x/wk since March. Asked dr. About an MRI and he is looking into it. He said metal and magnets don't give good results, but I've heard of others having MRI after THR. I was very active before surgery and haven't worked out since. Starting to lose my mind.
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replied November 25th, 2012
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hipster4,

Sorry that you are continuing to have problems.

I'm not sure if Dklewando will respond or not, as that was his/her one and only post.


You do not state what type of total hip you had placed (not what it was made of, but how it was fixed to the femur; ie was it cemented or press fit?)

It is not uncommon for total hip patients to develop midthigh pain, especially what is called “start up” pain, or discomfort when first getting up and moving. In cemented implants this usually goes away pretty quickly. However, it can persist for significant time after press fit replacements. It is one of the perplexing persistent problems that total joint surgeon are trying to figure out how to prevent/stop it.

It is thought to be continuing micromotion at the tip of the femoral prosthesis. In fact, in some patients, they develop a thickening of the cortex (the outer hard bone) just at the end of the prosthesis. In these cases, it is pretty easy to diagnose in those cases. Some have increased uptake at that spot on bone scanning, again, this usually makes the diagnosis.

But, unfortunately, in others, the cause of the midthigh pain can never really be determined.


As to the MRI, they can usually be done with total joint implants, without too much problems. If the implant is titanium, there is no problem with the magnet, since titanium is not a ferrous material. But, even patients with the stainless steel and chrome-cobalt implants can have MRI studies done.

The main problem is with the artifact or distortion of the images because of the implant, making the study less than optimal. Some MRI machines can run programs to lessen the distortion produced by the metal, but again, the images are not always the greatest. And, what exactly would the surgeon be looking for with the MRI, which he/she does not already know from other studies?


Again, sorry that you are continuing to have difficulties. There is no easy answer or solution to the problem. Some patients with midthigh pain do have resolution of the discomfort after many months (even up to 18 months out), so hopefully, you will be in the same situation.

Wishing you the best. Good luck.
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replied December 1st, 2012
Thanks for your input. I'm not sure if it was cemented or press fit, but I do know it is titanium. The reason for the MRI is that all other "tests" have not shown why I am experiencing more pain now than before surgery. I am unable to climb stairs normally, lift my leg in/ out of car, put socks/pants on normally. In addition, just touching my outer thigh and my scar is very sensitive and sore. No matter how much soft tissue massage I receive, my thigh is so tight it feels like it's going to snap. I'm nine months out, I shouldn't be in such pain.
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replied December 1st, 2012
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hipster4,

Sorry you are not getting the usual results from a total joint replacement. While a total joint can never give a patient a "normal" joint, it should provide a solid, functional, mostly pain free joint.

Unfortunately, some patient's tissues just respond badly to the trauma of surgery. Some patients develop signficant amounts of fibrosus and scar tissues all around the region of the surgery. This can cause singificant tightness, firmness, "woody edema" in the soft tissues. This usually does not respond very well to massage or other conventional methods of edema reduction. In some patients, the scar tissue will mature and soften with time, but it can takes years for it to occur. In other patients, the tissues remain tight and contracted.

All of the usual etiologies for continued discomfort after surgery have to be ruled out; infection, loosening, and improper implant placement. If an etiology can be found, then it can be addressed. These are the "easy" cases.

The difficult cases are the ones where no etiology for the continued discomfort can be identified. In those cases, about all that can be done, short of trying a revision surgery (which usually do not solve the problem, but everyone wants to try something/anything), is to provide pain management and therapy for the patient to be as functional as possible. This is not ideal, of course, but it is reality.

Again, sorry that you are continuing to have problems. Do try to be as functional as possible. Becoming very sedentary, losing motion and strength, usually just make matters worse.

Good luck. Do hope that your surgeons can find an etiology for your discomfort.
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replied October 2nd, 2013
Hello, better late than never. Been 1.5 years since THR. Pain still ongoing/unchanged. Saw Surgeon two days ago, said not likley loosening (by looking at Xray) but wants to do a bone scan just in case. I explained the pain as what I thought to be musclular, (stiff, worse with increased activity and not in the joint area) and he said that loosening can cause this type of pain. Cortisone injections for bursitis helped alot, and this makes me think it is all bursitis with IT band stuff. Pain is lateral thigh from trochanter to knee. MRI was normal. Why did he not do exam or think about possible bursectomy (cannot continue to have cortisone injections due to risk of tendon rupture he said). Any thoughts as to if I should have bone scan $$$ versus getting another opinion. thanks.
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replied December 31st, 2012
Thanks for the input from this site.
I had a THR - Anterior procedure - a little over 16 months ago. Titanium Femur - joints ceramic - but not sure if cemented or uncommented.
If I walk for 30 minutes or so -- briskly - but not at 'pace-walking' pace - I will invariably suffer pain the following day. The pain in my case appears to come from the top of the incision to about midway down the thigh. It is often centrally located - i.e. in a direct line down from the incision. Sometimes however it will occur about midway down the inner thigh - or half way between the anterior and inner thigh. As an example this morning I awoke and as a New Years day present had pain in both middle and inner thigh area. Could not be described as excruciating - but certainly severe enough to create a limp and the occasional addition pain grab.
I went for a short walk and then enjoyed 10 minutes in the surf (it is summer down under) Feel much better and now almost no sign of any pain. This is fairly typical -- as if moving and getting circulation helps -- but I remain concerned that the leg is not back to 'normal' after such a long period and I fear for ongoing restriction in my active life.
I am making a further appointment with the surgeon. Would an ultra Sound or better still an MRI be useful before I see him??
Any other advice would be appreciated. I am 77 year old male - very fit

Regards,
L12
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replied December 31st, 2012
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L12,

Sorry that you are still having problems after your total hip.

From your description of the symptoms, it sounds like you do have some inflammation. The hallmark of an inflammatory problem is that the patient has discomfort and stiffness after an extended period of rest (as sleeping overnight), but that it gets better with some activity. This is why patients with inflammatory arthropathies (such as RA - rheumatoid arthritis) do not like to take a rest, as they tend to get stiff, their joints tend to "gel".

But, it also sounds like you are having problems in the muscles of the anterior and medial thigh. The medial muscles include the adductors of the hip joint and the gracilius. The anterior muscles include the quadriceps, sartorious, and the rectus femoris (besides a few other small muscles around the anterior hip joint).


So, it will take a thorough evaluation to determine what is going on. As to other studies, it is best to let the total joint surgeon determine which one(s) would be the best.

It is difficult to get MRI and CT scans around metal prostheses. The newer machines can filter out some of the artifact produced by the prosthesis. The titanium makes it easier to do an MRI, because it is not a ferrous metal. But, it still produces artifact and distortion of the images.

So, again, it is best to let the surgeon make the decision as to what studies would provide the needed information.


The muscles may have healed with some significant scar tissue. Since you had the anterior approach, the anterior muscles have been violated. They heal, but it is with scar tissue. Scar just does not respond like "normal" tissues do.

If you have not tried deep friction massage, or myofascial muscle releases from your physical therapist, these may actually help significantly.

Therapeutic ultrasound can also sometimes break up scar tissue. But, it has to be used with caution around metal implants (deep heating).

Occasional use of corticosteroid injections can also help to soften and stretch out bands of scar tissue.


But, again, it is going to take a very thorough evaluation to figure out what is going on in your anterior thigh.


Hope you get some treatment for your problem, and you can get back to the activities that you want.


Wishing you the best in the new year. Good luck.
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replied June 7th, 2013
I am just returning from my year check up post anterior hip replacement. I am 50 year old female with severe RA, Fibro and diabetic. I have been having most all of everyone elses issues that have been mentioned above. Horrible thigh pain when transitioning from sitting to walking and paying for the next few days after walking and or doing things. The "hip" itself feels awesome, but the thigh pain is killing me. The dr said yesterday basically the same thing that of soft tissue issues. Oh my surgery took almost 7 hrs due to my stubborn bone so the muscles/tendons etc were in a non normal position a lot longer than normal. They want me to have ultrasound PT and mentioned shots also. I am hoping this heals as I am unable to move with it as it is now and with all my other dx I can not afford to be not moving.
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replied June 7th, 2013
I am just returning from my year check up post anterior hip replacement. I am 50 year old female with severe RA, Fibro and diabetic. I have been having most all of everyone elses issues that have been mentioned above. Horrible thigh pain when transitioning from sitting to walking and paying for the next few days after walking and or doing things. The "hip" itself feels awesome, but the thigh pain is killing me. The dr said yesterday basically the same thing that of soft tissue issues. Oh my surgery took almost 7 hrs due to my stubborn bone so the muscles/tendons etc were in a non normal position a lot longer than normal. They want me to have ultrasound PT and mentioned shots also. I am hoping this heals as I am unable to move with it as it is now and with all my other dx I can not afford to be not moving. Need to mention that all exrays should bone and joint looked great. She said she would have liked to see more bone attachment but with my history she was happy.
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replied February 16th, 2014
Anterior replacement now suffering excruciating pain daily
I am a 52 year old female, healthy, had a total left hip replacement 11/18/13. My first 6 weeks went wonderful, from walker to cane, ice and pain meds no longer needed. Then from week 7 to present I have had an onset of excruciating pain in my high right under my incision. Also bursa and lower buttock pain on left side. I have been pushing to walk but now have a limp or can't walk at all. My surgeon keeps telling me all is well just exercise, it will go away. However I returning to working just after the new year and now find myself unable to walk, get in the car without pain, stand, sit it just doesn't matter what I do it hurts. Thigh is hot yet no swelling which they told me is normal. Can this be nerve/muscle damage from the moving of all the tissue around the area! I cannot live like this, I waited 4 years before giving in to the replacement anyone have any ideas?
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replied February 22nd, 2014
I had R anterior hip replacement November 2013. Pain not only in thigh but in hip too. Acupuncture, massage therapy, all the PT I have been instructed on including Ai Chi. Warm pool time seems to help the most. I had 12 week x-rays standing and revealed a downward tilted pelvis. Nerve issue? An extension can be added but surgery just ain't as fun as it once was. Still working with my surgeon.
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replied February 22nd, 2014
Forgot to mention 5 years ago I had my other hip resurfaced with a posterior procedure and recovery was definitely simpler looking back. I was walking well in a month without much discomfort
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replied April 24th, 2014
Anterior THR
I am a week out from anterior THR and have the expected pain, just hope that it subsides and does develop as others have had here.
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