Cuckler John M
Alabama Spine and Joint Center, P.C., Birmingham, Alabama, USA.
Orthopedics. 2010 Sep 7;33(9):648. doi: 10.3928/01477447-20100722-28.
Early causes of hip pain within the first year of total hip replacement (THR) include failure of fixation, infection, instability, other sources of pain (eg, lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft tissue irritation. Metal-on-metal THRs may present with pain due to hypersensitivity within the first 1 to 3 years after arthroplasty. Late causes of pain include loosening, wear reactions, or mechanical dysfunction such as subluxation associated with wear of the articular couple. Late hematogenous infection is often sudden in onset, but may be subtle. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Evaluation of the painful hip should start with a careful history: is the current pain similar or different to the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. Careful comparison of serial radiographs is necessary to identify loosening. Serologic tests should include a sedimentation rate and C-reactive protein; if both are elevated, aspiration of the joint under radiograph control for culture is indicated. In the absence of abnormalities in the studies described above, serial Technetium bone scans performed every 6 to 12 months may suggest loosening if progressive increases in uptake are observed about a component. Malposition of the acetabular component may be associated with psoas tendon impingement (symptomatic with active flexion of the hip) and may be confirmed by computed tomography scan or a psoas tenosynogram. Hypersensitivity of metal-on-metal THRs should be suspected in the presence of early (subtle) osteolysis, and the presence of predominantly mononuclear cells on the sterile aspirate. Perseverance and patience are encouraged in the pursuit of an accurate diagnosis, and objective analysis of the data is necessary. Do not operate without sufficient cause.
全髋关节置换术（THR）后第一年出现髋部疼痛的早期原因包括固定失败、感染、不稳定、其他疼痛来源（如腰椎）以及机械功能障碍，如腰大肌肌腱撞击或其他软组织刺激。金属对金属全髋关节置换术在关节成形术后1至3年内可能因超敏反应而出现疼痛。晚期疼痛原因包括松动、磨损反应或机械功能障碍，如与关节对磨损相关的半脱位。晚期血源性感染通常起病突然，但也可能不明显。其他疼痛来源，如椎管狭窄或腰椎退行性椎间盘疾病，也可能表现为髋部疼痛。对疼痛髋部的评估应从详细的病史开始：当前疼痛与术前症状相似还是不同？回顾术前X线片将为病理程度提供线索，如果不明显，可能提示疼痛综合征的其他来源。仔细比较系列X线片对于识别松动很有必要。血清学检查应包括血沉和C反应蛋白；如果两者都升高，则需要在X线引导下对关节进行穿刺抽吸以进行培养。如果上述检查无异常，每6至12个月进行一次系列锝骨扫描，如果观察到植入物周围摄取逐渐增加，可能提示松动。髋臼组件位置不当可能与腰大肌肌腱撞击有关（髋关节主动屈曲时出现症状），可通过计算机断层扫描或腰大肌肌腱造影来确诊。如果存在早期（轻微）骨溶解以及无菌抽吸物中主要为单核细胞，则应怀疑金属对金属全髋关节置换术存在超敏反应。在寻求准确诊断时应鼓励坚持和耐心，并且对数据进行客观分析是必要的。没有充分理由不要进行手术。
