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After total hip arthroplasty (THA), many studies report that a small percentage of patients mention painful symptoms, whose origin remains more or less obscure. We investigated 1,000 patients who had undergone a THA at least one year before their inclusion in the survey protocol. Among these 1,000 patients, 64 were complaining of pain in the region of the operated hip. These were later examined and investigated, both clinically (physical and psychiatric examination) and paraclinically (radiography, biology). Those requiring it received adequate treatment and the others were only regularly followed up. We identified the cause of all but one patient’s pain. In all cases except one, the symptoms of pain without physical cause had a psychiatric origin. The results of our study show that, if the clinical picture is not perfectly clear, a psychiatric screening before surgery could contribute to decreasing the incidence of pain syndrome after THA.
Comme le rapportent de nombreuses études, un pourcentage limité de patients conservent des douleurs après prothèse totale de hanche, douleur dont l'origine reste relativement obscure. Nous avons analysé 1000 patients ayant bénéficié d'une prothèse totale de hanche dont le recul était au moins égal à un an. Parmi ces 1000 patients, 64 se plaignaient de douleurs dans la région de la hanche. Ces patients ont été explorés sur le plan clinique, paraclinique et psychiatrique. Certains ont bénéficié d'un traitement, d'autres ont été seulement régulièrement suivis. Nous avons identifié l'origine de la douleur chez tous les patients (sauf un). Les douleurs qui n'avaient pas une origine somatique étaient d'origine psychiatrique. Les résultats de notre étude montrent que si le tableau clinique n'est pas tout à fait clair, un examen psychiatrique réalisé avant la chirurgie peut contribuer à diminuer les syndromes douloureux après intervention chirurgicale.
The majority of patients who undergo total hip arthroplasty (THA) feel well and quickly forget the prosthetic addition, typically within a few months. In some rare instances, however, patients complain of more or less specific post-surgery pains. As noted by Dambreville , it is difficult to study these pains for a number of reasons. Firstly, pain cannot be easily quantified, although there are approximate (partial) measuring scales. Furthermore, in addition to handling objective clinical data, the study of pain must allow for the influence of subjective elements. Often, patients tend to confuse successful post-surgery THA satisfaction with the absence of pain—two things that are not strictly equivalent. Though the absence of pain contributes to a general feeling of satisfaction, it is not the only factor; for example, some patients are still satisfied, despite tolerable levels of pain . Why do some patients suffer post-surgical THA hip pain then? Can it be treated? And, if not, could it be that some of it is neither of orthopaedic nor of psychiatric origin?
In our quest for some answers to the above questions, we carried out a survey on 1,000 patients who underwent THA. This prospective study took place between 2004 and 2006. It was co-directed by a psychiatrist and several senior surgeons. Its object was to evaluate the frequency and causes of THA post-surgical pain and also the means whereby it could be alleviated. Specifically, we sought to determine:
Our study strove to define the best way to handle (face) reports of pain lacking a specific organic location and origin. Finally, we pondered the eventual precautions which, taken prior to the initial THA surgery, might avert the onset of pain.d
This prospective study took place between 2004 and 2006. Starting from a given date, we included all of the patients who underwent THA surgery in our own ward or elsewhere more than 12 months prior to that date, all of whom had also attended clinical follow-up sessions with one of our senior surgeons. Regardless of the date, the chosen methods and the ward in which surgery took place, we surveyed 1,042 patients in total (20% of whom suffered from bilateral THA, though none of them, it must be noted, ever complained of bilateral pain), including 64 who had spontaneously mentioned “hip pain” during the interviews. Only 35 out of 64 had undergone surgery in our own ward. These 19 men and 45 women, aged 24 to 82, were subjected to both somatic and psychiatric examinations. The somatic examination involved clinical, radiological and biological trials, in search of post-surgical complications. The psychiatric examination carried out by the ward’s consulting psychiatrist involved a semi-directed interview centred on the history of the maligned prosthesis, as well as a psychiatric evaluation based on the DSM standard.
The interview touched on the following:
We also noted whether the pain seemed real (i.e. “lived,” rather than narrated) and quantified it on the scales of the EVA standard evaluation, a scale for evaluating pain from 0 (painless) to 10 (painful). We avoided using the traditional scales of appraisal of quality of life or even the Merle d’Aubigné grading score, since prior studies  have shown that a high score on these scales may not always correlate with the absence of spontaneous admissions of pain.
Patients shown to suffer because of an actual somatic cause were re-operated on whenever necessary; some were given medical treatment and all attended several follow-up sessions for at least 12 months following surgery to alleviate the pain disclosed during the selection interviews. At the end of that year, a new round of consultations with the surgeons and psychiatrist provided a conclusive evaluation of the patient’s development from a somatic and psychiatric point of view (again, the psychiatric evaluation involved a semi-directed interview based on the DSM IV standard criteria and the EVA quantification of pain). In the course of the study, one patient died and the whereabouts of six others became unknown.
The clinical, biological and radiological investigations carried out by the surgeons, which match the examinations summed up in Bozic and Rubash’s decision-making algorithm , yielded the following results (see Table 1):
The analysis of the study’s final results confirms our initial suspicions:
The question of the advent and the persistence of hip pain following THA remains a little fraught, as evidenced by the scant literature on the subject.
The operated hip does not actually hurt; in the mercifully uncommon occurrence of pain in the wake of THA, one has to look for causes “in the prosthesis” instead (either by infection or aseptic loosening) or consider the possibility of some extrinsic cause located in the general region of the hip.
In recent years, the means of investigating the presence of local causes—even minor ones—have progressed and the number of “baseless” painful prosthetic additions has decreased , while the handling of patients has steadily improved.
The methods and timing of these investigations are refined in the minute search for the multiple and potentially intertwined causes of post-THA pain [5, 7]. The occasionally complex treatment is hard to undertake but it is important to avoid another operation in response to potential feelings of “pain” or “disappointment” in the absence of a clear diagnosis of pain . For some time now , the potential dissatisfaction of the patient following THA has been an indirect means of evaluating the presence of post-THA pain, most notably when the latter appears to be baseless, or even linked to some psychiatric condition, however mild [2, 8, 10].
We now know, without hesitation, that the period leading to the intervention, i.e. when the patient is waiting to be operated on, deserves our undivided attention on two counts. First, we ought to properly evaluate the patient’s expectations from surgery and detect the potential presence of psychopathological peculiarities that need to be addressed [4, 12]. Second, we should convey to the patient some information prior to the intervention, which may contribute, in many cases, to the decrease of post-surgical pain [6, 11].
Total hip arthroplasty (THA) is an increasingly common surgical intervention that usually leads to a spectacular increase in the patient’s quality of life. Post-THA pain is quite rare.
Our study shows that most of the post-THA complaints of pain with no established orthopaedic origin are usually of psychiatric nature. In addition, when neither somatic nor psychiatric cause can be established in a first stage examination, a further follow-up may later reveal a somatic aetiology.
We, therefore, recommend that, should some doubt arise prior to the undertaking of THA, surgeons do not hesitate in requesting a psychiatric evaluation, in order to assess precisely the patient’s expectations and detect any potential psychiatric pathology, even minor, that should be addressed prior to the operation.
Thanks to these precautionary measures, the occurrence of the post-THA pain syndrome will probably significantly decrease.