"end of stem pain"

[Alice]

Hi, I was happy to discover this website. I have a few questions but I'll start with this one.
I had a left THR 8/09 and a right THR 2/1/2010. At the end of December, I developed "end of stem" pain approximately 1/3 of the way down on the outside of my left thigh. I only feel the pain when I am weight bearing. The left hip was evaluated by a bone scan prior to the recent surgery and I was reassured that there was no sign of infection or loosening. While I was trying to find information on "end of stem" pain, I came across an article that suggested that taking NSAIDS could interfere with bone regrowth. Since I had been taking an NSAID on a daily basis for a couple years, I decided to stop prior to the second THR. I was wondering if anyone's doctor has discouraged them from taking an NSAID medication for this reason while their hip is healing? Also, since I developed end of stem pain on the left is that more likely to happen on the right? Thanks in advance

 

[grenouille]

Hello Alice,
None of my doctors mentioned this fact about NSAIDS, so off i went googling the correlation between the two. Seems its been a known side effect for quite some time.I did find an interesting article as it pertains to hip surgery though, and am going to ask my OS on tuesday about this, since I totally lack the knowledge to make any discerning judgement on it at all.I found the article here https://inflammablog2.blogspot.com/2008/11/nsaids-your-bones-and-surgery.html.
It is an interesting read.I did take NSAIDS before the surgery, but i need to know if I should take them now.

 

[Josephine]

I think I found that article. It said

"There is another potential problem with the use of these drugsboth in elderly and younger patients for pain relief after orthopaedicsurgery.

However,the effect of these drugs on bone metabolism is often overlooked.They inhibit osteoblasts (bone growing cells) at the endosteal bone surface (between prosthesis and bone) and alsoreduce both the immune response and the inflammatory response."
blue inserts are mine

Two points jumped out at me on this
1. it was written by two junior doctors at a provincial hospital with, apparently, no backup of empirical research (and I have thus far been unable to find any follow-up commentary),
2. your surgery was, according to your post, four months post-op. Since bone healing takes about twelve weeks to complete, your bone healing would have been well established long before this symptom began to show itself and
3. in any case you fit neither the 'elderly' nor the 'younger' patient groups!!

I haven't heard of anyone on this forum or elsewhere being told not to take NSAIDs for that reason.

Since I can't really tell what is causing your pain, it's unlikely I could assure you it wouldn't happen in the other leg. I'd be interested to know who told you it was 'end of stem' pain or why you think it is so. It's much more likely, given that scans were all negative, that you have a sciatic pain which some chiropractic treatment might help.

 

[Jamie]

Hi, Alice....welcome to BoneSmart! So glad you decided to join us. I'm sorry to hear you are suddenly having pain. Have you given any thought to the IT Band? You can read about it here and try some of the stretches. It might help.

Don't hesitate to post any time. We are always here to provide support and help for you.

 

[kjt]

My docs put me on a HEAVY NSAID after surgery for 10 days to prevent heterotropic ossification.

This was after both hip surgeries. After the scope - the surgeon didn't want me taking any more anti-inflamms till I hit the 8 week mark.

This time, they told me to go ahead and start taking Celebrex again if it helped.

I got the impression that the first one was to protect the cartilage that they had shaved....but I don't really know.

 

[Alice]

Hello again, I just wanted to mention where I found the reference regarding NSAIDS interfering with bone growth in case someone wants to investigate more. On Ortho Supersite, I found a one page summary of a study presented by Kjaersgaard-Andersen, MD and colleagues from Vejle Hospital, Denmark at the Academy of Orthopaedic Surgeons Annual Meeting. Feb 23-27, 2005 in Washington </st1:State>by Dave Levitan titled, “Risk of aseptic loosening following uncemented THA linked to NSAID use”.

The summary states that researchers found an almost three fold increase in revision risk due to aseptic loosening among uncemented implant patients who used NSAIDs for at least one week postop, primarily to prevent heterotopic ossification. The researchers also found a 10 fold increase in risk among patients 55 years of age or younger compared to the mean. A subanalysis showed the increased revision risk to be stem-related. After reading this, I decided to quit taking Celebrex.

Another article that I would like to share from Ortho Supersite was titled, “Thigh Pain After Total Hip Replacement: A Pathophysiological Review and a Comprehensive Classification” by Luca M.C. Pierannunzii, MD from Gaetano Pini Orthopaedic Institute, Milan, Italy ORTHOPEDICS 2008; 31:691.

When my mid thigh pain developed, I shared this article with my general practitioner, surgeon and most recently my PT. It is a very complicated but comprehensive discussion of what could be causing the thigh pain, how to diagnose it and possible treatments. My pain developed after a pain-free interval as I became more active around 4 months postop.

The pain is dynamic (only when I’m weight bearing), located where the end of the stem meets my bone. I have been told that the pain is caused by micromotions of the stem tip inside my bone because the titanium stem is more rigid than my bone which needs to continue to fill in around the stem and become stronger. I should mention I have osteopenia but I imagine that many individuals that need a THR may have bone quality issues also.

On the Hip and Knee Institute website I found a list titled, "Complications of Hip Replacement Surgery". Among his list of complications, Dr. Huddleston states that, “About 5% of patients with an uncemented hip replacement develop mid-thigh-pain (also called “end-of-stem” pain). The cause is unknown but is thought to be related to a mismatch between the rigidity of the implant, versus the elasticity of the bone.

Some patients with uncemented hip replacements develop mid thigh pain. The pain is usually mild, and almost always resolves after 18-24 months.” My thigh pain has been intense at times but I’m hoping it will diminish as the bone strengthens around the end of the stem.

The last thing I want to mention is that I developed bursitis in my left hip only 1½ months following the left THR. My PT started treating the bursitis with iontophoresis (dexamethasone) at 2 months postop. Now that I have started PT for the right THR, I was thinking of starting the iontophoresis treatments again on the left. Now I’m wondering if iontophoresis could also inhibit bone healing? Thanks in advance for your comments.

[HASH=30]#heterotopicossification[/HASH]

 

[Josephine]

Yes, I've read all those articles, Alice, and they mostly fall into the biggest issue in those reports which is a rather small subject base. Some of them only cite figures based on about 200 patients which is nothing. Which is not to totally refute their conclusions, just that they shouldn't be taken as totally all encompassing.

The issue about your prosthesis is not that it is titanium but that it is metal. All prostheses have this propensity for producing micro-movement and if you have that, then I would suggest the only treatment is revision as there is little or nothing can be done to stop it once the movement has begun.

Plus I would point out that dexamethasone is a steriod and that can also cause osteopenia.
Just a thought . . . . .

 

[Alice]

Josephine, <O:p
Are you saying that the tissue ingrowth around the stem can't continue to strengthen over time? Mentioning a revision surgery as the only treatment is devastating news for someone four weeks post op. I have had two THR's six months apart. My surgeon is telling me this thigh pain in the first THR should resolve within the first year post op as my bone gets stronger around the stem. <O:p
I guess I'll pass on the iontophoresis. Does a tens unit help bursitis and bone healing?
<O:pThe Kjaersgaard research study reportedly analyzed 46,844 THR. This included 24,496 cemented, 9050 uncemented and 13,298 hybrid implants. A total of 7518 patients received NSAIDs for at least one week postop. The Danish Hip Arthroplasty Register contains records of every THA performed in <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:country-region w:st="on">Denmark</ST1:p</st1:country-region> since 1995, including primary and revision surgeries. That's not a small number of patients.
<O:pThe article I mentioned, "Thigh Pain After Total Hip Replacement: A Pathophysiological Review and a Comprehensive Classification" has continuing medical education accreditation for orthopedic surgeons so it must have met certain criteria.
<O:pIs there anyone else who developed the "end of stem" thigh pain I described and did it diminish over time? Is there anyone else who developed bursitis following their THR and did it eventually go away? Thanks

 

[jls0113]

I am 14 weeks post op and saw my surgeon for a check up today. I told him of pain that I have when I 'overdo' on the outside of my thigh - similar to bursitis pain. He explained that they used to think it was caused by the scar when the surgery incision is posterior. But as patients experienced it with anterior scars also, now the theory is that the bones that are realigned during surgery (I don't know which bone it is) push outward against a muscles that runs down the side. A very poor explanation, but he said it can take up to 6 months for all the pain to go away. Gave me a couple of exercises to stretch the muscle, and told me to take Advil or Aleve for the pain.

Janet

 

[Josephine]

The Kjaersgaard research study

I must have missed that one - a link would be helpful. In fact, links to all those articles would be helpful, just so I can make sure they are the ones I think they are!

Are you saying that the tissue ingrowth around the stem can't continue to strengthen over time? Mentioning a revision surgery as the only treatment is devastating news for someone four weeks post op. I have had two THR's six months apart. My surgeon is telling me this thigh pain in the first THR should resolve within the first year post op as my bone gets stronger around the stem.

I said "IF" you have it. In your first post you said there was no sign of loosening so it would seem you have nothing to worry about.
Where there is micro-movement, as long as the movement goes on, it will inhibit bone growth as it moves around inside the shaft, however slightly. The same thing happens when someone breaks a bone. If there are certain kinds of movement at the fracture site then bone growth will not readily occur.

Is there anyone else who developed bursitis following their THR and did it eventually go away?

Like most inflammatory processes, bursitis is ultimately self-limiting which means that it will settle in time. Things can be done to make it more tolerable in the meantime and to hasten its healing. Anti-inflammatories and stretches and other treatments like injections of steriods. So don't despair about that. It's just tough toughing it out!

 

[philzoel]

Yes. took me off 2 weeks before and still off. Did here they inhibate bone growth so likely will stay off.