An Unusual Case of Persistent Groin Pain after Total Hip Arthroplasty

A Case Report

Praveen Konala; Thomas K Schaefer; Farhad Iranpour; Niklaus F Friederich; Michael T Hirschmann

Disclosures

J Med Case Reports. 2011;5(1) 

In This Article

Abstract and Introduction

Abstract

Introduction: Arthroplasty is a well-established routine elective surgical procedure in orthopaedics. To a great extent, diagnosis, treatment and post-operative rehabilitation in these patients is standardised. In a busy clinic, surgeons from time to time tend to focus their attention on common causes of joint pain, but it may lead them to overlook sinister but less common pathologies. Here we report a case of a patient with groin pain due to pre-operatively undetected pelvic metastases from a pyeloureteral carcinoma who underwent total hip arthroplasty. There are several case reports which deal with primary or secondary tumours which were either discovered at the time of replacement surgery or developed at the site of prosthesis years after total hip or knee replacement. To the best of our knowledge, this is the first case report in which a metastatic cancer was missed pre-operatively and intra-operatively both by the radiologist and by the orthopaedic surgeon and should be reported so that surgeons are reminded to be careful when dealing with seemingly routine cases.
Case presentation: A 79-year-old Caucasian woman presented to the arthroplasty clinic with groin pain. Initial radiographs showed subtle bilateral abnormalities in the pelvis. Neither the radiologist nor the orthopaedic surgeon recognized it. A diagnosis of osteoarthritis of the hip was established, and she underwent total hip arthroplasty. Despite initial improvement, the patient came back with worsening hip pain three months later. Further radiological examination revealed multiple metastatic lesions throughout the pelvis due to a pyeloureteral carcinoma.
Conclusions: This case report emphasizes the importance of meticulous, unbiased pre-operative assessment of patients and their radiographs, even in so-called routine clinical cases. Often subtle radiological changes are classed as normal, especially if they are bilateral. Further radiological imaging should be recommended in all cases where unexplained clinical features or radiological findings are present.

Introduction

Total hip arthroplasty (THA) is a well-established routine surgical procedure in orthopaedics.[1–3] To a great extent, diagnostics, treatment and postoperative rehabilitation in these patients are standardised.[1–3] In a busy hip clinic, surgeons from time to time tend to focus their attention on common causes of hip pain, but it may lead them to overlook other sinister but less common pathologies.

Here we report a case of a patient with groin pain due to pre-operatively undetected pelvic metastases from a pyeloureteral carcinoma who underwent THA. There are several case reports that deal with primary or secondary tumors which have either been discovered at the time of replacement surgery or developed at the site of prosthesis years after total hip or knee replacement.[4–9] To the best of our knowledge, this is the first case report in which a metastatic cancer was missed pre-operatively and intra-operatively both by the radiologist and by the orthopaedic surgeon and should be reported so that surgeons are reminded to be careful when dealing with seemingly routine cases.

Upper urinary tract tumours are uncommon and constitute 5% to 7% of all urinary tract tumours.[10] A ratio of 56% to 98% of patients with pyeloureteral carcinoma present with microscopic or macroscopic haematuria.[11] Around 30% present with flank pain, and 19% present with features of advanced disease, including bone pain, anorexia and weight loss. The thin layer of smooth muscle around the upper urinary tract predisposes these patients to early local invasion and metastasis. Urothelial tumours spread by local invasion as well as lymphatic and haematogenous spread. The incidence of bone metastasis in upper urothelial tumours is hard to compute in view of its rarity and the lack of large data sets. Studies of metastatic urinary tract tumours by Sengeløv et al.[12,13] showed that the most common sites of metastasis are lymph nodes (26%-57%) and bone (35%-40%). Among those with bone metastasis, the spine was involved in 40% of the cases, followed by pelvis in 26%.[12,13]

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