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

Case Presentation

A 79-year-old, active Caucasian woman with left groin pain was referred to the orthopaedic clinic by her general practitioner to undergo THA. She complained about progressive left groin pain for 12 months that was worst in the morning and exacerbated by physical activity and prolonged sitting. Clinical examination revealed left-sided antalgic gait and tenderness in her left groin. Left hip internal rotation was limited to 10°. Anteroposterior pelvic and true lateral hip radiographs revealed typical signs of osteoarthritis (Figure 1). In addition, there was a 25-mm-diameter calcification in the lesser pelvis, which was reported by the radiologist to be a calcified uterine myoma. Finally, the patient was scheduled for elective left THA. At the preadmission clinic, a routine urine dipstick test revealed 3 to 20 erythrocytes and no leucocytes or nitrites. On the basis of the urine dipstick stick, a diagnosis of urinary tract infection (UTI) was made, although the patient was asymptomatic and urine was sent for culture. The patient was empirically treated with oral antibiotics, and the surgery was postponed. Urine cultures showed no bacterial growth, and no further tests or referral to other specialties were done. Four weeks later she underwent a THA with satisfactory recovery. At the first follow-up six weeks postoperatively, the patient was almost pain-free and was using two crutches for stability. Her examination was unremarkable at that time. Standard radiographs showed an acceptable implant position (Figure 2). The orthopaedic surgeon and the radiologist did not report any other abnormality. Further physiotherapy was recommended, and routine follow-up was recommended six months from the time of surgery. Unexpectedly, the patient presented to us four months after surgery complaining of worsening left hip pain. Because she was still on crutches, she noted weakness, loss of appetite and weight loss of 5 kg. Further examination revealed generalized tenderness of the left iliac crest, gluteal region and groin. The radiographs then showed bilateral cloudy bone formation in the pelvis (Figure 3). Further investigation with a technetium-99 m bone scan and computed tomography (CT) revealed widespread osteolytic and osteoblastic lesions bilaterally in the superior and inferior pubic ramii, sacrum, iliac wings, acetabula and left transverse process of the L4 and L5 vertebrae, which were most likely metastatic (Figures 4 and 5). Screening for the primary tumor (CT of the chest abdomen and pelvis) revealed a left pyeloureteral carcinoma. No further invasive tests or histopathological examinations were done because of the advanced stage of the disease, and a decision was made to provide palliative treatment to the patient. The patient received palliative chemotherapy and radiotherapy and died one year after diagnosis.

Figure 1.

Pre-operative antero-posterior pelvic (left) and true lateral (right) radiographs of the left hip showing bilateral osteoarthritis of the hip and a calcified uterine myoma.

Figure 2.

Initial postoperative antero-posterior pelvic (left) and true lateral (right) hip radiographs with acceptable implant position.

Figure 3.

Comparison of anteroposterior pelvic hip radiographs preoperatively and six weeks and three months post-operatively (from left to right).

Figure 4.

A technetium-99 m bone scan revealed widespread osteolytic and osteoblastic lesions in the entire pelvis, spine and chest.

Figure 5.

Computed tomography confirmed the widespread osteolytic and osteoblastic lesions in the entire pelvis, spine and chest.

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