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An unusual cause of thigh pain after total hip arthroplasty
The Journal of Arthroplasty Vol. 10 No. 2 1995
An Unusual Cause of Thigh Pain After Total Hip Arthroplasty J. E. D. H i g g s , F R A C S , * A. C h o n g , M B , B S , * R H a e r t S c h , F R A C S , ] R. S e k e l , F R A C S , : ~ a n d A. L e i c e s t e r , F R A C S *
Abstract: The aim of total hip arthroplasty surgery is to relieve pain. There are
many postulated causes of thigh pain following total hip arthroplasty, some of which are not easily corrected. Muscle hernia as a result of hip surgery is a cause of thigh pain that is disabling, relatively easy to diagnose, and may be preventable: Key words: thigh pain, arthroplasty, myocele, muscle hernia.
Thigh pain, in the absence of implant loosening or infection, is a well-documented complication of total hip arthroplasty. The inddence of thigh pain has been reported to range from 8 to 50%. 1,2 Many reasons have been put forth as to the etiology, ranging from the shape and size Of the femoral component ~ to the mechanism of fixation of the stem to the bone. 3"4In m a n y cases, the pain is not debilitating and m a y improve with time. 2 We report a cause of thigh pain that can be severely debilitating if left untreated. Muscle hernias have been d o c u m e n t e d in the forearm, 5 thigh, and anterior compartment of the l e g Y To our knowledge, however, induding an extensive literature search, vastus lateralis hernia as a cause of thigh pain has not been previously reported after hip arthroplasty. We have experience with six patients w h o have suffered from muscle hernias after having a total hip arthroplasty.
fascia lata defect and a s u b s e q u e n t vastus lateralis muscle hernia. There w e r e two m e n and four w o m e n ; the patients were b e t w e e n 65 and 71 years of age (average, 68 years). The average follow-up period was 31 m o n t h s (range, 12-96 months). All patients p r e s e n t e d w i t h thigh symptoms w i t h i n the first 5 m o n t h s following arthroplasty. In one patient, the h e r n i a occurred after revision arthroplasty. Five of the six patients w e r e in a series of 780 total hip arthroplasties. Some clinical features help to distinguish the discomfort caused by a muscle hernia from other causes of thigh pain after total hip arthroplasty: 1. There is little or no pain at rest. Activity, including standing, causes severe, localized pain. 2. The pain m a y be reduced by a thigh support or firm stocking. 3. The patients are able to localize the pain using one finger. This contrasts with other causes of thigh pain, w h e r e the pain is often diffuse and the patient indicates the area of pain with the whole hand. 4. The hallmark on examination is a palpable defect in the fascia lata located within the w o u n d . The vastus lateralis muscle can be seen herniating t h r o u g h this defect w h e n the thigh c o m p a r t m e n t pressure is raised, for example, by standing.
Discussion Six patients w h o u n d e r w e n t total hip arthroplasty suffered f r o m thigh pain that was due to a
From the Departments of *Orthopaedics and tPlastic Surgery, Repatriation General Hospital Concord, and ¢St. George Hospital Kogarah, New South Wales, Australia.
For two patients, the clinical diagnosis was confirmed by xerogram and magnetic resonance imaging, respectively (Fig. 1).
Reprint requests: A. Chong, FRACS, 96 Bateman Road, Mount Pleasant, Australia 6153.
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The Journal of Arthroplasty Vol. 10 No. 2 April 1995 diate relief of symptoms. One recurrence required revision of the repair. We postulate that a cause of the thigh hernia m a y be a fascia lata incision that is incompletely repaired because its extent is b e y o n d the lower edge of the skin incision. We r e c o m m e n d that w h e n dividing the fascia lata, do not extend the incision b e y o n d the lower edge of the skin w o u n d and pay careful attention to making a complete closure of the fascial layer. Also, because the fibers of the fascia lata are oriented vertically, repair of this structure m a y be less prone to dehiscence if "bites" of varying depth are taken during the repair.
References
Fig. 1. Magnetic resonance image of the right thigh, demonstrating the defect in the fascia lata (f). Arrow indicates muscle hernia.
In each case the w o u n d was explored and we discovered that the lower extent of the fascia lata defect extended distal to the lower margin of the skin incision. The hernias were repaired using a combination of direct primary suture and Marlex m e s h (C. R. Bard), w h i c h is used to bridge large defects. Correction of the defect resulted in i m m e -
1. Haddad R, Cook S, Brink M: A comparison of three varieties of noncemented porous coated total hip replacement. J Bone Joint Surg 72B:2, 1990 2. Kim Y-H, Kim VE: Results of the Harris-Galante cementless hip prosthesis. J Bone Joint Snrg 74B:83, 1992 3. Engh C, Glassman A, Suthers K: The case for porous coated hip implants: the femoral side. Clin Orthop 261:63, 1990 4. Welch R, McGann W, Rasmussen L: Femoral stem fixation: the case for cement. Clin Orthop 261:134, I990 5. Roberts JO, Regan PJ, Dickinson JC, Bailey BN: Forearm muscle herniae and their treatment. J Hand Surg I4B:319, 1989 6. Kogler J, Stark GB, Fiackmann A: Autologous corium-plasty in closure of muscle hernia: a case report. Handchir Mikrochir Plast Chit 23:107, 1991 7. Schechter D, Palmieri A, Vaden M: Myocele of the lower limb. Arch Surg 83:825, 1961
An Unusual Cause of Thigh Pain After Total Hip Arthroplasty J. E. D. H i g g s , F R A C S , * A. C h o n g , M B , B S , * R H a e r t S c h , F R A C S , ] R. S e k e l , F R A C S , : ~ a n d A. L e i c e s t e r , F R A C S *
Abstract: The aim of total hip arthroplasty surgery is to relieve pain. There are
many postulated causes of thigh pain following total hip arthroplasty, some of which are not easily corrected. Muscle hernia as a result of hip surgery is a cause of thigh pain that is disabling, relatively easy to diagnose, and may be preventable: Key words: thigh pain, arthroplasty, myocele, muscle hernia.
Thigh pain, in the absence of implant loosening or infection, is a well-documented complication of total hip arthroplasty. The inddence of thigh pain has been reported to range from 8 to 50%. 1,2 Many reasons have been put forth as to the etiology, ranging from the shape and size Of the femoral component ~ to the mechanism of fixation of the stem to the bone. 3"4In m a n y cases, the pain is not debilitating and m a y improve with time. 2 We report a cause of thigh pain that can be severely debilitating if left untreated. Muscle hernias have been d o c u m e n t e d in the forearm, 5 thigh, and anterior compartment of the l e g Y To our knowledge, however, induding an extensive literature search, vastus lateralis hernia as a cause of thigh pain has not been previously reported after hip arthroplasty. We have experience with six patients w h o have suffered from muscle hernias after having a total hip arthroplasty.
fascia lata defect and a s u b s e q u e n t vastus lateralis muscle hernia. There w e r e two m e n and four w o m e n ; the patients were b e t w e e n 65 and 71 years of age (average, 68 years). The average follow-up period was 31 m o n t h s (range, 12-96 months). All patients p r e s e n t e d w i t h thigh symptoms w i t h i n the first 5 m o n t h s following arthroplasty. In one patient, the h e r n i a occurred after revision arthroplasty. Five of the six patients w e r e in a series of 780 total hip arthroplasties. Some clinical features help to distinguish the discomfort caused by a muscle hernia from other causes of thigh pain after total hip arthroplasty: 1. There is little or no pain at rest. Activity, including standing, causes severe, localized pain. 2. The pain m a y be reduced by a thigh support or firm stocking. 3. The patients are able to localize the pain using one finger. This contrasts with other causes of thigh pain, w h e r e the pain is often diffuse and the patient indicates the area of pain with the whole hand. 4. The hallmark on examination is a palpable defect in the fascia lata located within the w o u n d . The vastus lateralis muscle can be seen herniating t h r o u g h this defect w h e n the thigh c o m p a r t m e n t pressure is raised, for example, by standing.
Discussion Six patients w h o u n d e r w e n t total hip arthroplasty suffered f r o m thigh pain that was due to a
From the Departments of *Orthopaedics and tPlastic Surgery, Repatriation General Hospital Concord, and ¢St. George Hospital Kogarah, New South Wales, Australia.
For two patients, the clinical diagnosis was confirmed by xerogram and magnetic resonance imaging, respectively (Fig. 1).
Reprint requests: A. Chong, FRACS, 96 Bateman Road, Mount Pleasant, Australia 6153.
203
204
The Journal of Arthroplasty Vol. 10 No. 2 April 1995 diate relief of symptoms. One recurrence required revision of the repair. We postulate that a cause of the thigh hernia m a y be a fascia lata incision that is incompletely repaired because its extent is b e y o n d the lower edge of the skin incision. We r e c o m m e n d that w h e n dividing the fascia lata, do not extend the incision b e y o n d the lower edge of the skin w o u n d and pay careful attention to making a complete closure of the fascial layer. Also, because the fibers of the fascia lata are oriented vertically, repair of this structure m a y be less prone to dehiscence if "bites" of varying depth are taken during the repair.
References
Fig. 1. Magnetic resonance image of the right thigh, demonstrating the defect in the fascia lata (f). Arrow indicates muscle hernia.
In each case the w o u n d was explored and we discovered that the lower extent of the fascia lata defect extended distal to the lower margin of the skin incision. The hernias were repaired using a combination of direct primary suture and Marlex m e s h (C. R. Bard), w h i c h is used to bridge large defects. Correction of the defect resulted in i m m e -
1. Haddad R, Cook S, Brink M: A comparison of three varieties of noncemented porous coated total hip replacement. J Bone Joint Surg 72B:2, 1990 2. Kim Y-H, Kim VE: Results of the Harris-Galante cementless hip prosthesis. J Bone Joint Snrg 74B:83, 1992 3. Engh C, Glassman A, Suthers K: The case for porous coated hip implants: the femoral side. Clin Orthop 261:63, 1990 4. Welch R, McGann W, Rasmussen L: Femoral stem fixation: the case for cement. Clin Orthop 261:134, I990 5. Roberts JO, Regan PJ, Dickinson JC, Bailey BN: Forearm muscle herniae and their treatment. J Hand Surg I4B:319, 1989 6. Kogler J, Stark GB, Fiackmann A: Autologous corium-plasty in closure of muscle hernia: a case report. Handchir Mikrochir Plast Chit 23:107, 1991 7. Schechter D, Palmieri A, Vaden M: Myocele of the lower limb. Arch Surg 83:825, 1961