Abstract
Background
Groin pain is a common long-term complication of total hip arthroplasty (THA). Femoral head size has been proposed as one of the primary causes. The implants used in dual mobility (DM) THA have large outer-bearing articulations, which could increase the risk of post-operative groin pain. Hip resurfacing (HR), too, has been shown to be associated with a risk of groin pain.
Questions/Purposes
The goals of this study were to compare the incidence of groin pain at 1 year after hip arthroplasty in patients with different femoral head diameters and in patients undergoing conventional THA, DM THA, and HR.
Methods
After combing an institutional registry for all patients who had undergone THA or HR for primary hip osteoarthritis, we included 3193 patients in the analysis; 2008 underwent conventional THA, 416 underwent DM THA, and 769 underwent HR. We used logistic regression modeling to analyze the relation of groin pain at 1 year after surgery to patient demographics and clinical characteristics, including age, sex, body mass index (BMI), University of California at Los Angeles activity score at 1 year after surgery, bearing couple, and the ratio of acetabular diameter to femoral head diameter. We also measured cup inclination and anteversion in a subset of patients with and without groin pain at 1 year to assess whether pain could be related to implant position.
Results
Overall, 8.7% of patients reported groin pain at 1 year. Patients with groin pain were younger and had lower BMIs. There were increased odds of groin pain with a greater cup-to-head ratio, although DM implants, interestingly, were not significantly associated with groin pain; this may be attributable to so much of their movement taking place inside the implant. Subgroup analysis measuring cup inclination and anteversion showed no difference in cup position between patients with and without pain.
Conclusion
In this population of hip arthroplasty patients, the incidence of groin pain 1 year after surgery did not differ among patients undergoing DM and conventional THA; DM THA in particular was not associated with a higher risk of groin pain, despite its comparatively larger femoral head sizes. HR, on the other hand, was associated with a higher risk of pain. Appropriate implant sizing and bearing couple choice may optimize the functional benefit of THA.
Electronic supplementary material
The online version of this article (10.1007/s11420-020-09764-6) contains supplementary material, which is available to authorized users.
Keywords: dual mobility, hip resurfacing, groin pain
Introduction
It has been suggested that a positive association exists between femoral head size and groin pain after total hip arthroplasty (THA). Previous studies suggest that hip resurfacing (HR) patients have an increased risk of groin pain post-operatively, as compared with THA patients [2, 6]. One possible cause may be iliopsoas tendonitis secondary to acetabular component “uncoverage,” malposition, or oversizing relative to the native acetabulum. Other possible etiologies include component loosening and adverse soft tissue reaction secondary to metal debris [2, 6, 9]. Bin Nasser et al. evaluated the incidence of groin pain after HR and its impact on patient function. The authors found that although all patients had functional improvements post-operatively, 18% reported groin pain at a minimum of 12 months of follow-up. Furthermore, 10% of patients reported that the pain limited their ability to perform activities of daily living, and 10% required medication for pain [6].
Bartelt et al. evaluated the incidence of groin pain after HR, large head metal-on-metal THA, and ceramic-on-polyethylene THA. At a minimum of 12 months of post-operative follow-up, the rates of groin pain were 18% with HR, 15% with metal-on-metal THA, and 7% with ceramic-on-polyethylene bearing THA [2]. They also found that younger patients were at higher risk for post-operative groin pain. They attributed these findings to greater risks of impingement with HR and large-head metal-on-metal THA, as well as to higher activity levels and, possibly, higher expectations in patients undergoing HR.
Large-diameter femoral heads have also been associated with increased risks of anterior hip and groin pain believed to be most often related to anterior soft tissue impingement of the iliopsoas tendon and occasionally to bony impingement [2, 4, 9, 12, 15]. More recently, there has been concern that larger femoral heads increase the risk of corrosion at the head–neck taper junction, leading to adverse local tissue reaction in the surrounding tissues [10]. This greater risk can be explained by the fact that larger heads generate greater frictional torque and bending moments on the trunnion, thereby contributing to corrosion at the junction [11, 12, 27]. The true incidence of this complication has yet to be determined because taper corrosion is a complex problem that depends on several factors, such as material composition of the head and trunnion, taper geometry, head size, and frictional torque at the bearing surface [11, 12, 17, 27].
The implants used in dual mobility (DM) THA have large outer-bearing articulations, which could increase the risk of post-operative groin pain. To our knowledge, no study has evaluated the incidence of groin pain specifically in DM THA. The purpose of this study was to compare the incidence of groin pain at 1 year after hip arthroplasty in patients with different femoral head diameters and in patients undergoing conventional THA, DM THA, and HR.
Methods
We retrospectively examined an institutional joint replacement registry to identify all patients who had undergone primary unilateral THA or HR for primary hip osteoarthritis between 2012 and 2014. Patients were included if they had answered “yes” or “no” to a groin pain survey at 1 year after surgery and had a documented University of California at Los Angeles (UCLA) activity score at 1 year. Exclusion criteria were the following: incomplete groin pain survey data, incomplete demographic and body mass index (BMI; the weight in kilograms divided by the square of the height in meters) data, incomplete implant records, simultaneous or staged bilateral THA, and revision hip surgery within 2 years after index surgery.
Conventional THA bearings were defined as metal, oxidized zirconium, or ceramic on a polyethylene liner, with head diameters less than or equal to 40 mm. DM bearings could be either anatomic DM or modular DM acetabular designs (Stryker Orthopedics, Mahwah, NJ, USA). With DM THA, the outermost bearing diameter was considered for analysis.
Logistic regression models were used to determine the odds of groin pain at 1 year, reported as odds ratios (ORs), in relation to patient age, sex, BMI, UCLA activity score at 1 year, bearing couple, and acetabular diameter–femoral head diameter ratio. We conducted a post hoc power analysis to assess the ability of this sample size to detect differences between the outcome variables. A p value less than 0.05 was considered to be statistically significant.
We measured inclination and anteversion in a subset of patients who reported groin pain and patients who denied groin pain at 1 year after surgery to assess whether groin pain could be related to implant position. These groups were matched in a 1:1 ratio according to age, sex, BMI, implant type (Birmingham Hip Resurfacing® system, conventional, and DM), and date of surgery. We performed the measurements using Ein-Bild-Röntgen-Analyze software (EBRA, University of Innsbruck, Innsbruck, Austria), which has been validated for the assessment of acetabular component position [5, 20].
Results
A total of 3193 patients were included in the analysis: 2008 underwent conventional THA, 416 underwent DM THA, and 769 underwent HR. The mean age of patients was 61.96 years, 50.45% of patients were female, and the mean BMI was 27.79 kg/m2. Overall, 278 patients (8.7%) reported groin pain. Older patients were less likely to have groin pain at 1 year, as were patients with a higher BMI (p < 0.0001 and p = 0.0404, respectively). There was no difference on the basis of sex in rates of groin pain at 1 year. There were also no differences in mean pre-operative or 1 year post-operative UCLA activity scores (Table 1).
Table 1.
Characteristics of total patient population in relation to groin pain at 1 year after surgery
| Groin pain at 1 year | ||||
|---|---|---|---|---|
| No (n = 2915) | Yes (n = 278) | All patients (N = 3193) | p value | |
| Age, mean | 61.96 | 58.28 | 61.64 | < 0.0001 |
| BMI, mean | 27.79 | 27.16 | 27.73 | 0.0404 |
| Sex, % | ||||
| Female | 50.45 | 46.93 | 50.14 | 0.2635 |
| Male | 49.55 | 53.07 | 49.7 | |
| UCLA score, meana | ||||
| Pre-operative | 5.28 | 5.48 | 5.3 | 0.2731 |
| At 1 year | 6.41 | 6.16 | 6.39 | 0.0874 |
BMI, body mass index; UCLA, University of California at Los Angeles
aScore on a scale of 1 to 10, 1 being complete inactivity and being regular participation in contact sports
There was no difference in rates of groin pain among groups when cup sizes of less than or equal to 50 mm, 52 to 56 mm, and greater than or equal to 58 mm were used (p = 0.8186). Interestingly, 11.9% of conventional THA patients with femoral heads smaller than 32 mm reported groin pain, as compared with 7.1% for 32-mm, 7.3% for 36-mm, and 10.7% for 40-mm heads (p < 0.0001). The HR group had the greatest incidence of groin pain at 1 year, 12.5%, as compared with 7.5% of conventional THA patients, and 7.7% of DM THA patients (p < 0.0001). When HR was compared with all primary THA (conventional and DM together), the HR group still had a greater incidence of groin pain at 1 year (12.5% vs. 7.5%; p < 0.0001) (Table 2).
Table 2.
Groin pain in relation to implant characteristics at 1 year after surgery
| Groin pain at 1 year | |||
|---|---|---|---|
| No n (%) | Yes n (%) | p value | |
| Cup size in mm, mean | 0.8186 | ||
| ≤ 50 | 934 (91.7) | 84 (8.3) | |
| 52–56 | 1467 (91.1) | 143 (8.9) | |
| ≥ 58 | 514 (91) | 51 (9) | |
| Femoral head size in mm, mean | 0.005 | ||
| < 32 | 118 (88.1) | 16 (11.9) | |
| 32 | 1120 (92.9) | 86 (7.1) | |
| 36 | 598 (92.7) | 47 (7.3) | |
| > 36 | 1079 (89.3) | 129 (10.7) | |
| Bearing type | 0.0001 | ||
| HR | 673 (87.5) | 96 (12.5) | |
| Conventional | 1858 (92.5) | 150 (7.5) | |
| DM | 384 (92.3) | 32 (7.7) | |
| Case type | |||
| HR | 673 (87.5) | 96 (12.5) | < 0.0001 |
| Primary THA (conventional + DM) | 2242 (92.5) | 182 (7.5) | |
| Total | 2915 (91.3) | 278 (8.7) | |
HR, hip resurfacing; DM, dual mobility; THA, total hip arthroplasty
Results of logistic regression modeling showed no association between femoral head size and risk of groin pain at 1 year. However, the odds of groin pain did increase when the cup-to-head diameter ratio increased (OR, 4.38; 95% confidence interval [CI], 1.02 to 18.74; p = 0.0465). The odds of groin pain were also greater with HR, when compared with conventional THA (OR, 3.51; 95% CI, 1.57 to 7.85; p = 0.0022), but no increase in the risk of groin pain was seen when DM and conventional THA were compared (Table 3).
Table 3.
Logistic regression analysis of possible confounding variables vis-à-vis groin pain at 1 year after surgery
| Groin pain at 1 year | |||
|---|---|---|---|
| OR | 95% CI | p value | |
| Age | 0.98 | 0.97–0.99 | 0.0001 |
| Sex (male) | 1.05 | 0.77–1.44 | 0.7523 |
| BMI | 0.96 | 0.94–0.99 | 0.0065 |
| UCLA activity score | 0.85 | 0.79–0.91 | < 0.0001 |
| Femoral head size | |||
| < 32 vs. 32 | 1.76 | 0.96–3.21 | 0.0671 |
| 36 vs. 32 | 0.97 | 0.65–1.47 | 0.8991 |
| > 36 vs. 32 | 0.6 | 0.08–4.70 | 0.6265 |
| Cup-to-head ratio | 4.38 | 1.02–18.74 | 0.0465 |
| Bearing type | |||
| BHR vs. conventional | 3.51 | 1.57–7.85 | 0.0022 |
| DM vs. conventional | 2.41 | 0.95–6.12 | 0.065 |
OR, odds ratio; CI, confidence interval; BMI, body mass index; UCLA, University of California at Los Angeles; BHR, Birmingham Hip Resurfacing® system; DM, dual mobility
The subgroup analysis that measured cup inclination and anteversion in 260 patients who reported groin pain at 1 year and 260 matched patients who denied it showed no difference in cup position between the two groups (Table 4). In patients for whom results of multiple post-operative pain surveys were available, groin pain reported at 6 weeks, 3 months, and 6 months post-operatively was predictive of groin pain at 1 year (p < 0.0001) (Table 5).
Table 4.
Cup position post-operatively
| Groin pain at 1 year | |||||
|---|---|---|---|---|---|
| No (n = 260) | Yes (n = 260) | ||||
| Mean | SD | Mean | SD | p value | |
| Inclination | 44.48 | 7.78 | 43.49 | 7.2 | 0.136 |
| Anteversion | 17.34 | 7.12 | 17.13 | 7.01 | 0.729 |
SD, standard deviation
Table 5.
Groin pain reported on post-operative pain surveys
| Groin pain at 1 year | |||
|---|---|---|---|
| No (%) | Yes (%) | p value | |
| 6 weeks | 1636 (87.1) | 243 (12.9) | < 0.0001 |
| 3 months | 970 (89.6) | 113 (10.4) | < 0.0001 |
| 6 months | 342 (89.5) | 40 (10.5) | < 0.0001 |
Discussion
In this study, when activity and patient characteristics were controlled for, there was no difference in groin pain at 1 year between DM and conventional THA, specifically in relation to bearing articulation. HR, however, was associated with a higher risk of groin pain. To our knowledge, this is the first study that specifically compared the incidence of post-operative groin pain after conventional THA, DM THA, and HR. These findings may allay previously raised concerns regarding the potential of greater groin pain associated with use of DM [12].
There are several limitations to this study. First, an institutional registry was used for this analysis. Registry data are sometimes incomplete, and in this study in particular, patients were excluded if they had incomplete groin pain survey data, demographic or BMI data, or incomplete implant records. Therefore, the true number of patients who underwent primary THA for primary hip osteoarthritis was not captured. Additionally, patients were excluded from the analysis if they had undergone revision hip surgery within 2 years after index surgery. The primary purpose of excluding these patients was to decrease the number of patients reporting groin pain that could be attributed to other causes, such as prosthetic joint infection, implant loosening, hip instability, and peri-prosthetic fracture. However, exclusion of such cases may have led to an underestimation of the risk of groin pain seen in HR secondary to adverse local tissue reactions or iliopsoas impingement that required revision surgery. Another limitation of the study is that we assessed patients’ groin pain as an absolute “yes” or “no,” rather than measuring its intensity using a pain-rating scale.
Our results are of particular relevance to the THA population at high risk for dislocation because hip instability is the most common cause of revision THA [7, 8, 16, 18, 21, 22, 29]. DM THA may provide a way to increase the functional head size without the increased risk of groin pain seen with HR and large-head THA. Our findings support evidence that the primary design objective in DM implants is achieved: the majority of motion in the bearings occurs at the inner bearing and motion at the outer bearing only occurs at an extreme range of motion [19, 24]. It is possible that the motion being at the inner bearing obviates a number of causes of pain that are associated with large-head bearing surfaces, such as iliopsoas impingement and greater force on the femoral trunnion, which can result in corrosion, metal release, and adverse local tissue reactions [2, 6, 9, 12].
The higher rate of groin pain seen in the HR group is consistent with rates reported in other studies. Bin Nasser et al. found an 18% incidence of groin pain after HR, with 10% of patients with pain limiting their activities of daily living at a mean of 26 months after surgery [6]. Similarly, Bartelt et al. reported a more than twofold higher incidence of groin pain in patients who underwent HR, as compared with conventional THA (18% vs. 7%, respectively), at a mean of 14-month follow-up [2]. Lavigne et al. noted a 30.5% incidence of groin pain in an HR group at 3 months after surgery, versus 18.3% in a conventional THA group. At 2 years, however, the incidences decreased to 14.9% and 12.9%, respectively [23].
Interestingly, our findings show that patients with a greater cup-to-head ratio were at increased risk for developing groin pain post-operatively. This can in part be explained by an increased risk of impingement of the iliopsoas tendon against the anterior lip of an oversized cup and underscores the importance of choosing an appropriate size acetabular component. Batailler et al. performed a retrospective study evaluating 46 patients who underwent cup revision secondary to iliopsoas impingement [3]. Eighty-three percent of patients had prominence of the anterior cup rim, and 76% had cup malposition. At a mean of 21 months after revision, 85% reported satisfaction with the surgery. Recurrent groin pain at final follow-up was reported by only 8.7% of patients. These findings may help explain those in our study and are also consistent with those of several published case reports [1, 28].
Our study did not find a greater risk of groin pain with the use of DM implants, despite the comparatively larger femoral head sizes. DM THA appears to have several advantages over HR and conventional THA. Most importantly, it has been shown to result in a lower incidence of post-operative hip instability in both primary and revision THA settings. DM implants have been shown to have very high short-term survival rates—approximately 98 to 100% at 3 years—although more research is needed to evaluate the long-term survival of DM implants [13, 14, 25, 26].
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Compliance with Ethical Standards
Conflict of Interest
Alexandra I. Stavrakis, MD, Amir Khoshbin, MD, Amethia Joseph, MS, and Lily Y. Lee, MS, declare that they have no conflicts of interest. Mathias P. Bostrom, MD, reports royalties or licensing payments and consulting and other fees from Smith and Nephew, outside the submitted work. Geoffrey H. Westrich, MD, reports royalties or licensing payments and consulting fees from Stryker and consulting fees from Exactech, outside the submitted work. Alexander S. McLawhorn, MD, reports consulting and other fees from Ethicon and Intellijoint Surgical, outside the submitted work.
Human/Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.
Informed Consent
Informed consent was waived from all patients for being included in this study. Each author certifies that his or her institution has approved the reporting of these cases.
Required Author Forms
Disclosure forms provided by the authors are available with the online version of this article.
Footnotes
Level of Evidence: Level III: Retrospective Cohort Study.
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