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  • A thorough clinical history and a detailed physical examination are essential to delineate various intrinsic and extrinsic causes of pain in patients with hip and knee total joint replacements.
  • Radiographs with orthogonal and weight-bearing views should be ordered to assess signs of implant-related complications.
  • Laboratory investigations should include both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as screening serologic markers for joint infection.
  • A high index of suspicion for infection must always be maintained, especially in patients with comorbidities such as diabetes, inflammatory arthritis, and compromised immunity.
  • Awareness of adverse soft-tissue reaction to metal wear debris in patients with painful metal-on-metal total hip replacements is important in light of its increasing use in young and active patients.

Total hip and knee joint replacement surgery is one of the most successful operations in medicine in terms of patient satisfaction, reduction in pain, and improvement in function. Despite the overwhelming success of total joint arthroplasty, the painful hip and knee prosthetic joint remains a challenge for the physician to evaluate and manage. Because a painful prosthetic hip and knee joint has various intrinsic and extrinsic causes (Table 13–1), a thorough clinical history, a detailed physical examination, as well as radiographic and laboratory tests are essential to delineate the potential causes of the pain (Figure 13–1).

Table 13–1. Differential Diagnosis for the Painful Prosthetic Joint.
Figure 13–1.

Clinical evaluation of a patient with painful total hip and knee arthroplasty. CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood count.


A complete history is critical in the evaluation of patients with painful hip and knee replacements. The temporal onset, duration, severity, location, and character of the pain help narrow the differential diagnosis. The presence of pain since surgery suggests either infection, failure to obtain initial implant stability, a periprosthetic fracture, or a misdiagnosis of the initial reason the arthroplasty was performed. If the pain comes after a pain-free interval following surgery, the likely causes include aseptic loosening or late infection.

Activity-related pain that is relieved with rest suggests implant loosening, fracture, or either neurogenic or vascular claudication. The presence of persistent pain, pain at rest, or night pain may indicate sepsis or malignancy.

Precipitating causes of the pain should be elucidated. Onset of pain after ...

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