One hundred sixty-five patients underwent 171 preoperative aspiration arthrograms to evaluate a painful total hip arthroplasty. Intraoperative cultures and histologic specimens were obtained in all cases. Of the 166 aspirations where fluid was obtained, there were 140 true negative, 5 true positive, 18 false positive, and 3 false negative cultures. Sensitivity of hip aspiration to identify periprosthetic sepsis correctly was 50%; specificity was 88%. Hip aspiration with a 50% sensitivity rate lacks the ability to consistently predict those patients with occult periprosthetic sepsis. The routine use of aspiration in evaluation of a painful total hip is probably not indicated. Selective use in patients with a history of wound healing problems, radiographic changes, and elevated laboratory values should be considered.