THR: Psoas Tendonitis

- Discussion:  (see work up of painful THR) / psoas tendon
     - clinical findings:
             - pain in the groin
             - pain when getting in and out of an automobile or a chair (requires active flexion and rotation of hip) 
             - sometimes there will be delayed onset of pain;         
     - risk factors: 
                    - acetabular cup overhanging (with or w/o retroversion) of more than 8-12 mm;
                             - avoid a rim position exceeding the level of the anterior acetabular rim
                    - acetabular liner position:
                             - avoid any portion of the high wall over the superior aspect of the cup;
                             - note that in some patients, the psoas muscle will sweep laterally during gait, and will cover the surface of the hip components;
                             - any portion of a high wall liner that juts out superiorly, may end up causing pain;
                             - also realize that it is virtually impossible to document the exact position of the polyethylene component with radiographic studies;
                      - lesser trochanteric impingement
                             - decrease horizontal offset causing the lesser trochanter to abut against the ischium (and tendonitis)
                             - palpation to detect possible impingement by assessing the relationship of the tip of the lesser trochanter to the tip of the ischium;
                             - there should be at least one if not two finger breadth of space between lesser troch and ischium;
                    - low cup placement
                    - verticle cup alignment (exposed inferior lip contacts psoas)
                    - excessive anteversion of cup
                            - Cup-neck impingement due to the malposition of the implant as a possible mechanism for metallosis in metal-on-metal total hip arthroplasty.
                    - excessively large cup;
                            - mechanical irritation of the iliopsoas tendon and an oversized or retroverted acetabular cup
                            - Iliopsoas Impingement After Primary THA: Operative and Nonoperative Treatment Outcomes
                    - excessively large femoral head:
(see femoral component)
                            - femoral head acts as a major pulley for the action of psoas at the hip joint region;
                            - pressure on the femoral head and tension on the muscle is greatest from 0° to 30° of flexion;
                            - may explain the anatomical basis for possible groin pain in THR patients
                            - excessively large femoral head (from metal on metal heads)
                            - references:
                                     - Failure of larger-diameter metal-on-metal total hip arthroplasty resulting from anterior iliopsoas impingement.
                                     - Why large-head metal-on-metal hip replacements are painful: the anatomical basis of psoas impingement on the femoral head-neck junction.

                    - impingement on femoral collar
                            - Iliopsoas tendonitis caused by overhang of a collared femoral prosthesis.
                    - painful component screws (acetabular screws)
                            - do not assume that prominent intrapelvic screws are causing psoas tendon pain (rather screws may be causing pain due to the adjacent iliac vessels;
                            - ref: Iliopsoas Tendonitis due to the Protrusion of an Acetabular Component Fixation Screw After Total Hip Arthroplasty.

- Treatment Measures:
             - psoas tendon injections:
                    - repeated injections can sometimes give results equivalent to surgery;
                    - references:
                           - Iliopsoas bursa injections can be beneficial for pain after total hip arthroplasty.
                           - Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections
                           - Treatment of iliopsoas tendinitis after a left total hip arthroplasty with botulinum toxin type A
             - psoas tendon release:
 
                   - as with hamstring harvest (for ACL) some evidence that the psoas tendon will regenerate after release;
                    - may release the psoas from the pelvic brim vs. lesser trochanter  
                    - consider release of the anterior capsule;
                    - references:
                             - Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision.
                             - Surgical release of iliopsoas tendon for groin pain after total hip arthroplasty.
                             - Technique and results of endoscopic tenotomy in iliopsoas muscle tendinopathy secondary to total hip replacement: a series of 10 cases.
                             - Regrowth of the Psoas Tendon After Arthroscopic Tenotomy: A Magnetic Resonance Imaging Study
                             - Prospective randomized study of 2 different techniques for endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome.
                             - New arthroscopic tendon release relieves snapping hip pain
                             - Technique and results of endoscopic tenotomy in iliopsoas muscle tendinopathy secondary to total hip replacement: A series of 10 cases
                             - Arthroscopic psoas release for iliopsoas impingement after total hip replacement
                             - Arthroscopic treatment of iliopsoas impingement (IPI) after total hip replacement.
             - revision surgery
                    - references:
                             - Use of an Anatomical Acetabular Component for Treatment of Iliopsoas Impingement


             - references:         
                    - Iliopsoas Tendonitis A Complication After Total Hip Arthroplasty.
                    - [Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and conservative treatment in 9 cases]. 
                    - [Iliopsoas impingement in 12 patients with a total hip arthroplasty].
                    - Iliopsoas bursitis following total hip replacement.
                    - [Iliopsoas tendinitis--rare cause of pain following implantation of a total hip endoprosthesis.
                    - Impingement with total hip replacement.  
                    - Anterior iliopsoas impingement after total hip arthroplasty
                    - Iliopsoas Cyst Causing Persistent Pain After Total Hip Arthroplasty
                    - Why large-head metal-on-metal hip replacements are painful: The anatomical basis of psoas impingement on the femoral head-neck junction.
                    - Iliopsoas Tendon Impingement After Total Hip Arthroplasty with Use of a Large-Diameter Femoral Head: A Case Report
                    - Iliopsoas impingement on the acetabular component: radiologic and computed tomography findings of a rare hip prosthesis complication in eight cases.




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Saturday, September 2, 2017 6:15 am