- 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 Protrusion of 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.
- An operative technique for psoas impingement following total hip arthroplasty: a case series of day case, extra articular, arthroscopic psoas tenotomy.
- 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 MOM THR 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
- Iliopsoas impingement on the acetabular component: radiologic and computed tomography findings of a rare hip prosthesis complication in eight cases.