We have reviewed a group of patients with iliopsoas impingement after total hip replacement with radiological evidence of a well-fixed malpositioned or oversized acetabular component. A consecutive series of 29 patients (30 hips) was assessed. All had undergone a trial of conservative management with no improvement in their symptoms. Eight patients (eight hips) preferred continued conservative management (group 1), and 22 hips had either an iliopsoas tenotomy (group 2) or revision of the acetabular component and debridement of the tendon (group 3), based on clinical and radiological findings. Patients were followed clinically for at least two years, and 19 of the 22 patients (86.4%) who had surgery were contacted by phone at a mean of 7.8 years (5 to 9) post-operatively. Conservative management failed in all eight hips. At the final follow-up, operative treatment resulted in relief of pain in 18 of 22 hips (81.8%), with one hip in group 2 and three in group 3 with continuing symptoms. The Harris Hip Score was significantly better in the combined groups 2 and 3 than in group 1. There was a significant rate of complications in group 3. This group initially had better functional scores, but at final follow-up these were no different from those in group 2.

Tenotomy of the iliopsoas and revision of the acetabular component are both successful surgical options. Iliopsoas tenotomy provided the same functional results as revision of the acetabular component and avoided the risks of the latter procedure.

Aims. Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation. Methods. This was a retrospective cohort study of patients who underwent THA surgery that included 23 symptomatic patients diagnosed with iliopsoas tendonitis, and 23 patients not diagnosed with iliopsoas tendonitis. All patients received postoperative CT imaging, postoperative standing radiography, and had minimum six months’ follow-up. 3D models of each patient’s prosthetic and bony anatomy were generated, landmarked, and simulated in a novel iliopsoas impingement detection model in supine and standing pelvic positions. Logistic regression models were implemented to determine if the probability of pain could be significantly predicted. Receiver operating characteristic curves were generated to determine the model’s sensitivity, specificity, and area under the curve (AUC). Results. Highly significant differences between the symptomatic and asymptomatic cohorts were observed for iliopsoas impingement. Logistic regression models determined that the impingement values significantly predicted the probability of groin pain. The simulation had a sensitivity of 74%, specificity of 100%, and an AUC of 0.86. Conclusion. We developed a computational model that can quantify iliopsoas impingement and verified its accuracy in a case-controlled investigation. This tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis. Cite this article: Bone Jt Open 2023;4(1):3–12

Aims

Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes.

Iliopsoas impingement occurs in between 5–30% of patients after hip arthroplasty and has been thought to only be caused by an oversized cup, cup malpositioning, or the depth of the psoas valley. However, no study has associated the relationship between preoperative measurements with the risk of impingement. This study sought to assess impingement between the iliopsoas and acetabular cup using a novel validated model to determine the risk factors for iliopsoas impingement. 413 patients received lower limb CT scans and lateral x-rays that were segmented, landmarked, and measured using a validated preoperative planning protocol. Implants were positioned according to the preference of ten experienced surgeons. The segmented bones were transformed to the standing reference frame and simulated with a novel computational model that detects impingement between the iliopsoas and acetabular cup. Definitions of patients at-risk and not at-risk of impingement were defined from a previous validation study of the simulation. At-risk patients were propensity score matched to not at-risk patients. 21% of patients were assessed as being at-risk of iliopsoas impingement. Significant differences between at-risk patients and not at-risk patients were observed in standing pelvic tilt (p << 0.01), standing femoral internal rotation (p << 0.01), medio-lateral centre-of-rotation (COR) change (p << 0.01), supine cup anteversion (p << 0.01), pre- to postoperative cup offset change (p << 0.001), postoperative gross offset (p = 0.009), and supero-inferior COR change (p = 0.02). Impingement between the iliopsoas and acetabular cup is under-studied and may be more common than is published in the literature. Previously it has been thought to only be related to cup size or positioning. However, we have observed significant differences between at-risk and not at-risk patients in additional measurements. This indicates that its occurrence is more complex than simply being related to cup position

Introduction. Iliopsoas impingement is a well described cause of groin pain after direct anterior total hip arthroplasty (THA). We proposed to evaluate the incidence, natural history and response to treatment of iliopsoas impingement after direct anterior total hip arthroplasty. Methods. A retrospective chart review of 725 consecutive patients who underwent anterior approach total hip arthroplasty between 2009 and 2014 was conducted. All surgeries were performed by one of two surgeons. Patients were included if they underwent primary anterior approach THA and had a minimum of 2 years of follow up. Patients who had a posterior approach, revision surgery or had less than 2 years of follow up were excluded. Iliopsoas impingement was identified if patients reported groin pain at greater than 6 weeks of postoperative follow up and in association with pain with resisted seated hip flexion. The natural history and response to treatment was recorded for patients identified as having iliopsoas impingement. Results. 900 patients met inclusion criteria. Of these, 120 (13.4%) developed groin pain following direct anterior total hip arthroplasty. The average time of onset was at 21 months postoperatively. At 2 years postoperatively, 16% of patients had symptoms, whereas 84% had resolution. 28% of patients responded to structured physical therapy, 22% improved with home stretching, 19% improved after arthroscopic psoas release, 9% after psoas sheath injection, and 6% required acetabular component revision. Conclusion. In our study population, iliopsoas impingement is not an uncommon finding after direct anterior total hip arthroplasty, but nearly half of these patients responded well to home stretching or physical therapy. In some cases, psoas injection and arthroscopic release was necessary. Rarely, cup revision was required for symptomatic relief

Introduction. Hip Resurfacing Arthroplasty (HRA) has been performed in the United States for over 10 years and is an alternative to standard Total Hip Arthropastly (THA). It is appealing to younger patients with end stage osteoarthritis who seek to maintain active lifestyles. Benefits of HRA versus THR include a larger femoral ball size, potential to return to impact activities, decreased dislocation rates, and restoration of normal hip biomechanics. Patients ≤50 years old are a particularly challenging patient group to treat with THA because of their young age and high activity level, and as such, are well-suited for HRA. However, there are limited reports in the literature about clinical, radiographic and functional outcomes for this patient cohort. We present results of a clinical investigation at our institution for this patient cohort with minimum 5-year follow up, including long term survivorship and outcome scores. Methods. HRA, using the Birmingham Hip Resurfacing (BHR), was performed for 538 procedures between 2006–2009 by a single surgeon at a United States teaching hospital. After Institutional Review Board approval, medical and radiographic study records were retrospectively reviewed. Harris Hip Scores (HHS) were routinely collected. Patients who had not returned for follow-up examination were contacted by telephone for information pertaining to their status and implant, and a modified HHS was also administered. A Kaplan Meier survival curve was constructed to evaluate time to revision. Statistical analysis was performed (SAS version 9.3; SAS Institute, Cary, NC). Results. Of the 538 patients who underwent HRA from 2006–2009, 238 were aged ≤50 years (44%). Five-year follow up data was obtained from 209 of these patients (88%), using medical record documentation, and telephone survey as needed. The mean follow-up for all patients was 6 years (range 5–8 years). A total of 3% (8/238) were revised. Reasons included: (i) femoral loosening in 4, (ii) Iliopsoas impingement in 1, (iii) metallosis/adverse tissue reaction in 1, (iv) femoral neck fracture following motor vehicle accident in 1, and (v) unknown reasons in 1. Of the 238 patients, 55 (23%) were female, 2 (2/55; 3.6%) of whom have since undergone revision surgery for either metallosis/adverse tissue reaction, or unknown reasons. Of the 53 women who retained their BHR at 5-year follow up, the average HHS was 96.5. Of the 238 patients, 183 (77%) were male patients, 6 (6/183; 3.2%) of whom have since undergone revision surgery for femoral component loosening, iliopsoas impingement, or femoral neck fracture sustained in a motor vehicle accident. At 5-year follow-up, 177 male patients retained their implant and had an average Harris Hip Score of 98.8. The overall implant survival was 96.6% at approximately 5 years. Conclusion. In our cohort of patients aged ≤50 treated with BHR [Fig. 1], our results demonstrated 5-year survivorship of 96.6%, with average HHS of 98.8 in males and 96.5 in females. This study demonstrates HRA is a successful alternative to traditional THA in a challenging cohort of younger, active patients

Persistent groin pain after seemingly successful total hip replacement (THR) appears to have become more common. Recent studies have indicated a high incidence after metal-on-polyethylene and metal-on-metal conventional THR and it has been documented in up to 18% of patients after metal-on-metal resurfacing. There are many causes, including acetabular loosening, stress fracture, and iliopsoas tendonitis and impingement. The evaluation of this problem requires a careful history and examination, plain radiographs and an algorithmic approach to special diagnostic imaging and tests. Non-operative treatment is not usually successful. Specific operative treatment depending on the cause of the pain usually involves revision of the acetabular component, iliopsoas tenotomy or other procedures, and is usually successful. Here, an appropriate algorithm is described.