Iliopsoas Tendonitis due to the Protrusion of an Acetabular Component Fixation Screw After Total Hip Arthroplasty

Postoperative pain after total hip arthroplasty can have a wide range of underlying causes. Iliopsoas tendonitis secondary to the impingement of this tendon is a relatively rare cause of pain after arthroplasty. This condition is characterized by pain on active flexion and an absence of signs or symptoms of loosening or infection. In this report, we describe the case of a patient who had signs and symptoms of iliopsoas tendonitis secondary to the protrusion of an acetabular fixation screw through the ilium after primary total hip arthroplasty. Nonoperative treatment was ineffective, and the patient ultimately underwent surgical removal of the screw. The severity of the patient's symptoms decreased significantly after the operation.     

Iliopsoas Impingement After Direct Anterior Approach Total Hip Arthroplasty: Epidemiology,Risk Factors,and Treatment Options

BackgroundThe objective of this study is to evaluate the incidence, natural history, response to treatment, and risk factors for anterior iliopsoas impingement (AIPI) after direct anterior approach (DAA) total hip arthroplasty (THA).MethodsBetween January 1, 2009 and January 4, 2014, 600 patients (655 hips) who underwent primary DAA THA were retrospectively reviewed. AIPI incidence was calculated. Natural history and response to a stepwise treatment approach was assessed. Radiographic anterior acetabular component overhang was measured. Asymptomatic controls were used to identify risk factors for the development of AIPI.ResultsIn total, 518 patients (559 hips) met the inclusion criteria. The incidence of AIPI was 32/559 (5.7%). Symptom resolution occurred in 22/32 (68.8%) patients at final follow-up. Nonoperative management was successful in 15/32 (46.9%) patients. Operative intervention resulted in symptom resolution in 5/8 (62.5%) patients. On univariate analysis, female gender (odds ratio [OR] 2.79), acetabular component to native femoral head diameter ratio above 1.1 (OR 3.85), and any measurable overhang (OR 7.07) significantly raised the risk of AIPI, while increasing native femoral head diameter was protective for AIPI (OR 0.83).ConclusionAIPI is a cause of groin pain after DAA THA, which often improves with conservative measures. Significant predisposing factors for AIPI include female gender, small native femoral head diameter, increased acetabular component to femoral head diameter ratio, and most notably, any measurable acetabular component overhang.Level of EvidenceLevel III, retrospective cohort study.     

Outcomes of Nonoperative Management,Iliopsoas Tenotomy,and Revision Arthroplasty for Iliopsoas Impingement after Total Hip Arthroplasty: A Systematic Review

BackgroundNonoperative and operative management of iliopsoas impingement (IPI) is commonly performed following total hip arthroplasty (THA). The purpose of this systematic review is to compare patient-reported outcomes (PROs) following conservative treatment, iliopsoas (IP) tenotomy, and revision arthroplasty in patients presenting with IPI after THA.MethodsThe PubMed and Embase databases were searched for articles regarding IPI following THA. Studies were included if (1) IPI after THA was treated with conservative management, an IP tenotomy, or acetabular component revision and (2) included PROs.ResultsEleven articles were selected for review and there were 280 hips treated for IPI following THA. Harris Hip Scores reported for the conservative group, the IP tenotomy group, and the cup revision group were 59.0 preoperatively to 77.8, 58.0 preoperatively to 85.4, and 58.1 preoperatively to 82.4 at latest follow-up, respectively. The IP tenotomy cohort also demonstrated superior postoperative functional outcomes using the Western Ontario and McMaster Universities Index, Medical Research Council score, Oxford Hip Score, and Merle d'Aubigné-Postel Pain Score. Patients who had a revision exhibited higher Oxford Hip Scores, higher Medical Research Council scores, and lower Visual Analog Scale Pain scores postoperatively.ConclusionManagement of IPI following THA includes nonoperative measures, IP tenotomy, or acetabular component revision. Patients have been shown to experience favorable PROs at latest follow-up, with an apparent advantage for surgical treatment. Compared to revision arthroplasty, IP tenotomy resulted in a lower overall rate of complications with less severe complication types. Therefore, IP tenotomy should be considered as a second line of treatment for patients who failed conservative measures. Revision arthroplasty should be reserved for recalcitrant cases.Level of EvidenceIV.     

Risk Factors and Cup Protrusion Thresholds for Symptomatic Iliopsoas Impingement After Total Hip Arthroplasty: A Retrospective Case-Control Study

Background

Groin pain and functional limitations may occur after total hip arthroplasty (THA) due to iliopsoas impingement (IPI). We aimed to determine the risk factors and thresholds of cup protrusion for symptomatic IPI.

Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty

BackgroundIliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks.MethodsA consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort.ResultsAt last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P = .005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P = .002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series.ConclusionEndoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA.     

Risk Factors for Iliopsoas Tendinopathy After Anterior Approach Total Hip Arthroplasty

BackgroundIliopsoas tendinopathy is a cause of groin pain following total hip arthroplasty (THA). With the anterior approach becoming increasingly popular, our aim was to determine the prevalence of iliopsoas tendinopathy following anterior approach THA, to identify risk factors and to determine an influence on patient-reported outcomes.MethodsThis is a retrospective case-control study of prospectively recorded data on 2,120 primary anterior approach THA (1,815 patients). The diagnosis of iliopsoas tendinopathy was based on (1) persistent postoperative groin pain, triggered by hip flexion; (2) absence of dislocation, infection, loosening, or fracture; and (3) decrease of pain after fluoroscopy-guided iliopsoas tendon sheet injection with xylocaine and corticosteroid. Outcomes included hip reconstruction (inclination/anteversion and leg-length), complication rates, reoperation rates, and patient-reported outcomes including Hip disability and Osteoarthritis Outcome Score.ResultsForty four patients (46 THAs) (2.2%) were diagnosed with iliopsoas tendinopathy. They were younger than patients who did not have iliopsoas tendinopathy (51 years [range, 27-76] versus 62 years [range, 20-90]; P < .001). Logistic regression analyses demonstrated that younger age (P < .001) and presence of a spine fusion (P = .008) (odds ratio 4.6) were the significant predictors of iliopsoas tendinopathy. These patients had lower Hip disability and Osteoarthritis Outcome scores, reported more often low back pain (odds ratio 4.8), and greater trochanter pain (odds ratio 5.4).ConclusionWe found an incidence of 2.2% of iliopsoas tendinopathy patients after anterior approach THA that compromised outcomes. Younger age and previous spine fusion were identified as most important risk factors. These patients were 5 times more likely to report low back pain and greater trochanter pain post-THA.     

Guidelines for Implant Placement to Minimize Impingement During Activities of Daily Living After Total Hip Arthroplasty

Impingement, both prosthetic and bony, precedes the vast majority of dislocations after total hip arthroplasty and may adversely impact component wear. Reconstructed computer hip models of 8 subjects were used to evaluate hip range of motion for activities of daily living (ADLs) associated with posterior instability and anterior instability. Variables examined included acetabular position, femoral offset, and head size. The majority of flexion ADLs (associated with posterior instability) encountered prosthetic impingement, whereas extension ADLs demonstrated bony impingement with the 45/20 cup placement position. Cup placement in natural anteversion and adduction allowed normal joint motion in anterior and posterior impinging activities. Insufficient femoral offset and smaller head size negatively impacted range of motion. Any anterior cup and posterior cup protrusions greater than 5 mm should be avoided.     

Retroperitoneal Hematoma : An Unusual Cause of Pain After Total Hip Arthroplasty

Pain following total hip arthroplasty due to impingement of the iliopsoas is a recognized complication of the procedure with a reported incidence as high as 4.3%. The pain is most often due to direct mechanical irritation of the iliopsoas due to a malpositioned or oversized acetabular cup. Definitive treatment of iliopsoas impingement often requires surgical revision or iliopsoas tenotomy, although many cases remain undiagnosed or are managed conservatively. We present an unusual case of pain after total hip arthroplasty due to a large retroperitoneal hematoma secondary to acetabular cup irritation of the iliopsoas tendon. This case represents a potentially important complication of undiagnosed or conservatively managed iliopsoas impingement, particularly in patients taking anticoagulants or antiplatelet medications.     

Incidence and Risk Factors of Iliopsoas Tendinopathy After Total Hip Arthroplasty: A Radiographic Analysis of 1,602 Hips

BackgroundIliopsoas tendinopathy (IPT) can cause persistent groin pain and lead to dissatisfaction after total hip arthroplasty (THA). This study aimed to report the characteristics, incidences, risk factors, and treatment outcomes of IPT after THA.MethodsWe reviewed primary THAs performed at a single institution between January 2012 and May 2018. Clinical and radiographic analyses were performed on 1,602 THAs (1,370 patients). Patient characteristics, component sizes, inclination and anteversion angles, and antero-inferior cup prominence (≥8 millimeters (mm)), were compared between the groups with and without IPT. Changes in teardrop to lesser trochanter distance were measured to estimate changes in leg length and horizontal offset caused by THA. Logistic regression models were used to identify the risk factors for IPT. IPT was identified in 53 hips (3.3%).ResultsPatients with IPT had greater leg lengthening (12.3 versus 9.3 mm; P = .001) and higher prevalence of antero-inferior cup prominence (5.7 versus 0.4%; P = .002). There was no significant difference in inclination, anteversion, and horizontal offset change between the two groups. In multivariate analyses, greater leg lengthening, prominent acetabular cup, women, and higher body mass index were associated with IPT. All patients reported improvement in groin pain after arthroscopic tenotomy, while 35.7% with nonoperative management reported improvement (P < .001).ConclusionsSymptomatic IPT occurred in 53 (3.3%) of the 1,602 primary THAs. Our findings suggest that leg lengthening as well as prominent acetabular cup in THAs can be associated with the development of IPT. Arthroscopic tenotomy was effective in relieving groin pain caused by IPT.     

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

Background

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

Iliopsoas Tendonitis Caused by Overhang of a Collared Femoral Prosthesis

Pain after total hip arthroplasty can be due to a variety of causes, one of the less common being iliopsoas tendonitis. We report an unusual case of iliopsoas tendonitis caused by overhang of the femoral calcar by a collared femoral prosthesis resulting in impingement on the iliopsoas tendon. An ultrasound-guided corticosteroid and local anesthetic diagnostic injection to the site of impingement confirmed the diagnosis with temporary symptom relief. Revision of the femoral stem to a collarless prosthesis resulted in immediate and complete resolution of symptoms.     

Prevention of Dislocation After Total Hip Arthroplasty

Background

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BackgroundThere has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.MethodsThe PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .ResultsAfter propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.ConclusionPatients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.     

Hematoma Following Primary Total Hip Arthroplasty: A Grave Complication

Hematoma following primary total hip arthroplasty (THA) can require a return to the operating room. The purpose of this study was to uncover risk factors for hematoma and how it affects the outcome of THA. This case–control study identified 38 patients requiring reoperation due to hematoma following THA between 2000 and 2007. The 38 patients were matched with 117 patients without hematoma. The mean follow-up was 4.1 years (range, 2.1–9.6). Multivariate regression showed that blood loss, administration of fresh frozen plasma and Vitamin K, perioperative anticoagulation and hormonal therapy were independent predictors for hematoma formation. Chronic anticoagulation and autologous blood transfusion were independent risk factors for mortality. Hematoma itself was found to be an independent risk factor for adverse outcomes, increasing morbidity and mortality, despite adequate treatment.     

Complications After Revision Total Hip Arthroplasty in the Medicare Population

Background

The purpose of this study was to identify the incidence and types of complications after revision total hip arthroplasty (THA) within the first year, and determine the relative risk factors for these complications and of re-revision.

Chronic Expanding Hematoma of the Lateral Thigh and Massive Bony Destruction After a Failed Total Hip Arthroplasty

Pseudotumors have been described around both stable and failed total hip arthroplasties. The causes are varied and include polyethylene debris and masses associated with metal-on-metal bearings. We present a patient with a massive tumor of the thigh that grossly and pathologically was associated with recurrent bleeding and extensive bony destruction. The characteristics of this tumor most resemble those of a chronic expanding hematoma. To our knowledge, this has not previously been reported in association with a total hip arthroplasty.     

Sexual Activity After Total Hip Arthroplasty: A Motion Capture Study

Relative risk of impingement and joint instability during sexual activities after total hip arthroplasty (THA) has never been objectively investigated. Hip range of motion necessary to perform sexual positions is unknown. A motion capture study with two volunteers was performed. 12 common sexual positions were captured and relevant hip joint kinematics calculated. The recorded data were applied to prosthetic hip 3D models to evaluate impingement and joint instability during motion. To explore the effect of acetabular component positioning, nine acetabular cup positions were tested. Four sexual positions for women requiring intensive flexion (> 95°) caused prosthetic impingements (associated with posterior instability) at 6 cup positions. Bony impingements (associated with anterior instability) occurred during one sexual position for men requiring high degree of external rotation (> 40°) combined with extension and adduction at all cup positions. This study hence indicates that some sexual positions could be potentially at risk after THA, particularly for women.     

Total Hip Arthroplasty After Failed Internal Fixation of Proximal Femoral Fractures

Between February 1987 and October 2008, we performed 102 total hip arthroplasties (THAs) after failed internal fixation of a prior hip fracture. There were 39 intertrochanteric fractures and 63 femoral neck fractures. Etiology of failure included 35 cases of osteonecrosis, 32 cases of arthritis, 25 cases of early failure of fixation, and 10 cases of nonunion. There were 12 patients who had early surgical complications related to the procedure (11.8%, 12/102). These included 5 patients who had dislocations (4.9%), 4 periprosthetic fractures (3.9%), 2 hematomas (2.0%), and 1 infection (1%). Of these 102 THAs, 50 were available for at least 2 years of follow-up (mean, 3.2 years). At a minimum 2-year follow-up, THA after failed internal fixation of hip fracture in these patients was clinically successful with an elevated risk of periprosthetic fracture and dislocation.     

Oversized Cups as a Major Risk Factor of Postoperative Pain After Total Hip Arthroplasty

After total hip arthroplasty (THA) some patients have persistent postoperative pain (POP). Some of these POP are anterior and are caused by an anterior iliopsoas impingement (AIPI). We have hypothesized that oversized implanted cups could be responsible for POP and especially AIPI. We screened 237 patients who had a primary THA and compared the size difference (ΔS) between the native femoral head and the implanted cup, in patients with and without POP. Median ΔS was 2 mm [− 6; 11 mm] and patients with POP had a significantly increased ΔS (P < 0.0001). The threshold above which pain was significantly more frequent was ΔS ≥ 6 mm. Odds ratio was 14.4 for POP and 26 for AIPI pain when ΔS ≥ 6 mm.     

Etiology and Complications of Early Aseptic Revision Total Hip Arthroplasty Within 90 Days

BackgroundThe etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.MethodsA national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.ResultsFour hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).ConclusionEarly aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.Level of EvidenceLevel III.