Stress fracture of the medial wall of the acetabulum adjacent to a cementless acetabular component.

There are numerous potential causes of hip pain after total hip arthroplasty other than loosening or infection. A case is described that is consistent with stress fracture of the medial wall of the acetabulum after cementless acetabular revision. The clinical presentation, diagnosis, and treatment are described. This is an uncommon cause for localized groin pain after total hip arthroplasty, which should be considered particularly in an elderly woman with a relatively acute onset of symptoms after an increase in activity level.     

Iliopsoas tendinitis after total hip arthroplasty

Determination of the cause of groin pain after total hip arthroplasty can be difficult. The case of a patient with an unusual cause of groin pain after total hip arthroplasty, iliopsoas tendinitis, is presented. The patient failed nonoperative treatment and underwent surgical release of the iliopsoas tendon with complete resolution of symptoms.     

Impingement of the iliopsoas muscle after revision of a loosened acetabular cup with an acetabular reinforcement ring

Impingement of the iliopsoas muscle due to a protruding acetabular component is an uncommon cause of pain after total hip arthroplasty. We report the case of a 59 year old female patient who developed groin pain one year after revision arthroplasty and reconstruction of the acteabular defect with an acetabular reinforcement ring due to a loosened cup. THERAPY AND FOLLOW UP: After revision of the right hip via an anterior approach we used bone cement to smooth the anterior edge of the acetabular reconstruction ring and created a smooth rim for the iliopsoas tendon. At follow up 2 years later the patient was satisfied with the result, she complained about very rare recurrent groin pain, without any need for further treatment.     

Migration of intrapelvic cement after total hip arthroplasty

Intrapelvic extrusion of cement during total hip arthroplasty is a frequent occurrence. We report a case in which the intrapelvic cement mass broke free 3 years after the primary procedure and migrated proximally to lie against the posterior abdominal wall, resulting in intractable groin pain. The patient was relieved of pain after removal of the cement mass.     

Recurrent Hematomas Within the Iliopsoas Muscle Caused by Impingement After Total Hip Arthroplasty

Impingement of the iliopsoas muscle after total hip arthroplasty is a potential cause of postoperative groin pain. In addition, hematoma within the iliopsoas sheath has been documented as a cause of groin pain in patients on long-term anticoagulation. We present the case of a patient on long-term anticoagulation presenting after total hip arthroplasty with recurrent, symptomatic iliopsoas sheath hematomas. We believe this was due to iliopsoas impingement caused by a malpositioned acetabular component. His pain was relieved after revision of the acetabular component and debridement of the inflamed psoas tendon.     

Psoas impingement syndrome in hip osteoarthritis

The degenerative processes underlying osteoarthritis of the hip produce both anatomical and biomechanical changes in and around the involved joint. A good understanding of hip anatomy and the forces crossing the hip joint is essential to understand both hip pathology and current treatment techniques. Total hip arthroplasty (THA) has become a mainstay of treatment for advanced osteoarthritis of the hip. Several factors contribute to post-operative hip pain in THA patients. Iliopsoas impingement on the prosthetic cup after total hip replacement is one of the causes of pain following hip surgery, often due to an anterior overlap of the implant with respect to the acetabulum. The anatomic shape of the anterior acetabular ridge, which may be straight or curved, influences this overlap. In this paper we present a case illustrating a psoas impingement-like syndrome in a patient with severe hip osteoarthritis who has not undergone hip replacement surgery. We discuss the compensatory strategies employed by the patient to reduce pain and prevent falls, and show CT scan images depicting the underlying anatomic pathology.     

Wound Drainage After Metal-On-Metal Hip Arthroplasty Secondary to Presumed Delayed Hypersensitivity Reaction

An emerging concern with metal-on-metal total hip arthroplasty is metal-induced hypersensitivity. Currently, this is a diagnosis of exclusion in patients with groin pain after metal-on-metal total hip arthroplasty. We describe a patient presenting nearly a year after arthroplasty with incisional drainage. Infection was presumed; but preoperative studies were nondefinitive, and the wound was explored. The operative cultures were negative; the histology revealed lymphocytic vasculitis. The patient recovered uneventfully after exchange to a metal polyethylene bearing couple. We believe that metal-induced hypersensitivity should be considered with draining wounds with this bearing couple if infection cannot be proven.     

Editorial Commentary: The Cause of Groin Pain Is Difficult to Determine: The Elusive “Nether-Nether Region”

As one of the many causes of groin pain, iliopsoas tendinitis can be hard to identify and even harder to treat. It occurs in the setting of both the native hip joint and following total hip arthroplasty. Internal snapping, or coxa saltans, can result from the iliopsoas snapping over the anterior hip capsule or iliopectineal eminence and can be a source of labral pathology. The snapping can be painful or painless. Iliopsoas impingement over total hip components either from the cup or collar of a femoral stem are causes of anterior groin pain. However, there are multiple other causes of groin pain, both intra- and extra-articular, that can make finding the source of the pain difficult. Referred pain from the spine, gynecologic, and gastrointestinal systems can all cause pain in the groin. Core muscle injuries and athletic pubalgia can all cause groin pain and frequently mimic intra-articular hip pathology or iliopsoas tendinopathy. Ultrasound-guided diagnostic injection into the iliopsoas bursa or the juxtaposed hip joint (intra-articular injection) can be helpful in differentiating the source of the pain. Combining a clear history, detailed physical, basic and advanced imaging, as well as diagnostic injection is essential in diagnosing this elusive entity and guiding appropriate treatment.     

全髋关节置换术治疗晚期髋臼发育不良

目的探讨全髋关节置换术治疗晚期髋臼发育不良致髋关节骨关节炎时人工髋臼的安放方法。方法对2002年1月至2008年1月因髋臼发育不良导致骨关节炎行全髋关节置换术的病例进行随访,有52例(60髋)获得随访。其中男6例,女46例;年龄46~72岁,平均62岁;双髋8例,单髋44例。主要症状为疼痛及跛行。在行人工全髋置换术时,根据髋臼发育不良的程度,采用了加深髋臼、髋臼内陷及髋臼外上缘植骨等三种方法。术后随访应用H arris评分进行髋关节功能评价,术后第3、6、9、12个月及以后每1年以同等条件投照双髋关节正位X线片,观察髋臼假体与髋臼骨床愈合的情况。随访2~8年,平均4年6个月。结果加深髋臼和髋臼内陷的病例,髋臼假体与髋臼骨床接触良好,无松动,关节功能恢复优良。而髋臼外上缘植骨的6髋中有5髋,术后2年时植骨块与髋臼假体间出现透亮带,但髋臼假体无松动。结论髋臼发育不良导致髋关节骨关节炎的病例在施行人工关节置换术时应根据髋臼骨床的情况采用不同的手术方式安放人工髋臼。在髋臼底部骨质较多的情况下,应采用加深髋臼的方法。加深髋臼后仍有少量髋臼假体外露时可采用髋臼内陷安放人工髋臼。髋臼外上缘结构植骨的患者仍需长期随访观察。     

Conversion of hemiarthroplasty to total hip arthroplasty: Can groin pain be eliminated?

In this study 45 patients with groin or buttock pain after hemiarthroplasty were evaluated 2 to 7 years after conversion to total hip arthroplasty. Groin or buttock pain was completely relieved in 36 patients (80%) and partially relieved in an additional 4 patients (9%). After conversion surgery, 9 patients continued to have groin or buttock pain, but no factor could be identified that would predict an unsuccessful result. The hypothesis tested in this study was whether conversion of a hemiarthroplasty to a total hip arthroplasty eliminates groin pain. Because a significant number of patients (up to 20%) will continue to have some groin or buttock pain after conversion surgery, patients should be warned of this contingency before surgery.     

Intraoperative dislocation of the prosthetic femoral head into the pelvis during total hip arthroplasty

An 86-year-old woman with severe osteoarthritis and severe pain in her left hip underwent total hip arthroplasty. Intraoperatively, the 22 mm femoral head impinged on the anterior rim of the acetabulum during a reduction maneuver, and disengagement of the femoral head from the neck occurred with migration of the head over the pelvic brim along the inner table of the pelvis. This complication related with hip arthroplasty is underestimated by many orthopaedic surgeons.     

Bipolar versus total hip arthroplasty for hip osteonecrosis in the same patient

The authors studied 28 patients with bilateral avascular necrosis of the femoral head who were treated with a cementless bipolar endoprosthesis in one hip and cementless total hip arthroplasty in the other. All the hips selected for bipolar endoprostheses were classified as having avascular necrosis of the femoral head Ficat Stage III, and all the hips selected for total hip arthroplasty were classified as having Ficat Stage IV avascular necrosis. After a midterm followup of an average of 6.4 years (range, 4-12 years), 24 of 28 hips that received bipolar endoprostheses were considered satisfactory, whereas 23 of 28 hips in which an arthroplasty was done were considered satisfactory. After a followup of more than 6 years, the cartilaginous space of the acetabulum could be preserved in 25 hips (89.3%) that received a bipolar endoprosthesis. There were no statistical differences in both groups in terms of clinical result, thigh pain, groin pain, osteolysis, dislocation, and revision rate. Total hip arthroplasty is not the preferred treatment for all patients with hip osteonecrosis. In young patients with Ficat Stage III osteonecrosis with Grade 0 or Grade I cartilage, the use of a cementless bipolar endoprosthesis with a bone ingrowth stem may be considered as an alternative to total hip arthroplasty.     

Iliopsoas tendonitis a complication after total hip arthroplasty

The causes of pain after total hip arthroplasty are multiple. We present a series of 15 patients (16 cases) who presented with pain related to the iliopsoas tendon. All patients had previously undergone cementless hip arthroplasty and presented with similar symptoms and clinical signs. Surgery was carried out after failure of conservative measures. Release of the iliopsoas tendon from the lesser trochanter gave good symptomatic relief in all except one patient who required reposition of acetabular prosthesis, with the average Harris Hip Score improving from 58 (range, 44-70) to 91 (range, 78-95) postoperatively. This relatively uncommon condition should be considered in the differential diagnosis of all patients who present with groin pain after total hip arthroplasty. Surgical release of the iliopsoas tendon can give excellent results in these patients.     

Failure of larger-diameter metal-on-metal total hip arthroplasty resulting from anterior iliopsoas impingement

Anterior iliopsoas impingement is a recognized cause of persistent groin pain after total hip arthroplasty. We report 3 patients with failed total hip arthroplasties resulting from anterior iliopsoas and capsular impingement secondary to a metal femoral ball with a diameter larger than the native femoral head. All patients had the same implant design. Resolution of symptoms occurred in all patients after revision surgery. To our knowledge, this is the first report of this potential failure mechanism with these large-diameter implant designs and should be considered in the appropriate clinical scenario.     

Iliopsoas cyst causing persistent pain after total hip arthroplasty

Persistent pain after total hip arthroplasty (THA) has many potential causes. The most common are aseptic loosening, infection, and heterotopic ossification. Irritation of the iliopsoas tendon due to the acetabular component is an underestimated cause of persistent groin pain and functional disability after THA with rare incidence. Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs). This article presents a case of a 50-year old man with clinical and radiological signs of osteoarthritis of the right hip joint. A THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve causing an iliopsoas tendonitis. The patient underwent surgical resection of the cyst was performed by an anterior approach; a conjunction to the hip joint was not present. The implanted components of the prosthesis showed good osseointegration with no signs of loosening. The cyst was removed and the iliopsoas tendon was released. A few weeks after the operation, the patient was pain free. At 17-month follow-up, no problems were reported. In cases such as this, finding the correct diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.     

Intrapelvic cyst formation after hip arthroplasty with a carbon fibre-reinforced polyethylene socket

Carbon fibre-reinforced polyethylene cups were inserted in total hip arthroplasties for both hips of a male patient. Ten years after the arthroplasty of the right hip, an intrapelvic cyst was observed. The cyst was connected to the inner acetabular wall. The endoprosthetic cup showed gross loosening with a marked osteolysis of the acetabulum. Revision arthroplasty with allograft bone and an uncemented endoprosthesis was successfully performed. The fibrotic tissue at the bone-cement interface showed numerous histiocytic cells with cytoplasmic infiltrates of carbon and polyethylene particles. The left hip was also later revised for loosening, but no cyst formation was observed on that side.     

Comparison between bipolar hemiarthroplasty and THA for osteonecrosis of the femoral head

It is controversial whether bipolar hemiarthroplasty or total hip arthroplasty should be done for Ficat Stage III osteonecrosis of the femoral head. A prospective comparative study was done using the same cementless femoral components for both procedures. Forty cementless bipolar hemiarthroplasties and 31 cementless total hip arthroplasties were done in 54 patients with Ficat Stage III osteonecrosis of the femoral head. Age, gender, and followup were matched between patients having bipolar hemiarthroplasty and total hip arthroplasty. Treatment with total hip arthroplasty increased the total hip score more than treatment with bipolar hemiarthroplasty. The final pain score especially showed a significant difference between patients who had a bipolar hemiarthroplasty (5.5) and patients who had a total hip arthroplasty (5.9). Thigh pain occurred in four patients (four hips) from the bipolar hemiarthroplasty group and in six patients (six hips) from the total hip arthroplasty group. In the bipolar hemiarthroplasty group, gluteal pain occurred in six patients (six hips, 15%) and groin pain occurred in eight patients (eight hips, 20%). Dislocation occurred in two hips (two patients) in each group. The outer head migrated superiorly in nine hips (nine patients) (23%) from the bipolar hemiarthroplasty group. Because of the incidence of gluteal and groin pain and migration, total hip arthroplasty is a better procedure than bipolar hemiarthroplasty for patients with Ficat Stage III osteonecrosis of the femoral head.     

Outcome of hemiresurfacing in osteonecrosis of the femoral head

Hemiresurfacing of the femoral head for treatment of osteonecrosis has been proposed as a reasonable alternative to total hip arthroplasty. The results of 59 patients with Ficat Stage III osteonecrosis done by a single surgeon are reviewed. At an average followup of 4.5 years, 16 patients were considered failures because of conversion to total hip arthroplasty or considerable groin pain requiring medication. Failure did not correlate with age, body mass index, preoperative length of symptoms, acetabular articular cartilage status at the time of surgery, or cause of the underlying disease. The only factor associated with failure was a lower preoperative Harris hip score. Conversion of the failed implants to total hip arthroplasty was straightforward, confirming the conservative nature of the procedure. However, pain relief and recovery after resurfacing are less reliable than that associated with total hip arthroplasty. This procedure may be appropriate for patients younger than 30 years, given the ease of conversion to THR if failure occurs. The patient should be counseled regarding expectations.     

Revision total hip arthroplasty performed through the Hueter interval

Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers some advantages in exposure of the acetabulum. This study presents a retrospectively reviewed consecutive series of fifty-one patients who underwent revision total hip arthroplasty through the anterior approach utilizing various extensions of this technique. The anatomic approach is discussed as well as problems as encountered in our series.     

Hip spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity.

BACKGROUND CONTEXT: Significant lumbar spinal stenosis and lower extremity arthritis may coexist in the elderly. This combination of lumbar stenosis with radiculopathy and lower extremity arthritis may lead to diagnostic uncertainty. PURPOSE: To describe the findings of hip spine syndrome, a constellation of symptoms with extensive overlap of radiculopathy and lower extremity arthritis. CONCLUSIONS: Evaluation of the patient with lower extremity pain in consideration for total joint arthroplasty should include functional inquiry of the spinal nerves. Diagnostic tests and injections may allow an informative weighting of the patient's symptoms, leading to a better understanding of the patient's pain syndrome. There is a group of patients who have a total hip arthroplasty and then develop or may continue to have pain of groin and buttock, secondary to sciatica of lumbar spinal stenosis. For the patient undergoing total hip arthroplasty with asymptomatic spinal stenosis, there may be increased neurological risk at surgery, related to the stenosis. The patient with both conditions may require surgical decompression of the lumbar stenosis as well as joint arthroplasty of the arthritic joint.