Review Question - QID 219797

THA Iliopsoas Impingement Treatment Operative QID: 219797 (SBQ24HK.16)

QID 219797 (Type "219797" in App Search)

A 69-year-old woman presents to the clinic for a second opinion 18 months after a routine primary total hip arthroplasty performed through a posterior approach. She endorses pain in the front of the hip that is worse with ascending stairs and when getting up from the couch after sitting for more than 30 minutes. She denies any feelings of instability, any history of dislocation, as well as any history of fevers, chills, or redness and fullness about the hip. Radiographs taken in the clinic demonstrate the finding demarcated in Figure A, and a subsequent CT scan confirms the radiographic findings. She is referred to radiology for an image-guided iliopsoas tendon injection which alleviates all of her pain for 8 weeks. If she returns to the clinic with a recurrence of her pain, which of the following treatments is most likely to alleviate her symptoms permanently?

Type & Select Correct Answer

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Acetabular component revision

50%

329/656

Arthroscopic iliopsoas tendon release

41%

271/656

Liner exchange with placement of a lipped liner

18/656

Repeat intra-tendinous steroid injection

3/656

Revision of both components to correct combined anteversion

31/656

Select Answer to see Preferred Response

The patient has iliopsoas impingement due to excessive acetabular component overhang, which is best definitively managed by acetabular component revision (answer choice 1)

Iliopsoas Impingement is an under-recognized cause of recurrent groin pain after total hip arthroplasty that may be caused by a malpositioned acetabular component that excessively overhangs the anterior acetabulum. The diagnosis is suggested clinically by anterior groin pain with resisted seated hip flexion or straight leg raise and typically presents within 20 months of the index total hip arthroplasty. A corticosteroid injection into the iliopsoas sheath is both diagnostic and therapeutic; however, in the setting of recurrent pain, additional treatments may be necessary. In the setting of a normal cup version and positioning, an arthroscopic iliopsoas tenotomy can be therapeutic. In the setting of a malpositioned cup, revision of the acetabular component is often indicated to correct the causative excessive anterior overhang.

Bozic et al. reviewed the painful total hip replacement. The authors note that the evaluation and treatment of the painful total hip replacement is one of the most difficult challenges for the arthroplasty surgeon. They conclude that, despite this, with a careful and thorough evaluation, the cause of the painful total hip replacement can be determined in most patients, and the appropriate treatment can be initiated.

Lachiewicz et al. reviewed anterior iliopsoas impingement and tendinitis after total hip arthroplasty. The authors note that while anterior iliopsoas impingement and tendinitis is a poorly understood and likely under-recognized cause of groin pain and functional disability after total hip arthroplasty, non-surgical management may not resolve the problem. Surgical treatment, consisting of release or resection of the iliopsoas tendon, alone or combined with acetabular revision for an anterior overhanging component, usually provides permanent pain relief.

Figure A is a cross-table lateral radiograph demonstrating an anteverted acetabular cup with anterior overhang that overlies the anterior acetabulum.

Incorrect Answers:
Answer 2: Given cup malpositioning, tendon release alone is not the best definitive treatment.
Answers 3: A lipped liner may exacerbate the problem, and is not indicated as a treatment for iliopsoas impingement.
Answer 4: Repeat injection is not a definitive treatment strategy for recurrent symptoms.
Answer 5: There is no indication in the stem that the femoral component is excessively anteverted.