Updated: 7/29/2021

THA Iliopsoas Impingement

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  • Summary
    • THA Iliopsoas Impingement is an under recognized cause of recurrent groin pain after total hip replacement which may be caused by a malpositioned acetabular component.
    • Diagnosis may be suspected clinically with pain with resisted seated hip flexion or straight leg raise and the presence of anterior cup overhang on CT. Diagnostic cortisone injection into iliopsoas sheath is helpful in diagnosis.
    • Treatment is generally arthroscopic iliopsoas tenotomy in the setting of normal cup position. Revision of the acetabulum component may be indicated in cases of excessive anterior overhang.
  • Etiology
    • May be caused by
      • retained cement
      • malpositioned acetabular component
      • limb length discrepancy
      • excessive length of screws
  • Anatomy
    • Illiopsoas 
  • Presentation
    • Symptoms
      • groin pain
    • Physical Exam
      • findings are subtle and may include
        • slight limp
        • tenderness in the groin.
        • palpable snap may be detected (rare)
      • provocative tests
        • pain may be reproduced or exacerbated by resisted seated hip flexion or straight leg raise
  • Imaging
    • Radiographs
      • required views
        • AP pelvis
        • AP and lateral of hip
    • CT scan
      • helpful to determine postition of prosthesis and rule out other caused of symtpoms
    • MRI
      • usually not valuable due to artifact.
  • Studies
    • Diagnostic injection
      • diagnostic cortisone injection into iliopsoas sheath is helpful in diagnosis
  • Treatment
    • Nonoperative
      • observation
        • indications
          • rare
            • most patients require operative intervention for complete resolution of symptoms
    • Operative
      • arthroscopic iliopsoas tenotomy
        • indications
          • in cases of normal post-op radiographs
      • acetabular component revision
        • indications
          • in cases of excessive anterior cup overhang
  • Technique

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Flashcards (3)
Cards
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Questions (6)

(SBQ16HK.13) A 62-year-old man undergoes total hip arthroplasty 6 months ago. He is now presenting with groin pain, which is exacerbated when he is going up the stairs, but not down the stairs. He has pain and significant weakness with resisted hip flexion. He is afebrile and laboratory markers are unrevealing for infection. His recent radiographs are depicted in Figures A and B. Which of the structures depicted in the representative image in Figure C (labeled 1-5) is responsible for his pain?

QID: 211251
FIGURES:
1

1

64%

(1000/1558)

2

2

16%

(253/1558)

3

3

6%

(87/1558)

4

4

5%

(84/1558)

5

5

8%

(121/1558)

L 3 A

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(OBQ12.234) A 67-year-old female complains of anterior groin pain one year following a primary, uncemented total hip arthroplasty. The pain is exacerbated when she tries to climb stairs or get up from a seated position. She denies any recent fevers or chills. On physical exam, the pain is reproduced with resisted seated hip flexion. Laboratory analysis, including WBC, ESR, and CRP are within normal limits. Radiographs reveal that the components are appropriately positioned without evidence of loosening or fracture. Which of the following is the most appropriate at this time?

QID: 4594
1

Revision of the acetabular component

1%

(28/3985)

2

Image-guided diagnostic injection of lidocaine into the iliopsoas tendon sheath

77%

(3067/3985)

3

Hip aspiration

4%

(140/3985)

4

Bone scan

5%

(204/3985)

5

Conservative management including activity modifications, NSAIDs, and physical therapy

13%

(523/3985)

L 3 C

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(OBQ11.167) A 62-year-old female has persistent activity related anterior groin pain 10 months after total hip arthroplasty (THA). Infection workup is negative. New radiographs are unchanged compared to the intial films provided in Figures A and B. Pain is temporarily relieved following an injection of lidocaine and cortisone into the iliopsoas tendon sheath. What is the next appropriate treatment option?

QID: 3590
FIGURES:
1

Indefinite activity modification

2%

(75/3489)

2

Iliopsoas tendon release

75%

(2620/3489)

3

Femoral component revision

6%

(226/3489)

4

Acetabular component revision

15%

(509/3489)

5

Femoral and acetabular component revision

1%

(40/3489)

L 2 C

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(OBQ10.191) A 65-year-old male complains of continued groin pain 18 months following total hip arthroplasty. The pain is worse with activity, specifically with hip extension during gait. Hip radiographs show no fracture or loosening of the components. Lab values including ESR and CRP are within normal limits, and a hip aspiration yields a nucleated cell count of 500 and no growth on culture. Which of the following is most likely to determine the nature of the continued pain?

QID: 3283
1

Greater trochanteric bursa injection

2%

(56/3259)

2

Repeat aspiration of the hip joint

1%

(39/3259)

3

Local anesthetic injection of the iliopsoas tendon sheath

90%

(2946/3259)

4

Ober test on physical exam

4%

(140/3259)

5

Radiographs of the knee

2%

(68/3259)

L 1 C

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