Pitfalls in the use of acetabular reinforcement rings in total hip revision

Artificial intelligence planning and 3D printing augmented modules in the treatment of a complicated hip joint revision: a case report

Total hip revision with osseous defects can be very difficult. Artificial intelligence offers preoperative planning, real-time measurement, and intraoperative judgment, which can guide prothesis placement more accurately. Three-dimensional printed metel augment modules which are made according to the individualized osseous anatomy, can fit the osseous defects well and provide mechanical support. In this case, we used AI to plan the size and position of the acetabular cup and 3D-printed augmented modules in a complicated hip revision with an acetabular bone defects, which achieved stable fixation and relieved hip pain postoperatively.

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

BACKGROUND

Iliopsoas 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.

METHODS

We 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%).

RESULTS

Patients 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).

CONCLUSIONS

Symptomatic 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.

Outside-in arthroscopic psoas release for anterior iliopsoas impingement after primary total hip arthroplasty

PURPOSE

1 of the causes of groin pain after total hip arthroplasty (THA) is impingement of the iliopsoas tendon. The purpose of this study was to present our results with outside-in arthroscopic tenotomy for iliopsoas impingement after THA.

METHODS

We retrospectively reviewed 12 patients treated between 2009 and 2016 with a minimum follow-up of 2 years. Anterior acetabular component prominence was measured on a true lateral hip radiograph. A transcapsular tenotomy was performed near the edge of the acetabular component through an outside-in arthroscopic approach. The primary clinical outcomes evaluated were groin pain, assessed with a visual analogue scale (VAS), and the Harris Hip Score (HHS). Secondary outcomes included strength of hip flexion, measured with the Medical Research Council (MRC) scale.

RESULTS

All patients had groin pain improvement, though one patient continued to have moderate pain. The mean VAS score was significantly lower postoperatively (1.08) than preoperatively (6.2) (p < 0.001). The mean HHS improved from 58.8 (range, 37-76) to 86.1 (range, 59-98) (p = 0.001). The average postoperative MRC Scale was 4.58. The mean anterior prominence was 7.25 mm (range 3-12 mm). In patients with <10 mm of component prominence, tenotomy provided groin pain resolution in all cases (n = 8). In patients with ⩾10 mm of prominence, symptoms resolved in 3 out of 4 cases.

CONCLUSIONS

Outside-in arthroscopic iliopsoas release provided a high rate of success with no complications in this study, even in patients with moderate acetabular component prominence.

Delayed Presentation of Sciatic Nerve Injury after Total Hip Arthroplasty: Neurosurgical Considerations, Diagnosis, and Management

Background

 Total hip arthroplasty (THA) is an established treatment for end-stage arthritis, congenital deformity, and trauma with good long-term clinical and functional outcomes. Delayed sciatic nerve injury is a rare complication after THA that requires prompt diagnosis and management.

Methods

 We present a case of sciatic nerve motor and sensory deficit in a 52-year-old patient 2 years after index left THA. Electromyography (EMG) results and imaging with radiographs and CT of the affected hip demonstrated an aberrant acetabular cup screw in the posterior-inferior quadrant adjacent to the sciatic nerve.

Case Description

 The patient underwent surgical exploration that revealed injury to the peroneal division of the sciatic nerve due to direct injury from screw impingement. A literature review identified 11 patients with late-onset neuropathy after THA. Ten patients underwent surgical exploration and pain often resolved after surgery with 56% of patients recovering sensory function and 25% experiencing full recovery of motor function.

Conclusions

 Delayed neuropathy of the sciatic nerve is a rare complication after THA that is most often due to hardware irritation, component failure, or wear-related pseudotumor formation. Operative intervention is often pursued to explore and directly visualize the nerve with limited results in the literature showing modest relief of pain and sensory symptoms and poor restoration of motor function.

Arthroscopic treatment of iliopsoas impingement (IPI) after total hip replacement

PURPOSE

The purpose of the study was to present our arthroscopic surgical technique and the results in patient with an iliopsoas impingement (IPI) syndrome after a hip replacement.

MATERIALS AND METHODS

Between 1999 and 2011, 35 patients with the clinical picture of an IPI after total hip replacement were diagnosed and treated arthroscopically. The age was ranged from 58 to 82 years. All patients underwent conservative treatment for at least 6 months without success. The indication for the arthroscopic procedure was the failure of the conservative therapy as well as typical clinical signs as painful hip flexion, a positive local anesthesia test and radiological evidence of the presence of a prominent anterior acetabular component. The arthroscopic treatment was performed in all patients with anterior capsulotomy and partial capsulectomy of the hip joint. After identification of the pathology an arthroscopic release of the iliopsoas tendon in the region of the proved lesion was performed. The average follow-up period was 3.6 years (6 months to 12 years).

RESULTS

In all patients osseous integrated acetabular components were found. In six cases there was a surface replacement, in three cases it was a cementless screw-in cup and in the other three cases it was a cementless modular press-fit cup. 8 out of 12 patients suffered from a hip dysplasia with a secondary osteoarthritis. After establishing an anterior capsular window arthroscopically, the iliopsoas tendon could be visualized in all cases. In addition to multiple local tendinitis all patients already showed mechanical limitation with partial rupture of variable extent in the iliopsoas tendon. During the arthroscopy the lesion was detected at the level of the anterior prominent acetabular component as well as distal to it. 10 out of 12 patients reported immediately after postoperative mobilization that the typical preoperative complaints have disappeared. Two patients still had residual pain. In one of those patients this was relieved by the time of the follow-up examination. Clinically a temporary weakness of hip flexion in the first days of the postoperative period was detected. In the first follow-up 6 weeks later there was no evidence of weakness in any of the patients.

CONCLUSION AND CLINICAL RELEVANCE

An arthroscopic release of the iliopsoas tendon with evidence of iliopsoas impingement after total hip replacement gives predictably good results. A clinically relevant weakness of hip flexion is not expected after the procedure.

Iliopsoas impingement: a report of 2 cases

Iliopsoas impingement is an under recognized cause of failed total hip arthroplasty. We report 2 cases of iliopsoas impingement resolution diagnosed with the aid of imaging techniques and fluoroscopically guided injection.

The role of ultrasound in the assessment of post-operative complications following hip arthroplasty

Hip arthroplasty is one of the most commonly performed orthopedic procedures. Clinicians can be faced with the diagnostic dilemma of the patient presenting with a painful hip following arthroplasty and satisfactory post-operative radiographs. Identifying the cause of symptoms can be challenging and ultrasound is increasingly being utilized in the evaluation of potential soft tissue complications following hip surgery. In this article, we describe the common surgical approaches used during hip arthroplasty as this can influence the nature and location of subsequent complications. A review of the literature is presented along with the imaging appearances frequently encountered when imaging this patient population.

Technique and results of endoscopic tenotomy in iliopsoas muscle tendinopathy secondary to total hip replacement: a series of 10 cases

INTRODUCTION

There have been numerous recommendations for management of iliopsoas tendinopathy secondary to hip replacement: medical treatment, cup replacement, and open or arthroscopic tenotomy.

MATERIAL AND METHOD

We report on a series of 10 endoscopic iliopsoas tenotomies. Arthroplasty comprised five primary conventional total prostheses, two large head diameter metal-metal models, one resurfacing and one revision arthroplasty. All patients underwent clinical (PMA, WOMAC), imaging (X-ray, CT, scintigraphy) and biological assessment. Seven cases showed mechanical impingement (six involving the anterior edge of the cup, and one a cement fragment); the other three involved large femoral components (two large head diameter models, one resurfacing). Infiltration test was positive in eight cases out of nine. Endoscopic iliopsoas tenotomy for recurrence was performed in dorsal decubitus on an ordinary table, under fluoroscopy, using two approaches (inferior for the endoscope, superior for the instruments) converging on the lesser trochanter.

DISCUSSION

There were no complications. At a mean 20 months' follow-up (range, 12-60 months), mean pain grade was 5.5 (4-6). Eight patients showed complete relief, and two partial relief (two atypical cases). Mean PMA score was 16.9 (15-18) and mean WOMAC score 84 (60-95). Muscle force was recovered at a mean 3.25 months (0.5-6). Eight patients were very satisfied, one satisfied and one moderately satisfied.

CONCLUSION

This technique is much less heavy than implant replacement; postoperative course is shorter than for open tenotomy and the technique is simpler than arthroscopic tenotomy, with lower risk. Subsequent cup change, where necessary, is not compromised.

LEVEL OF EVIDENCE

IV, retrospective, case series.

Groin pain after replacement of the hip

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.

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.

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.

Oversized acetabular socket causing groin pain after total hip arthroplasty

The causes of groin pain after total hip arthroplasty are numerous, and the condition itself is disabling. Therefore, it is imperative that the cause of the pain is identified and managed appropriately. We report a case where the patient had groin pain after total hip arthroplasty as a result of an oversized cementless acetabular component, which caused a breach in the anterior wall of the acetabulum. The anterior wall of the acetabulum was reconstructed with femoral head allograft, and the patient has been symptom free since.

Anterior iliopsoas impingement and tendinitis after total hip arthroplasty

Anterior iliopsoas impingement and tendinitis is a poorly understood and likely underrecognized cause of groin pain and functional disability after total hip arthroplasty. The patient history and physical examination findings are usually only suggestive, and the symptoms frequently subtle. The diagnosis may be confirmed by one or more imaging studies, including a cross-table lateral radiograph, computed tomography, magnetic resonance imaging, and ultrasonography, in combination with a confirmatory diagnostic injection. Nonsurgical management may not resolve the problem. Surgical treatment, consisting of release or resection of the iliopsoas tendon, alone or in combination with acetabular revision for an anterior overhanging component, usually provides permanent pain relief.

Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision

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.

Sciatic neuropathy: case report and discussion of the literature on postoperative sciatic neuropathy and sciatic nerve tumors

Sciatic nerve injury and dysfunction is not an uncommon cause of lower extremity symptoms in a musculoskeletal practice. We present the case of a man who presented with lower extremity weakness, pain, and cramps, and was initially diagnosed at an outside institution with bilateral S1 radiculopathies and recommended for spine surgery. He came to us for a second opinion. Electrodiagnostic testing revealed an isolated sciatic neuropathy and the patient was referred for imaging, which showed a sciatic nerve sheath tumor. Review of the literature on sciatic neuropathies shows that there can be many possible etiologies of sciatic nerve dysfunction, but that hip arthroplasty continues to be the leading risk factor. Sciatic nerve tumors are not commonly described in the literature and their definitive management remains unclear.