Endoscopic Tenotomy for Iliopsoas Tendinopathy Following Total Hip Arthroplasty Can Relieve Pain Regardless of Acetabular Cup Overhang or Anteversion

Acetabular revision for iliopsoas impingement: a study of 55 cases at 3 years of follow-up. Does the procedure achieve the Minimal Clinically Important Difference (MCID) in the Oxford-12 score in more than 80% of cases?

INTRODUCTION

Several surgical options can be offered to manage iliopsoas impingement. Research published on cup replacements often concerns a small population size or multicentre studies, suggesting a variety of indications. We conducted a retrospective single centre study screening according to a specific protocol of a population of patients who had a cup replacement for iliopsoas impingement. The objectives were: 1) to specify the functional outcomes and the achievement of the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) according to the Oxford-12 score, and 2) to assess the complication rate.

HYPOTHESIS

Our hypothesis was that acetabular replacements achieve a Minimal Clinically Important Difference (MCID) in more than 80% of cases.

PATIENTS AND METHODS

Fifty-five hips underwent acetabular revision between 2011 and 2020. Forty-three were performed as first-line surgery, eight after failed tenotomy and four after failed anterior hip capsule thickening plasty. A CT scan of all the hips revealed a median overhang of 9 mm (7; 12) and a 7 ° cup anteversion (2; 19). Follow-up included assessment of the Oxford-12 score using MCID and PASS, the Merle d'Aubigné score, an assessment of hip flexion muscle strength using the Medical Research Council scale, and an assessment of satisfaction and complications.

RESULTS

At a mean follow-up of 3 years (2-10), the difference in the Oxford score before and at follow-up was 18 points (15; 27) (p < 0.001), the median Medical Research Council score was 4.5 (4; 5) and patients were satisfied or very satisfied in 73% of cases (40/55). The MCID was achieved for 87% of the hips (48/55), and the PASS was achieved in 67% of cases (33/55). The rate of complications involving surgical revision was 10.9% (6/55) with respectively: two anterior dislocations, one early infection on day 10 resolved after wound irrigation and appropriate antibiotic therapy, one intraoperative fracture of the trochanter requiring osteosynthesis and one arthroscopic revision to remove a free cement fragment.

CONCLUSION

Due to a good functional outcome but a high complication rate, a cup replacement can be offered for iliopsoas impingement associated with acetabular malposition or significant overhang.

LEVEL OF EVIDENCE

IV.

Assessment of function and muscle strength after endoscopic iliopsoas tenotomy to treat iliopsoas impingement after total hip arthroplasty

PURPOSE

The objective of this study was to evaluate the functional outcome during follow-up (FU) after endoscopic tenotomy for iliopsoas (IP)-cup impingement and to quantitatively analyze the hip flexion strength.

METHODS

This was a monocentric, retrospective cohort study of a single surgeon series. Functional assessment was based on the modified Harris score, the Oxford score and the visual analog scale score. Strength was measured with a handheld dynamometer in the sitting and lying position.

RESULTS

Thirty-six IP tenotomies for cup impingement were performed between May 2013 and November 2021. Seven (19%) patients were lost to FU. At the time of tenotomy, the mean (standard deviation) age was 62,6 (12,2) and BMI was 26,5 (4,1). The mean FU time after tenotomy to the last FU was 3,6 (0,8) years. All three outcome scores improved from preoperatively to six months postoperatively (p < 0.001). There were no significant change from six months to last FU. The minimal clinically important difference (MCID) of the modified Harris score was set at 25. 20 (69%) patients had values that exceeded the threshold at one month and six months and neutral 19 (65.5%) had values that exceeded the threshold at the last FU. The limp symmetry index concerning hip flexion strength was 63% at 90° and 40% at 30° at the last FU.

CONCLUSION

Most patients significantly improved their outcome scores after endoscopic iliopsoas tenotomy, with results remaining consistently stable over time. Despite a significant loss in hip flexion strength, the majority of patients did not report any impairment of their quality of life.

STUDY DESIGN

Level III, Retrospective cohort study.

Arthroscopic and endoscopic techniques for iliopsoas release in THA are safe and effective: a systematic review of the literature

BACKGROUND

Hip replacement surgery is highly effective in relieving pain and improving mobility in patients with various hip conditions. However, some patients develop groin pain after surgery, often due to iliopsoas impingement (IPI), which can be challenging to diagnose. Conservative treatments are initially recommended, but when these are not effective, surgical options may be considered. This study aims to evaluate the clinical outcomes, success and failure rates, revision rates, and complications associated with arthroscopic and endoscopic surgery for IPI, thereby providing a comprehensive understanding of the effectiveness and risks of these surgical interventions.

MATERIALS AND METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including a thorough search of five main databases: PubMed, Scopus, Embase, Medline, and Cochrane. Eligible articles were meticulously evaluated according to predefined criteria for levels of evidence (LoE), with retrospective studies assessed using the Coleman Methodology Score (mCMS). This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO).

RESULTS

Among the 16 included studies, 431 patients with 434 hips underwent either endoscopic or arthroscopic tenotomy. Both techniques showed favorable outcomes, with arthroscopic tenotomy demonstrating slightly higher success rates than endoscopic tenotomy. Common complications included mild pain and occasional infections, with recurrence observed in some cases. Both techniques offer direct visualization of prosthetic components and potential preservation of psoas function.

CONCLUSIONS

Arthroscopic and endoscopic iliopsoas tenotomy are effective treatments for alleviating symptoms and improving hip function in patients with IPI post-total hip arthroplasty (THA).

LEVEL OF EVIDENCE

IV.

Arthroscopic Fractional Lengthening After Total Hip Arthroplasty Results in Improved Patient-Reported Outcomes and Low Rates of Revision Total Hip Arthroplasty

Purpose

To report the clinical outcomes and reoperation rates of arthroscopic and endoscopic iliopsoas release at short-term follow-up after ipsilateral total hip arthroplasty (THA) at 2 separate medical institutions and to evaluate whether demographic and radiographic parameters are associated with postoperative patient-reported outcomes (PROs).

Methods

Patients with iliopsoas tendinitis in the setting of prior THA who underwent arthroscopic iliopsoas fractional lengthening from 1988 to 2023 at 2 academic institutions were reviewed. Patients were included if they had 12 months of follow-up and underwent evaluation of preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score, Single Assessment Numeric Evaluation score, Tegner activity scale score, visual analog scale (VAS) score, and revision hip arthroplasty.

Results

Sixty hips in 58 patients (19 male and 39 female patients) were followed up for a mean of 39.3 months (range, 12.0-105.9 months) postoperatively. Of the patients, 77% reported feeling "much better" or "slightly better," 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. The surgery satisfaction rating was 7.2 ± 3.3 (scale of 0 to 10). The mean postoperative modified Harris Hip Score, VAS score for pain at rest, VAS score for pain with use, and Single Assessment Numeric Evaluation score were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9, respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and did not significantly correlate with postoperative PROs (P ≥ .45). The Tegner score improved from 2.5 ± 1.7 preoperatively to 2.9 ± 1.4 postoperatively (P = .0253). Three patients underwent revision arthroplasty at a mean of 25.3 months (range, 11.6-40.4 months) postoperatively, with an acetabular component revision rate of 3.3%.

Conclusions

Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening after THA. There was no statistically significant relation between anterior acetabular component overhang and final PROs.

Level of Evidence

Level IV, therapeutic case series.

Satisfactory mid-term clinical outcomes of endoscopic tenotomy for iliopsoas tendinopathy following total hip arthroplasty

PURPOSE

To report 5-year outcomes of endoscopic iliopsoas tenotomy in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether clinical scores are associated with cup position.

METHODS

Patients who underwent endoscopic iliopsoas tenotomy for iliopsoas tendinopathy following THA (2014-2017) were contacted. Indications for endoscopic iliopsoas tenotomy after THA were groin pain during active hip flexion, exclusion of other causes of groin pain, and no pain relief after 6 months of conservative treatment. Pretenotomy cup inclination and anteversion were measured on radiographs; axial and sagittal cup overhang were measured on computed tomography (CT) scans. Oxford hip score (OHS), modified Harris hip score (mHHS), and groin pain were assessed.

RESULTS

The initial cohort comprised 16 men (17 hips) and 31 women (32 hips), aged 60.7 ± 10.6 years. Cup inclination and anteversion were, respectively, 46.2 ± 6.2° and 14.6 ± 8.4°, while axial and sagittal cup overhang were, respectively, 4.4 ± 4.0 mm and 6.9 ± 4.5 mm. At ≥5 years follow-up, four hips underwent cup and stem revision, two underwent isolated cup revision and one underwent secondary iliopsoas tenotomy. OHS improved by 23 ± 10 and mHHS improved by 31 ± 16. Posttenotomy groin pain was slight in 20.0%, mild in 17.5% and moderate in 12.5%. Regression analyses revealed that net change in mHHS decreased with sagittal cup overhang (β = -3.1; 95% confidence interval [CI] = -4.6 to -1.7; p < 0.001), but that there were no associations between cup position and net change in OHS.

CONCLUSIONS

Endoscopic iliopsoas tenotomy provides good mid-term clinical outcomes in patients with iliopsoas tendinopathy following THA. Furthermore, improvements in mHHS were found to decrease with increasing sagittal cup overhang, in cases for which adequate preoperative imaging was available.

LEVEL OF EVIDENCE

Level IV.

Endoscopic Tendon Release for Iliopsoas Impingement After Total Hip Arthroplasty-Excellent Clinical Outcomes and Low Failure Rates at Short-Term Follow-Up

PURPOSE

To investigate the clinical effectiveness of endoscopic iliopsoas tendon release (IPR) at the lesser trochanter (LT) in patients with iliopsoas impingement (IPI) after total hip arthroplasty (THA).

METHODS

Between November 2017 and March 2021, a consecutive series of 36 patients were treated with endoscopic IPR for diagnosed IPI. Patients included had acetabular cup position confirmed by functional imaging (OPS, Corin, Pymble, NSW), typical clinical symptoms of IPI, and a positive response to diagnostic injection. Clinical assessment included validated patient-reported outcome measures (PROMs) along with hip flexion strength and active range of motion at different time marks up to 2-year follow-up, as well as surgical complications.

RESULTS

Overall, 36 consecutive patients (11 males) with a mean age of 62 ± 12 years were included. All patients had failed nonoperative management. Dynamic computed tomography assessment was available in 89% of the patients, edge loading was reported in 10%, and variable cup overhang was reported in 50%. Clinically, PROMs were significantly improved at every time mark when compared with preoperative values (P < .001), showing the biggest improvement within the first 4 weeks after surgery. At the 6-month follow-up, peak isometric hip flexion strength on the operated side was 20% lower than the contralateral side (P < .001). Failure rate of the procedure was 2.8% (1 case). Linear regression showed no association between cup overhang and clinical outcomes.

CONCLUSIONS

Endoscopic IPR at the LT is a safe and reproducible technique associated with significant and immediate improvement in pain, functional outcomes, and high patient satisfaction. With minimal short-term weakness, no complications, and only a single revision, even in cases with cup malposition and/or edge loading, we believe that endoscopic IPR can be considered as one of the first-line operative options in patients with symptomatic IPI, irrespective of component position.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: For Post-Hip Arthroplasty Iliopsoas Tendonitis, Psoas Tenotomy Is the Preferred First-Line Treatment, Even in Cases of Cup Overhang

Iliopsoas impingement pathology is one of the causes of persistent pain after total hip arthroplasty. It is reported as occurring in approximately 4% of cases; this may be significantly greater (in cases of postarthroplasty pain of unknown etiology). Inflammation is a result of impingement of the tendon against the acetabular component. This may occur with anteroinferior prominence when the cup is properly positioned in anteversion or when the cup is oversized. Other causes of impingement include a cup-reinforcement ring or acetabular cage, a collared femoral component, screws penetrating through the ilium, cement extrusion, anterior wall hypoplasia, or increased femoral offset. When conservative treatment does not achieve the best outcome, the 2 main therapeutic options are psoas tenotomy or revision of the cup component. Tenotomy can be performed either arthroscopically or by an open approach and may be considered the best option for many patients, even in cases with anterior component prominence, as it is less invasive, presents fewer complications, and has faster recovery. The debate is open. The level of tenotomy remains controversial, with risks and benefits of both a lesser trochanter and transcapsular approach.

What happens to endoscopic/arthroscopic tenotomies with iliopsoas impingement in the medium term? Review of a prospective cohort of 64 patients with a minimum follow-up of 5 years

INTRODUCTION

The occurrence of iliopsoas impingement (IPI) after total hip arthroplasty (THA) is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective multicenter series. We carried out a review of the patients at more than 5 years of follow-up in order to assess the stability of the results over time.

HYPOTHESIS

Our main hypothesis was that endoscopic/arthroscopic tenotomies allow stable medium-term resolution of the painful symptoms of IPI. Our secondary hypothesis was that medium-term survival was satisfactory.

MATERIAL AND METHOD

This study is a continuation of a multicenter prospective series. Patients were contacted through multiple channels in order to: obtain an Oxford score, assess for satisfaction, psoas irritation, and daily pain on a visual analogue scale (VAS).

RESULTS

Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7±7.7 [12-48]. There was a significant difference between the Oxford scores preoperatively, at 8 months and at the last follow-up. The mean satisfaction out of 10 was 8.0±2.1 [1-10]. We found 84% satisfaction at 5 years against 83% at 8 months. The VAS was 2.1±2.3 [0-10]. A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in four cases, while it reappeared during the interval in six cases. Survival was 91.2% (95% CI: 80.2-96.3) at 5 years.

CONCLUSION

Endoscopic/arthroscopic iliopsoas tenotomies represent a permanent medium-term solution to treat IPI after THA. The existence of a force differential or an acetabular overhang does not seem, within a certain limit, to impact the results in the medium term.

LEVEL OF EVIDENCE

IV; prospective series without control group.

The Anterior Position of the Hip Center of Rotation Is Related to Anterior Cup Protrusion Length and Symptomatic Iliopsoas Impingement in Primary Total Hip Arthroplasty

BACKGROUND

Iliopsoas impingement (IPI) is an important complication after total hip arthroplasty (THA), and anterior cup protrusion is believed to be its main cause; however, the relationship between the hip center of rotation (COR) and symptomatic IPI or cup protrusion remains poorly understood. Therefore, the present study investigated these relationships.

METHODS

The medical records of 138 patients who underwent unilateral primary THA were retrospectively reviewed. There were 8 patients (5.8%) who had symptomatic IPI. The COR and cup protrusion length measured with 2 methods were assessed on computed tomography. Risk factors for symptomatic IPI and the relationship between the COR and protrusion length were evaluated.

RESULTS

Logistic regression analyses showed that anteroposterior position of the COR, sagittal cup protrusion length (SCPL) at the COR, and both axial and SCPLs at the most anterior margin of the cup were related to symptomatic IPI. Multivariable regression analyses showed that acetabular offset was related to axial protrusion length at the COR, and anteroposterior position of the COR was related to both axial and sagittal protrusion lengths at the most anterior margin of the cup.

CONCLUSION

Anterior position of the cup was related to symptomatic IPI and both axial and sagittal protrusion lengths at the most anterior margin of the cup. Anterior reaming and cup protrusion should be avoided as much as possible to prevent symptomatic IPI.

Endoscopic iliopsoas lengthening for treatment of recalcitrant iliopsoas tendinitis after total hip arthroplasty

Iliopsoas (IP) tendinitis from impingement upon the acetabular component after total hip arthroplasty (THA) has been treated with open and endoscopic IP tenotomy or acetabular component revision. This study describes the results of a consecutive series of patients treated with endoscopic IP tenotomy as a less invasive alternative. Twenty-eight patients with IP impingement after THA underwent endoscopic IP lengthening from 2012 to 2021 at a single-center academic institution. The follow-up of 24 of these patients was achieved with a mean follow-up of 7.6 months (range 1-28). Outcomes included the modified Harris Hip Score (mHHS), visual analog pain scale (VAS), satisfaction, component positioning and complications. Seventy-one percent of patients were satisfied or very satisfied after their operation. The median mHHS preoperatively was 57 (Interquartile range [IQR] 43-60) and postoperatively was 75 (IQR 66-92, P < 0.001). Clinically meaningful improvements in mHHS were seen in patients with VAS pain scores <5, cup prominence >8 mm, body mass index >30, and less than 2 years from their index THA. Two patients developed a deep infection 7 and 10 months postoperatively (neither related to the release), and one patient underwent open psoas release for persistent impingement. Endoscopic IP tenotomy is a safe and effective treatment for impingement after THA. Patients with cup prominence >8 mm, body mass index >30 and less than 2 years since their index THA may have more clinically meaningful improvements in pain and function.

Arthroscopic Peripheral Compartment Iliopsoas Release for Iliopsoas Impingement After Primary Total Hip Arthroplasty

Anterior iliopsoas (IP) impingement after total hip arthroplasty is an underrecognized and continued cause for postoperative pain. There are multiple etiologies for this impingement from cup positioning and sizing to changes in the leg length, and offset must be evaluated to confirm no need for implant revision. Additionally, tension of the IP tendon can be increased in patients with diminished spinal mobility, either from prior fusion or with increasing age. Managing this surgically after failing conservative treatment options is best done arthroscopically to prevent additional large, open procedures that place the arthroplasty at unnecessary risk of infection and potential instability. In this article, we describe an arthroscopic technique using fluoroscopy to guide the release of the iliopsoas tendon from the peripheral compartment.

Arthroscopic iliopsoas tenotomy after total hip arthroplasty: safe method for the right patient

PURPOSE

To evaluate the outcome of arthroscopic treatment for iliopsoas impingement after total hip arthroplasty (THA) 2 years after surgery using patient reported outcomes (PROM).

METHODS

In this study 12 patients (13 hips) were included from a local hip arthroscopy registry. Patients completed web-based PROMs preoperatively and at a minimum of 2 years postoperatively. The PROMs included the International Hip Outcome Tool short version (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analog Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery.

RESULTS

The mean age was 64.4 years (±15.1SD), mean body mass index (BMI) was 26.6 (±4.3SD), mean follow-up time was 49.8 months (±25SD). Comparing PROMs preoperatively with 2-year follow up showed an improvement for many of the PROMs used. The PROMs scores were iHOT-12 (24.9 vs 34.5, p = 0.13), HAGOS subscales (symptoms 38.2 vs 54.5, p = 0.05; pain 36 vs 53, p = 0.04; sport 14.1 vs 35.1, p = 0.03; daily activity 31 vs 47.5, p = 0.04; physical activity 21.8 vs 24, p = 0.76; quality of life 24 vs 35, p = 0.03), EQ-VAS (57.9 vs 58, p = 0.08), EQ-5D (0.34 vs 0.13, p = 0.07) and VAS for overall hip function (43.1 vs 46.2, p = 0.14). In total, 10 out of the 12 patients (83%) were satisfied with the intervention.

CONCLUSION

Patients undergoing surgery for iliopsoas impingement after previous THA showed improved self-reported hip function where most patients were satisfied with treatment.

Tendinopathies and Allied Disorders of the Hip

There are many soft tissue structures around the hip joint that may serve as a source of pain in both the native and prosthetic hip. In this review, the role of the gluteal, piriformis, iliopsoas, and rectus femoris musculotendinous units in the etiology of pathology around the hip joint will be discussed. Management options ranging from tailored physical therapy regimens to local steroid infiltration along with more invasive open and arthroscopic surgical techniques will be reviewed for each pathological entity. While not all conditions are well understood, advancements have been made in the management of each of these often challenging cases in both the native and prosthetic hip settings. This review explores these advancing treatment methods which will supplement the practice of any hip surgeon who is presented with problematic tendinopathy around both the native and prosthetic hip joint.

A Case of Iliopsoas Bursitis With Compressive Femoral Nerve Palsy Treated With Iliopsoas Tendon Release

Iliopsoas bursitis is a well-established cause of groin pain after total hip arthroplasty (THA), and it can become dramatically more complex when associated with neurovascular compression. Iliopsoas bursitis may be caused by a variety of pathologies in the setting of a THA but most frequently due to a prominent acetabular component or implant wear. Here we report a rare case of a female patient presenting with iliopsoas tendonitis, an accompanying femoral nerve palsy, and debilitating pain beginning 12 years after a previously successful primary THA without apparent implant wear. Ultimately, our patient was treated successfully with iliopsoas tendon release for anterior prominence of the acetabular component.

Editorial Commentary: Iliopsoas Tenotomy for Pain After Total Hip: A Great Operation IF the Diagnosis Is Right

Iliopsoas tendon pain can be a frustrating condition for both patients and surgeons after total hip arthroplasty. It is difficult to diagnose definitively, as there is no imaging modality that offers reliable information and there are numerous causes of persistent groin pain in this patient population. The pain can ruin the results of an otherwise well-functioning total hip arthroplasty. Patients who respond best to arthroscopic iliopsoas tenotomy are those with isolated pain with hip flexion activities and reproducible pain with resisted hip flexion on examination or other provocative iliopsoas maneuvers. Patients with these symptoms in addition to more generalized pain findings (pain with weight-bearing, pain at night, pain with passive range of motion) tend not to respond as favorably to isolated iliopsoas tenotomy. In addition, optimal treatment for refractory cases has been controversial historically, as both acetabular component revision and iliopsoas tendon lengthening have been advocated. With the ever-increasing popularity of hip arthroscopy and recent clinical outcome reports, arthroscopic (or endoscopic) iliopsoas tenotomy has proven to be a very safe and effective treatment option for these patients, with one caveat: the diagnosis must be correct.