Arthroscopic techniques for treating ilio-psoas tendinopathy after hip arthroplasty

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 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.

Arthroscopic Iliopsoas Fractional Lengthening After Total Hip Arthroplasty: Using the Iliopsoas Air Bursogram Technique to Hit the Target

Iliopsoas tendinitis following total hip arthroplasty has been linked to retroverted acetabular cup position with associated anterior overhang. For severely malpositioned components, preferred treatment is in the form of revision arthroplasty. However, for a substantial number of cases, iliopsoas tendinitis as well as associated pain and disability are observed in the presence of modest acetabular overhang. In such cases, patients may benefit substantially from arthroscopic iliopsoas fractional lengthening. Given altered postarthroplasty anatomy, we present an arthroscopic approach employing an iliopsoas air bursogram. In such a way, safe and predictable access can be provided for efficient tendon lengthening without capsular violation or inadvertent instrumentation of the nearby medial neurovascular bundle.

What happens in the medium-term to capsule-thickening plasties for iliopsoas impingement after total hip arthroplasty? Evaluation of 14 procedures at 4years' follow-up

INTRODUCTION

In 2015, we described a capsule-thickening technique via an anterior approach for iliopsoas cup impingement. To our knowledge, medium-term results have not been reported. We therefore retrospectively analyzed all cases in the initial series and those since 2015, to assess this original technique over a longer follow-up: (1) to analyze complications, and (2) to assess functional outcome.

HYPOTHESIS

The study hypothesis was that this surgical solution has a success rate sufficient for it to be included in the therapeutic armamentarium for iliopsoas impingement.

MATERIAL AND METHOD

Fourteen patients were included. Nine plasties were in first line, 3 after tenotomy, and 2 after cup exchange. The anterior Hueter approach was used, visualizing anterior cup overhang, sometimes associated with penetration of the anterior capsule, and enabling capsule-thickening by a folded Vicryl™ mesh. Functional results were analyzed.

RESULTS

At a median 4years' follow-up (IQR: 2-5; range: 1-9), change over baseline in Oxford score was 7 points (p=0.004), median Medical Research Council thigh flexion strength score was 5 (IQR: 5-5), and 50% of patients (7/14) were satisfied or very satisfied. The major complications rate was 7% (1/14), for 1 irrigation of infected hematoma, cured without recurrence; there was also 1 minor case of injury to the lateral cutaneous nerve of the thigh. Forty-three percent of patients (6/14) exhibited a minimal clinically important difference (MCID) and 64% (9/14) a patient-acceptable symptom state (PASS). Median anatomic overhang on anatomic CT transverse slice was 7mm (IQR: 3-8; range: 0-13). Four patients underwent secondary acetabular component exchange; their median overhang was 7.5mm (IQR: 7-8) compared to 5mm (IQR: 2-8) for the other patients (p-value non-calculable).

CONCLUSION

This surgical option seems interesting when acetabular overhang is not too great, especially as it does not affect flexion strength.

LEVEL OF EVIDENCE

IV.

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.

Clinical efficacy of arthroscopic treatment in ischial tuberosity cyst: A retrospective comparison study

Ischial tuberosity cyst is a common disease, and the conventional incision procedure is associated with several disadvantages, leading to unsatisfactory therapeutic outcomes. The aim of the study was to evaluate the clinical outcomes of arthroscopic treatment for ischial tuberosity cyst and compared it with conventional incision surgery.The clinical data of 57 patients with ischial tuberosity cyst from May 2016 to September 2018 were retrospectively analyzed. According to the inclusion and exclusion criteria, a total of 49 patients were included. Of these patients, 24 patients received arthroscopic procedure (N = 24) and 25 patients received conventional incision procedure (N = 25). The operation time, intraoperative blood loss, postoperative drainage, postoperative hospital stay, and postoperative complications were compared between the 2 groups. Visual analogue scale scores was used to evaluate pain at 1 day, 1 week, and 1 month after the surgery.All 49 patients were followed up for (11.3 ± 3.3) months. All patients in the arthroscopy group achieved phase I healing while 3 patients in conventional incision group developed complications. The operation time, intraoperative blood loss, postoperative drainage, and hospital stay in the arthroscopy group were (54.7 ± 7.7) minutes, (20.8 ± 3.5) mL, (20.3 ± 5.6) mL, and (2.8 ± 0.6) days, and were significantly better than those of (71.8 ± 8.8) minutes, (67.3 ± 12.0) mL, (103.6 ± 20.3) mL, and (7.8 ± 2.9) days in the conventional incision group, respectively. In the arthroscopy group, the visual analogue scale scores at 1 day, 1 week, and 1 month after the surgery [(2.6 ± 0.7), (0.5 ± 0.6), (0.3 ± 0.5) points] were significantly lower than those in the conventional incision group [(6.0 ± 0.7), (3.0 ± 1.0), and (1.1 ± 1.0) points], and the differences were statistically significant (P < .05). Finally, no significant difference was observed in the incidence of postoperative complications between the 2 groups (P > .05).In the treatment of ischial tuberosity cysts, arthroscopy has advantages of minimal invasion, less blood loss during perioperative period, milder postoperative pain, and rapid recovery when compared with conventional incision surgery.

Screw penetration of the iliopsoas muscle causing late-onset pain after total hip arthroplasty: A case report

BACKGROUND

Postoperative pain following total hip arthroplasty (THA) may occur in a few patients but may pose a significant challenge to surgeons if the etiology is not identified. Herein, we report the case of a patient who developed late-onset pain following THA due to screw penetration of the iliopsoas tendon.

CASE SUMMARY

We report the case of a 77-year-old man who developed inguinal pain 7 years after THA. While the symptoms resembled that of iliopsoas impingement by the acetabular cup, the pain resolved only when the supplementary acetabular screw protruding through the ilium was decompressed. Decompression was performed using the pararectus approach. The patient was able to ambulate pain-free immediately after surgery.

CONCLUSION

A protruded screw through the ilium may penetrate the iliopsoas muscle, causing pain following THA. Pain may resolve with the decompression of the protruded screw.

Endoscopic treatment of iliopsoas impingement after total hip arthroplasty: a minimum 2-year follow-up and comparison of tenotomy performed at the acetabular rim versus lesser trochanter

Iliopsoas impingement is an underdiagnosed cause of groin pain after total hip arthroplasty (THA), being responsible for 4.4% of cases. Non-surgical treatment may be effective in ∼50% of cases. Endoscopic surgery has gained popularity as an option for non-responsive patients because of its non-invasive characteristics, faster recovery and encouraging results. This study compares two different sites of endoscopic psoas tenotomy performed following THA: at the edge of the acetabulum (AR) versus at the lesser trochanter (LT). This is a retrospective review of prospectively collected data from a single-surgeon case series. Thirty-five iliopsoas tenotomy cases which had >24-month follow-up were identified. There were 21 tenotomies at the lesser trochanter. Demographic data, preop and postop pain, mHHS and NAHS scores, strength and patient satisfaction data were collected and analysed. Average age at the time of surgery was 62. Mean follow-up for the LT group was 49.11 months and 42.42 months for the AR group. Pain decreased significantly for both groups (P < 0.001). Both mHHS and NAHS showed superiority in the LT group, but this difference did not reach significance (P = 0.06). LT patients showed better strength with 71.42% of them having normal strength at latest follow-up, compared with 41.6% in the AR group. There were no complications in either group. Endoscopic tenotomy is a safe and reliable surgical option, giving significant pain relief and good functional outcomes. Tenotomy at the level of the lesser trochanter might be preferable since it shows better outcomes. Larger studies are necessary to achieve statistically significant results.

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.

Iliopsoas Muscle/Tendon Proportions at Three Levels of Described Arthroscopic Tenotomy: An Anatomic Study in Fresh Cadaveric Specimens

Purpose

To calculate the iliopsoas muscle/tendon ratio at 3 levels of arthroscopic iliopsoas tenotomy sites in fresh cadaveric specimens.

Methods

An anatomic study design was performed using 16 iliopsoas musculotendinous units from the level of the hip joint to their insertion on the lesser trochanter. All specimens came from 16 fresh cadaveric specimens (10 male, 6 female), with a median age of 41 years (range 31-55.25 years). Circumferential measurements of the composite musculotendinous unit and the iliopsoas tendon were then made at the lesser trochanter insertion, the site of transcapsular tenotomy, and the site of tenotomy at the level of the labrum. Anatomical variance of the iliopsoas tendon at the insertion on the lesser trochanter and muscular extension below the lesser trochanter level also were described. The difference between the median circumference of the iliopsoas musculotendinous units or the isolated tendons at the 3 levels was calculated.

Results

The median circumference of the iliopsoas musculotendinous unit at the level of the labrum, orbicularis zone (transcapsular tenotomy site), and the lesser trochanter was 140.9 mm (range 137.9-148.9), 136.7 mm (range 132.9-140), and 99.5 mm (range 96.5-104.8), respectively. The median circumference of the iliopsoas tendon at these same levels was 25.6 mm (range 22.7-33.7), 28.9 mm (range 25.1-32.2), and 30.9 mm (range 27.9-36.1), respectively. Accordingly, the proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site, and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively.

Conclusions

The proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively. The distal muscular projection below the tendinous insertion on the lesser trochanter may maintain the functional connection of the iliopsoas between origin and insertion even after releasing the tendon.

Clinical relevance

This finding may have implications for a new understanding of arthroscopic tenotomy of the iliopsoas around the hip, as previously described muscle/tendon proportions were not calculated in fresh cadavers.

Groin pain caused by iliopsoas synovial cyst treated with endoscopic approach. A case report

The diagnosis of iliopsoas synovial cyst is a rare finding. The normal approach to treat this condition has been conservative therapies or open surgery, with its associated complications and morbidity. The arthroscopic – endoscopic surgery is less invasive and with an increase in complications and days of hospitalization. We report the case of a 70-year old woman with clinical and imaging signs of a fluid-filled cyst near iliopsoas distal tendon. After fluid aspiration, the patient reported symptom-free interval of several weeks, but then groin pain and swelling feeling return, increased with hip movements. The cyst was removed through arthroscopy approach and the iliopsoas tendon was released. The removal of iliopsoas synovial cyst is necessary to avoid complications such as pain and functional limits. Arthroscopy has the advantage of less soft-tissue damage and quicker recovery. The treatment of associated tendon pathology can be done. Hip arthroscopy can be a safe and effective technique for the removal of iliopsoas synovial cyst. (www.actabiomedica.it)

New combined anteversion technique in hybrid THA: cup-first procedure with CT-based navigation

PURPOSE

Combined anteversion (CA) technique (stem-first procedure) is generally accepted as the optimal technique to attain an appropriate CA value in total hip arthroplasty (THA). However, cup anteversion is strongly influenced by the native femoral anteversion. Accordingly, anterior protrusion of the cup in the acetabulum might occur. The purpose of the present study is to investigate the achievement of the optimal CA while avoiding anterior cup protrusion and examine the significance of our new CA technique with cup-first procedure in hybrid THA.

METHODS

Seventy-nine hybrid THAs with the cup-first procedure used a CT-based navigation system for cup positioning. In the preoperative planning, cup anteversion was aimed at approximately 20°. However, in actuality, sufficient cup coverage in the original acetabulum based on individual anatomy is given priority over cup placement based on CT-based planning to ensure adequate cup coverage. The target stem anteversion was determined following Widmer's mathematical formula (37.3 = femoral stem anteversion × 0.7 + cup anteversion). Cemented stem was inserted according to the target stem anteversion angle.

RESULTS

Regarding the assessment of overall alignment, the calculated Widmer's CA values during surgery and postoperative CT evaluation were 34.1° ± 6.0° (range 20.7°-51.2°) and 35.1° ± 6.7° (range 21.6°-50.7°). There were 72 hips (91.1%) within 25°-50° of CA. Cup protrusion length averaged 2.0 mm ± 2.6 mm (0-8.8 mm) in the axial view and 0.4 mm ± 1.0 mm (0-3.6 mm) in the sagittal view. Cup protrusion length of more than 5 mm was indicated in 10 hips, and no hips observed more than 10 mm.

CONCLUSION

Our new CA technique (cup-first procedure) with hybrid THA was able to achieve optimal CA value while avoiding anterior cup protrusion.