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

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.

Iliopsoas impingement after total hip arthroplasty: Does the CT-scan have any role? Our Algorithm proposal

Introduction

The first surgical option considered in managing iliopsoas impingement following THA is endoscopic/arthroscopic iliopsoas tenotomy, because of its low risk and minimal invasiveness. Acetabular revision is a much more aggressive surgery, recommended only in cases of substantial cup malposition. However, there are no clear indications for this procedure. The purpose of this article is to analyse the role of CT-scan measurement of acetabular cup positioning in a therapeutic algorithm for iliopsoas impingement.

Methods

In this retrospective observational study, we reviewed 25 patients treated for iliopsoas impingement following THA between 2011 and 2019. We studied acetabular cup positioning using CT-scan. We compared radiological parameters of patients who presented with significant clinical improvement with conservative treatment and with tenotomy against those who did not. Finally, we developed a proposed therapeutic algorithm.

Results

Forty-eight percent of patients presented a significant clinical improvement following conservative treatment. Patients who did not improve were found to have greater acetabular cup axial and sagittal overhang (p-values 0.016 and 0.003). These patients were considered for tenotomy. Of this group, those who did not improve with surgery (38%) showed greater axial overhang (p-value 0.005).

Conclusions

Conservative management should be the first line of treatment. In cases of non-operative treatment failure, axial acetabular cup overhang measured by CT-scan can be a useful tool in choosing between iliopsoas tenotomy or cup-revision surgery in selected cases of very severe acetabular malposition. A cut-off point of 10 mm of axial overhang is a reliable predictor of higher failure risk with iliopsoas tenotomy.

An all-arthroscopic light bulb technique to treat osteonecrosis of the femoral head through outside-in fashion without distraction: A case report

The technique of distraction has been widely used in hip arthroscopy for opening joint spaces. However, an all-arthroscopic light bulb technique through outside-in fashion without distraction has not been reported for the treatment of osteonecrosis of the femoral head (ONFH). A 29-year-old man was admitted to our department with hip pain and limited range of motion (ROM) in both hips over 4 months. X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) showed a mixed appearance, including sclerosis and cysts on the anterosuperior site of the bilateral femoral heads. The patient had an 11-year history of liquor intake. In addition, no other pathologies were found before the operation. After diagnosing bilateral ONFH (stage II) according to the Ficat classification, the patient underwent an all-arthroscopic light bulb technique through outside-in fashion without distraction because of failing conservative treatment. At the 2-year postoperative follow-up, the patient had neither pain nor limitation of ROM. The postoperative x-ray, CT, and MRI revealed a well-healed area of the previous bone grafting in the bilateral femoral heads. An all-arthroscopic light bulb technique through outside-in fashion without distraction can be a feasible method for the treatment of early-stage ONFH. This case reminds us that distraction- and perforation-related complications may be avoided in patients with ONFH without the concomitant pathologies of the central compartment.

The Modified Longitudinal Capsulotomy by Outside-In Approach in Hip Arthroscopy for Femoroplasty and Acetabular Labrum Repair-A Cohort Study

Hip arthroscopy is difficult to perform due to the limited arthroscopic view. To solve this problem, the capsulotomy is an important technique. However, the existing capsulotomy approaches were not perfect in the surgical practice. Thus, this study aimed to propose a modified longitudinal capsulotomy by outside-in approach and demonstrate its feasibility and efficacy in arthroscopic femoroplasty and acetabular labrum repair. A retrospective cohort study was performed and twenty-two postoperative patients who underwent hip arthroscopy in our hospital from January 2019 to December 2021 were involved in this study. The patients (14 females and 8 males) had a mean age of 38.26 ± 12.82 years old. All patients were diagnosed cam deformity and labrum tear in the operation and underwent arthroscopic femoroplasty and labrum repair by the modified longitudinal capsulotomy. The mean follow-up time was 10.4 months with a range of 6−12 months. There were no major complications, including infection, neurapraxias, hip instability or revision in any patients. The average mHHS were 74.4 ± 15.2, 78.2 ± 13.7 and 85.7 ± 14.5 in 3 months, 6 months and 12 months after surgery, respectively, which were all better than that before surgery (44.9 ± 8.6) (p < 0.05). The average VAS were 2.8 ± 1.2, 1.5 ± 0.6 and 1.2 ± 0.7 in 3 months, 6 months and 12 months after surgery, respectively, which were all lower than that before surgery (5.5 ± 2.0) (p < 0.05). The modified longitudinal capsulotomy by outside-in approach is proved to be a safe and feasible method for hip arthroscopy considering to the feasibility, efficacy and security. The arthroscopic femoroplasty and labrum repair can be performed conveniently by this approach and the patient reported outcomes after surgery were better that before surgery in short-term follow-up. This new method is promising and suggested to be widely used clinically.

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.

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

PURPOSE

To report outcomes of endoscopic iliopsoas tenotomy (EIT) in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether improvements in clinical scores are associated with acetabular cup anteversion measured on plain radiographs or overhang measured using established and alternative computed tomography (CT)-based methods.

METHODS

We evaluated patients who underwent EIT for iliopsoas tendinopathy after THA (2014-2017), performed between the lesser trochanter and psoas valley. Indications were groin pain during active hip flexion, exclusion of other complications, and no pain relief after 6 months of conservative treatment. Pretenotomy inclination and anteversion were measured on radiographs; sagittal and axial overhang were measured on CT scans on slices passing through: (Method 1) prosthetic head center and (Method 2) anterior margin of acetabular cup. Modified Harris hip score (mHHS), Oxford Hip Score (OHS), and level of groin pain were recorded at 12 or more months. Wilcoxon signed-rank tests were used to compare pre- and post-tenotomy scores, and intraclass correlation coefficients (ICCs) to assess intermethod agreement.

RESULTS

The cohort comprised 16 men (17 hips) and 32 women (33 hips), aged 60.8 ± 10.5 years at EIT. For the 30 (60%) hips that had pretenotomy CT scans, axial and sagittal overhang were, respectively, 3.4 ± 3.7 mm and 4.6 ± 4.6 mm, using Method 1, compared with 3.9 ± 3.9 mm and 6.9 ± 5.0 mm using Method 2. Intermethod agreement was good for axial (ICC, 0.67; P < .001) and sagittal (ICC, 0.68; P < .001) overhang. At a minimum 1 year after EIT, 3 hips had cup and stem revision and 1 hip had isolated cup revision, leaving 46 hips for clinical assessment. No complications were noted. mHHS improved by 26 ± 19 (P < .001) and OHS improved by 20 ± 11 (P < .001). Twenty-six hips (57%) achieved the patient acceptable symptom state for mHHS, whereas 42 hips (91%) achieved the patient acceptable symptom state for OHS. Post-tenotomy groin pain was slight in 15%, mild in 17%, and moderate in 11%. Regression analyses revealed no associations between clinical scores and overhang/anteversion.

CONCLUSIONS

For patients with iliopsoas tendinopathy following THA, endoscopic iliopsoas tenotomy granted clinically important improvements of mHHS in 76% and OHS in 89%, despite moderate residual groin pain in 11%. Improvements in clinical scores did not seem to be associated with the extent of cup overhang or anteversion in the cases for which adequate preoperative imaging was available.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.