Iliopsoas abscesses

Iliopsoas abscess is a relatively uncommon condition that can present with vague clinical features. Its insidious onset and occult characteristics can cause diagnostic delays, resulting in high mortality and morbidity. The epidemiology, aetiology, clinical features, and management of iliopsoas abscess are discussed.

Diagnostic and Therapeutic Use of Sonography-Guided Iliopsoas Peritendinous Injections

OBJECTIVE

Our objective was to review our experience performing sonography-guided iliopsoas bursal/peritendinous injections as a diagnostic and therapeutic tool in the workup and treatment of patients with hip pain.

CONCLUSION

Sonography-guided iliopsoas bursal/peritendinous injections are useful in determining the cause of hip pain. They can provide relief to most patients with iliopsoas tendinosis/bursitis after hip replacement. The results of injection alone are not as successful in cases of idiopathic iliopsoas tendinosis/bursitis, but the technique can help determine which patients may benefit from a surgical tendon release.

Imaging features of iliopsoas bursitis

The aim of this study was firstly to describe the spectrum of imaging findings seen in iliopsoas bursitis, and secondly to compare cross-sectional imaging techniques in the demonstration of the extent, size and appearance of the iliopsoas bursitis as referenced by surgery. Imaging studies of 18 patients (13 women, 5 men; mean age 53 years) with surgically proven iliopsoas bursitis were reviewed. All patients received conventional radiographs of the pelvis and hip, US and MR imaging of the hip. The CT was performed in 5 of the 18 patients. Ultrasound, CT and MR all demonstrated enlarged iliopsoas bursae. The bursal wall was thin and well defined in 83% and thickened in 17% of all cases. The two cases with septations on US were not seen by CT and MRI. A communication between the bursa and the hip joint was seen, and surgically verified, in all 18 patients by MR imaging, whereas US and CT failed to demonstrate it in 44 and 40% of the cases, respectively. Hip joint effusion was seen and verified by surgery in 16 patients by MRI, whereas CT (4 of 5) and US ( n=12) underestimated the number. The overall size of the bursa corresponded best between MRI and surgery, whereas CT and US tended to underestimate the size. Contrast enhancement of the bursal wall was seen in all cases. The imaging characteristics of iliopsoas bursitis are a well-defined, thin-walled cystic mass with a communication to the hip joint and peripheral contrast enhancement. The most accurate way to assess iliopsoas bursitis is with MR imaging; thus, it should be used for accurate therapy planning and follow-up studies. In order to initially prove an iliopsoas bursitis, US is the most cost-effective, easy-to-perform and fast alternative.

A molecular map of titin/connectin elasticity reveals two different mechanisms acting in series

In the I-band of skeletal muscle sarcomeres, the elastic region of titin consists of immunoglobulin (Ig) domains, and non-modular regions rich in proline, hydrophobic, and charged residues (PEVK). Using immunoelectron microscopy with sequence-assigned monoclonal antibodies, we demonstrate that extension of the Ig regions in M. psoas occurs largely at sarcomere lengths between 2 and 2.8 micron, decreasing in slope towards higher lengths. The Ig domains do not unfold. Above 2.6 micron, length changes are increasingly due to the PEVK-rich regions. We therefore propose that rubber-like properties of the PEVK-rich regions are mainly contributing to skeletal titin elasticity.

A benign psoas mass following metal-on-metal resurfacing of the hip

As metal-on-metal arthroplasty becomes more widespread, concerns are being raised about the potential dangers of metal particulate debris. We present the case of a benign psoas mass secondary to the presence of such particles. The mass was excised and the hip resurfacing subsequently revised to a total hip replacement.

Arthroscopic treatment of the painful "internal" snapping hip: results of a new endoscopic technique and imaging protocol

BACKGROUND

Traditional surgical treatment for a painful snapping iliopsoas tendon has been an open lengthening of the tendon.

HYPOTHESIS

An endoscopic release will alleviate painful snapping of the tendon.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Six patients with painful snapping hips who had no pain relief after magnetic resonance arthrography, which included injection of bupivacaine into the hip joint, subsequently had an ultrasound evaluation of their iliopsoas tendons and an anesthetic injection into the psoas bursa. In all 6 patients, the injection relieved their hip pain, and in 4, real-time imaging demonstrated snapping of the tendon. All hips were evaluated with the 100-point Harris hip scoring system before and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

Preoperative hip scores averaged 58 points. After surgery, all patients had hip flexor weakness, used crutches for 5 weeks, and had 6-week scores that averaged 62 points. The patients continued to improve, and at 6 and 12 months, their scores averaged 90 and 96 points, respectively, and none had recurrence of their snapping or pain.

CONCLUSION

Ultrasound-guided anesthetic injection of the psoas bursa is useful to confirm snapping of the iliopsoas tendon as the cause of a patient's hip pain. Endoscopic release of the tendon is a safe outpatient procedure that provides effective relief of the snapping and pain.

Injuries to the lateral femoral cutaneous nerve during spine surgery

STUDY DESIGN

A prospective study to locate patients with injured lateral femoral cutaneous nerve after elective spine surgery.

OBJECTIVES

To assess the prevalence of injury of the lateral femoral cutaneous nerve and to identify the cause of injury according to the position of the patients at surgery and the surgical approach.

SUMMARY OF BACKGROUND DATA

Injuries to the lateral femoral cutaneous nerve, also known as meralgia paresthetica, may cause pain and therefore result in restriction of activity. Compression of the nerve by disc hernia, retroperitoneal tumors, and external pressure around the anterior superior iliac spine are among the more common causes.

METHODS

One hundred five patients admitted for elective spine procedures were grouped according to position on the operating table and surgical approach. All patients were examined before and after surgery for signs of injury to the lateral femoral cutaneous nerve, and those found injured were followed up for 1 year after surgery.

RESULTS

Injury to the lateral femoral cutaneous nerve was found in 21 (20%) patients. In 6 of them, all of whom underwent surgery on the Hall-Relton frame, the injury was bilateral. In 7 patients the injury was not associated with discomfort. In addition to injury by external pressure at the anterior superior iliac spine from the Hall-Relton frame, the nerve was also injured at the retroperitoneum by hematoma or traction and at the anterior iliac crest when bone was harvested. In 89% of the patients, the nerve completely recovered within 3 months of surgery. Two patients still had pain 1 year after surgery and hypoesthesia of the anterolateral thigh.

CONCLUSION

Injuries to the lateral femoral cutaneous nerve during spine surgery are frequent, and patients should be informed of the possible risk. It usually has a benign course, but some preventive steps should be taken: keep posterior to the anterior superior iliac spine and minimize retraction when harvesting a bone graft, pad the posts of the Hall-Relton frame over the anterior superior iliac crest, and avoid traction on the psoas muscle during the retroperitoneal dissection.

Surgical correction of internal coxa saltans: a 20-year consecutive study

PURPOSE

To report the complications associated with surgical correction of internal snapping hip.

STUDY DESIGN

Retrospective review.

METHODS

A review of 92 cases of internal coxa saltans (12 bilateral) from 1982 to 2002 was performed to identify complications following primary surgical correction. An inguinal approach was used for iliopsoas tendon fractional lengthening. The average follow-up time per patient was 5.4 years.

RESULTS

A total of 40 complications occurred in 32 patients. Complications included persistent hip pain (n = 6), sensory deficit (n = 8), and hip flexor weakness persisting longer than 1 month (n = 3). Additionally, painful bursa formation (n = 1), hematoma requiring reexploration (n = 1), and superficial infection (n = 1) were noted. Some patients developed recurrent snapping after a 3-month snapping-free interval (n = 9), and some patients never had complete resolution of snapping and were considered failures (n = 11). Of these failures/recurrences, 8 patients had a second tenotomy with 4 failures. Two had a third tenotomy, with 1 failure.

CONCLUSIONS

In this series, primary iliopsoas tendon lengthening in patients with internal coxa saltans was without any complication in only 60% of patients; however, overall patient satisfaction was 89%.

A Comparison of Psoas Compartment Block and Spinal and General Anesthesia for Outpatient Knee Arthroscopy

The optimal anesthetic technique for outpatient knee arthroscopy remains controversial. In this study, we evaluated surgical operating conditions, patient satisfaction, recovery times, and postoperative analgesic requirements associated with psoas compartment block, general anesthetic, or spinal anesthetic techniques. Sixty patients were randomized to receive a propofol/nitrous oxide/fentanyl general anesthetic, spinal anesthesia with 6 mg of bupivacaine and 15 micro g of fentanyl, or psoas compartment block with 40 mL of 1.5% mepivacaine. All patients received IV ketorolac and intraarticular bupivacaine. The frequency of postanesthesia recovery room admission was 13 (65%) of 20 for patients receiving general anesthesia, compared with 0 of 21 for patients receiving spinal anesthesia and 1 (5%) of 19 for patients receiving psoas block (P < 0.001). The median time from the end of surgery to meeting hospital discharge criteria did not differ across groups (131, 129, and 110 min for general, spinal, and psoas groups, respectively). In the hospital, 45% of general anesthesia patients received opioid analgesics, compared with 14% of spinal anesthesia and 21% of psoas block patients (P = 0.087). There was no difference among groups with respect to the time of first analgesic use or the number of patients requiring opioid analgesia. Pain scores were highest in patients receiving general anesthesia at 30 min (P = 0.032) and at 60, 90, and 120 min (P < 0.001). Patient satisfaction with anesthetic technique (P = 0.025) and pain management (P = 0.009) differed significantly across groups; patients receiving general anesthesia reported lower satisfaction ratings. We conclude that spinal anesthesia or psoas block is superior to general anesthesia for knee arthroscopy when considering resource utilization, patient satisfaction, and postoperative analgesic management.

IMPLICATIONS

Outpatient knee arthroscopy may be performed using a variety of anesthetic techniques. We report that spinal anesthesia and psoas compartment block are superior to general anesthesia when considering resource utilization, patient satisfaction, and postoperative analgesic management.

Quantifying Sarcopenia Reference Values Using Lumbar and Thoracic Muscle Areas in a Healthy Population

BACKGROUND

Sarcopenia is defined as the loss of skeletal muscle mass and function associated with aging. Muscle mass can be reliably and accurately quantified using clinical CT scans but reference measurements are lacking, particularly in healthy US populations.

METHODS

Two-phase CT scans from healthy kidney donors (age 18-40) at the University of Michigan between 1999-2010 were utilized. Muscle mass was quantified using two thoracic and two lumbar muscle cross-sectional area (CSA) measures. Indexed measurements were computed as area divided by height-squared. Paired analyses of non-contrast and contrast phases and different Hounsfield Unit (HU) ranges for muscle were conducted to determine their effect on CSA muscle measures. We report the means, standard deviations, and 2SD sarcopenia cutoffs from this population.

RESULTS

Healthy population CSA (cm2) cutoffs for N=604 males/females respectively were: 34.7/20.9 (T12 Dorsal Muscle), 91.5/55.9 (T12 Skeletal Muscle), 141.7/91.2 (L3 Skeletal Muscle), 23.5/14.3 (L4 Total Psoas Area), and 23.4/14.3 (L4 Psoas Muscle Area). Height-indexed CSA (cm2/m2) cutoffs for males/females respectively were: 10.9/7.8 (T12 Dorsal Muscle), 28.7/20.6 (T12 Skeletal Muscle), 44.6/34.0 (L3 Skeletal Muscle), 7.5/5.2 (L4 Total Psoas Area), and 7.4/5.2 (L4 Psoas Muscle Area). We confirmed that a mask of -29 to 150 HU is optimal and shows no significant difference between contrast-enhanced and non-contrast CT scan CSA measurements.

CONCLUSIONS

We quantified reference values for lumbar and thoracic muscle CSA measures in a healthy US population. We defined the effect of IV contrast and different HU ranges for muscle. Combined, these results facilitate the extraction of clinically valuable data from the large numbers of existing scans performed for medical indications.

Hematomas within the iliopsoas muscles in hemophilic patients: the Latin American experience

The majority of bleeding episodes in patients who have hemophilia occur within the musculoskeletal system, primarily in the joints, but approximately 30% occur within the muscles. Iliopsoas muscle bleeding episodes are often large in volume, causing muscular function inhibition, angular deformities, and nerve involvement. Recurrent hemorrhages are common (14.2%) and neural involvement is as high as 37%. Three hundred patients are being observed in the authors' hemophilia center, 63 of whom have suffered 127 hemorrhages. Absolute bed rest and long term factor replacement are the mainstay of therapy. The experiences of physicians in other countries are appendixed to this article.

Time resolved measurements show that phosphate release is the rate limiting step on myofibrillar ATPases

The myofibril is a good model to study the ATPase of the muscle fibre. When myofibrillar ATPase reaction mixtures are quenched in acid, there is a burst of Pi formation, due to AM.ADP.Pi or Pi, as shown in the scheme: AM+ATP<-->A.M.ATP<-->AM.ADP.Pi<-->AM.ADP+Pi<-->AM+ADP. Therefore, in the steady state, either AM.ADP.Pi or AM.ADP or both predominate. To determine which, we studied the reaction using a Pi binding protein (from E. coli) labeled with a fluorophore such that it is specific and sensitive to free Pi [Brune, M. et al. (1994) Biochemistry 33, 8262-8271]. We show that the Pi bursts with myofibrillar ATPases (calcium-activated or not, or crosslinked) are due entirely to protein bound Pi. Thus, with myofibrillar ATPases the AM.ADP.Pi state predominates.

Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery

BACKGROUND

The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications.

METHODS

Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery.

RESULTS

The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications.

CONCLUSION

The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery

Iliopsoas haemorrhage in patients with haemophilia: results from one centre

Iliopsoas haematoma is a well-recognized complication of haemophilia, and is considered as potentially life threatening and significantly associated with morbidity. There are only rare reports on the incidence or outcomes of iliopsoas bleeding since the widespread usage of modern therapies for haemophilia. In this study, we present the experience of Ege University Haemophilia Centre with iliopsoas bleeding and its early and late complications. We reviewed 146 haemophiliacs (106 haemophilia A, 40 haemophilia B). Fourteen iliopsoas bleeding episodes were identified in eight haemophiliacs. Three patients (37%) had one episode, four (50%) had two episodes and one (13%) had three episodes. Two patients had a high titre inhibitor against factor VIII and accounted for three bleeding episodes (21%). We did not observe any episodes in six patients receiving prophylaxis. Iliopsoas haematomas were confirmed by ultrasonography in all patients. In physical examination, the most common symptoms were thigh, hip and groin pain, hip flexion contracture, abdominal tenderness and paraesthesia in the distribution of the femoral nerve. The mean duration of therapy with clotting factor concentrate was 7.8 +/- 1.6 days. The mean duration of hospitalization was 4.8 +/- 2.0 days. All patients started to receive a physical therapy program 6.0 +/- 2.4 days after the initiation of haemostatic therapy which lasted 20.0 +/- 6.0 days. Ultrasonographic findings related to iliopsoas haematoma disappeared in all patients within 3 months from the initial episodes. Only in one patient with mild haemophilia A, heterotopic bone formation (myositis ossificans) developed as a long-term complication. In conclusion, pain around the hip joint, femoral neuropathy and hip flexion contracture in a patient with haemophilia should alert the physician to the possibility of an iliopsoas haematoma. Early and effective factor replacement therapy is essential in the prevention of the complications.

Life-threatening spontaneous psoas haematoma treated by transcatheter arterial embolization

We report two cases of large spontaneous psoas haematoma in patients on anticoagulant therapy. Active bleeding was well demonstrated on spiral CT. Transcatheter arterial embolization was used successfully to stop bleeding. The diagnostic strategy, the relevance of spiral computed tomography and our therapeutic approach to this complication are discussed.

Spontaneous haematoma of the iliac psoas muscle: a case report and review of the literature

Spontaneous haematomas of the iliac psoas muscle are rare lesions seen in patients receiving anticoagulant agents or suffering from clotting disorders. We report the rare case of a spontaneous iliac psoas haematoma causing femoral neuropathy in a patient not undergoing anticoagulant treatment or suffering from a coagulopathy. After conservative treatment the patient was entirely asymptomatic, and magnetic resonance imaging demonstrated complete dissolution of the haematoma. Spontaneous iliac psoas haematomas should be considered in the differential diagnosis of leg pain in otherwise healthy patients.

Bilateral iliopsoas hematomas complicating anticoagulant therapy

An 85-year-old woman receiving anticoagulant therapy for transient ischemic attack suddenly developed bilateral femoral nerve palsy and severe pain in the bilateral groin and thighs. Her platelet count, prothrombin time and activated partial thromboplastin time were within the therapeutic range. Hematomas in the bilateral iliopsoas muscles were clearly detectable on CT scan. The right hematoma was larger than the left one and caused more severe femoral neuropathy, but improved gradually without surgical decompression. This case is reported here because bilateralism is exceptional, and iliopsoas hematoma should be suspected when a patient receiving anticoagulant therapy presents with pain in the groin or thigh.

Continuous Psoas Compartment Blocks After Major Orthopedic Surgery in Children: A Prospective Computed Tomographic Scan and Clinical Studies

Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV); Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient's weight (0.2 mg x kg(-1) x h(-1)). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature.

IMPLICATIONS

Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.

Intrathecal morphine provides better postoperative analgesia than psoas compartment block after primary hip arthroplasty

PURPOSE

Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques.

METHODS

Patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine (Group I, n = 27) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 26). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's acceptance and satisfaction of the postoperative analgesic technique were also recorded.

RESULTS

During the first 24 hr, pain scores (3.3 +/- 9.6 mm vs 22.8 +/- 27.1 at H+6, 3.3 +/- 8.3 mm vs 25 +/- 26.7 mm at H+12, 7 +/- 14.9 mm vs 21.9 +/- 29 mm at H+18) and morphine consumption (0.56 +/- 2.12 mg vs 9.42 +/- 10.13 mg) were lower in Group I than in Group II. Urinary retention was the more frequent side-effect occurring in 37% of cases in Group I vs 11.5% in Group II (P < 0.05). No major complication occurred. Despite better analgesia provided by the use of intrathecal morphine, there was no difference in the satisfaction scores between groups.

CONCLUSION

0.1 mg intrathecal morphine administration provides better postoperative analgesia than single-shot psoas compartment block after primary hip arthroplasty.

Hemispheric cups do not reproduce acetabular rim morphology

BACKGROUND

Iliopsoas impingement is a recurrent complication following THA, caused by muscle friction against a protrusive prosthetic cup.This study was designed to quantify the dimensional variations in acetabular rim profiles, with particular regard to the iliopubic valley, in order to suggest means to prevent iliopsoas impingement.

MATERIAL AND METHODS

34 cadaver pelvises were analyzed using a hip navigation system. The morphometric data were processed to plot profiles of all acetabular rims with particular regard to the shape and depth of the psoas valley.

RESULTS

The acetabular rim is an asymmetric succession of 3 peaks and 3 troughs. The psoas valley is a salient feature in most pelvises and there is only a weak correlation between its depth (mean 3.8 mm, SD 2.0) and acetabular diameter, anteversion, or inclination.

INTERPRETATION

It would be difficult to obviate the anterior overlap of the acetabulum using a hemispheric cup, a fortiori in certain morphotypes, without compromising range of motion or risk of dislocation. The solution for prevention of iliopsoas impingement would be to adapt cup design to acetabular anatomy, which may require different implants for the right and left sides, and hence a doubled inventory.

In with the new, out with the old? Comparison of two approaches for psoas compartment block

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.