Hip Arthroscopy for the Painful Hip Arthroplasty Victor M - - PowerPoint PPT Presentation

Hip Arthroscopy for the Painful Hip Arthroplasty

Victor M Ilizaliturri Jr., MD National Rehabilitation Institute of Mexico

Disclosure

• Victor M. Ilizaliturri Jr. MD.

–Consulting income from:

–Conmed-Linvatec –DePuy Synthes –Zimmer Biomet

–Research support from: – Conmed-Linvatec. –DePuy Synthes.

Introduction

• Up to 4.3% of the patients with anterior hip pain

after THR may be due to iliopsoas impingement.

• Posterior hip pain must study offset reconstruction,

HO, probable isquiofemoral impingement.

• Iliopsoas impingement after THR constitutes a

differential diagnosis.

• Cup must be stable.
• Infection must be ruled out.
• MARS MR and/or Ion level analysis.
• Metal on metal ion levels.
• Taper corrosion.

Dora, JBJS, Br, 2007

Diagnosis

• Persistent anterior hip pain after THR.
• Tenderness in groin.
• Pain in activities that require hip flexion.
• Climb stairs.
• Exit a car.
• Pain relief after US guided injections.

US Guided Iliopsoas Injection

Imaging

• AP Pelvis View.
• Lateral acetabular view.

Chalmers, JBJS, 2017

Imaging

• CT

Dora, JBJS, Br, 2007

Treatment

• Dora et al. JBJS Br 2007.
• Psoas impingement after THR, conservative vs cup revision vs open

tenotomy

• 29 patients, 30 hips.
• 8 conservative treatment (All failed no symptom improvement one cup

revision) mean F/U 41 months.

• 22 operative treatment.
• Revision 14. High incidence of complications, 1 trochanteric non-union, 1 anterior

dislocation, 1 superficial infection, 5 troch bursitis, 1 unexplained neuropathic pain, multiple revisions and deep infection (resection arthroplasty).

• Tenotomy 6. All patients improved at three months, one patient presented HO and

symptom recurrence after 18 months. Mean f/U 36 months.

Treatment

Treatment

• Dora et al, JBJS Br 2007.

Treatment

• Jerosch, Arch Orthop Trauma Surg, 2013.
• Psoas impingement after THR.
• 35 patients, supine endoscopic release,

anterior capsulotomy, traction.

• 12 resurfacing, 11 screw in uncemented

cups and 12 uncemented pressfit cup.

• 15 cases secondary to DDH.
• 3 cases protrusion of the anterior cup was
• nly identified at arthroscopy.

Treatment

• 32 of 35 patients presented immediate pain

relief after endoscopic release of the iliopsoas.

• One patient had pain relief at 6 weeks and
• ne remained symptomatic but referred

improvement over preoperative status

Treatment

• Batailler el al, Orthopaedics &

Traumatology: Surgery & Research (in press).

• Cup revision for iliopsoas

impingement after THR.

• Multicentre retrospective study (10

surgeons, 4 centres), 46 patients.

• Anterior cup un-coverage at foux

profile and CT.

• 11 had also release of the iliopsoas

because of tendon injury or protrusion of the new cup (lack of anterior wall).

Treatment

• Mean hospital stay after cup revision 6 nights (4-15).
• 40 patients full weight bearing, 6 toe touch because of suboptimal stability
• f new cup.
• Mean F/U 21 months (6 months to 6 years).
• 39 were satisfied at last F/U with significant improvement of Oxford Hip

Score.

• 4 Failures because of recurrent pain.
• 1 full improvement after endoscopic iliopsoas release at lesser trochanter.
• Other 3 accepted to live with slight pain.
• Complications in 3 patients.
• 1 deep vain thrombosis, 1 anterior dislocation (revised through anterior approach)

and 1 deep infection (2 stage revision).

Treatment

• Chalmers et al, JBJS 2017.
• Retrospective analysis of patients with diagnosis of painful THR due to

iliopsoas impingement (hemispherical uncemented cup and PE bearing).

• 49 patients included, 21 cup revision, 8 tenotomies and 20 non operative.

Mean F/U 4 years.

• Measurements of acetabular prominence was done in true lateral x rays.
• 10 patients were successful in non operative group (50%).
• With les than 8mm anterior cup prominence tenotomy was successful in 5
• f 5 patients.
• More than 8mm anterior cup prominence cup revision was successful in 12
• f 13 patients and tenotomy in one of 3 patients.

Treatment

Chalmers, JBJS, 2017

My approach

• Release at the lesser trochanter.
• Access portals for iliopsoas bursa.
• No traction, lateral position.
• No implant assessment.
• Fluoro navigation to lesser

trochanter.

• RF retrograde release at lesser

trochanter.

Treatment, Iliopsoas Release

• Protruding cup anteriorly (<8mm).
• Lateralized cup.
• Large cup.
• Slight retroversion without instability.
• No metal on metal implant.

Treatment Acetabular Revision.

• Grossly malposition of implant.
• Protruding more than 8mm.
• DDH (anterior wall deficient).
• Very large or very lateralized).
• Retroverted.
• Implant impingement.
• Dislocation.
• Metal on metal implants

increased ion levels or poor track record.

Treatment

• Iliopsoas impingement with anterior uncemented cup prtrusion.
• 1 mal positioned ring.
• Endoscopic release at lesser trochanter.
• 16 patients.
• 1 failure.

Summary

• Psoas impingement is a differential diagnosis.
• Anterior hip pain after THR.
• Not loose not infected.
• US guided injections.
• Focal anterior protrusion of less than 8mm maybe a good option for

iliopsoas release.

• Endoscopic release is a great option (lesser trochanter).
• Grossly mal-positioned implants require cup revision.
• Cup revision has more morbidity than tenotomy.

Gracias vichip2002@yahoo.com.mx