Ultrasound-guided Tenotomy and Osteectomy for the Treatment of Iliopsoas Impingement Post-total Hip Replacement

I liopsoas impingement is a common cause of groin pain posttotal hip replacement (THR) and has a reported incidence as high as 8.3%.1 Iliopsoas impingement causes ill-defined groin pain which is worsened by active hip flexion. Pain exacerbated by activities such as walking up stairs and lifting the leg in and out of a motor vehicle can be helpful diagnostic clues. The most common site of impingement is at the acetabular cup where there is friction with the deep aspect of the iliopsoas tendon. The iliopsoas tendon is positioned immediately anterior to the hip, separated from the capsule only by the iliopsoas bursa. Causes of impingement include bony excrescence, cement extrusion, a Rouviere’s sulcus, inadequate implant anteversion, or projecting studs or screws, excessive size of reinforcement ring, or by an increase in hip offset or hip length ≥ 1 cm.1 We describe iliopsoas tendon impingement secondary to bony excrescence. Conservative management of iliopsoas tendon impingement includes ultrasound (US)-guided anesthetic/corticosteroid injections, activity modification and nonsteroidal anti-inflammatory medications are often initially trialed. After conservative management options fail, surgical alternatives such as open or arthroscopic psoas tenotomy and revision hip arthroplasty can reliably improve the patient’s symptoms. Open surgical procedures however carry a higher risk of infection, accrue longer hospital and recovery periods,2 and arthroscopic procedures have increased risk of neurovascular damage. The use of US is gaining traction in orthopedic procedures, with some utilizing its benefits for placement of portal placement in hip arthroscopies.3 We propose US-guided tenotomy and ostectomy for management of ilipsoas impingement post-THR as it provides a less invasive option with reduced hospital stay and recovery time. TECHNIQUE