Anterior Revision Arthrolasty for Psoas Iingeent – FESCH.TV

FESCH.TV INFORMIERT:

Psoas tendinitis or iliopsoas tendinitis is a massive subject. There are numerous causes that have been described and numerous etiologies. You can spend hours talking about different surgical approaches or some of the potential anatomic factors that lead to this problem. But when we are talking about some of the etiologies of psoas tendinopathy relating to component impingement upon the psoas tendon, I think there’s some advantages to the anterior approach for revision.

I’d like to present a couple of cases as they relate to this. The first one here is a 54-year-old morbidly obese male manual labor for a workman’s comp related injury with a total hip performed for osteoarthritis. He presented after being seen at numerous locations for persistent groin pain with activities – specifically hip flexion climbing stairs, climbing ladders, and climbing to get in and out of the cab of his truck. When you look at his AP radiograph, it doesn’t look too bad. You can get fooled just by looking at this one view and think the component is well positioned. But when you look at the cross table lateral image, you see that there’s a fair amount of anterior overhang. The component appears to be slightly retroverted so it’s interesting that he’s stable and he hasn’t dislocated his hip yet.

I think this is the case for a lot of large diameter articulations. We know that in dual mobility constructs, there is a slightly higher rate of psoas impingement. The hip is more tolerant of malposition from the standpoint of dislocation, but more susceptible to cup overhang due to the large acetabular component required.

Some of the tools that have been effective in helping me manage this problem are both the explant device and the modified explant device. Here are the modified versions of that explant device which we actually described back in 2012 in a JBJS supplement. Specifically, modifying the handles about 45 degrees gives you a little bit more access to the posterior or ischial portion of the acetabular component. In this particular case, that becomes important because if you’re just working anteriorly, you’re going to bottom out the explant device on the acetabulum and you will not be able to access fully posteriorly along the cup without some sort of offset. You can make it work, but you risk some bone loss and I think this is a good way of addressing that. And as seen in this case, if you can get the component out without much bone loss you can go back in with a primary cup, and the remainder of the radiograph looks like a primary case. In this case, the patient did well with this procedure and had complete resolution of symptoms by approximately six weeks and he was back at full duty by three months.

A component doesn’t necessarily have to be grossly mispositioned ie retroverted for it to cause impingement. This is another case where you have seemingly good component position. However when you have a slightly dysplastic hip and you template based on the AP radiograph, you can sometimes miss acetabular cup overhang as a consequence of too large an acetabular component. This patient had a CT scan, where you can actually see the component overhang, and its impingement upon the psoas tendon. So, this case is addressed in a similar fashion. The first step is to perform the approach and identify the pathology. We use an explant device to work the interface between the acetabular component and the bone. After removal of this 52 millimeter shell we were actually able to go back in with a 48 reamer and both medialize and proximalize the hip center just slightly to bury the acetabular component. And in this case, a multi-hole 48 millimeter shell was placed in an acetabulum that previously accommodated a 52 millimeter shell.

One of the advantages of the anterior approach is that Itallows direct fluoroscopic control of this maneuver, and the ability to dial in the ideal acetabular component position based upon anatomic landmarks, as well as radiographic references. In this case the Velys system was utilized. We accepted a slightly increased anteversion to really make sure that anterior cup was hidden well beneath the acetabular rim..

And here’s the clinical photo, with the acetabular component now well recessed underneath the acetabular rim. With the acetabular component in the ideal position we minimize some of the risk of impingement of the skirted neck. The cross table lateral really does demonstrate the change in the amount of acetabular component overhang. So, as you would expect when you address the relevant patho-anatomy, you’re going to see improvement of the symptoms. In this case the patient had complete resolution of symptoms by six weeks. At this point, she’s doing well but still on very short term follow up.

Please feel free to reach out with any questions. Thank you.