Tenotomy of the iliopsoas ( tendon release )

YES. November 2017.

I had a right hip replacement 1/2017. Recovery went well, was bicycling by 6 weeks. I had nothing but good initially – no problems walking level or uphill or lifting my leg. Jump ahead 19 months to 8/2018. I was playing badminton and fell as I was going backwards. I landed on my back, with my hips flexed. No immediate pain, I even went back to playing, but over the next 2 days I had increasing difficulty with flexing my right hip. Over a month it got to the point that when I would get into a car from the right side, I had to lift my right leg manually. This is called “the car sign.” Also, in order to put on shoes, socks or paints, I had to sit down and lift my leg up by hand. I saw my ortho surgeon, who say it was iliopsoas tendinitis, and told me to avoid doing any movements that hurt, and to take anti-inflammatory, such as naproxen 500mg twice a day. He told me it gets better in 2 weeks to 6 months. If it wasn’t better in 6 months, he could recommend radiologically-guided steroid injection. He does not perform psoas release surgery, or psoas lengthening surgery. He also looked at the plain x-ray and said that there was nothing wrong with my acetabular cup position.

After four months, I was not getting better functionally. I did some reading, and I will posted below, or in a second posting if it is too long, medical literature search. Brief findings:

1. its damage from the scar tissue rubbing over the edge of the acetabular cup, not inflammation, so the anti-inflammatories don’t really help. There is a study that looked at anti-inflammatories and steroids, and found that they were not helpful towards long-term recovery.
2. some docs recommend advanced radiology, using ultrasound or CT to determine if there is an acetabular cup impingement. One surgeon recommends tendon release or lengthening if the impingement is less than a certain amount, and acetabular cup revision only if the impingement is greater than a certain amount, because acetabular cup revision is much more major surgery than tendon release.

   Disappointed that my surgeon did not was to consider surgery, and did not even want to use advanced radiology to look at the impingement, I did what I could. Under the theory that psoas tendon release or lengthening could be avoided if I lengthened the tendon by stretching it, I began yoga, and iliopsoas stretching. There are a number of videos on YouTube on how to stretch the psoas, but the best for me was the Warrior 1 position, which is a standing psoas stretch. I started to do that and my symptoms got a lot better over 6 weeks. Now, I do not need manual assistance to dress or get into the car. When I stand, I can flex my left (good) hip 135 degrees, and my right hip only 90 degrees. So I’m not at the end of the program yet. But at this point, I wouldn’t want either surgery or injection.

   References on a separate post.

See my prior posting today. Here are references:

1. Treatment of Iliopsoas Tendinitis after a Left Total Hip Arthroplasty with Botulinum Toxin Type A Fish DE and Chang WS (2007). Pain Physician 2007; 10:565-571 • ISSN 1533-3159 Conclusion: The use of botulinum toxin A provided significant pain relief, functional improvement, and may represent an alternative to the surgical management of iliopsoas tendinitis.2. Iliopsoas Bursa Injections Can be Beneficial for Pain after Total Hip Arthroplasty 3. Nunley R, Wilson R et al. Published online: 23 October 2009 Abstract Impingement of the iliopsoas tendon is an uncommon cause of groin pain after total hip arthroplasty (THA). We asked whether selective steroid and anesthetic injections for iliopsoas tendonitis after THA would relieve pain and improve function. We retrospectively reviewed 27 patients with presumed iliopsoas tendinitis treated by fluoroscopically guided injections of the iliopsoas bursa. Pre- and immediately post-injection, questionnaires and telephone followup questionnaires were administered to determine patient outcomes. Four patients were lost to followup and we were unable to obtain information from relatives on an additional four; the questionnaire was administered to the remaining 19 patients, including six who subsequently had surgery at an average of 44.6 months (range, 25–68 months) after their first injection. The average modified Harris hip score in the 19 patients improved from 61 preinjection to 82 postinjection and the average pain improved from 6.4 preinjection to 2.9 postinjection, but eight patients (30%) required a second injection at an average of 8.2 months after the first injection. Ultimately, six patients (22%) had an additional surgical procedure to address the underlying cause of the iliopsoas irritation. Iliopsoas tendonitis is uncommon after THA but should be considered in the differential diagnosis of all patients who present with groin pain after THA. Selective steroid and anesthetic injections of the iliopsoas bursa give adequate pain relief in the majority of patients and should be considered part of the nonoperative treatment plan before surgical release of the iliopsoas tendon or component revision. 4. Anterior Iliopsoas Impingement and Tendinitis After Total Hip Arthroplasty. Poster. Anterior iliopsoas impingement and tendinitis is a poorly understood. It is likely under recognized cause of groin pain and functional disability after THR. It may be the cause of painful THA in up to 4.3% of patients. The symptoms are frequently subtle. The diagnosis may be confirmed by one or more imaging studies, including a cross‐table lateral radiograph, computed tomography, magnetic resonance imaging, and ultrasonography, in combination with a confirmatory diagnostic injection. Nonsurgical management may not resolve the problem. Surgical treatment, consisting of release or resection of the Iliopsoas tendon, alone or in combination with acetabular revision for an anterior overhanging component, usually provides permanent pain relief. Persistent pain after primary total hip arthroplasty (THA) is uncommon. The possible causes are various, including infection, component loosening, and periprosthetic osteolysis resulting from the presence of wear debris. It is important to consider anterior impingement. Pain resulting from anterior Iliopsoas impingement and tendinitis may be related to a prominent or malpositioned acetabular component. Although the Iliopsoas tendon is considered to be extra‐articular, if the anterior capsule has been divided or resected during a THA, the tendon is then intra‐articular. This muscle serves as the major flexor of the hip and has a lesser role in hip external rotation. Affected patients typically report persistent groin pain that is exacerbated by stair climbing, getting into and out of bed, rising from a seated position, and entering and exiting an automobile. Rarely, patients describe a snapping or "clunking" sensation. The onset of these symptoms has been described from 1 to 96 months after THA. With significant bursitis, a palpable mass may be detected. The pain may be reproduced or exacerbated by resisted seated hip flexion or straight leg raise. Pain may also occur with passive hyperextension as well as with active external rotation and extension of the hip. Diagnosis 1.Persistent groin pain after THA: infection, aseptic loosening, and occult periprosthetic fracture. 2. If anterior Iliopsoas impingement and tendinitis are suspected, further diagnostic evaluation is recommended. This should include one or more imaging studies: plain radiography, computed tomography (CT), MRI, or ultrasonography. A diagnostic injection test is nearly always warranted. Plain radiographs should include anteroposterior views of the pelvis and hip, as well as a cross‐table (ie, "shoot‐through") lateral view of the hip. The acetabular component should be evaluated for loosening, pelvic osteolysis, prominent intrapelvic screws, and retained cement as sources of mechanical irritation. CT has been used to measure acetabular component version and to detect how much of the acetabular component is uncovered anteriorly, as well as to detect iliopsoas tendon or bursal hypertrophy. Acetabular component prominence >12 mm was seen on CT in eight cases with anterior iliopsoas impingement syndrome. MRI is infrequently used to view a prosthetic hip joint, and an MRI scan may be difficult to evaluate because of depreciation of signal quality and periprosthetic soft tissues. However, when the authors of one study implemented new software algorithms for MRI evaluation of pelvic osteolysis and the soft tissues adjacent to prosthetic hip joints, MRI scans demonstrated fluid collection and increased signal intensity in the periprosthetic soft tissues. Ultrasonography has been described in several studies as helpful in the diagnosis and treatment of anterior Iliopsoas impingement and tendinitis.In the hands of an experienced radiologist, ultrasonography has been reported to show a greater degree of soft‐tissue contrast than have either CT scans or plain radiographs. The most frequently reported technique for the evaluation of anterior Iliopsoas impingement and tendinitis is an image‐guided diagnostic injection of contrast material into the Iliopsoas tendon sheath. Nonsurgical Treatment: Rest, analgesics, nonsteroidal anti‐inflammatory drugs, and physical therapy. Although the injection of a local anaesthetic and corticosteroid into the Iliopsoas tendon sheath is helpful for diagnosis and temporary pain relief, most patients require surgical treatment to achieve successful resolution of symptoms caused by anterior Iliopsoas impingement and tendinitis. Release or resection of the Iliopsoas tendon is the simplest procedure. A posterior approach with a 4‐cm incision from the tip of the greater trochanter to the vastus tubercle. The femur is internally rotated. Electrocautery is used to release the quadrates femoris muscle until the lesser trochanter can be palpated. With the leg in maximum internal rotation, the psoas tendon is palpated and released from the lesser trochanter with electrocautery, using a bent tip. A curved 1‐cm osteotome is then used to release the anterior and medial capsule from the femoral neck. Intravenous antibiotics are administered for 24 hours postoperatively, and the patient is allowed full weight bearing with one support. Another report described the use of an anterolateral or direct lateral approach. Acetabular revision is usually recommended when the preoperative plain radiographs or CT scan demonstrate that the anterior edge of the acetabular component protrudes in front of the anterior bony acetabular rim. 5. Arthroscopic Technique for Iliopsoas Fractional Lengthening for Symptomatic Internal Snapping of the Hip, Iliopsoas Impingement Lesion, or Both. Chandrasekaran S et al (2018).. Abstract: Pathology of the iliopsoas may cause painful internal snapping of the hip or labral damage from soft impingement. Favorable outcomes have been reported after arthroscopic release or fractional lengthening of the iliopsoas. In patients with risk factors for instability, restoration of other soft-tissue constraints such as the labrum and capsule should be performed if iliopsoas fractional lengthening is undertaken. The purpose of this article is to detail the step-bystep surgical technique of arthroscopic iliopsoas fractional lengthening, in addition to the indications, pearls, and pitfalls of the technique. Conclusion: An arthroscopic IPFL at the level of the hip joint is achieved through extension of the medial capsulotomy. Theoretically, it should not reduce hip flexion strength as much as a complete tenotomy more distally. IP lengthening creates a communication between the hip joint and peritoneal cavity and fluid extravasation needs to be monitored. Restoration of labral and capsular function is important to minimize complications in patients with instability. 6. Surgical Release of Iliopsoas Tendon for Groin Pain After Total Hip Arthroplasty. Heaton K. Dorr L (2002). J Arthroplasty 17( 6). Balancing of the soft tissues around the hip during THA has been described previously [6,7]. Proper soft tissue tension remains as important as correct positioning of the components. Even with proper placement of the acetabulum and appropriate soft tissue balancing, patients occasionally may develop iliopsoas tendinitis. Conservative treatments should be attempted initially, including anti-inflammatory medication, physical therapy, and injections with corticosteroids and local anesthetics. If nonoperative treatment is not successful, patients benefit from surgical release. This operation is simple and can be performed through a small segment of the previous surgical incision. In our experience, these patients obtain substantial pain relief with no perceived impairment of strength or function. The treatment of iliopsoas tendon release is a much simpler operation for the surgeon and the patient than revision of the cup and should be tried initially. If the cup is determined to be in retroversion or is laterally placed on the radiograph, which means the anterior wall can be prominent above the bony wall, release of the iliopsoas tendon can be curative. If the patient is dislocating, the cup should be revised rather than the tendon released. 7. Summer 2015 | Vol 14 • No 4 Page 47 Iliopsoas tendon impingement following total hip replacement surgery. Riemer B et al. (2015). SA Orthopaedic Journal. We have recently seen and successfully treated four patients with iliopsoas-related groin pain post total hip replacement. Their clinical pictures were all typical of iliopsoas-related groin pain. After the exclusion of other causes, surgical release of this tendon resulted in successful treatment with complete resolution of symptoms. We subsequently carried out an anatomic dissection of the iliopsoas tendon on a cadaver torso to better understand the relationship between the iliopsoas tendon and the acetabular component in total hip replacement surgery. It was apparent that cup position and placement were critical to prevent contact of the iliopsoas tendon with the rim of the acetabular component. We have subsequently modified our positioning of the acetabular component.

I apologize for this long post but I am wondering if anyone has an opinion on the following:

At the last my appointment with my surgeon on Aug. 8th. and in response to the psoas impingement of my left hip (surgery Nov. 2017, which I have described in previous posts) he suggested that I should have my entire hip removed without replacement!

During my appointment: He did not explain in any way all, anything about this drastic surgery or how it would affect me in the future, telling me to google 'Girdlestone arthroplasty'.

Several times he reiterated the phrases “Well if it isn’t working for you and you have pain, better to just take it out” and "Well I don’t know what’s wrong, let’s just take it out"

At my previous appt. Dr. H. had seen the results of the MARS MRI and knew perfectly well what was wrong. The procedure that he now suggested is akin to amputating a leg because of an ingrown toe nail.

I can’t help but feel that his suggestion of a drastic procedure that would essentially cripple me for life, one that is used very rarely and usually in cases of massive life threatening infection, was prompted by anger at a fax that I had sent him (polite but not happy) and the image of the new hip implant done by another surgeon and was an extraordinarily unprofessional, passive aggressive attempt to scare and upset me and to get me to go away.

I would love to know if this procedure has ever been suggested to anyone else.

Some examples from my Google search:

Results of a previous study of 21 patients who underwent conversion of infected total hip arthroplasties to Girdlestone resection arthroplasties suggested that Girdlestone resection arthroplasty provides a functionally poor salvage technique and is often painful.

The Girdlestone procedure is a type of surgery performed on individuals experiencing severe, painful hip conditions, and is generally only used in circumstances where no other options are viable.

Although the Girdlestone procedure is effective in addressing joint pain, the most prominent downside is that it leaves the affected limb shorter than the other, meaning the patient will require crutches or a cane to walk postoperatively. In more severe cases, the patient will become reliant on a wheelchair. The leg will also be locked into a straight position as it can no longer bend at the hip, hampering movement.

Any decision to undergo this type of surgery will therefore need to balance their mobility requirements with their current level of pain.It is also worth noting that issues can occur during the Girdlestone procedure: for example, the joint cavity may become infected and sealed off, or the sciatic nerve could be injured.

The purpose of the Girdlestone procedure is to decrease the pain and to preserve the life of the patient despite the considerable shortening of the extremity. It is an alternative to hospice or alternative care. It is the simplest and the least complex procedure for the patient. Counseling should be provided to the patient and their family.