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Findings Radiographs show a prominent overhang of the cup of a THA particularly on the AP pelvis view. There is a questioned overhang of the cup on the cross table lateral view. MRI shows moderate fluid distention of the iliopsoas bursa and the uncovered anterior aspect of the cup abutting/impinging upon the traversing iliopsoas tendon. The CT exam shows more clearly the prominent overhang of the cup in both the axial and sagittal planes. The oblique sagittal reformation image shows a retroversion of the cup.
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Diagnosis: Iliopsoas Impingement Following Total Hip Arthroplasty Although uncommon, an etiology that needs to be thought of particularly in the setting of anterior groin pain following THA. Many factors are though to be contributory to the development of this entity including approach during surgery, positioning of the cup in a less amount of anteversion than classically described as the safe zone of Lewinnek of 5 to 25 degrees, decreased cup inclination of the classic 30 to 50 degrees, overhang in the axial and sagittal planes (varying in the literature but often quoted as 12mm axial and 8mm sagittal), and increased size of the cup relative to the native femoral head (> 6mm difference). Patients presenting with anterior pain and corresponding imaging findings for iliopsoas impingement often benefit from conservative measures including ultrasound guided injection. If symptoms are recalcitrant, iliopsoas tenotomy can be performed. However, as in this case, if there is a marked degree of overhang, revision of the cup may be necessary. This patient is scheduled for revision procedure of the cup.
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References Iliopsoas Impingement After Direct Anterior Approach Total Hip Arthroplasty: Epidemiology, Risk Factors, and Treatment Options. Leonard T. Buller, MD Luke G. Menken, DO Evan J. Hawkins, MD, BA Gilbert C. Roc Jr., MD H. John Cooper, MD Jose A. Rodriguez, MD. The Journal of Arthroplasty. December 12, 2020 DOI:https://doi.org/10.1016/j.arth.2020.12.01 Risk Factors and Cup Protrusion Thresholds for Symptomatic Iliopsoas Impingement After Total Hip Arthroplasty: A Retrospective Case-Control Study. Takuro Ueno, MD Tamon Kabata, MD, PhD Yoshitomo Kajino, MD, PhD Daisuke Inoue, MD, PhD Takaaki Ohmori, MD Hiroyuki Tsuchiya, MD, PhD. The Journal of Arthroplasty. May 17, 2018 DOI:https://doi.org/10.1016/j.arth.2018.05.017 What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone for Acetabular Component Position. Matthew P. Abdel, MD, Philipp von Roth, MD, Matthew T. Jennings, BS, Arlen D. Hanssen, MD, and Mark W. Pagnano, MD. Clin Orthop Relat Res. 2016 Feb; 474(2): 386– 391. Published online 2015 Jul 7. doi: 10.1007/s11999-015-4432-5 Iliopsoas Impingement After Primary Total Hip Arthroplasty: Operative and Nonoperative Treatment Outcomes. Brian P Chalmers 1, Peter K Sculco, Rafael J Sierra, Robert T Trousdale, Daniel J Berry. J Bone Joint Surg Am. 2017 Apr 5;99(7):557-564. doi: 10.2106/JBJS.16.00244.
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