Orthopedics

Case Reports 

Iliopsoas Cyst Causing Persistent Pain After Total Hip Arthroplasty

Markus Wuenschel, MD; Beate Kunze, MD

Abstract

Persistent pain after total hip arthroplasty (THA) has many potential causes. The most common are aseptic loosening, infection, and heterotopic ossification. Irritation of the iliopsoas tendon due to the acetabular component is an underestimated cause of persistent groin pain and functional disability after THA with rare incidence. Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs). This article presents a case of a 50-year old man with clinical and radiological signs of osteoarthritis of the right hip joint. A THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Finally, magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve causing an iliopsoas tendonitis. The patient was taken to the operating room and surgical resection of the cyst was performed by an anterior approach; a conjunction to the hip joint was not present. The implanted components of the prosthesis showed good osseointegration with no signs of loosening. The cyst was removed and the iliopsoas tendon was released. A few weeks after the operation, the patient was pain free. At 17-month follow-up, no problems were reported. In cases such as this, finding the correct diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.

The most common causes of persistent pain after total hip arthroplasty (THA) are aseptic loosening, infection, heterotopic ossification, irritation of the greater trochanter, and referred pain from the spine or knee.1-3 Soft tissue irritation and impingement of the iliopsoas tendon due to the acetabular component are underestimated causes of persistent groin pain and functional disability after THA with rare incidence.4 Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs).3,4

Diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.

A 50-year-old man presented with clinical and radiological signs of osteoarthrosis of the right hip joint and a cementless THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Certain movements, such as getting up to an upright position, worsened the pain. Other weight-bearing activities did not aggravate the symptoms.

Clinical examination revealed no rotational or strain pain, but a painful arc after forced flexion over 70°. No suspicious swelling in the groin could be observed and an abdominal hernia was excluded.

Native radiographs and computed tomography (CT) scans showed a well-positioned and osseointegrated THA with no anterior overhang of the acetabular cup or malpositioning (Figures 1, 2). An aspiration puncture of the right hip ruled out an infection. Scintigraphy displayed no pathological findings. Finally, magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve (Figure 3).

The patient underwent resection of the cyst via an anterior approach. Intraoperatively, it became obvious that the cyst was originating from the iliopsoas tendon muscle (Figure 4) and in direct contact to the femoral nerve, thus becoming irritated. A conjunction to the hip joint was not present. The implanted prosthetic components showed good osseointegration with no signs of loosening. A minimal ventral overhang of the inlay due to its design was observed (Figures 1, 2). The cyst was removed and the tendon was released.

Histopathological examination disclosed synovial tissue on a neomembrane typical for a…

Abstract

Persistent pain after total hip arthroplasty (THA) has many potential causes. The most common are aseptic loosening, infection, and heterotopic ossification. Irritation of the iliopsoas tendon due to the acetabular component is an underestimated cause of persistent groin pain and functional disability after THA with rare incidence. Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs). This article presents a case of a 50-year old man with clinical and radiological signs of osteoarthritis of the right hip joint. A THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Finally, magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve causing an iliopsoas tendonitis. The patient was taken to the operating room and surgical resection of the cyst was performed by an anterior approach; a conjunction to the hip joint was not present. The implanted components of the prosthesis showed good osseointegration with no signs of loosening. The cyst was removed and the iliopsoas tendon was released. A few weeks after the operation, the patient was pain free. At 17-month follow-up, no problems were reported. In cases such as this, finding the correct diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.

The most common causes of persistent pain after total hip arthroplasty (THA) are aseptic loosening, infection, heterotopic ossification, irritation of the greater trochanter, and referred pain from the spine or knee.1-3 Soft tissue irritation and impingement of the iliopsoas tendon due to the acetabular component are underestimated causes of persistent groin pain and functional disability after THA with rare incidence.4 Pain specific to iliopsoas tendonitis includes activities such as hyperextension of the hip, forced flexion, and activities of daily living (eg, ascending stairs).3,4

Diagnosis may be difficult and misleading. Conservative and operative therapeutic options are discussed and compared with divergent findings in the literature.

Case report

A 50-year-old man presented with clinical and radiological signs of osteoarthrosis of the right hip joint and a cementless THA was performed. After a symptom-free interval of several weeks postoperatively, the patient reported pain projecting from the right groin and radiating ventromedially along the leg. Certain movements, such as getting up to an upright position, worsened the pain. Other weight-bearing activities did not aggravate the symptoms.

Clinical examination revealed no rotational or strain pain, but a painful arc after forced flexion over 70°. No suspicious swelling in the groin could be observed and an abdominal hernia was excluded.

Native radiographs and computed tomography (CT) scans showed a well-positioned and osseointegrated THA with no anterior overhang of the acetabular cup or malpositioning (Figures 1, 2). An aspiration puncture of the right hip ruled out an infection. Scintigraphy displayed no pathological findings. Finally, magnetic resonance imaging of the hip showed a fluid-filled cyst in anatomical proximity to the femoral nerve (Figure 3).

Figure 1 Figure 2
Figure 1: Native mediolateral radiograph 3 months after THA. Abbreviation: R, right. Figure 2: CT of the pelvis showing a good position and osseointegration of the cup 4 months postoperatively.

Figure 3
Figure 3: MRI of the pelvis (axial reconstruction) showing a fluid-filled cyst (*) originating from the iliopsoas tendon and is connected to the femoral nerve (N) 2 years postoperatively. Abbreviations: A, artery; V, vein.

The patient underwent resection of the cyst via an anterior approach. Intraoperatively, it became obvious that the cyst was originating from the iliopsoas tendon muscle (Figure 4) and in direct contact to the femoral nerve, thus becoming irritated. A conjunction to the hip joint was not present. The implanted prosthetic components showed good osseointegration with no signs of loosening. A minimal ventral overhang of the inlay due to its design was observed (Figures 1, 2). The cyst was removed and the tendon was released.

Figure 4
Figure 4: Intraoperative situs with fluid-filled cyst originating from the iliopsoas tendon muscle.

Histopathological examination disclosed synovial tissue on a neomembrane typical for a cyst with no signs of malignancy.

Postoperative full weight-bearing activities were allowed. Wound healing was without complications. The patient was pain free a few weeks postoperatively. At 17-month follow-up, the patient remained symptom free. Clinical examination at that time revealed a normal range of motion without local pressure pain. Activities of daily living as well as sports (eg, bicycling, taking a walk) were possible with no problems.

Discussion

Multiple differential diagnoses of groin pain after THA exist. Soft tissue irritation and impingement of the iliopsoas tendon is an underestimated cause of persistent groin pain and functional disability after THA. An oversized acetabular cup, protruding screws, or bone cement may cause iliopsoas impingement. A relationship was also seen depending on the used material combination.5 Ala Eddine et al4 reported an incidence of postoperative iliopsoas tendonitis of 4.3%. Pain specific to iliopsoas irritation included activities such as hyperextension of the hip, forced flexion, active raising of the straightened leg, and activities of daily living (eg, ascending stairs).3,4 A relationship to weight-bearing activities is uncommon and differentiates this entity from component loosening.

The delayed symptoms seem to be variable, but a pain-free period occurs after the primary surgical procedure.4

Diagnosing iliopsoas tendonitis may be difficult. Different imaging modalities (eg, radiograph, ultrasound, CT) may be helpful to rule out bursitis, malposition of components, or aseptic loosening. Magnetic resonance imaging is the most sensitive study to determine soft tissue pathologies despite frequent artifacts due to metallic implants.6,7

In our patient, the components had a good position and were well osseointegrated with no anterior overhang or malpositioning of the acetabular cup.

To confirm the diagnosis, local steroid and anaesthetic injections of the iliopsoas bursa are possible. A study from Nunley et al8 found an improvement of the Harris Hip score and pain relief after local injections, but nonsurgical treatment may not solve the problem. Therefore, different surgical procedures such as tenotomy of the iliopsoas or revision of the acetabular component are possible with good functional outcomes.9-11 Especially in rare patients like the one presented, with local cysts as the cause of persistent pain, surgical resection should be performed.

Iliopsoas tendonitis should be considered in the differential diagnosis of all patients with the presented symptoms. Other causes (eg, infection, aseptic loosening) should be ruled out. Correct cup position and size are necessary to avoid anterior overhang and impingement symptoms. Malpositioning of the acetabular cup can be detected by radiograph or CT, but malposition may not necessarily be the cause of a diagnosis such as in our patient, where the design of the acetabular inlay was the cause of pain. Temporary pain relief can be achieved by local injections. For final therapy, a surgical treatment, consisting of the release of iliopsoas tendon alone with removal of possible cysts or in combination with acetabular revision for an anterior overhanging component is recommended.

References

  1. Nolan DR, Fitzgerald RH Jr, Beckenbaugh RD, Coventry MB. Complications of THA treated by reoperation. J Bone Joint Surg Am. 1975; 57(7):977-981.
  2. Postel M. Les prothèses douloureuses. Les causes possibles. Rev Chir Orthop Reparatrice Appar Mot. 1975; 61(Suppl II):57-61.
  3. Jasani V, Richards P, Wynn-Jones C. Pain related to the psoas muscle after total hip replacement. J Bone Joint Surg Br. 2002; 84(7):991-993.
  4. Ala Eddine T, Remy F, Chantelot C, Giraud F, Migaud H, Duquennoy A. Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and conservative treatment in 9 cases. Rev Chir Orthop Reparatrice Appar Mot. 2001; 87(8):815-819.
  5. Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ. The Prevalence of groin pain after metal-on-metal total hip arthroplasty and total hip resurfacing. Clin Orthop Rel Res. 2010; 468(9):2346-2356.
  6. Cyteval C, Sarrabère MP, Cottin A, et al. J Comput Assist Tomogr. 2003; 27(2):183-188.
  7. Potter HG, Nestor BJ, Sofka CM, Ho ST, Peters LE, Salvati EA. Magnetic resonance imaging after total hip arthroplasty: evaluation of periprothetic soft tissue. J Bone Joint Surg Am. 2004; 86(9):1947-1954.
  8. Nunley RM, Wilson JM, Gilula L, Clohisy JC, Barrack RL, Maloney WJ. Iliopsoas bursa injections can be beneficial for pain after total hip arthroplasty. Clin Orthop Rel Res. 2010; 468(2):519-526.
  9. Dora C, Houweling M, Koch P, Sierra RJ. Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision. J Bone Joint Surg Br. 2007; 89(8):1031-1035.
  10. Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009; 17(6):337-344.
  11. O’Sullivan M, Tai CC, Richards S, Skyrme AD, Walter WL, Walter WK. Iliopsoas tendonitis a complication after total hip arthroplasty. J Arthroplasty. 2007; 22(2):166-170.

Authors

Drs Wuenschel and Kunze are from the Orthopedic Department, University Hospital Tüebingen, Germany.

Drs Wuenschel and Kunze have no relevant financial relationships to disclose.

Correspondence should be addressed to: Beate Kunze, MD, Department of Orthopedics, Eberhard Karls University Tübingen, Hoppe-Seyler-Str 3, 72076 Tübingen, Germany.

doi: 10.3928/01477447-20110317-25

10.3928/01477447-20110317-25

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