iliopsoas impingement after primary total hip...

Iliopsoas Impingement After Primary TotalHip Arthroplasty: Operative and Nonoperative

Treatment OutcomesBrian P. Chalmers, MD, Peter K. Sculco, MD, Rafael J. Sierra, MD, Robert T. Trousdale, MD, and Daniel J. Berry, MD

Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

Background: A potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoastendon. Treatment options include conservativemanagement, tenotomy, and acetabular revision, but the literature, to ourknowledge, has been limited to small case series on each technique. We present a series of patients with iliopsoasimpingement after total hip arthroplasty and evaluate efficacy and risk factors for success or failure of each treatmentstrategy.

Methods: Forty-nine patients treated at one institution for a diagnosis of iliopsoas impingement after primary total hiparthroplasty with hemispherical acetabular component and polyethylene bearing were retrospectively reviewed. Twenty-one patients underwent acetabular revision, 8 patients underwent tenotomy, and 20 patients had nonoperative man-agement. The mean follow-up was 4 years. Anterior acetabular component prominence was measured on true lateral hipradiographs.

Results: At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution comparedwith 22 patients (76%) in the operative group (p = 0.06). In patients with <8 mm of component prominence, tenotomyprovided resolution of groin pain in 5 (100%) of 5 patients and amean Harris hip score of 89 points. In patients with ‡8mmof prominence, acetabular revision led to groin pain resolution in 12 (92%) of 13 patients compared with 1 (33%) of3 patients treated with tenotomy (p = 0.07).

Conclusions: Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. Inpatients with minimal acetabular component prominence, iliopsoas release provided a high rate of success. Acetabularrevision was more predictable for groin pain resolution in patients with ‡8 mm of anterior component prominence.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Iliopsoas impingement is an underrecognized cause ofpersistent pain after primary total hip arthroplasty, but ithas been reported to be the underlying cause of pain after

total hip arthroplasty in up to 4.4% of cases1-6. Typical pre-senting symptoms include groin pain with ascending stairs andgetting in and out of automobiles. On physical examination,the most common finding is groin pain with resisted hipflexion (particularly resisted straight-leg raise) and stretchingof the iliopsoas tendon2. The prominence of the acetabular

component at the anteroinferior acetabular rim may causemechanical irritation to the iliopsoas tendon, leading to ten-dinitis1-3,6, as illustrated in Figures 1-A through 1-E. However,retained cement6,7, excessively long screws penetrating throughthe ilium6,8, and a prominent femoral collar6,9,10 also have beendescribed as etiologies.

The diagnosis is largely made from the patient history,physical examination, and radiographs1,2, including true lat-eral hip radiographs. Computed tomographic (CT) scans may

Disclosure: There were no external sources of funding utilized for this study. On the Disclosure of Potential Conflicts of Interest forms, which areprovided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship inthe biomedical arena outside the submitted work and “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadlyrelevant to this work (http://links.lww.com/JBJS/B591).

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewedby an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication.Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

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J Bone Joint Surg Am. 2017;99:557-64 d http://dx.doi.org/10.2106/JBJS.16.00244

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also demonstrate anteroinferior component prominence11.Ultrasonography and magnetic resonance imaging (MRI)may be used to evaluate for iliopsoas tendinitis12. Finally, di-agnostic or therapeutic injection of an anesthetic agent and

corticosteroid into the iliopsoas tendon sheath helps to con-firm the diagnosis2,13,14.

Nonoperative treatment includes physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs)6, and iliopsoas

Fig. 1-A Fig. 1-B

Fig. 1-C Fig. 1-D

Fig. 1-E

Figs. 1-A through 1-E A 60-year-old man who presented with a painful total hip arthroplasty was diagnosed with iliopsoas impingement, and was treated

with acetabular component revision. Images show preoperative anteroposterior (Fig. 1-A) and true lateral (Fig. 1-B) radiographs demonstrating 13mm of

anteroinferior acetabular component prominence. The intraoperative photograph (Fig. 1-C) shows the retracted, inflamed iliopsoas bursa causing

recurrent hematomas. Postoperative anteroposterior (Fig. 1-D) and true lateral (Fig. 1-E) radiographs after acetabular component revision show proper

bone coverage of the cup. The Harris hip score improved to 92 points postoperatively.

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THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORG

VOLUME 99-A d NUMBER 7 d APRIL 5, 2017IL IOPSOAS IMPINGEMENT AFTER PRIMARY TOTAL HIP ARTHROPLASTY

tendon sheath corticosteroid injections6,13,14. Operative man-agement includes open or arthroscopic tendon debridement ortenotomy6,15-19 and/or full acetabular component revision2,6,20.To our knowledge, most literature on the treatment of iliopsoasimpingement after total hip arthroplasty has been limited tosmall series. The largest cohort, reported by Dora et al.6, in-cluded revision of threaded acetabular components that mayhave resulted in the high complication rate. In this study, wepresent, to our knowledge, the largest cohort with a diagnosisof iliopsoas impingement occurring after total hip arthroplastywith contemporary components. The aim was to evaluateclinical outcomes of operative and nonoperative treatment andto evaluate radiographic and diagnostic variables to identifypredictors of success or failure with each treatment strategy.

Materials and Methods

We identified all patients with a diagnosis of iliopsoas impingement aftertotal hip arthroplasty from January 1, 1996, to December 31, 2013,

at a single institution for retrospective review by searching our institutionaldiagnosis-based registries. Institutional review board approval was obtained.We included patients who had undergone a primary cementless total hip ar-throplasty with a hemispherical acetabular component, subsequently sustainediliopsoas impingement, and had aminimumof 1 year of clinical follow-up frominitiation of treatment. We identified 42 patients treated with revision for thisdiagnosis, comprising 0.7% (42 of 6,001) of all total hip arthroplasty revisionsperformed at our institution during that time. We excluded 6 patients withmetal-on-metal prostheses and 13 patients who were treated with iliopsoasimpingement after revision, rather than primary, total hip arthroplasty. Allpatients were evaluated for infection with laboratory studies (erythrocytesedimentation rate [ESR] and C-reactive protein [CRP]) and/or a joint aspi-ration; 2 patients diagnosed with concomitant infection were excluded.

Forty-nine patients treated at one institution for a diagnosis of iliopsoasimpingement after primary total hip arthroplasty with hemispherical acetab-ular component and polyethylene bearing were retrospectively reviewed.Twenty-one patients underwent acetabular revision, 8 patients underwenttenotomy, and 20 patients had nonoperative management without any pre-liminary or subsequent surgical hip operations after primary total hip ar-throplasty. The mean follow-up was 4 years. The primary clinical outcomesanalyzed were the presence of continued groin pain at the time of the mostrecent follow-up and the Harris hip score

21. Groin pain was evaluated at 2

years and at the time of the latest follow-up by a clinical visit and patientquestionnaires. Patients who reported no groin pain were considered as havinggroin pain resolved, but any other mention of continued groin pain such asmild or continued was constituted as being not resolved. Secondary outcomesincluded revisions, reoperations, and complications. In all treatment groups,we analyzed true lateral preoperative radiographs, measuring the amount ofacetabular component prominence above the anteroinferior acetabular rim(Fig. 2).

PatientsNonoperativeTwenty patients who met inclusion criteria were treated nonoperatively withconservative measures. Nine other patients who did not have a further surgicalprocedure were lost to follow-up or did not pursue recommended injection.The mean acetabular component prominence on the true lateral radiographwas 8 mm (range, 2 to 18 mm). The mean age was 69 years, and 13 patients(65%) were female. The mean follow-up was 4.2 years (range, 1 to 12 years)from diagnosis. Patients underwent a mean of 1.4 injections, with 6 patients(30%) receiving ‡2 injections. Clinical outcomes were measured at the latestclinical follow-up of at least 1 year from diagnosis and initiation of treatment.

OperativeTwenty-one patients who underwent acetabular revision and 8 patients whounderwent open iliopsoas tenotomy by a surgeon trained in revision hip ar-throplasty met inclusion criteria. Twenty-two patients underwent diagnostictendon sheath injections prior to surgical management; the remaining 7 pa-tients were diagnosed on clinical symptoms, physical examination, and analysisof the radiographs alone. The mean acetabular component prominence was8 mm (range, 3 to 18 mm). Intraoperatively prior to revision, surgeons con-firmed implant fixation and prominence of the component anteroinferior rimimpinging on the iliopsoas tendon (Fig. 1). Thirteen patients (45%) were fe-male, and the mean age was 62 years. Clinical outcomes were measured at thestandard 2-year follow-up and at the time of the latest clinical follow-up (mean,3.5 years [range, 2 to 8 years]).

Statistical MethodsAll continuous variables were analyzed with 2-tailed or 1-tailed Student t tests.All dichotomous variables, including those in a subgroup analysis for patientswith ‡8 mm or <8 mm of acetabular component prominence, were analyzedwith Fisher exact or chi-square tests. Significance was set at p < 0.05. Statisticswere analyzed using JMP version 10.0 (SAS Institute).

ResultsOperative Compared with Nonoperative Management

Nonoperative management resulted in the resolution ofgroin pain in 50% of patients so treated. The mean Harris

hip score for nonoperatively treated patients was 79 points atthe time of the most recent follow-up. Severity of acetabularcomponent prominence was not a significant risk factor (p =0.6) for continued groin pain, analyzed as a dichotomous vari-able, with conservative treatment (Table I). In patients treatednonoperatively who had continued groin pain, the mean Harriship score was 65 points compared with 89 points in those withpain resolution (p < 0.001).

Operative management in the 29 patients so treated re-sulted in groin pain resolution in 76% of patients, a higher ratethan nonoperative management (p = 0.06). In operatively treatedpatients, the prevalence of groin pain did not change from the2-year follow-up to each individual’s latest follow-up (mean,3.5 years [range, 2 to 8 years]). The mean Harris hip scorein the operatively treated group improved from 57 pointspreoperatively to 82 points postoperatively (p < 0.001). Themean Harris hip score in the operative group (82 points) wasnot significantly better than the score (79 points) in patientswho underwent nonoperative management (p = 0.6).

One patient with 13 mm of acetabular prominence onthe true lateral radiographwho initially underwent open iliopsoastenotomy and trimming of the acetabular component atthe anteroinferior rim with a metal-cutting burr subsequentlywas treated with acetabular component revision for continuedgroin pain. There were no other revisions, reoperations, orcomplications associated with operative or nonoperativemanagement.

Acetabular RevisionTwenty-one (72%) of the 29 operatively treated patients un-derwent acetabular component revision. Of these, 3 underwentsimultaneous iliopsoas tendon release and acetabular revision.Acetabular revision resulted in groin pain resolution in 76%

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(16 of 21) (Table II) at the standard 2-year follow-up and at thetime of the latest follow-up. The mean Harris hip score im-proved from 58 points preoperatively to 79 points postopera-tively (p < 0.001). Greater anteroinferior prominence of theacetabular component on true lateral hip radiographs prior torevision correlated with better outcomes after revision. Whenanterior acetabular prominence was analyzed dichotomously,groin pain resolution in patients with prominence of ‡8 mmwas 92% (12 of 13) compared with 50% (4 of 8) in patientswith cup prominence of <8 mm (p = 0.05). The mean Harriship score at the time of the latest follow-up was 82 pointsin patients with ‡8 mm of pre-revision acetabular promi-nence compared with 75 points in patients with <8 mm of pre-revision acetabular prominence (p = 0.4). Two patientsundergoing acetabular revision with ‡8 mm of prominence

had a Harris hip score of <65 points: 1 had continued groinpain and the other developed a limp and trochanteric painwithout groin pain. Excluding these 2 patients, themeanHarriship score in that subset was 89 points.

Iliopsoas TenotomyEight patients were treated with open iliopsoas tenotomy andacetabular component retention. In 1 case, the anteroinferiorrim of the retained cup was trimmed. Iliopsoas tenotomy re-sulted in groin pain resolution in 75% of patients (6 of 8)(Table II). The mean Harris hip score improved from 53 pointspreoperatively to 86 points postoperatively (p < 0.001). Therate of groin pain resolution in patients with ‡8mmof acetabularcomponent prominence was 33% (1 of 3 patients) comparedwith100% (5 of 5 patients) in patients with <8 mm of prominence

Fig. 2

Retrospectively proposed treatment algorithm for patients with groin pain after primary total hip arthroplasty (THA) with suspected iliopsoas impingement.

The algorithm is based on the level of pain and dysfunction and the amount of acetabular component prominence.

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(p = 0.10). The 1 revision (discussed above) was a patient withcontinued groin pain with 13 mm of acetabular componentprominence who underwent initial iliopsoas tenotomy.

Acetabular Component Prominence and Clinical OutcomeIn patients with ‡8 mm of acetabular prominence, acetabularrevision resolved groin pain in 92% of patients (12 of 13)compared with 33% of patients (1 of 3) undergoing tenotomy(p = 0.07) (Table II). Iliopsoas tenotomy resolved groin painin 100% of patients (5 of 5) with <8 mm of acetabular promi-nence; these patients had ameanHarris hip score of 84 points. Incontrast, cup revision with <8 mm of cup prominence resulted

in a groin pain resolution rate of 50% (4 of 8) (p = 0.08) anda mean Harris hip score at the time of the latest follow-up of75 points (p = 0.75). In this cohort, component prominence of‡8 mm was not a risk factor for failure of nonoperative man-agement (Table I).

Operative Treatment AlgorithmOn the basis of the above analysis of the data in this study, aproposed treatment algorithm was retrospectively developed(Fig. 2). Applying this algorithm retrospectively, 18 patientsunderwent operative management in accordance with the al-gorithm; 13 patients with ‡8mm of cup prominence underwent

TABLE I Clinical Outcomes in the Nonoperative Treatment Cohort

No. of Patients Resolution of Groin Pain Harris Hip Score* P Value

Total 20 10 (50%) 79

Prominence† 0.6

‡8 mm 12 5 (42%) 81

<8 mm 8 5 (63%) 77

Groin pain <0.001

Resolved 10 89

Unresolved 10 65

*The values are given as the mean score, in points, at the time of the latest follow-up.†Anterior acetabular component prominence was based onthe true lateral radiograph.

TABLE II Clinical Outcomes in the Operative Treatment Cohort

No. of PatientsResolution ofGroin Pain P Value Harris Hip Score* P Value

Total 29 22 (76%) 82

Surgery type 1.00 0.4

Tenotomy 8 6 (75%) 86

Acetabular revision 21 16 (76%) 79

Prominence ‡8 mm† 0.07 0.8

Tenotomy 3 1 (33%) 84


Prominence <8 mm† 0.08 0.07

Tenotomy 5 5 (100%) 89


Tenotomy 0.10 0.5

Prominence ‡8 mm† 3 1 (33%) 84

Prominence <8 mm† 5 5 (100%) 89

Acetabular revision 0.05 0.4

Prominence ‡8 mm† 13 12 (92%) 82

Prominence <8 mm† 8 4 (50%) 75

*The values are given as the mean score, in points, at the time of the latest follow-up.†Anterior acetabular component prominence was based onthe true lateral radiograph.

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acetabular component revision and 5 patients with <8 mm ofcup prominence underwent iliopsoas tenotomy. Eleven patientsunderwent operative treatment not in accordance with this al-gorithm (Table III). Patients treated in accordance with the al-gorithm had a significantly higher rate of groin pain resolution(p = 0.001) at 94% compared with 36% in patients treatedsurgically at variance to the algorithm.

Discussion

Diagnosis and treatment of iliopsoas impingement afterprimary total hip arthroplasty remain challenges. Groin

pain after total hip arthroplasty can be secondary to numerousetiologies including component loosening, infection, synovitisrelated to implant wear or corrosion, and iliopsoas tendinitis. Thedifficulty of making an accurate diagnosis and the limited infor-mation about clinical outcomes after operative and nonoperativetreatment make management of these patients challenging. Theresults of this study suggest that operative management can suc-cessfully lead to groin pain resolution in some cases, especiallywith careful patient selection.

The rate of groin pain resolution with conservative man-agement is mixed in the literature. Ala Eddine et al.4 showed im-provement of symptoms in 5 (56%) of 9 patients treatedconservatively withmultiple injections at aminimum follow-up of3 months. In contrast, Dora et al.6 reported failure in all 8 patientstreated with conservative management. The current study showsthat conservativemanagement with physical therapy, NSAIDs, andinjections of the tendon sheath led to resolution of groin pain in50% of patients at the intermediate-term follow-up. In patientswith groin pain resolution, clinical outcomeswere favorable, with amean Harris hip score of 89 points. The amount of acetabularprominence measured on the true lateral hip radiographwas not arisk factor for failure of conservative management (Table I). Onereason for varied results in the literature and possibly this studymay be lack of a definitive test for iliopsoas impingement and that

anteroposterior and lateral radiographs evaluate a 3-dimensionalproblem from only 2 perspectives.

Although the mean Harris hip score significantly im-proved from preoperatively to postoperatively in operativelytreated patients as a cohort, this study also shows that carefulselection of operative candidates is paramount to the success ofoperative treatment. Clinical outcomes after tenotomy werebetter in patients with <8 mm of acetabular prominence, with100% groin pain resolution and a mean Harris hip score of 89points (Table II). O’Sullivan et al.22 and Dora et al.6 showedexcellent pain relief after open tenotomy, with groin pain res-olution in 15 of 16 patients in the study by O’Sullivan et al. and5 of 6 patients in the study by Dora et al. In the study by Doraet al., the mean Harris hip score at the time of the latest follow-up after tenotomy was low. Neither report commented on theeffect of acetabular prominence. In the current study, patientswith ‡8 mm of cup prominence treated with acetabular revisionhad a high rate of success, with 92% resolution of groin pain anda mean Harris hip score of 82 at the time of the latest follow-up.ThemeanHarris hip score was reduced by 2 patients (previouslydiscussed) with a Harris hip score of <65 points. The meanHarris hip score of 89 was achieved both in the cohort of patientswith <8 mm of prominence treated with tenotomy and in pa-tients with ‡8 mm of prominence treated with acetabular revi-sion, excluding the above-mentioned 2 patients.

To our knowledge, there has been a paucity of dataregarding functional outcomes and muscle strength after iliop-soas tenotomy. One study reviewing 10 patients who underwentendoscopic iliopsoas tenotomy after total hip replacements foundthat patients regained full hip flexion strength at a mean time of 3months postoperatively17. In our experience, most patients regainreasonable hip flexion strength because of secondary muscles,most notably the flexor portion of the abductor musculature. Alliliopsoas tenotomies in this series were performed as open pro-cedures, which allowed confirmation of component positioning,

TABLE III Comparison of Algorithmic Treatment with Non-Algorithmic and Nonoperative Treatment

Treatment Approaches* No. of PatientsGroin PainResolution P Value

Harris HipScore† P Value

Algorithmic operative compared with nonoperative treatment 0.002 0.07

Algorithmic operative treatment‡ 18 94% 86

Nonoperative treatment 20 50% 79

Non-algorithmic compared with algorithmic operative treatment 0.001 0.09

Non-algorithmic operative treatment§ 11 36% 78

Algorithmic operative treatment‡ 18 94% 86

Non-algorithmic operative compared with nonoperative treatment 0.7 0.9

Non-algorithmic operative treatment§ 11 36% 79

Nonoperative treatment 20 50% 79

*The algorithmic treatment is that from Figure 2. †The values are given as the mean score, in points, at the time of the latest follow-up. ‡Thisgroup comprised patients with ‡8-mm prominence treated with acetabular revision and patients with <8-mm prominence treated with tenotomy.§This group comprised patients with <8-mm prominence treated with acetabular revision and patients with ‡8-mm prominence treatedwith tenotomy.

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evaluation of the stability of the acetabular component, and athorough evaluation of the hip joint to rule out other abnormalprocesses that might contribute to the patient’s groin pain. Sev-eral studies have shown good outcomes of endoscopic tenot-omy15-17, which has the advantage of being less invasive but allowslimited evaluation of component stability.

Among patients with ‡8 mm of cup prominence treatedwith tenotomy and patients with <8mm of prominence treatedwith acetabular revision, only 36% (4 of 11 patients) had res-olution of groin pain and the mean Harris hip score at the timeof the latest follow-up was 78 points (Table III). An algorithmicapproach based on acetabular prominence of ‡8 mm treatedwith cup revision or acetabular prominence of <8 mm treatedwith iliopsoas tenotomy was proposed retrospectively (Fig. 2).Comparing outcomes between surgical treatment as suggestedand not suggested by the algorithm, we found a significantlyhigher rate (p = 0.001) of groin pain resolution (94% comparedwith 36%) and a trend (p = 0.09) toward an improved meanHarris hip score (86 points compared with 78 points) when theproposed algorithm was followed (Table III). We acknowledgethat the algorithm presented here was developed retrospec-tively and application to the same patient population mayexaggerate its value. However, this algorithm may guide eval-uation and treatment of iliopsoas impingement (Fig. 2), butfurther prospective study of this proposed algorithm is neededto clarify its utility.

Acetabular revision of hemispherical, cementless cups wasnot associated with an increased re-revision or complication ratein this patient series. Dora et al.6 reported high complication andreoperation rates associated with acetabular revision. However,all of the acetabular components in that study were threadedimplants, which may have increased bone loss.

We acknowledge the limitations of this retrospectivestudy. We attempted to have multiple control groups for com-parison and subgroup analysis, but it was not possible to furthersubdivide a relatively small numbers of patients. Surgeons andpatients together decided on nonoperative compared with op-erative management, which was subject to selection bias. Manypatients treated surgically initially underwent a trial of conser-vative management. Therefore, the success rate of conservativemanagement may be lower than 50% if analyzed on an intent-to-treat basis. The algorithm presented here was developedretrospectively without regard to specific patient factors thatmayinfluence surgeon decision. However, it is consistent with similarguidance based on preoperative radiographic analysis of ace-tabular component prominence published by Lachiewicz andKauk2. Although, to our knowledge, the current study has beenthe largest series to date, the number of patients was still small.

Some of the strong clinical trends might have been significantwith a larger number of patients. Few patients underwent bothtenotomy and acetabular revision, so we cannot comment onadvantages or disadvantages of this combined procedure.

The strengths of this study were that, to our knowledge, itwas the largest in the literature to analyze the outcomes ofnonoperative and operative treatment, including iliopsoas te-notomy and acetabular revision, with contemporary acetabularimplants and to evaluate the risk factors for treatment successor failure. Although there is no definitive test for iliopsoasimpingement, we utilized the clinical history, physical exami-nation, and tendon sheath injection to aid diagnosis and ex-cluded other causes of groin pain including failedmetal bearings,infection, and revision total hip arthroplasty, which would haveconfounded the diagnosis.

Persistent conservative management resolved groin painin only 50% of patients. Although the results were unpredictable,if groin pain did resolve with nonoperative management, pa-tients often had good clinical outcomes. Operative managementled to significantly improved Harris hip scores from preopera-tively to postoperatively in most patients, groin pain resolutionin the majority of patients, and a low rate of complications incarefully selected patients. The amount of anteroinferior ace-tabular component prominence was a significant risk factorfor success or failure with operative management. Patientswith ‡8 mm of prominence had a high success rate and ex-cellent clinical outcomes with acetabular revision. Patientswith <8 mm of component prominence experienced mostlygood outcomes and groin pain resolution with iliopsoas te-notomy. The results of this study can be used to guide oper-ative decision-making in an algorithmic approach (Fig. 2) inpatients with suspected iliopsoas impingement after primarytotal hip arthroplasty. n

Brian P. Chalmers, MD1

Peter K. Sculco, MD1

Rafael J. Sierra, MD1

Robert T. Trousdale, MD1

Daniel J. Berry, MD1

1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

E-mail address for B.P. Chalmers: [email protected] address for P.K. Sculco: [email protected] address for R.J. Sierra: [email protected] address for R.T. Trousdale: [email protected] address for D.J. Berry: [email protected]

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