Arthroscopic Iliopsoas Fractional Lengthening After Total Hip Arthroplasty: Utilization of the Iliopsoas Air Bursogram Technique for Safe and Efficient Access

Abstract

Background:

Patients with persistent symptomatic iliopsoas tendonitis following total hip arthroplasty may benefit from iliopsoas fractional lengthening. We present an arthroscopic approach utilizing an air bursogram that provides safe and predictable access to the iliopsoas tendon for efficient tendon lengthening without violating the capsule or unintentional instrumentation of the nearby medial neurovascular bundle.

Indications:

Arthroscopic iliopsoas fractional lengthening is indicated for patients with clinical evidence of symptomatic iliopsoas tendonitis following total hip arthroplasty and have no radiographic evidence of frank acetabular malpositioning. A diagnosis of iliopsoas tendinitis amenable to surgical management can be established with substantial but nondurable relief following image-guided anesthetic injection to the iliopsoas bursa.

Technique Description:

Under fluoroscopic guidance, an air bursogram is employed in the anatomic plane of the iliopsoas tendon to accurately identify its course. This allows for hip portal placement with precise subsequent instrumentation. This technique is preferred in the setting of postarthroplasty anatomy because it avoids capsular violation and the challenge of working in an altered anatomic space with a nearby, medially based neurovascular bundle.

Results:

Arthroscopic and endoscopic approaches to iliopsoas release have been shown to provide excellent functional and patient-reported outcomes in >85% of patients, and several studies have shown that an arthroscopic approach not only provides a less invasive technique but also results in comparable or improved clinical outcomes with lower revision rates compared to open release or acetabular cup revision. Our technique for arthroscopic iliopsoas fractional lengthening using the air bursogram is both safe and reproducible and offers distinct advantages, including maintenance of an intact capsule, visual confirmation of the correct anatomic structure to be released, and percutaneous access with standard arthroscopic access cannulas without the need for hip distraction.

Conclusions:

Arthroscopic fractional iliopsoas lengthening is a minimally invasive and successful treatment option for patients with persistent groin pain after total hip arthroplasty, especially without substantial acetabular component malpositioning. This technique includes using an air bursogram to safely identify and navigate to the iliopsoas tendon without violating the hip capsule, thereby reducing the risk of inadvertent instrumentation of adjacent critical neurovascular structures.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In the following video, we will demonstrate our preferred technique for performing an arthroscopic iliopsoas fractional tendon lengthening in patients following total hip arthroplasty. This technique uses an air bursogram to provide safe and efficient access to the anatomic structure to be directly visualized and released. Our authors report the following disclosures. We will begin with a review of the background surrounding iliopsoas tendonitis after total hip arthroplasty. Next, we will review the proposed surgical technique, highlighting tips and tricks for successful execution. Finally, we will finish by describing postoperative management and review patient outcomes that have been reported in the literature.

Background and Indications

Iliopsoas tendonitis has been reported to occur in up to 18% of patients after total hip arthroplasty.^2,5,10 Anterior acetabular overhang as the result of a relatively retroverted or oversized acetabular component has been associated with iliopsoas impingement. Patients will most often present with hip pain that is exacerbated with active hip flexion and can also display decreased hip strength and groin pain with straight-leg raise on physical examination. ⁵ Hip radiographs with a cross-table lateral view provides visualization of the amount of anterior overhang of the acetabular component. After radiographs are reviewed for any evidence of component malpostion or loosening and infection has been ruled out, an ultrasound-guided anesthetic and corticosteroid injection into the iliopsoas tendon sheath is often employed to confirm the diagnosis and that the tendon remains intact. ⁹ Once the diagnosis has been established, treatment options range from oral nonsteroidal anti-inflammatory drugs to ultrasound-guided iliopsoas bursal injections, ⁶ open or arthroscopic iliopsoas release, or acetabular component revision, which is historically indicated for patients with an acetabular cup overhang >8 mm.^1,7,8 If conservative treatment measures fail, an arthroscopic fractional lengthening of the iliopsoas tendon, using the technique described in this video, is an appealing treatment option that is indicated for patients with modest acetabular overhang but otherwise satisfactory implant positioning.

Technique Description

To perform this surgical technique, the patient is first positioned supine on a hip distraction table with their feet inserted into padded boots. A padded post is also preferred for further stability given the medially applied force used for precise initial arthroscopic access. The operative lower extremity is placed in 10° of external rotation. Slightly more external rotation can be applied for patients with femoral torsion, recognizing that this will bring the iliopsoas tendon, along with its nearby medially situated neurovascular bundle, closer to the operative field.

Once the patient is prepared and draped in the usual sterile fashion, fluoroscopic guidance is used to visualize anatomic landmarks, including the lesser trochanter and the vastus ridge. A 17-gauge access needle is inserted through an anterolateral (AL) portal approximately 2 cm medial to the anterior border of the femur. It is advanced medially just until it passes the medial border of the femur in line with the vastus ridge. It is then further advanced 1 cm into the anatomic location of the iliopsoas bursa. The stylet is removed and replaced with a 30-mL syringe that is used to perform an air bursogram. Visualization of a strip of radiolucent soft tissue running along the course of the iliopsoas tendon, from the inner pelvic brim to the lesser trochanter, confirms successful access. The syringe is replaced with a 1.2-mm nitinol wire with a felt soft stop, corresponding to the medial aspect of the iliopsoas sheath. Fluoroscopic imaging is repeated to ensure secured wire placement without deeper medial penetration.

A 5.0-mm inner diameter polymer cannula is advanced over the nitinol wire through a small incision to dilate a tract for instrumentation. The distal end of the wire is braced firmly by an assistant while the surgeon advances the cannula over the wire. Fluoroscopic guidance is used intermittently as needed during this step to confirm that the cannula reaches and stops at the medial tip of the wire. The wire is then removed and replaced with a 70° arthroscope, and water inflow is started immediately at 35 mm Hg. A second modified anterior portal (MAP) is created 3 cm medial and approximately 3 cm distal to the first AL portal. This portal should be at the level of the lesser trochanter in terms of the proximal-distal axis and not cross-medial to the “safety line” connecting the anterior superior iliac spine and lateral aspect of the patella. A 17-gauge needle is used to triangulate the MAP to the tip of the arthroscope, and a nitinol wire is inserted. A small incision is made and a 5.0-mm cannula is introduced over the wire to dilate the tract. The cannula is removed and replaced with a 4.2-mm straight shaver percutaneously.

The shaver is gently applied to clear the bursal tissue and access the iliopsoas tendon. The anterior joint capsule can be identified by the coursing white longitudinal fibers of the iliofemoral ligament, and fluoroscopic imaging with placement of the shaver on identified structures can help to differentiate the capsule from medial aspects of the iliopsoas tendon. Once the iliopsoas tendon is visualized after bursal debridement, it is tracked to its insertion on the lesser trochanter using fluoroscopy and followed 3 to 4 cm proximally to the femoral head-neck junction to confirm accurate identification of the structure to be released. Anatomically, the tendon is located on the posterior and lateral aspect of the iliopsoas muscle.

The shaver is replaced with an arthroscopic radiofrequency ablator, which is used to cut the tendon at its midpoint between the lesser trochanter and femoral head-neck junction. Care is taken to ensure all tendon fibers are cut without damaging underlying muscle. This action will result in retraction of both ends of the tendon by a total of approximately 3 to 4 cm. This distance can be measured fluoroscopically by using the radiofrequency ablator's tip as a radio-opaque probe.

Once complete circumferential release of the tendon has been confirmed, all instruments are removed from both the AL and MAPs. 3-0 Nylon sutures are used to close the 2 incisions in a horizontal mattress fashion, and a sterile dressing is applied. Immediately postoperatively, patients are allowed to weightbear as tolerated on the operative extremity, most often using crutches for 2 to 3 days while their hip pain, strength, and gait improve. Patients return to the clinic 2 weeks later for suture removal and physical therapy evaluation with gait training. Additional therapy sessions are scheduled as needed based on patient comfort levels at this time.

Results and Discussion

We have found the following tips and tricks to lead to a successful procedure. Shifting the standard AL portal anteriorly by 2 cm provides access to the iliopsoas lying around the corner of the anterior femoral cortex. Distalizing the standard AL portal to be in line with the vastus ridge allows for easier access to the anatomic location of the iliopsoas sheath. It is important to immediately turn on water flow after the AL portal trocar is placed. Failing to do so will result in dry scoping, which prevents the creation of a potential space for the triangulation necessary to establish MAP access. Careful consideration should be taken to ensure a circumferential release of the iliopsoas tendon to avoid leaving any bridging fibers behind that inhibit appropriate fractional lengthening.

Arthroscopic iliopsoas fractional tendon lengthening offers a minimally invasive surgical treatment option for symptomatic iliopsoas impingement after total hip arthroplasty with high patient surgery satisfaction, alleviation of anterior groin pain in up to 92% of cases, ³ and low complication and revision rates.^1-3,9 While each surgical treatment option has its own advantages and indications, an arthroscopic approach using this method offers an arthroscopic minimally invasive alternative for a previously open procedure. Several studies have reported arthroscopic tenotomy to offer equal or improved clinical outcomes with lower complication and revision rates when compared to conventional surgery.^2-5,9,10

Conclusion

Our proposed technique for arthroscopic iliopsoas fractional lengthening after total hip arthroplasty offers a reproducible and precise method, through utilization of an air bursogram, to safely reach the iliopsoas tendon using standard-access cannulas by way of the peripheral compartment, eliminating the need for hip distraction. Maintenance of an intact hip capsule can potentially decrease the risk of postoperative instability or periprosthetic injection while employing a bursogram to help avoid inadvertent instrumentation of nearby neurovascular structures. This technique is therefore a safe and predictable option for arthroscopic iliopsoas fractional lengthening after total hip arthroplasty. The authors thank you for your time and attention during this video.