Persistent groin pain after hip replacement

People will send us emails that go something like this:

I had hip replacement surgery over a year ago. I have had chronic groin pain ever since. Now my doctors are suggesting to me that I have some type of impingement and now I need another replacement and a hardware adjustment. I am looking at alternatives to this second hip replacement surgery.

The problems of persistent groin pain after Total Hip Arthroplasties (replacement) is a growing concern. Doctors in Germany revealed troubling complication rates: (1)

The prevalence of groin pain after conventional total hip replacement ranges from 0.4 to 18.3 % and
activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9 to 40.9 % of cases in some series.

Doctors at the Mayo Clinic writing in the Journal of bone and joint surgery (2) suggest that a potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoas tendon. Treatment options include conservative management, tenotomy, and acetabular revision (surgery to adjust or replace the hip socket component).

In looking to suggest treatment options the Mayo doctors looked at 49 patients with a diagnosis of iliopsoas impingement after primary total hip arthroplasty

21 patients underwent acetabular revision,
8 patients underwent tenotomy,
and 20 patients had nonoperative management (conservative treatments).

At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution compared with 22 patients (76%) in the operative group.

Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. In patients with minimal acetabular component prominence, iliopsoas release provided a high rate of success.

The greater the hardware problem the greater the need for surgical resolution.

Is it iliopsoas impingement?

In February 2021 doctors writing in the journal Cureus (3) wrote that “persistent groin pain after total hip arthroplasty can result from iliopsoas impingement on the acetabular rim. Controversy exists over the risks and benefits of tenotomy versus revision as a surgical solution.” In this paper the doctors reported on their “limited experience with combined acetabular revision and partial iliopsoas tenotomy when other conservative treatments have failed.”

The doctors assessed eight patients diagnosed with iliopsoas impingement following hip replacement. All patients had prolonged groin pain for an average of two years and had failed conservative treatment for at least six months.

All patients underwent acetabular revision with partial psoas tendon release. No stems (hardware) were revised. Dislocations, complications, and clinical outcomes are reported in this study.

Of the eight patients, seven had a positive diagnostic challenge with an image-guided injection (a painkiller was injected to see if it resolved the groin pain).
During the revision surgery the cup hardware was adjusted.
There were no major postoperative complications.
At a average follow-up of 3.3 years, the mean Hip disability and Osteoarthritis Outcome Score for Joint Replacement was 75 points (range: 32-100 points).
Conclusion iliopsoas impingement may be effectively managed with combined acetabular revision and tenotomy. The challenges of implant placement and positioning may be aided with intraoperative imaging.

Cortisone for iliopsoas tendonitis

A December 2022 from Rush University Medical Center, published in The Journal of arthroplasty (7) evaluated the effectiveness of ultrasound-guided corticosteroid injections for iliopsoas tendonitis following total hip replacement. In this study, 42 patients who received an ultrasound-guided corticosteroid injection for iliopsoas tendonitis after primary hip replacement were assessed at one year follow up for need for another surgery, groin pain at last follow-up, the need for additional intra-bursal injection and pain and function scores. Further, scans were taken to determine hardware failure or mispositioning (anterior cup overhang) as a cause of iliopsoas tendonitis.

Among the 22 patients who did not have anterior cup overhang, four (18.2%) had persistent groin pain at average follow-up of 40 months after ultrasound-guided corticosteroid injections. Three patients had a second injection, none had groin pain at most recent follow-up. No patients required acetabular revision. Resolution of groin pain was demonstrated in 78.6% of patients in the group; however, those who did not have acetabular overhang had higher rates of success. The overall revision surgery rate was 11.9%. The study concludes: “Ultrasound-guided corticosteroid injections appears to be safe and effective in the diagnosis and treatment of iliopsoas tendonitis following primary total hip replacement.”

Is it the size of the implant? Possibly, but may that is not it all.

Doctors at the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, the University of Toronto and the Adult Reconstruction and Joint Replacement Division, at the Hospital for Special Surgery in New York combined to assess the causes of chronic groin pain after hip replacement with a focus on possibly the oversized femoral implant head size characteristic of implants used in dual mobility total hip replacement. (4) Dual mobility hip replacement adds an addition polyethylene component which is seen as superior in younger patients who are more active and this type of device reduces or even eliminates the risk of dislocation of the implant. What this research stuyd found was that “Overall, 8.7% of hip replacement patients reported groin pain at one year. Patients with groin pain were younger and had lower body mass index (BMI).

Conclusion: In this population of hip arthroplasty patients, the incidence of groin pain one year after surgery did not differ among patients undergoing Dual mobility and conventional hip replacement; Dual mobility hip replacement in particular was not associated with a higher risk of groin pain, despite its comparatively larger femoral head sizes. Traditional hip replacement, on the other hand, was associated with a higher risk of pain.”

Success of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty

A July 2019 paper in The Journal of arthroplasty (6) wrote: “Iliopsoas impingement after total hip arthroplasty (replacement) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision.” In this paper the researchers wanted to demonstrate effectiveness and risks in patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after total hip replacement.

60 patients with iliopsoas impingement after total hip arthroplasty (replacement) treated with endoscopic iliopsoas tenotomy was retrospectively evaluated.
Outcomes assessed were resolution of pain, function, and complications.

Results:

At last follow-up (average 5.5 months), 93.3% of patients had resolution of pain. Clinically important improvements in function, and low rate of complications. According top the paper: “Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after total hip arthroplasty.”

Persistent groin pain following total hip replacement treated with physical therapy

A March 2022 paper in the journal Physiotherapy theory and practice (5) wrote that hip impingement syndrome can occur after total hip replacement and that nonoperative treatment is inconsistently recommended and surgical options include iliopsoas tenotomy. In this case, a patient with persistent groin pain after total hip replacement and iliopsoas tenotomy is presented:

The patient was a 72-year-old male who had a 4-year history of persistent groin pain following total hip replacement and an unsuccessful iliopsoas tenotomy. He had pain and limited right hip range of motion during active and passive hip flexion, abduction, and external rotation.
This patient was treated with (physical therapy) high-grade joint mobilization to improve the range of motion of the right hip and an exercise program.
The patient was treated for six visits over 3 weeks. Clinically important improvements were noted in pain, function, and perceived level of improvement. Pain during hip flexion improved on the Numeric Pain Rating Scale, and function improved on the Lower Extremity Functional Scale. Improvements in the range of motion and strength were also observed. At 6-month follow-up, he reported maintenance of improvements .Discussion: Joint mobilization and exercise were effective for improving range of motion, groin pain, and function in a patient with a 4-year history of persistent groin pain after THA and subsequent iliopsoas tenotomy.

1 Fink B, Lass R. [Diagnostic Algorithm for Failure Analysis of Painful Total Hip Arthroplasties]. Z Orthop Unfall. 2016 Oct;154(5):527-544. Epub 2016 Oct 11. [Google Scholar]
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3 Yun A, Qutami M, Pasko KB. Surgical Management of Iliopsoas Impingement With Combined Acetabular Revision and Partial Psoas Tenotomy. Cureus. 2021 Feb;13(2). [Google Scholar]
4 Stavrakis AI, Khoshbin A, Joseph A, Lee LY, Bostrom MP, Westrich GH, McLawhorn AS. Dual Mobility Total Hip Arthroplasty Is Not Associated with a Greater Incidence of Groin Pain in Comparison with Conventional Total Hip Arthroplasty and Hip Resurfacing: A Retrospective Comparative Study. HSS Journal®. 2020 Dec;16(2_suppl):394-9. [Google Scholar]
5 Peterson S. Physical therapy management of a patient with persistent groin pain after total hip arthroplasty and iliopsoas tenotomy: a case report. Physiotherapy Theory and Practice. 2020 Jun 6:1-1. [Google Scholar]
6 Bell CD, Wagner MB, Wang L, Gundle KR, Heller LE, Gehling HA, Duwelius PJ. Evaluation of endoscopic iliopsoas tenotomy for treatment of iliopsoas impingement after total hip arthroplasty. The Journal of arthroplasty. 2019 Jul 1;34(7):1498-501. [Google Scholar]
7 Weintraub MT, Barrack T, Burnett III RA, Serino III J, Bhanot S, Della Valle CJ. Ultrasound-Guided Iliopsoas Bursal Injections for Management of Iliopsoas Bursitis after Total Hip Arthroplasty. The Journal of Arthroplasty. 2022 Dec 16. [Google Scholar]

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