Rare disease
CASE REPORT
Iliopsoas tendon rupture: a new differential for atraumatic groin pain post-total hip arthroplasty Robert Pearse Piggott,1 Orla Doody,2 John Francis Quinlan1 1
Trauma and Orthopaedics, AMNCH, Dublin 24, Ireland 2 Radiology Department, AMNCH, Dublin 24, Ireland Correspondence to Robert Pearse Piggott, [email protected] Accepted 29 January 2015
SUMMARY Groin pain post-total hip arthroplasty (THA) is of concern for the patient and the surgeon, especially when there is no history of any traumatic event. Obvious concern centres on complications from the prosthesis. The use of multiple imaging modalities allow for accurate diagnosis of groin pain. Atraumatic iliopsoas rupture is rare and has only been reported once before in the setting of THA. We present the case of 53-year old female with atraumatic rupture of the iliopsoas tendon that presented with severe groin pain and limited flexion. We discuss the clinical presentation, radiological features and follow-up of the patient. We also discuss the relevant published literature on the topic. This is a rare phenomenon but should be consider in patients with groin pain post-THA, especially after prosthesis complications have been ruled out.
BACKGROUND Groin pain secondary to iliopsoas tendon rupture is uncommon and has a wide range of pathologies depending on the demographics of the patient. In children and adolescence, avulsion fractures of the lesser trochancter of the femur are well documented.1 In adults, the same finding is highly suggestive of metastasis from malignancy.2 3 An isolated iliopsoas tendon tear in the absence of lesser trochancter fracture is uncommon and is usually seen in conjunction with athletic injuries or direct trauma.4 5 Spontaneous atraumatic rupture of the iliopsoas tendon is extremely rare. In the setting of total hip arthroplasty (THA), it has only been reported once in the literature.6 We present a second case of spontaneous rupture of the iliopsoas tendon 22 months after undergoing THA. Awareness of this phenomenon aids in the diagnosis of the condition and also should be considered as part of the differential in a patient with groin pain post-THA.
Her pain was severe and not fully relieved by analgesia. She subjectively described inability to lift her leg into bed at night and was compensating by active—assisted flexion with the contralateral leg. The pain was interfering with her daily activities and impeding her ability to work. The patient denied any preceding traumatic event. She denied any similar symptoms during her postoperative course. On examination, she ambulated with an antalgic gait; however, no walking aids were required. Her straight leg raise was severely limited and could not be maintained. Objectively, right hip flexion was 3/5 on the Oxford muscle strength grading scale. She had pain on passive flexion, extension and internal rotation of her hip joint. She had no pain on static weight bearing on her right leg. There was no tenderness or ecchymosis in the groin. No masses or hernias were identified. Her distal neurovascular status was intact. The operating surgeon did not recall any intraoperative complications or interference with the iliopsoas tendon.
INVESTIGATIONS A plain radiograph of the pelvis did not demonstrate any evidence of implant loosening, osteolysis, wear, malposition or heterotopic ossification (figure 1). The patient initially underwent investigations for a complication of the prosthesis, which were negative. Inflammatory and infective markers were within normal range. An isotope bone scan with technetium 99 m labelled methylene-diphosphonate (MDP), demonstrated a solidly fixed femoral and acetabular components without evidence of loosening. MRI of the pelvis was then performed which
CASE PRESENTATION
To cite: Piggott RP, Doody O, Quinlan JF. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208518
A 53-year old, fit and healthy woman was referred to the Orthopaedic arthroplasty service for sudden severe onset of right groin pain post right THA. She had undergone a right uncemented THA 22 months prior to presentation for degenerative right hip disease. She had an uncomplicated operative course and recovered full mobility postoperatively with routine follow-up at our outpatients’ facility according to local policy. She developed acute onset of right groin pain and an early follow-up was expedited. She described pain on walking, difficulty in rising from a seated position and negotiating stairs.
Figure 1 Pelvic radiograph demonstrates a normal appearance of the right hip prosthesis. The remaining bony pelvis is unremarkable.
Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
1
Rare disease
Figure 2 Axial T2-weighted MRI pelvis demonstrates increased signal within the distal right psoas muscle (arrow), which is oedematous and enlarged relative to the normal contra lateral left psoas muscle. demonstrated acute oedema and fluid extending along the right psoas muscle (figure 2). There was disruption of the distal psoas component of the iliopsoas tendon that was slightly retracted, consistent with an acute tear of the distal psoas component of the right iliopsoas tendon (figures 3 and 4). The iliacus component of the iliopsoas was intact. There were no features to suggest prosthetic loosening or infection. A subsequent CT demonstrated moderate atrophy of the right psoas muscle, consistent with a tear of the psoas tendon distally (figure 5). There were no features to suggest underlying malignancy in any of the imaging modalities.
Figure 4 Coronal T2-weighted MRI of the pelvis demonstrates diffuse oedema extending along the right psoas muscle (solid arrow) with disruption of the psoas tendon distally (dashed arrow), consistent with a complete tear of the tendon. distance has greatly improved. She has returned to driving; however prolonged journeys continue to be problematic secondary to the repeated hip flexion needed to operate the car pedals. The patient has returned to work on a full time basis. Clinically on examination, her hip flexion strength is 5/5.
DIFFERENTIAL DIAGNOSIS
DISCUSSION
Pain in the groin post-total hip arthroplasty has a wide differential, including fracture, wear and osteolysis, sepsis, aseptic loosening, heterotrophic ossification, referred pain from spine or knee, abdominal pathology and neurological and vascular causes. Soft tissue irritation and rupture must also be considered.
Iliopsoas pain is well documented in the orthopaedic and radiology literature. It is seen commonly in sports medicine and is being increasing recognised as a cause of groin pain after THA. Specifically these reports relate to an iliopsoas tendonitis7 8 and not to an iliopsoas rupture. To the best of our knowledge this is only the second report of a spontaneous atraumatic rupture of the iliopsoas tendon in the setting of THA.6 Further reports in the literature have documented two cases of spontaneous rupture of the distal iliopsoas tendon in a native hip9 and two
TREATMENT A diagnosis of acute atraumatic rupture of the psoas tendon was performed. In the absence of any well-documented surgical option, our patient was managed conservatively with physiotherapy and non-steroidal anti-inflammatory drugs.
OUTCOME AND FOLLOW-UP At her 6 months follow-up post onset of symptoms, the patient showed marked improvement. Pain is minimal and walking
Figure 3 Demonstrates abnormal fluid surrounding the distal right psoas tendon (arrow), which is disrupted at this level. A small reactive joint effusion is also present. 2
Figure 5 A subsequent axial CT demonstrates atrophy of the right psoas muscle (arrow), consistent with a subacute tear of the iliopsoas tendon. Note the normal muscle bulk of the contralateral left psoas. Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
Rare disease cases of atraumatic avulsion of the tendon from the lesser trochancter also, without the presence of THA.10 Iliopsoas tendon and myotendinous injuries have been shown to have a prevalence of 0.66%.4 MRI is the diagnostic modality of choice and allows grading of the injury into muscle sprain, partial tear and complete tear. The prevalence of complete tears was 0.16%, and was noted exclusively in women. All these patients were in the 7th to 10th decade of life. However, there is no data available regarding the incidence of injury in patients who have undergone THA. Iliopsoas tendinitis has been shown to be as high as 4.3% post-THA.11 Symptoms specific to iliopsoas irritation included difficulty in climbing stairs, getting in and out of a car, and walking on an uneven surface. This is related to the difficultly in hip flexion and adduction, which was observed in our patient. Causes of iliopsoas tendinitis post-THA have been attributed to irritation of the tendon from an anterior protruding cup and/or cement; limb lengthening and an increase in offset.8 Symptoms are greatly improved in patients by CT guided injection; however, some patients require operative exploration to manage the impingement lesion or to lengthen the psoas tendon. A small proportion will require revision of the acetabular component.7 8 Acute tears of the iliopsoas tendon presents with acute severe groin pain. There may be a palpable mass or eccymosis in the groin. Patients complain of an inability to flex the hip against resistance and pain is exacerbated by hip flexion and extension. This injury can be suspected clinically but higher level of imaging is required to make the diagnosis. Metal artifact reduction sequences optimise the quality of MRI in patients post arthroplasty.12 As demonstrated in our case, excellent visualisation of the distal right iliopsoas tendon was achieved. In the acute setting, partial or complete disruption of the tendon components of the iliopsoas, tendinous retraction, increased fluid within the tendon sheath and oedema extending proximally along the iliopsoas can be present. In the chronic setting, fatty atrophy of the psoas tendon on MRI or radiolucency of the lesser trochancter on plain film radiography may be seen.6 CT in the setting of THA is very limited in its evaluation of the iliopsoas tendon distally due to metallic artefact. Secondary signs, which may be helpful in the acute setting, include stranding and enlargement of the iliopsoas and fluid retention may be demonstrated by tracking along the muscle. In the subacute and chronic setting fatty atrophy of the psoas will be present. Lecouvet et al9 reported on two cases of spontaneous distal iliopsoas rupture and the associated MRI findings. In both patients psoas tendon demonstrated a complete tear, but the muscle fibres of the iliacus muscle remained in continuity and could be followed to their insertion on the inferior aspect of the lesser trochancter. The musclotendinous complex of the iliopsoas explains this. The psoas muscle and medial iliacus muscle fibres form the distal psoas tendon and are purely tendinous. The distal lateral iliacus muscle fibres remain muscular until its insertion on the lesser trochancter.13 These same features were identified in our patient and this preservation of muscle attachment has been attributed to as satisfactory recovery with conservative treatment.9 The only other reported spontaneous iliopsoas tear in the setting of THA was by Maheshwari et al.6 Their patient retrospectively developed clinical iliopsoas tendon tear 2 weeks postoperatively, which has raised the question of the possibility of intraoperative tendon damage. Give the long incubation period in our case, coupled with the complete interval recovery of the patient postoperatively until the 22-month mark, we do not Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
suspect that our case is secondary to intraoperative damage. The cause of this patient’s iliopsoas tear is not fully understood as complete tears are more common in the elderly and in patients with a history of trauma.4 In conclusion, we report a rare case of spontaneous rupture of the iliopsoas tendon on a background of a total hip arthroplasty. The condition should be included in the differential diagnosis of patients presenting with groin pain post-THA. We would caution that its low incidence should mean that the diagnosis should not be made clinically and that patients should undergo a thorough check-up for the more common causes of groin pain. Once diagnosed, patients should be managed conservatively with physiotherapy and antiinflammatory medication. Given that the tendon will retract medial to the femur and posterior to the inguinal canal, repair is technically difficult and due to the absence of a welldocumented surgical repair, primary surgical repair cannot be recommended at this time. Functional outcome postrehabilitation is still unknown. Maheshwari et al6 reported residual significant disability postrehabilitation; however, the chronicity of their patient’s symptoms (10 years) prior to diagnosis may have played a role. Lecouvet et al9 reported a return to activities of daily living (ADLs) and preinjury level of mobility following rehabilitation of an acute iliopsoas tear. This is supported by lack of documented hip flexor weakness in patients who undergo tenotomy for iliopsoas impingement.8 14 Awareness of this condition as a differential for groin pain post-THA and early diagnosis will lead to appropriate rehabilitation and hopefully minimisation of any functional deficit.
Learning points ▸ Iliopsoas rupture post-total hip arthroplasty causes severe groin pain and limited flexion of the hip joint. ▸ Diagnosis should be considered when prosthesis complications have been ruled out. ▸ Diagnosis is made on MRI and treatment is conservative. ▸ The lateral fibres of the iliacus muscle remain intact and result in a good functional outcome.
Contributors RPP wrote the manuscript, and collected all relevant data and performed the literature review. He also obtained patient consent for publication. OD was the radiologist who diagnosed the iliopsoas tendon rupture on imaging. She wrote the radiology findings of the manuscript and provided the images for publication. JFQ was the operating surgeon in this case. He lead the diagnosis and management of the patient. He performed a literature review and was actively involved in the drafting of the final manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
Theologis TN, Epps H, Latz K, et al. Isolated fractures of the lesser trochanter in children. Injury 1997;28:363–4. Afra R, Boardman DL, Kabo JM, et al. Avulsion fracture of the lesser trochanter as a result of a preliminary malignant tumor of bone. A report of four cases. J Bone Joint Surg Am 1999;81:1299–304. James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol 2006;16:512–4. Bui KL, Ilaslan H, Recht M, et al. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol 2008;37: 245–9.
3
Rare disease 5 6
7 8
9
Shabshin N, Rosenberg ZS, Cavalcanti CF. MR imaging of iliopsoas musculotendinous injuries. Magn Reson Imaging Clin N Am 2005;13:705–16. Maheshwari AV, Malhotra R, Kumar D, et al. Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of the lesser trochanter simulating a malignancy. J Orthop Surg Res 2010;5:6. Jasani V, Richards P, Wynn-Jones C. Pain related to the psoas muscle after total hip replacement. J Bone Joint Surg Br 2002;84:991–3. Dora C, Houweling M, Koch P, et al. Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision. J Bone Joint Surg Br 2007;89:1031–5. Lecouvet FE, Demondion X, Leemrijse T, et al. Spontaneous rupture of the distal iliopsoas tendon: clinical and imaging findings, with anatomic correlations. Eur Radiol 2005;15:2341–6.
10
11
12 13 14
DePasse JM, Varner K, Cosculluela P, et al. Atraumatic avulsion of the distal iliopsoas tendon: an unusual cause of hip pain. Orthopedics 2010;33:(8). doi:10.3928/01477447-20100625-25. Ala Eddine T, Remy F, Chantelot C, et al. [Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and conservative treatment in 9 cases]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur. 2001;87:815–9. Douleur inguinale isolee apres prothese totale de hanche et souffrance de l’ilio-psoas. Toms AP, Smith-Bateman C, Malcolm PN, et al. Optimization of metal artefact reduction (MAR) sequences for MRI of total hip prostheses. Clin Radiol 2010;65:447–52. Bancroft LW, Blankenbaker DG. Imaging of the tendons about the pelvis. AJR Am J Roentgenol 2010;195:605–17. Heaton K, Dorr LD. Surgical release of iliopsoas tendon for groin pain after total hip arthroplasty. J Arthroplasty 2002;17:779–81.
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4
Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
CASE REPORT
Iliopsoas tendon rupture: a new differential for atraumatic groin pain post-total hip arthroplasty Robert Pearse Piggott,1 Orla Doody,2 John Francis Quinlan1 1
Trauma and Orthopaedics, AMNCH, Dublin 24, Ireland 2 Radiology Department, AMNCH, Dublin 24, Ireland Correspondence to Robert Pearse Piggott, [email protected] Accepted 29 January 2015
SUMMARY Groin pain post-total hip arthroplasty (THA) is of concern for the patient and the surgeon, especially when there is no history of any traumatic event. Obvious concern centres on complications from the prosthesis. The use of multiple imaging modalities allow for accurate diagnosis of groin pain. Atraumatic iliopsoas rupture is rare and has only been reported once before in the setting of THA. We present the case of 53-year old female with atraumatic rupture of the iliopsoas tendon that presented with severe groin pain and limited flexion. We discuss the clinical presentation, radiological features and follow-up of the patient. We also discuss the relevant published literature on the topic. This is a rare phenomenon but should be consider in patients with groin pain post-THA, especially after prosthesis complications have been ruled out.
BACKGROUND Groin pain secondary to iliopsoas tendon rupture is uncommon and has a wide range of pathologies depending on the demographics of the patient. In children and adolescence, avulsion fractures of the lesser trochancter of the femur are well documented.1 In adults, the same finding is highly suggestive of metastasis from malignancy.2 3 An isolated iliopsoas tendon tear in the absence of lesser trochancter fracture is uncommon and is usually seen in conjunction with athletic injuries or direct trauma.4 5 Spontaneous atraumatic rupture of the iliopsoas tendon is extremely rare. In the setting of total hip arthroplasty (THA), it has only been reported once in the literature.6 We present a second case of spontaneous rupture of the iliopsoas tendon 22 months after undergoing THA. Awareness of this phenomenon aids in the diagnosis of the condition and also should be considered as part of the differential in a patient with groin pain post-THA.
Her pain was severe and not fully relieved by analgesia. She subjectively described inability to lift her leg into bed at night and was compensating by active—assisted flexion with the contralateral leg. The pain was interfering with her daily activities and impeding her ability to work. The patient denied any preceding traumatic event. She denied any similar symptoms during her postoperative course. On examination, she ambulated with an antalgic gait; however, no walking aids were required. Her straight leg raise was severely limited and could not be maintained. Objectively, right hip flexion was 3/5 on the Oxford muscle strength grading scale. She had pain on passive flexion, extension and internal rotation of her hip joint. She had no pain on static weight bearing on her right leg. There was no tenderness or ecchymosis in the groin. No masses or hernias were identified. Her distal neurovascular status was intact. The operating surgeon did not recall any intraoperative complications or interference with the iliopsoas tendon.
INVESTIGATIONS A plain radiograph of the pelvis did not demonstrate any evidence of implant loosening, osteolysis, wear, malposition or heterotopic ossification (figure 1). The patient initially underwent investigations for a complication of the prosthesis, which were negative. Inflammatory and infective markers were within normal range. An isotope bone scan with technetium 99 m labelled methylene-diphosphonate (MDP), demonstrated a solidly fixed femoral and acetabular components without evidence of loosening. MRI of the pelvis was then performed which
CASE PRESENTATION
To cite: Piggott RP, Doody O, Quinlan JF. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208518
A 53-year old, fit and healthy woman was referred to the Orthopaedic arthroplasty service for sudden severe onset of right groin pain post right THA. She had undergone a right uncemented THA 22 months prior to presentation for degenerative right hip disease. She had an uncomplicated operative course and recovered full mobility postoperatively with routine follow-up at our outpatients’ facility according to local policy. She developed acute onset of right groin pain and an early follow-up was expedited. She described pain on walking, difficulty in rising from a seated position and negotiating stairs.
Figure 1 Pelvic radiograph demonstrates a normal appearance of the right hip prosthesis. The remaining bony pelvis is unremarkable.
Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
1
Rare disease
Figure 2 Axial T2-weighted MRI pelvis demonstrates increased signal within the distal right psoas muscle (arrow), which is oedematous and enlarged relative to the normal contra lateral left psoas muscle. demonstrated acute oedema and fluid extending along the right psoas muscle (figure 2). There was disruption of the distal psoas component of the iliopsoas tendon that was slightly retracted, consistent with an acute tear of the distal psoas component of the right iliopsoas tendon (figures 3 and 4). The iliacus component of the iliopsoas was intact. There were no features to suggest prosthetic loosening or infection. A subsequent CT demonstrated moderate atrophy of the right psoas muscle, consistent with a tear of the psoas tendon distally (figure 5). There were no features to suggest underlying malignancy in any of the imaging modalities.
Figure 4 Coronal T2-weighted MRI of the pelvis demonstrates diffuse oedema extending along the right psoas muscle (solid arrow) with disruption of the psoas tendon distally (dashed arrow), consistent with a complete tear of the tendon. distance has greatly improved. She has returned to driving; however prolonged journeys continue to be problematic secondary to the repeated hip flexion needed to operate the car pedals. The patient has returned to work on a full time basis. Clinically on examination, her hip flexion strength is 5/5.
DIFFERENTIAL DIAGNOSIS
DISCUSSION
Pain in the groin post-total hip arthroplasty has a wide differential, including fracture, wear and osteolysis, sepsis, aseptic loosening, heterotrophic ossification, referred pain from spine or knee, abdominal pathology and neurological and vascular causes. Soft tissue irritation and rupture must also be considered.
Iliopsoas pain is well documented in the orthopaedic and radiology literature. It is seen commonly in sports medicine and is being increasing recognised as a cause of groin pain after THA. Specifically these reports relate to an iliopsoas tendonitis7 8 and not to an iliopsoas rupture. To the best of our knowledge this is only the second report of a spontaneous atraumatic rupture of the iliopsoas tendon in the setting of THA.6 Further reports in the literature have documented two cases of spontaneous rupture of the distal iliopsoas tendon in a native hip9 and two
TREATMENT A diagnosis of acute atraumatic rupture of the psoas tendon was performed. In the absence of any well-documented surgical option, our patient was managed conservatively with physiotherapy and non-steroidal anti-inflammatory drugs.
OUTCOME AND FOLLOW-UP At her 6 months follow-up post onset of symptoms, the patient showed marked improvement. Pain is minimal and walking
Figure 3 Demonstrates abnormal fluid surrounding the distal right psoas tendon (arrow), which is disrupted at this level. A small reactive joint effusion is also present. 2
Figure 5 A subsequent axial CT demonstrates atrophy of the right psoas muscle (arrow), consistent with a subacute tear of the iliopsoas tendon. Note the normal muscle bulk of the contralateral left psoas. Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
Rare disease cases of atraumatic avulsion of the tendon from the lesser trochancter also, without the presence of THA.10 Iliopsoas tendon and myotendinous injuries have been shown to have a prevalence of 0.66%.4 MRI is the diagnostic modality of choice and allows grading of the injury into muscle sprain, partial tear and complete tear. The prevalence of complete tears was 0.16%, and was noted exclusively in women. All these patients were in the 7th to 10th decade of life. However, there is no data available regarding the incidence of injury in patients who have undergone THA. Iliopsoas tendinitis has been shown to be as high as 4.3% post-THA.11 Symptoms specific to iliopsoas irritation included difficulty in climbing stairs, getting in and out of a car, and walking on an uneven surface. This is related to the difficultly in hip flexion and adduction, which was observed in our patient. Causes of iliopsoas tendinitis post-THA have been attributed to irritation of the tendon from an anterior protruding cup and/or cement; limb lengthening and an increase in offset.8 Symptoms are greatly improved in patients by CT guided injection; however, some patients require operative exploration to manage the impingement lesion or to lengthen the psoas tendon. A small proportion will require revision of the acetabular component.7 8 Acute tears of the iliopsoas tendon presents with acute severe groin pain. There may be a palpable mass or eccymosis in the groin. Patients complain of an inability to flex the hip against resistance and pain is exacerbated by hip flexion and extension. This injury can be suspected clinically but higher level of imaging is required to make the diagnosis. Metal artifact reduction sequences optimise the quality of MRI in patients post arthroplasty.12 As demonstrated in our case, excellent visualisation of the distal right iliopsoas tendon was achieved. In the acute setting, partial or complete disruption of the tendon components of the iliopsoas, tendinous retraction, increased fluid within the tendon sheath and oedema extending proximally along the iliopsoas can be present. In the chronic setting, fatty atrophy of the psoas tendon on MRI or radiolucency of the lesser trochancter on plain film radiography may be seen.6 CT in the setting of THA is very limited in its evaluation of the iliopsoas tendon distally due to metallic artefact. Secondary signs, which may be helpful in the acute setting, include stranding and enlargement of the iliopsoas and fluid retention may be demonstrated by tracking along the muscle. In the subacute and chronic setting fatty atrophy of the psoas will be present. Lecouvet et al9 reported on two cases of spontaneous distal iliopsoas rupture and the associated MRI findings. In both patients psoas tendon demonstrated a complete tear, but the muscle fibres of the iliacus muscle remained in continuity and could be followed to their insertion on the inferior aspect of the lesser trochancter. The musclotendinous complex of the iliopsoas explains this. The psoas muscle and medial iliacus muscle fibres form the distal psoas tendon and are purely tendinous. The distal lateral iliacus muscle fibres remain muscular until its insertion on the lesser trochancter.13 These same features were identified in our patient and this preservation of muscle attachment has been attributed to as satisfactory recovery with conservative treatment.9 The only other reported spontaneous iliopsoas tear in the setting of THA was by Maheshwari et al.6 Their patient retrospectively developed clinical iliopsoas tendon tear 2 weeks postoperatively, which has raised the question of the possibility of intraoperative tendon damage. Give the long incubation period in our case, coupled with the complete interval recovery of the patient postoperatively until the 22-month mark, we do not Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
suspect that our case is secondary to intraoperative damage. The cause of this patient’s iliopsoas tear is not fully understood as complete tears are more common in the elderly and in patients with a history of trauma.4 In conclusion, we report a rare case of spontaneous rupture of the iliopsoas tendon on a background of a total hip arthroplasty. The condition should be included in the differential diagnosis of patients presenting with groin pain post-THA. We would caution that its low incidence should mean that the diagnosis should not be made clinically and that patients should undergo a thorough check-up for the more common causes of groin pain. Once diagnosed, patients should be managed conservatively with physiotherapy and antiinflammatory medication. Given that the tendon will retract medial to the femur and posterior to the inguinal canal, repair is technically difficult and due to the absence of a welldocumented surgical repair, primary surgical repair cannot be recommended at this time. Functional outcome postrehabilitation is still unknown. Maheshwari et al6 reported residual significant disability postrehabilitation; however, the chronicity of their patient’s symptoms (10 years) prior to diagnosis may have played a role. Lecouvet et al9 reported a return to activities of daily living (ADLs) and preinjury level of mobility following rehabilitation of an acute iliopsoas tear. This is supported by lack of documented hip flexor weakness in patients who undergo tenotomy for iliopsoas impingement.8 14 Awareness of this condition as a differential for groin pain post-THA and early diagnosis will lead to appropriate rehabilitation and hopefully minimisation of any functional deficit.
Learning points ▸ Iliopsoas rupture post-total hip arthroplasty causes severe groin pain and limited flexion of the hip joint. ▸ Diagnosis should be considered when prosthesis complications have been ruled out. ▸ Diagnosis is made on MRI and treatment is conservative. ▸ The lateral fibres of the iliacus muscle remain intact and result in a good functional outcome.
Contributors RPP wrote the manuscript, and collected all relevant data and performed the literature review. He also obtained patient consent for publication. OD was the radiologist who diagnosed the iliopsoas tendon rupture on imaging. She wrote the radiology findings of the manuscript and provided the images for publication. JFQ was the operating surgeon in this case. He lead the diagnosis and management of the patient. He performed a literature review and was actively involved in the drafting of the final manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
Theologis TN, Epps H, Latz K, et al. Isolated fractures of the lesser trochanter in children. Injury 1997;28:363–4. Afra R, Boardman DL, Kabo JM, et al. Avulsion fracture of the lesser trochanter as a result of a preliminary malignant tumor of bone. A report of four cases. J Bone Joint Surg Am 1999;81:1299–304. James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol 2006;16:512–4. Bui KL, Ilaslan H, Recht M, et al. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol 2008;37: 245–9.
3
Rare disease 5 6
7 8
9
Shabshin N, Rosenberg ZS, Cavalcanti CF. MR imaging of iliopsoas musculotendinous injuries. Magn Reson Imaging Clin N Am 2005;13:705–16. Maheshwari AV, Malhotra R, Kumar D, et al. Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of the lesser trochanter simulating a malignancy. J Orthop Surg Res 2010;5:6. Jasani V, Richards P, Wynn-Jones C. Pain related to the psoas muscle after total hip replacement. J Bone Joint Surg Br 2002;84:991–3. Dora C, Houweling M, Koch P, et al. Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision. J Bone Joint Surg Br 2007;89:1031–5. Lecouvet FE, Demondion X, Leemrijse T, et al. Spontaneous rupture of the distal iliopsoas tendon: clinical and imaging findings, with anatomic correlations. Eur Radiol 2005;15:2341–6.
10
11
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DePasse JM, Varner K, Cosculluela P, et al. Atraumatic avulsion of the distal iliopsoas tendon: an unusual cause of hip pain. Orthopedics 2010;33:(8). doi:10.3928/01477447-20100625-25. Ala Eddine T, Remy F, Chantelot C, et al. [Anterior iliopsoas impingement after total hip arthroplasty: diagnosis and conservative treatment in 9 cases]. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur. 2001;87:815–9. Douleur inguinale isolee apres prothese totale de hanche et souffrance de l’ilio-psoas. Toms AP, Smith-Bateman C, Malcolm PN, et al. Optimization of metal artefact reduction (MAR) sequences for MRI of total hip prostheses. Clin Radiol 2010;65:447–52. Bancroft LW, Blankenbaker DG. Imaging of the tendons about the pelvis. AJR Am J Roentgenol 2010;195:605–17. Heaton K, Dorr LD. Surgical release of iliopsoas tendon for groin pain after total hip arthroplasty. J Arthroplasty 2002;17:779–81.
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Piggott RP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2014-208518
