Thank you for your time and attention. The following is a presentation on iliopsoas impingement and snapping. Iliopsoas impingement and snapping generally occurs following total hip arthroplasty with an incidence of 0.4 to 4.3%, although it has been described as painful and symptomatic in the native hip, particularly in the setting of multi-fit tendons. It generally presents with anterior groin pain and hip flexion weakness, and there are multiple proposed risk factors for this, including acetabular component overhang. It has been inherently challenging to ascertain incidence of iliopsoas impingement, given that this is generally under-recognized and some, if not many, episodes are self-limiting. There are two typical clinical presentations of impingement. Early after arthroplasty, this generally occurs in the previously inactive patient. It is not immediate at onset, and in my practice, this tends to be related to early overuse and resolved with physical therapy and non-steroidal anti-inflammatory medications. Later after arthroplasty, patients present with chronic iliopsoas irritation. This is usually indicative of an ongoing, long-standing process that is generally less responsive to conservative measures. Non-operative workup consists of the ABCs, namely activity, bacteria, and cup. In terms of activity, discuss any recent ramp-ups, such as running progression. For the overly motivated patient that is chainsawing in the forest post-operative day 1 from arthroplasty, discuss the important role of rest and gradual return to activity. B is for bacteria, namely that one must exclude infection. A complete blood count, erythrocyte sedimentation rate, and C-reactive protein can be helpful for this, as is consideration of aspiration for indeterminate values. Finally, C refers to cup position. This is best assessed on cross-table lateral radiographs, evaluating for acetabular retroversion and associated overhang. A computed tomography, or CT scan, with three-dimensional reconstructions may also be helpful to assess cup position and coverage. In terms of non-operative management and physical therapy, the main focus is on iliopsoas offloading, namely core strengthening and gluteal activation. Attention should also be given to posture and gait correction, understanding that addressing pelvic tilt and normalizing compensatory gait patterns may improve functional hip-spine relationships. Finally, soft tissue modalities, such as massage and dry needling, may be considered. In terms of iliopsoas bursal injections, these may have both diagnostic and therapeutic benefits. We generally employ local anesthetic and corticosteroid, and many patients report transient return of full hip flexion strength. Diagnostic injection also provides a concurrent opportunity for aspiration, if necessary. In terms of therapeutic benefit, up to 67% of patients report long-term benefit following iliopsoas bursal injections, and consideration can be given to repeat injections if these are both durable and efficacious, generally spacing these at least four months apart. In terms of surgical management, iliopsoas impingement highlights the concept of one target with many potential underlying causes. Such ideologies include acetabular component overhang, a multi-fit tendon, which is demonstrated in this surgical video of a right hip here and may cause snapping even in the native hip, proud femoral component collars, as shown here by the red asterisk, and subsequently highlighted in this surgical video demonstrating direct abutment of the collar and nearby iliopsoas tendon, and also other causes, including iliopsoas tendinopathy, or likely partial thickness laceration at the time of arthroplasty and associated retractor placement, as demonstrated in this arthroscopic video. Regardless of cause, these entities present clinically with iliopsoas impingement or snapping and associated anterior groin pain and often hip flexion weakness. In terms of preferred surgical technique, we prefer to perform arthroscopic iliopsoas fractional lengthening employing an air bursagram to access the tendon. This can be done both in the native hip and also status post-arthroplasty hip, and our written open access technique can be accessed at the QR code shown. For surgical instrumentation, when it comes to iliopsoas fractional lengthening, the air bursagram is key, as it allows for safe and efficient tendon sheath access. Subsequently, we are able to identify the tendon, shown here with its relationship with the anterior joint capsule and superior medial iliopsoas muscle belly. We then divide the tendon, while the muscle remains intact, thus constituting a fractional lengthening. I do feel that it is important to also release any adhesions between the tendon and underlying bursal sheath. When the tendon release is complete, one can appreciate the increased distance between one end of the tendon and the other. Thank you for your time and attention.

iliopsoas impingement

total hip arthroplasty

anterior groin pain

non-operative management

arthroscopic iliopsoas lengthening