ORIGINAL RESEARCH
Ultrasound in Total Hip Replacement
Value of Anterior Acetabular Cup Visibility and Contact
With the Iliopsoas Tendon
Rapha€el Guillin, MD , Valerie Bertaud, PhD, Marc Garetier, MD, Olivier Fantino, MD,
Jean-Louis Polard, MD, Jean-Christophe Lambotte, MD
Received June 8, 2017, from the Department of
Musculoskeletal Imaging, University Hospital,
H^opital Sud, Rennes, France (R.G.); Institut
National de la Sante et de la Recherche
Medicale, Unit 1099, Rennes, France (V.B.);
University of Rennes 1, Rennes, France (V.B.);
Departments of Dental Surgery (V.B.) and
Orthopedic Surgery (J.-L.P., J.-C.L.), University
Hospital of Rennes, Rennes, France; Depart-
ment of Imaging, Military Teaching Hospital
Clermont-Tonnerre, Brest, France (M.G.); and
Department of Imaging, Clinique du Parc,
Rhone, France (O.F.). Manuscript accepted for
publication August 29, 2017.
Address correspondence to Rapha€el
Guillin, MD, Department of Musculoskeletal
Imaging, H^opital Sud, 16 Blvd de Bulgarie,
35203 Rennes Cedex, France.
E-mail: raphael.guillin@chu-rennes.fr
Abbreviations
ANOVA, analysis of variance; CT, com-
puted tomography; THR, total hip replace-
ment; US, ultrasound
doi:10.1002/jum.14484
C 2017 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2018; 37:1439–1446 | 0278-4297 | www.aium.org
V
Objectives—To assess visibility of the acetabular cup in total hip replacement and
to determine the value of direct and indirect signs of iliopsoas impingement syn-
drome with ultrasound.
Methods—Ultrasound examinations were performed by a single operator in 17
patients with iliopsoas impingement syndrome and 48 control patients. Cup visibility,
contact between the cup and psoas tendon, and the presence of indirect signs of iliop-
soas impingement syndrome were investigated in all patients. When the acetabular
cup was visible, its size and position in relation to the psoas tendon were recorded.
Results—Anterior cup visibility (P 5 .03), contact with the psoas tendon
(P < .001), psoas tendinopathy (P 5 .02), and iliopsoas bursitis (P < .001) were
significantly associated with iliopsoas impingement syndrome, the latter reported
with specificity of 100%. In the sagittal plane at the level of the psoas tendon, a max-
imum sagittal length of greater than 5 mm and a posteroanterior cup shift of 3 mm
or greater yielded respective sensitivities of 82% and 59% and specificities of 81%
and 100%.
Conclusions—When iliopsoas impingement syndrome is clinically suspected, the
presence of iliopsoas bursitis or a posteroanterior cup shift of greater than 3 mm
under the psoas tendon serve to confirm the diagnosis. In the absence of these con-
ditions, a therapeutic test may be necessary because of the incomplete, albeit high,
specificity of other signs.
Key Words—extremities; iliopsoas bursitis; iliopsoas impingement syndrome;
invasive techniques; musculoskeletal (interventional); postoperative pain; total
hip replacement; ultrasound
T
otal hip replacement (THR) has changed the prognosis of
patients with severe hip osteoarthritis. Despite the fact that a
THR is often well tolerated, the functional outcome may be
impaired by intra-articular complications, including loosening, infec-
tion, fracture, and dislocation.1–3. More recently, iliopsoas tendon
impingement syndrome has been reported to account for up to 4%
of painful hip arthroplasties.4 In the typical form of this condition,
anterior overhang due to excessive acetabular cup retroversion causes
impingement against the deep aspect of the iliopsoas tendon.
Apart from lateral radiographs of the hip, some studies have
emphasized the role of computed tomography (CT)4–7 as a diag-
nostic tool because of the respectively high and moderate sensitiv-
ities afforded by evidence of anterior protrusion of the acetabular
cup with and without iliopsoas bursitis.6 Nevertheless, these signs
may lack specificity, given that a slight overhang has also been
Guillin et al—Ultrasound in Total Hip Replacement
reported in asymptomatic patients,6 whereas bursitis
may be seen in various conditions, including septic and
aseptic loosening of a THR.8–10 Additionally, CT
images are degraded by both metal artifacts and the
limited resolution of soft tissues. Effective visualization
of the impinged region is therefore often hampered. In
view of the poor accuracy of CT and despite their inva-
sive nature, therapeutic steroid and anesthetic injec-
tions into the iliopsoas bursa have been suggested as
the most effective diagnostic tests of iliopsoas impinge-
ment syndrome by some authors.4,6,11–13
Ultrasound (US) has recently shown remarkable
capabilities for assessing orthopedic hardware14–16
because of its high spatial resolution for soft tissues and
limited metal-induced artifacts. To the best of our
knowledge, only 1 case report has described the ability
of US to depict abnormal contact between a THR and
the iliopsoas tendon.16 The aim of our study was to
assess the value of psoas tendinopathy, iliopsoas bursi-
tis, and contact between the tendon and acetabular cup
in the diagnosis of iliopsoas impingement syndrome in
cases of anterior acetabular cup overhang visibility in
patients with clinical suspicion of iliopsoas impinge-
ment syndrome.
Materials and Methods
Ultrasound Examination Protocol
Rennes University Hospital Ethics Committee approval
was waived, and informed consent was obtained from all
patients included in the study. All patients in the study
were examined in the supine position with the hip in a
neutral position without flexion by a single operator
with 8 years of experience in musculoskeletal imaging
(iU22 US system; Philips Healthcare, Eindhoven, the
Netherlands). The iliopsoas tendon and surrounding
region were studied by placing the transducer in a trans-
verse oblique plane along the iliopubic line, as reported
in a previous study (Figure 1A).17 The iliopsoas tendon
appeared as a thick ovoid hyperechoic structure lying
against the superior pubic ramus. Tendon reflectivity
was assessed on the basis of susceptibility to anisotropy
and classified as high, moderate, or low, with the latter 2
stages suspected to indicate substantial tendinopathy.
Additionally, the presence of iliopsoas bursitis was con-
sidered when fluid was visible on at least 1 of the 2 arms
of the bursal cavity.18 Acetabular cup visibility was then
1440
assessed by a close examination of the superior pubic
ramus and considered present when a curvilinear line
interrupting the native pubic bone was visible (Figure
1B). As the edge of the cup lies a few millimeters proxi-
mal to the femoral head surface, a slight tilt of the trans-
ducer may be required in the vertical plane to
superimpose their respective surfaces on the same image.
Strict parallelism between the 2 lines results from the
fact that the 2 components of a prosthesis have the same
radius of curvature (Figure 1, A and B). We refer to this
as the “double-curve sign” and regard it as a valid clue to
anterior cup visibility. When present, maximum axial vis-
ibility of the acetabular cup was measured along the
oblique axial plane of investigation. A successive exami-
nation of the psoas tendon and underlying acetabular
cup with US provides an accurate representation of their
relationship. When contact was observed, the maximum
length of contact in the axial plane of investigation was
measured (Figure 1C), whereas when contact was not
observed, the gap between the 2 structures (psoas ten-
don and cup) was measured in the same oblique axial
plane.
The transducer was then placed in an oblique sagit-
tal plane perpendicular to the oblique axial plane,
roughly parallel to the femoral neck axis and perpendicu-
lar to the acetabular rim and cup (Figure 2A). When visi-
ble, the edge of the acetabular cup was seen as an echoic
line and usually produced reverberation artifacts.15 Due
to its oblique orientation anteriorly and inferiorly, the
size of the visible cup was quantified by measuring both
its maximum sagittal length and posteroanterior shift in
the posteroanterior plane (Figure 2B). This measure-
ment was performed under the psoas tendon, defining
the maximum sagittal length of the cup under the psoas
tendon and posteroanterior shift of the cup under the
psoas tendon, and at the location of maximum cup visi-
bility in the sagittal plane, defining the maximum sagittal
length of the cup at its point of maximum visibility and
posteroanterior shift of the cup at its point of maximum
visibility, a position along the acetabular bone that may
differ from the former one. When there was no contact
between the acetabular cup and overlying psoas tendon,
the gap between the 2 structures (psoas tendon and
cup) was measured in the same sagittal plane.
The mean anterior angle of reflection of the tendon
against the superior pubic ramus was calculated on the
basis of 2 consecutive measurements by the same opera-
tor. Last, the thickness of the articular lumen along the
J Ultrasound Med 2018; 37:1439–1446
 Guillin et al—Ultrasound in Total Hip Replacement

neck of the prosthesis was also measured, and the type
of transducer used to perform the study was noted.
Group With Iliopsoas Impingement Syndrome
From March 2011 to March 2013, 26 consecutive
patients with a primary THR and anterior groin pain
suspected to result from iliopsoas impingement
syndrome were referred by our orthopedic department
for the above-mentioned US investigation. The same
examination protocol and technique were routinely used
for all patients, allowing valid qualitative and quantitative
data to be collected retrospectively. Twenty patients
with evidence of a double-curve sign combined with
contact between the iliopsoas tendon and acetabular cup

Figure 1. A, Oblique axial orientation of the transducer along the superior pubic rim, allowing visualization of the acetabular cup, femoral head,
and overlying psoas tendon. The US beam, intercepting both the acetabular cup and the femoral head, appears as a dark shadow. B, Oblique
axial US view of the hip of a 48-year-old patient who had THR with anterior visibility and acetabular cup overhang. This image, obtained with the
transducer position shown in A, shows a double-curve sign. Both the acetabular cup (long arrows) and the femoral head (short arrows) are visible
on the same view with the same ray of curvature.The psoas tendon (open arrow) is seen in close vicinity to the acetabular cup. C, Anisotropy per-
mits clear delineation of the psoas tendon (arrow), which appears as a thick ovoid hyperechoic structure, confirming contact between the tendon
and acetabular cup and allowing measurement of the maximum length of contact (MLC) between them.

Figure 2. A, Oblique sagittal transducer orientation along the long axis of the psoas tendon. The US beam, intercepting the native acetabular
bone, the acetabular cup and the femoral head, appears as a dark shadow. B, Oblique axial US view of the hip, obtained in the same patient as
shown in Figure 1 and along the plane of investigation shown in A. The psoas tendon is visible superficially, overlying the acetabular cup and
adjacent to the femoral head. This image allows measurement of both the maximum sagittal length (MSL) and posteroanterior shift (PAS) of the
cup.

J Ultrasound Med 2018; 37:1439–1446 1441

Guillin et al—Ultrasound in Total Hip Replacement
were offered a US-guided injection of 1.5 mL of cortiva-
zol (Sanofi Pharmaceuticals, Paris, France) and 4 mL of
L-bupivacaine, 0.5% (AbbVie Pharmaceuticals, Rungis,
France). A substantial clinical response to the therapeu-
tic test with a decrease in pain and improvement of the
quality of life, which was subjectively recorded by a sen-
ior orthopedic surgeon at clinical follow-up, was used as
the reference standard to confirm the presence of iliop-
soas impingement syndrome. Patients lost to early
follow-up or with a negative response to the therapeutic
test were excluded from the study.
Control Group
Over a 13-month period, 52 consecutive patients with a
primary THR were clinically evaluated after a 6-month
postoperative period. Patients were physically examined
for evidence of iliopsoas impingement syndrome and
questioned about pain or discomfort. The absence of
substantial pain was confirmed by an Oxford hip score
of less than 26 of 60 points, as documented in the litera-
ture,19,20 and used as the reference standard for the
absence of iliopsoas impingement syndrome. Patients
with a primary THR and a low Oxford score 6 months
after surgery were included in the study. Conversely,
patients with a score of 26 or higher were excluded from
the study. All patients were prospectively investigated by
the same operator as for the iliopsoas impingement syn-
drome group, and the same routine protocol was used.
The side and type of THR, type of transducer required
for US examination, size and weight of patients, and
presence of pain at follow-up were also noted.
Statistical Analysis
The results were assessed with SPSS version 17.0 soft-
ware (IBM Corporation, Armonk, NY). Regarding qual-
itative data, percentages were compared by uncorrected
Yates, corrected v2, and Fisher exact tests. Regarding
quantitative data, mean values were compared by analy-
sis of variance (ANOVA). When the required test
Table 1. Patient Characteristics
Male Female Mean Age
Group (%) (%) (Range), y
Iliopsoas 5 (29) 12 (71) 60 (34–79)
impingement
(n 5 17)
Control (n 5 48) 20 (42) 28 (58) 66 (41–86)
P .37, v2 .12, ANOVA
1442
conditions were not met because of variance discrepan-
cies as calculated by the Barnett test, a Kruskal-Wallis
test was performed. P < .05 was considered statistically
significant.
Results
Control Group
Among the 52 patients evaluated with US, 4 with a
mean Oxford hip score of greater than 26 were excluded
from the study. Forty-eight patients, with a mean Oxford
hip score of 17.3 and including 28 female and 20 male
patients (mean age, 66 years [range, 41–86 years]), were
considered free of iliopsoas impingement syndrome and
included in the study. After a mean period of 26 months
(range, 16–37 months), none of the patients had re-
ported hip discomfort. The left hip was involved in 23
patients and the right hip in the remaining 25. All
patients had been operated on through an anterolateral
portal by the same surgeon with 20 years of experience
in hip surgery. A Tregor cementless acetabular cup
(Aston Medical, Saint Etienne, France) with a mean
diameter of 48.5 mm (range, 46–50 mm) was implanted
in the hips of 10 patients, and a Pinnacle cup (DePuy
Orthopedics, Inc, Warsaw, IN) with a mean diameter of
50 mm (range, 46–58 mm) was implanted in the hips of
38 patients. The main patient characteristics are shown
in Table 1.
Iliopsoas Impingement Syndrome Group
Seventeen patients, including 5 male and 12 female
patients with a mean age of 60 years (range, 34–79
years), were included in the study (Table 1), whereas 3
others who were lost to early follow-up were excluded.
Descriptive Study
In the iliopsoas impingement syndrome group
(n 5 17), bursitis and tendinopathy were seen in 7 and
15 cases, respectively. The acetabular cup was visible and
Visibility Presence of
Side Bursitis Tendinopathy of Cup Contact
5 right 12 left 7 15 17 17
25 right 23 left 0 18 34 6
.11, v2 <.001, .02, v2 <.03, Yates v2 .001, v2
Fisher
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 Guillin et al—Ultrasound in Total Hip Replacement

shown to impinge on the iliopsoas tendon in all cases. In
the control group (n 5 48), bursitis and tendinopathy
were seen in 0 and 18 cases. The acetabular cup was at
least slightly visible in 34 patients, whereas direct contact
between the acetabular cup and psoas tendon was noted
in 6 patients. When there was no contact, the mean dis-
tances between the tendon and cup were 4 mm in the
axial plane and 3 mm in the sagittal plane. When there
was contact, the mean maximum lengths of contact
between the cup and tendon in the axial plane of investi-
gation was 7.5 mm in the iliopsoas impingement syn-
drome group and 6 mm in the control group. When
assessing the control group (n 5 48; mean body mass
index, 26 kg/m2 (range, 19–39 kg/m2), a 12–5-MHz lin-
ear transducer was used in 43 patients, whereas a 9–4-
MHz curvilinear one was required in 5. The qualitative
and quantitative data of the groups are shown in Tables
1 and 2.
Analytic Study
The groups were comparable in terms of age (P 5 .12,
ANOVA), sex ratio (P 5 .37, v2), and laterality of the
Table 2. Quantitative Data
THR (P 5 .11, v2). Both visibility of the acetabular cup
(P 5 .03) and contact between the acetabular cup and
iliopsoas tendon (P < .001) were significantly more
prevalent in the symptomatic group. Similarly, suspected
indirect signs of iliopsoas impingement syndrome such
as iliopsoas bursitis (P < .001) and substantial tendinop-
athy (P 5 .02) were also associated with the condition.
The sensitivity and specificity of signs were respectively
estimated at 100% and 29% for acetabular cup visibility,
100% and 88% for contact between the acetabular cup
and iliopsoas tendon, 41% and 100% for bursitis, and
88% and 62% for iliopsoas tendinopathy (Table 1).
From a quantitative point of view, the maximum
axial length of the cup, maximum sagittal length of the
cup under the psoas tendon, maximum sagittal length of
the cup at its point of maximum visibility, posteroante-
rior shift of the cup under the psoas tendon, and poster-
oanterior shift of the cup at its point of maximum
visibility were significantly higher in the symptomatic
group (P < .0001). At the same time, the articular lumi-
nal thickness (P 5 .52), maximum length of contact in
the axial plane (P 5 .1), and angulation of the psoas

Length of
Sagittal Joint Contact in Angulation
Thickness, MAV, MV-MSL, MV-PAS, Axial Plane, GA, GS, of Psoas
Group mm mm mm mm mm mm mm Tendon,8
Iliopsoas 4.5 (2.5–7.5) 26 (9–40) 9 (2–18) 3.5 (0–10) 7.5 (3–11) 0 0 30 (21–38)
impingement
(n 5 17)
Control 4.5 (1.5–7.5) 17 (6–34) 3.5 (1–6) 1 (0–2.5) 6 (3–9) 4 (0–9) 3 (0–11) 30 (17–39)
(n 5 48)

Values in parentheses are ranges. GA indicates gap between the psoas tendon and cup in the axial plane; GS, gap between the psoas
tendon and cup in the sagittal plane; MAV, maximum axial visibility of the cup; MV-MSL, maximum sagittal length of the cup at its point
of maximum visibility; and MV-PAS, posteroanterior shift of the cup at its point of maximum visibility.

Table 3. Value of Quantitative Data

Area Under the Curve Best Cutoff Sensitivity at Specificity at

Parameter (95% CI) Point, mm Cutoff Point Cutoff Point

MAV 0.835 (0.710–0.961) 23.5 0.765 0.848

MV-MSL 0.873 (0.755–0.991) 5.25 0.882 0.735
MV-PAS 0.884 (0.795–0.973) 1.25 0.882 0.714
MV-MSL 1 MV-PAS 0.902 (0.796–1.000) 6.25 0.941 0.765
UP-MSL 0.898 (0.792–1.000) 5.25 0.824 0.812
UP-PAS 0.852 (0.735–0.970) 2.75 0.588 1.000
UP-MSL 1 UP-PAS 0.892 (0.782–1.000) 6.25 0.882 0.781

CI indicates confidence interval; MAV, maximum axial visibility of the cup; MV-MSL, maximum sagittal length of the cup at its point of
maximum visibility; and MV-PAS, posteroanterior shift of the cup at its point of maximum visibility; UP-MSL, maximum sagittal length of
the cup under the psoas tendon; and UP-PAS, posteroanterior shift of the cup under the psoas tendon.

J Ultrasound Med 2018; 37:1439–1446 1443

Guillin et al—Ultrasound in Total Hip Replacement
tendon in the sagittal plane (P 5 .99) were not associ-
ated with iliopsoas impingement syndrome (Table 2).
Indices significantly associated with iliopsoas
impingement syndrome were dichotomized at the opti-
mal cutoff points. Overall, maximum sagittal length of
the cup at its point of maximum visibility, with a cutoff
value of 5.25 mm, and a posteroanterior shift of the cup
at its point of maximum visibility, with a cutoff value of
1.25 mm, offered the best sensitivity when measure-
ments were considered separately, estimated at 88.2%,
with respective specificities of 73.5% and 71.4%. Both
sensitivity and specificity increased to 94% and 76.5%
when the sum of the variables was greater than 6 mm
(Table 3).
The sensitivity of the maximum length of the cup in
the axial plane was estimated at 85% for a cutoff value of
23.5 mm. When evaluating the acetabular cup under the
psoas tendon, a cutoff value for the maximum sagittal
length of the cup of greater than 5 mm gave sensitivity
of 82.4% with specificity of 81.2%, whereas posteroante-
rior cup shift of 3 mm or greater lacked sensitivity
(58.8%) but gave specificity of 100%. Similarly, a cutoff
value of greater than 6 mm for the sum of the measure-
ments improved test accuracy with respective sensitivity
and specificity of 88.2% and 78.1% (Table 3).
Discussion
Diagnosis of iliopsoas impingement syndrome is usually
established on the basis of a clinical examination, plain
radiographs, or CT and a therapeutic test consisting of
iliopsoas bursal injection.13 Clinically, the syndrome
causes groin pain during active hip flexion, active straight
leg raising, and flexion against resistance, whereas it is
not usually felt when walking on a flat surface.11,12
Cyteval et al6 showed the ability of CT to detect an
anterior overhang of the acetabular cup. Interestingly,
that study demonstrated that a slight overhang may be
observed in asymptomatic patients and suggested a cut-
off value of 12 mm in the axial plane as a strong indicator
of the condition. However, that study emphasizes the
need for better visualization of both contact between the
psoas tendon and cup and subsequent tendinopathy or
bursitis, which cannot be achieved with any accuracy by
CT because of substantial artefacts. In this regard, only 1
case report by Rezig et al16 has demonstrated the ability
of US to show these soft tissue changes. Its ability to
accurately analyze both the surface of orthopedic
1444
hardware15 and neighboring soft tissues in the groin
region17 makes US imaging a method of choice. In
agreement with the description by Rezig et al,16 we
believe that the acetabular cup may be typically recog-
nized when a curvilinear echoic line with the same ray of
curvature as the more distal femoral head is identified in
an oblique axial plane, a finding we refer to as the US
THR double-curve sign. This description is used to pre-
vent any confusion with the margin of the native bone
overlying the cup or protrusion of cement into the soft
tissues. In most patients, the use of a high-frequency 12–
5-MHz linear transducer was possible and provided the
high spatial resolution required to accurately assess the
psoas tendon region. A curvilinear 9–4-MHz transducer
was necessary for 5 patients only, all of them being over-
weight, with a mean body mass index of 33.5 kg/m2
(range, 27–39 kg/m2).
Due to the insufficient specificity of clinical tests
and imaging modalities, therapeutic tests are currently
regarded as the reference standards for iliopsoas
impingement syndrome by several authors.4,6,11–13,21 In
our study, all 17 patients with clinical suspicion of iliop-
soas impingement syndrome and contact between the
psoas tendon and acetabular cup responded positively to
these tests. The fact that no patients responded nega-
tively confirms the high positive predictive value of con-
tact visualized on US. For ethical reasons, as we could
not envision an invasive procedure in patients without
contact shown on US, our control group could not be
drawn from a cohort of symptomatic patients with a
negative test result but by studying 48 consecutive
patients who had hip arthroplasty and were free of pain
up to an average of 26 months postoperatively.
Overall, and in agreement with Cyteval et al,6 our
study confirms that anterior cup visibility is prevalent in
an asymptomatic patient group, and, considered in isola-
tion, the finding is therefore not sufficient for diagnosis
of iliopsoas impingement syndrome. In most cases, how-
ever, the metal was only just visible deep to the native
acetabular bone when the transducer was tilted slightly
and repeatedly while maintaining a substantial distance,
averaging 4 mm in the axial plane and 3 mm in the sagit-
tal plane, between the metal and tendon. As mentioned
above, an accurate assessment of the relationship
between the psoas tendon and the acetabular cup cannot
be achieved by CT. Direct contact was seen between the
psoas tendon and acetabular cup in as many as 12% of
the control group, resulting in sign specificity of 88%.
J Ultrasound Med 2018; 37:1439–1446

However, iliopsoas impingement syndrome occurrence
is directly related to the degree of overhang since, post-
eroanterior shift and the maximum sagittal cup length
are significantly associated with iliopsoas impingement
syndrome. Interestingly, a sum of these measurements
of greater than 6 mm offers even better accuracy, with
sensitivity of 88% and specificity of 78% at the level of
the iliopsoas tendon. In routine practice, cup assessment
at the latter level may be preferred to the site of the cup
maximum sagittal length, not only when considering its
relevance to the pathophysiologic characteristics of iliop-
soas impingement syndrome but also because poster-
oanterior shift of the cup under the psoas tendon of
greater than 3 mm provides a pecificity of 100% despite
its low sensitivity of 59%. This finding is therefore con-
sidered pathognomonic in a population with clinical sus-
picion of iliopsoas impingement syndrome.
Iliopsoas bursitis is the main indirect sign of iliop-
soas impingement syndrome and was reported from
CT scans of 5 of 12 patients in a study by Bricteux
et al.5 Although our study confirmed moderately high
sensitivity for this sign, estimated at 41%, its specificity
appeared to be even more pertinent, as the finding
was never observed in the control group, thus giving
100% specificity. Overall, it may be considered that
iliopsoas bursitis associated with contact between the
acetabular cup and psoas tendon is also pathogno-
monic of iliopsoas impingement syndrome in a recent
hip prosthesis with clinical suspicion of iliopsoas
impingement syndrome. Apart from this specific clini-
cal setting, bursitis may produce a lower positive pre-
dictive value, as this sign has also been reported for
other causes of THR pain such as nonseptic9 and sep-
tic loosening of the THR.8,10 Furthermore, our study
showed psoas tendinopathy to be associated with
iliopsoas impingement syndrome, with sensitivity of
88%, despite much lower specificity than iliopsoas
bursitis. The high prevalence of tendinopathy in iliop-
soas impingement syndrome is in agreement with
Dora et al,11 who reported partially torn and irritated
swollen tendons in 8 and 11, respectively, of the 19
patients included in their study during open surgery.
Our study had certain limitations. The first was that
acetabular cup visibility with US was not compared with
CT. However, US may be considered more effective
than CT for investigating the subtle relationship
between the metal and underlying native acetabular
bone and for showing indirect signs of the condition
J Ultrasound Med 2018; 37:1439–1446
Guillin et al—Ultrasound in Total Hip Replacement
because of its higher spatial resolution and lower suscep-
tibility to artifacts. Second, our therapeutic test, consid-
ered the reference standard, was only applied to patients
in whom contact between the iliopsoas tendon and ace-
tabular cup was shown by US, because of the ethical
concerns surrounding invasive procedures and notably
the subsequent risk of infection in patients with a THR.
At the same time, we believe that the use of an asymp-
tomatic cohort of patients as the control group offered
sufficient reliability for conducting the study. Given the
study design, we were unable to assess the possibility of
iliopsoas impingement syndrome without contact
between the acetabular cup and psoas tendon, a condi-
tion that has been rarely reported and may be explained
by alteration of the tendon course due to excision of the
femoral head.7,12 Further studies are required to assess
the value of US in these situations. Third and finally, the
reproducibility of the technique was not assessed, as a
single operator with a special interest in iliopsoas disor-
ders conducted the study in both groups.
In conclusion, this study confirms that the anterior
aspect of the hip is accessible to US imaging in all
patients with a THR. Due to the high sensitivity and
specificity of this method, diagnosis of iliopsoas impinge-
ment syndrome can be suggested when contact is visible
between the acetabular cup and iliopsoas tendon. When
contact is visible in patients with clinical suspicion of
iliopsoas impingement syndrome, iliopsoas bursitis or a
posteroanterior cup shift of 3 mm or greater under the
psoas tendon can confirm the diagnosis without the
need for a US-guided therapeutic test. Apart from these
situations and despite the accuracy achieved through the
sum of posteroanterior shift and maximum sagittal
length measurements in particular, a therapeutic test
may still be required because of the method’s incom-
plete specificity.
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