Endoscopic Iliopsoas Tendon Lengthening and Iliac Fossa Debridement After Total Hip Arthroplasty: A Surgical Technique.

Background: Iliopsoas tendinopathy is an established cause of persistent anterior groin pain after total hip arthroplasty (THA), with an incidence of 2% to 6%. Although frequently attributed to acetabular component malposition and anterior prominence, symptomatic iliopsoas irritation can also occur in cases with appropriately positioned implants. Ultrasound-guided corticosteroid injection targeted to the iliopsoas tendon can be diagnostic; however, a subset of patients remains refractory to nonoperative management. In these cases, arthroscopic intervention may be indicated. We present a case highlighting the role of iliac fossa osteophyte formation as a source of iliopsoas impingement after THA and demonstrate an arthroscopic technique to address both tendinopathy and osseous impingement. Technique Description: The procedure is performed supine on a traction table without traction, utilizing an outside-in extracapsular approach. An anterolateral portal is localized fluoroscopically superficial to the femoral head implant. After arthroscopic insertion, a mid-anterior portal is established. Significant tendinopathy within the iliopsoas tendon and associated bursal/pericapsular inflammation are debrided with an arthroscopic shaver and radiofrequency ablation. The iliac fossa is then exposed, and the osteophyte formation is systematically burred back to eliminate contact between the tendon and the prominent iliac fossa bone. After osteoplasty, a fractional lengthening is performed at the myotendinous junction, incising only the tendinous fibers to reduce tension while preserving muscle to minimize postoperative weakness. Results: Previous endoscopic iliopsoas lengthening studies after THA demonstrate consistent improvement in patient-reported outcomes with high rates of minimal clinically important difference achievement and low complication rates. Functional hip range of motion is preserved, and a mild reduction in hip flexor strength (approximately 15%-20%) is not clinically limiting in most patients. Comparative analyses also demonstrate lower complication rates for iliopsoas tendon lengthening versus acetabular component revision. Discussion/Conclusion: In patients with persistent iliopsoas-related pain after THA with well-positioned implants, iliac fossa osteophytes are an under-recognized source of mechanical irritation. Arthroscopic iliopsoas fractional lengthening, combined with targeted iliac fossa osteophyte debridement, represents a reproducible minimally invasive strategy that relieves tendon overload, restores appropriate tension, preserves implant integrity, and avoids revision arthroplasty. 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.