Dislodgement of hip arthroplasty into the psoas muscle: Case report of a rare complication and its management

Nidhi Chawla; Aliyah Stephens; Sanjay Thomas

doi:10.1016/j.jorep.2025.100602

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Case Report

2025

:4;

100602

doi:

10.1016/j.jorep.2025.100602

Dislodgement of hip arthroplasty into the psoas muscle: Case report of a rare complication and its management

Nidhi Chawla^a,, Aliyah Stephens^a, Sanjay Thomas^b

a Touro College of Osteopathic Medicine, Middletown, NY, 10940, USA

b Vassar Brothers Medical Center, Poughkeepsie, NY, 12601, USA

⁎Corresponding author: Nidhi Chawla. nchawla@student.touro.edu

Received: 2024-11-20, Accepted: 2025-2-1, Published: 2025-2-4

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Posterior dislocations are the most prevalent, with an occurrence of about 90 % of all THA dislocation complications.^1,2,6 The risk of dislocation after primary THA is about 2 %,^1,3 while dislocation rates after revision surgery can increase up to 28 %.^1-3,7 The increased sliding distance associated with larger heads may contribute to greater polyethylene wear.^11-13 Despite advances, dislocations remain a persistent issue, especially in revision cases, highlighting the need for a comprehensive understanding of the risk factors and mechanisms that contribute to these complications.

We present a case of a 73-year-old female who presented with anterosuperior prosthetic hip dislocation into the pelvis after a 10-year hip arthroplasty revision. The patient presented after a fall with anterosuperior dislocation of the left total hip prosthesis and a nondisplaced spiral fracture of the left hand. The patient underwent total hip arthroplasty revision with a Stryker +8 28 mm metal head. Written consent for the case report and the inclusion of diagnostic images was obtained from the patient's health care proxy.

The presented case represents a rare instance of an anterosuperior hip dislocation into the psoas muscle following revision THA. These rather uncommon presentations necessitate the importance of personalized treatment approaches and a deeper understanding of the biomechanical factors unique to revision cases. Consequently, dislocation prevention is critical and an area that should be further investigated. This requires not only thorough preoperative risk assessment but also the use of precise surgical techniques, including optimal component alignment, soft tissue balancing, an appropriate head-neck ratio, and sufficient surgical expertise.

1 Introduction

Dislocation remains one of the most common complications following total hip arthroplasty (THA).^1–5 Among the types of dislocation, posterior dislocations are the most prevalent, with an occurrence of about 90 % of all THA dislocation complications.¹^,²^,⁶ The risk of dislocation after primary THA is about 2 %,¹^,³ while dislocation rates after revision surgery can increase up to 28 %.^1–3^,⁷ These higher dislocation rates following revision procedures pose substantial challenges for patients and clinicians, often leading to further surgical interventions. Various strategies have been explored to mitigate this risk, with several studies showing that using larger femoral heads significantly reduces dislocation rates.²^,^8–10 However, despite this benefit, the increased sliding distance associated with larger heads may contribute to greater polyethylene wear.^11–13 Consequently, the advantages and disadvantages of using larger head sizes must be carefully weighed, balancing the reduced dislocation risk against the potential for increased wear. Despite these advances, dislocations remain a persistent issue, especially in revision cases, highlighting the need for a comprehensive understanding of the risk factors and mechanisms that contribute to these complications (see Fig. 1).

X-ray of Pelvis and Hip. Anterosuperior dislocation of left hip prosthesis was noted in both pelvis X-ray (A) and hip X-ray (B).

Fluoroscopic Imaging of Left Hip Prosthesis. Fluoroscopic imaging confirming relocation of the left hip prosthesis within the femoral acetabular space.

Pelvis X-ray. The Left prothesis post-THA revision. Implant: Stryker +8 28 mm metal head.

In this case report, we present a rare occurrence of an anterosuperior dislocation of the left hip prosthesis further underscoring the complexity of managing dislocation in revision THA cases (see Fig. 2).

2 Case report

2.1

2.1 Clinical Findings

The patient is a 73-year-old woman who presented to the ED after a fall where she noted she did not lose consciousness. She previously had a total hip arthroplasty eight years prior and has since endured several dislocations. Most recently in 2022, she had a revision of the total hip arthroplasty. The patient notes that this is the first time the prosthetic has dislocated since the revision procedure. On presentation, the patient was experiencing left hip pain and left-hand pain but denied lightheadedness, chest pain, and dizziness. She was hemodynamically stable, afebrile, and saturating well on room air. Radiographs taken in the ED of her left hip showed anterosuperior dislocation of the left total hip prosthesis (see Fig. 3).

2.2

2.2 Diagnostic Assessment And Therapeutic Intervention

The patient was taken to the OR by orthopedic surgery for revision and closed reduction correction of her left hip prosthesis dislocation. Post-procedure it was noted that the polyethylene prosthetic acetabulum dissociated from the femoral head and was displaced cephalad into the patient's pelvis. Imaging showed that the acetabulum had dislodged into the patient's left psoas muscle. She was taken back to the OR for attempted correction. Her original implant was a Stryker +4 28 mm metal head which was revised to a +8 given improved stability.

2.3

2.3 Follow-Up and Outcomes

The patient was advised to follow up with orthopedic surgery in regards to repeat imaging in order to ensure no further dislodgement or movement of arthroplasty. The patient has not been compliant to this recommendation.

3 Discussion

Dislocation remains one of the most frequently occurring and challenging complications following THA, with posterior dislocations consisting of the majority of cases. With 90 % of THA dislocations being posterior, this reflects the mechanics of hip movement and the anatomical vulnerabilities following surgery.¹^,²^,⁶ The overall incidence of dislocation after primary THA is reported to be around 2 %, but when analyzing statistics of revision surgery, the risk surges considerably to as much as 28 %.^1–3^,⁷ This increase poses clinical impediments, as recurrent dislocations after revision procedures often require further surgical interventions, ultimately leading to extended recovery times, increased healthcare costs, and minimized patient quality of life.

In an attempt to mitigate the risk of dislocation post-THA, several strategies have been investigated. One of the most well-documented approaches is the incorporation of larger femoral heads. Studies consistently demonstrate that larger femoral heads can reduce dislocation rates, primarily by increasing the jump distance—the amount of displacement required to dislocate the prosthetic head from the acetabulum.²^,^8–10 This biomechanical advantage this poses has led to the widespread incorporation of larger heads in both primary and revision THA, with some studies indicating that this can significantly decrease the incidence of dislocations in both settings.²^,^8–10

However, the benefit of larger femoral heads comes with trade-offs. A primary problem is the potential for increased wear on the polyethylene liners used in the prosthetic joints.¹²^,¹³ The larger head size allows for an increase in the sliding distance during movement, which over time leads to accelerated wear of the polyethylene component. This wear can lead to bone loss, implant loosening, and ultimately, the need for further revision surgery.¹²^,¹³ Therefore, while larger heads may reduce dislocation rates, the long-term effects of increased wear must be considered, particularly in younger, more active patients who are likely to place more strain on their prosthetic joints.

Despite advancements in implant design and surgical techniques, dislocation remains a pressing issue in THA, especially in revisions. Revision surgeries inherently carry a greater risk due to factors such as altered anatomy and scar tissue formation. These factors complicate the stability of the new prosthesis and may contribute to higher dislocation rates. Moreover, the mechanics of dislocation can vary based on the specific surgical approach, patient factors such as comorbidities, muscle strength and coordination, and the alignment of the prosthetic components.^1–4

In the case presented, we report a rare occurrence of an anterosuperior dislocation of the left hip prosthesis into the patient's left psoas muscle following a revision THA. This case exemplifies the complexity of managing dislocations, particularly those that deviate from the more commonly observed posterior dislocations.¹⁴ Anterosuperior dislocations, though less frequent, may involve different mechanisms and risk factors, potentially requiring alternative approaches to management and prevention. The occurrence of such a dislocation in a revision case further emphasizes the multifactorial nature of these complications and the need for a personalized, case-specific approach to treatment. Understanding the biomechanics, patient-specific factors, and the nuances of each revision case is essential in reducing the incidence of dislocations and improving outcomes for patients undergoing THA.

Future research should focus on refining surgical techniques, improving implant materials to reduce wear and migration, and developing more sophisticated preoperative planning tools to predict and prevent dislocations.¹⁵ The mechanisms of rarer migration patterns should be further studied, such as anterosuperior dislocations, which may help identify new strategies for preventing these complications in both primary and revision THA cases.

Authors Contribution

N.C., A.S. and S.T all contributed to the case report.

Ethical statement

The authors report no conflicts of interest.

The authors report no funding or monetary support in the research involved in this case report.

The ethical standards were upheld in the research required for this case report.

N.C., A.S, S.T all contributed equally to this case report.

Financial support and sponsorship

The authors report no financial support and sponsorship.

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