Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Navigation is Equal to Estimation by Eye and Palpation in Preventing Psoas Impingement in THA

Markus Weber MD, Michael Woerner MD, Benedikt Messmer Cand Med, Joachim Grifka MD, Tobias Renkawitz MD



Iliopsoas tendon impingement is one possible reason for persistent groin pain and diminished functional outcome after THA. So far, estimation by eye and palpation is the standard procedure to intraoperatively assess the distance of the cup to the anterior rim. However, novel technologies such as imageless navigation enable intraoperative measurements of the cup in relation to the psoas tendon and bony landmarks.


We asked whether psoas impingement (1) can be reduced using imageless navigation compared with the standard technique and (2) is associated with specific patient characteristics. Furthermore, we investigated (3) if anterior cup protrusion (overhang) is associated with lower outcome scores for pain and function.


The current study is a reanalysis of data from a randomized controlled trial evaluating navigation for THA; 135 patients were randomized for surgery with or without the use of imageless navigation. The risk for anterior protrusion of the cup above the acetabular rim and thus potential psoas impingement, defined as an overhang of the cup above the anterior acetabular rim as measured on postoperative CT, was either controlled with the help of navigation or standard control by eye and palpation intraoperatively. Postoperatively, the anterior protrusion of the cup above the acetabular rim was measured on three-dimensional (3-D) CT by a blinded, external institute. In addition to patient-related outcome measures, the Harris hip score, Hip disability and Osteoarthritis Outcome Score, and EuroQol were obtained 1 year postoperatively. Altogether 123 data sets were available for primary analysis and 115 were available for 1-year followup.


There was no difference, with the numbers available, between the navigated and the control groups in terms of the mean distance of the cup below the anterosuperior acetabular rim (3.9 mm; −5.3 to 12.6 mm versus 4.4 mm; −7.9 to 13.7 mm; p = 0.72) or the anteroinferior acetabular rim (4.7 mm; −6.2 to 14.8 mm versus 4.2 mm; −7.1 to 16.3 mm; p = 0.29). There was no difference, with the numbers available, in terms of the proportion of cups with anterior overhang (7%, four of 57 versus, 15%, 10 of 66; p = 0.16), respectively. After controlling for potential confounding variables such as cup inclination, cup size, patient age, BMI, stage of arthritis, and length of skin incision, we found cup anteversion (hazard ratio [HR], 0.87; 95% CI, 0.81–0.93; p < 0.001) and female sex (HR, 3.88; 95% CI, 1.01–14.93; p = 0.049) were associated with a propensity to potential psoas impingement. With the numbers available, there were no differences observed in clinical scores between groups with and without anterior cup protrusion.


We found no differences between imageless navigation and estimation by eye and palpation in preventing potential psoas impingement. Despite the comparable clinical outcome for patients with and without cup protrusion, the orthopaedic surgeon should be especially aware of propensity for psoas impingement in women.

Level of Evidence

Level II, therapeutic study.

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