Published on 26 November 2025 Hip surgery
The role of the anterior acetabular wall in groin pain after total hip replacement
After a total hip replacement, some patients experience persistent groin pain, particularly during flexion movements. While such discomfort usually resolves spontaneously within a few weeks, lasting pain may reveal a deeper mechanical conflict. At Inside the Hip , a center specialized in hip surgery in Lyon, special attention is given to the anterior wall of the acetabulum, a key structural element for proper joint function whose alteration may be responsible for postoperative groin pain.
Understanding groin pain after total hip replacement
Total hip replacement is primarily indicated for advanced coxarthrosis and aims to restore a mobile, stable, and pain-free hip. However, postoperative mechanical groin pain is not uncommon, particularly among young or athletic patients. In most cases, these symptoms subside within weeks or months.
When groin pain persists after hip replacement, imaging is required to identify potential issues with the prosthesis such as loosening, migration, or infection. An ultrasound examination is also recommended to assess the soft tissues around the hip. It often reveals psoas tendinopathy, sometimes associated with bursitis, and can include dynamic tests to detect impingement between the psoas tendon and a mechanical obstacle.
First-Line conservative treatments
If bursitis or tendinopathy is diagnosed, a corticosteroid injection into the psoas bursa, performed under ultrasound guidance, is often proposed. This procedure frequently leads to significant improvement or even complete resolution of groin pain. If the pain persists, further investigations are necessary.
A CT scan helps confirm the presence of psoas impingement against a mechanical obstacle, which may be caused by an anterior bony osteophyte or by direct mechanical conflict with the prosthetic cup.
The essential role of CT imaging in analyzing the anterior wall
CT imaging is crucial for assessing the positioning of the acetabular cup , which may reveal oversizing, retroversion, or malposition .
It also allows detailed evaluation of a key structure for proper prosthetic function – the anterior bony wall of the acetabulum .
The acetabulum is bordered by two very different bony walls:
- The posterior wall, thick and dense
- The anterior wall, thin and fragile
During hip replacement (especially using minimally invasive techniques ) excessive reaming may lead to partial or total destruction of the anterior wall. This risk is particularly high in osteoporotic or dysplastic patients.
When the anterior wall is deficient, the prosthetic cup may come into direct contact with the psoas tendon, leading to inflammation, pain, and weakness during active hip flexion.
Surgical options for mechanical conflict
Several surgical approaches can be considered when persistent groin pain is linked to a mechanical conflict.
Arthroscopic treatment
Hip arthroscopy can be used to remove bony impingement (e.g., anterior osteophyte) or eliminate contact with cement or a polyethylene liner.
In some cases, arthroscopy is performed to release the psoas tendon ( tenotomy ). While this can relieve pain, it carries significant drawbacks:
- Permanent weakness of active hip flexion
- Persistent residual pain
- Risk of anterior instability of the hip
The Inside the Hip approach: preserving the tendon, treating the cause
At Inside the Hip , psoas tenotomy is generally avoided. The surgical team prefers to preserve the tendon and address the underlying cause of the impingement.
A revision hip surgery is performed through an anterior approach, allowing the surgeon to reposition the cup anatomically, without oversizing or retroversion.
When the anterior acetabular wall is damaged, a bone graft may be used to reconstruct it, enabling optimal cup positioning and effectively eliminating the conflict and associated psoas pain.
Preventing groin pain: the key to success
Preventing cup–psoas impingement and preserving the anterior wall relies on three-dimensional (3D) preoperative planning based on CT imaging. Only a CT scan can determine the precise cup diameter suitable for the patient’s anatomy, thus avoiding oversizing.
During implantation, visual control of the anterior acetabular wall is essential to ensure it remains intact. Correct anatomical cup positioning , shielded from the tendon, helps prevent any mechanical conflict that could lead to groin pain.
Performing a “blind” surgery through an excessively small incision may appear aesthetically appealing but poses a significant mechanical risk. Ultimately, in hip surgery, mechanics must prevail over cosmetics.
