CASE REPORT Iliopsoas bursitis-associated femoral neuropathy exacerbated after internal fixation of an intertrochanteric hip fracture in rheumatoid arthritis: a case report Asami Tokita Æ Katsunori Ikari Æ So Tsukahara Æ Hiroe Toki Æ Motoko Miyawaki Æ Takeshi Mochizuki Æ Koichiro Kawamura Æ Taisuke Tomatsu Æ Shigeki Momohara Received: 25 June 2007 / Accepted: 12 February 2008 / Published online: 18 April 2008 Ó Japan College of Rheumatology 2008 Abstract We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertro- chanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoper- ative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present. Keywords Femoral neuropathy Á Iliopsoas bursitis Á Rheumatoid arthritis Introduction Enlargement of the iliopsoas bursa is an unusual clinical event that has been reported in patients with osteoar- thritis, microcrystalline arthropathies, infections, avascular necrosis, trauma, syphilis, gout, pigmented villonodular synovitis, synovial chondromatosis, osteonecrosis [1–3], and rheumatoid arthritis (RA) [4–8]. Iliopsoas bursitis has also sometimes been termed ‘‘iliopectineal bursitis’’ [9, 10]. Clinical manifestations of iliopsoas bursitis are usually limited to pain and/or a palpable mass in the inguinal area. However, iliopsoas bursitis has also been associated with acute destruction of the hip joint and rapid resorption of the femoral head in RA patients [4, 8]. Additionally, several reports have described femoral neuropathies caused by iliopsoas bursitis in RA patients [4, 7, 9]. In this paper, we present the case of an RA patient with iliopsoas bursitis and mild femoral neuropathy whose neuropathy was exacerbated after internal fixation of an intertro- chanteric fracture. Case report A 63-year-old woman had a six-year history of RA treated with methotrexate and low-dose corticosteroids. In 2001, she had total joint arthroplasties of both knees along with cervical laminoplasty for cervical spondylotic myelopathy. Despite good control of her RA disease activity (confirmed retrospectively by a C-reactive protein measurement of 0.5 mg/dl during the second half of 2004), she noticed a gradual increase in hip pain. A radiograph at this time showed evidence of ongoing progressive joint destruction (Fig. 1). A left inguinal soft tissue mass then appeared which was identified by computed tomography (CT) and magnetic resonance imaging (MRI) as an enlarged iliopsoas bursa (10.0 9 4.0 cm) with abnormal signal intensities in the anterosuperior region of the left femoral A. Tokita Á K. Ikari Á S. Tsukahara Á H. Toki Á M. Miyawaki Á T. Mochizuki Á K. Kawamura Á T. Tomatsu Á S. Momohara (&) Department of Orthopaedic Surgery, Institute of Rheumatology, Tokyo Women’s Medical University, 10-22 Kawada, Shinjuku, Tokyo 162-0054, Japan e-mail: smomohara@ior.twmu.ac.jp 123 Mod Rheumatol (2008) 18:394–398 DOI 10.1007/s10165-008-0060-1