Effect of Subspine Decompression on Rectus Femoris Integrity and Iliopsoas Excursion: A Cadaveric Study

Multifid Iliopsoas Tendons Are More Common in Patients With Painful Snapping Iliopsoas Tendons

Purpose

To retrospectively determine the prevalence of multifid tendons in a population of patients who underwent iliopsoas release for painful snapping iliopsoas tendons.

Methods

Patients who underwent iliopsoas release for painful snapping iliopsoas tendons were retrospectively identified from a database of patients who had undergone arthroscopic hip surgery performed by a single surgeon between 2011 and 2020. Patients who had incomplete data or who underwent prior fracture fixation, joint arthroplasty, pelvic surgery, or other interventions for snapping hip were excluded. Magnetic resonance imaging (MRI) and operative reports were reviewed and compared with those of an age-matched control group of patients who had undergone hip or pelvic MRI examinations in the past year for different indications.

Results

This study included 91 patients (78 female and 13 male patients; mean age, 23.3 years) who were treated operatively for painful snapping hip and 78 controls (54 female and 24 male patients; mean age, 28.4 years) who received hip or pelvic MRI for other indications. Among the patients who underwent iliopsoas release, there were 5 unifid iliopsoas tendons (5.5%) compared with 86 multifid iliopsoas tendons (94.5%) when classified with MRI whereas operative examination showed 19 unifid tendons (20.9%) compared with 72 multifid tendons (79.1%, P < .001). When the MRI scans of the operative group were compared with the MRI scans of the control group, the patients who underwent surgery for painful snapping hip had a higher rate of multifid tendons (94.5% of operative hips compared with 69.2% of control right hips [P < .001] and 74.4% of control left hips [P < .001]). However, when the operative reports were used to classify the iliopsoas tendon, there was no significance between the operative and control groups (79.1% of operative hips had multifid tendons compared with 69.2% of control right hips [P = .141] and 74.4% of control left hips [P = .464]).

Conclusions

For patients with symptomatic snapping hip undergoing iliopsoas lengthening, multifid iliopsoas tendons are more prevalent than in a control population.

Level of Evidence

Level IV, prognostic case series.

Snapping Hip Syndrome: Pathoanatomy, Diagnosis, Nonoperative Therapy, and Current Concepts in Operative Management

» Asymptomatic snapping hip affects 5% to 10% of the population; when pain becomes the primary symptom, it is classified as snapping hip syndrome (SHS).» The snap can be felt on the lateral side of the hip (external snapping hip), often attributed to an iliotibial band interaction with the greater trochanter, or on the medial side (internal snapping hip), often attributed to the iliopsoas tendon snapping on the lesser trochanter.» History and physical examination maneuvers can help distinguish the etiology, and imaging may help confirm diagnosis and rule out other pathologies.» A nonoperative strategy is used initially; in the event of failure, several surgical procedures are discussed in this review along with their pertinent analyses and key points.» Both open and arthroscopic procedures are based on the lengthening of the snapping structures. While open and endoscopic procedures both treat external SHS, endoscopic procedures typically have lower complication rates and better outcomes when treating internal SHS. This distinction does not appear to be as noticeable in the external SHS.

The narrow subspine space and relatively large labrum are radiographic features of subspine impingement: a case-control study

Background

Subspine impingement is considered a source of residual hip symptoms after primary hip arthroscopy, and the role of the subspine space and soft tissue is not clear. The purpose of this study was to analyze the relationship between the subspine space and labrum size in subspine impingement patients.

Methods

We performed a retrospective study of patients with femoroacetabular impingement between July 2016 and July 2020. Sixteen patients without hip symptom relief after primary hip arthroscopic treatment of femoroacetabular impingement and undergoing revision surgery for anterior inferior iliac spine compression were included as the study group. Forty-eight matched patients who underwent only primary surgery and whose hip discomfort was relieved without a diagnosis of subspine impingement were included as the control group. The patients’ preoperative computerized tomography data were reviewed, and the anterior inferior iliac spine dimensions and the size of the subspine space were measured. The size of the labrum at the 11:30, 1:30, and 3 o’clock positions was measured with the use of magnetic resonance imaging. The ratio of the subspine space to the labrum was also calculated.

Results

There was no significant difference in anterior inferior iliac spine dimensions between these two groups (p > 0.05). A relatively narrow subspine space was found in the study group, especially in the direction of the anterior inferior iliac spine. Compared with the control group, subspine impingement patients were identified with larger labrums at 11:30 (8.20 ± 1.95 mm vs. 6.81 ± 0.50 mm, p = 0.016), 1:30 (7.83 ± 1.61 mm and 6.25 ± 0.78 mm, p = 0.001) and 3:00 (9.50 ± 1.73 mm vs. 7.48 ± 0.99 mm, p = 0.001). A relative mismatch between the subspine space and the labrum was also identified in the study group. The ratios of the labrum width to the subspine area were significantly larger in the study group than in the control group.

Conclusion

This study reported potential additional criteria for subspine impingement—a large labrum and a relatively narrow subspine space—instead of abnormal anterior inferior iliac spine dimensions. For those with a large labrum and narrow subspine space, the diagnosis of subspine impingement should be carefully made, and arthroscopic anterior inferior iliac spine decompression may be important.

Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated with Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement

PURPOSE

The purpose of this article was to report prevalence of iliopsoas pathology in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI), incidence of rendered tenotomy, and outcomes of hips with iliopsoas involvement compared with those with primary FAI.

METHODS

A cohort study from a hip arthroscopy study group using a prospectively-collected multicenter database was performed. Patients who underwent isolated hip arthroscopy for FAI from January 2016 to March 2017 were assigned to the Iliopsoas group (defined as preoperative diagnosis of coxa saltans internus, intraoperative anteroinferior labral bruising or tear, and preoperative positive psoas injection) or control group. The prevalence of iliopsoas pathology, radiographic and intraoperative findings, and rendered procedures between groups were compared. Mean 2-year (minimum 1.8 year) outcomes of iliopsoas groups with and without rendered tenotomy and a control group were compared.

RESULTS

There were 1393 subjects, of which 92 (7%) comprised the iliopsoas study group with 1301 subjects control subjects. Sixteen subjects in the iliopsoas group received tenotomy (17% of iliopsoas group, 1% of all subjects), whereas 76 subjects (83% of iliopsoas group) with iliopsoas involvement did not. There was significant effect on postoperative International Hip Outcome Tool-12 (iHOT-12) scores based on iliopsoas involvement and treatment, F(2,1390) = 3.74, P = .02. Compared with the control group (M = 73, standard deviation [SD] = 24), the non-tenotomized iliopsoas group (M = 69, SD = 32) had similar postoperative scores (P = .46), whereas the tenotomized iliopsoas group (M = 57, SD = 28) averaged lower postoperative scores (P = .03). In the tenotomy group, 25% achieved the iHOT-12 substantial clinical benefit and patient acceptable symptomatic state value for normal function and 100% satisfaction, compared to 49% and 41% for the without tenotomy and control groups.

CONCLUSIONS

Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for FAI is infrequently performed and is associated with poorer outcomes. Co-afflicted patients treated without tenotomy have similar successful outcomes to patients with primary FAI. Indiscriminate tenotomy for iliopsoas pathology in this setting should be cautiously considered.

LEVEL OF EVIDENCE

Level III, cohort study.

An Anatomic Study of the Damage to Capsular Hip Stabilizers During Subspine Decompression Using a Transverse Interportal Capsulotomy in Hip Arthroscopy

PURPOSE

To quantify the damage to the soft tissue stabilizers of the hip after a transverse interportal capsulotomy and subspine trimming in hip arthroscopy.

METHODS

Eight human cadaveric hemipelvises underwent hip arthroscopy through a transverse interportal capsulotomy. Arthroscopic subspine trimming performed on all specimens was classified according to an anatomic index. The width of the proximal capsule was measured before and after subspine trimming. The extent of damage to the iliofemoral ligament (IFL) after dissection was recorded. Potential damage to pericapsular structures was assessed by measuring the distance between the capsulotomy and rectus femoris and iliocapsularis muscle with an electronic caliper.

RESULTS

In all specimens, ≥50% of the width of the IFL was damaged. The subspine trimming was successfully performed in 7 of 8 specimens (87.5%) according to the proposed index. The sizes of the trimmed bone area measured in the anteroposterior and proximal-distal axis were 21.2 ± 7.5 and 13.1 ± 9 mm, respectively (mean ± standard deviation). The width of the proximal capsule at the anterior and posterior corner of the capsulotomy was 19.8 ± 5.2 and 11.8 ± 1.7 mm, respectively. After subspine trimming, the mean width of the anterior and posterior proximal capsular attachments was 6.4 ± 1.4 and 7.0 ± 1.6 mm, respectively. On average, 13.4 mm of anterior capsule was damaged after anterior inferior iliac spine trimming, versus 4.7 mm of the posterior capsule. The distances from the capsulotomy to the rectus femoris direct and reflected head were 6.8 ± 4.9 and 6.3 ± 7.7 mm, respectively, and to the iliocapsularis muscle, 11.5 ± 7.8 mm.

CONCLUSION

High rates of damage to the IFL were observed with the interportal capsulotomy. Increased tissue damage at the anterior capsule was observed after subspine trimming. The width of the proximal capsular attachment was ≥5 mm in all specimens.

CLINICAL RELEVANCE

Surgeons should be aware of the potential damage to the native capsule and pericapsular structures when using a transverse interportal capsulotomy for the arthroscopic subspine decompression.

LEVEL OF EVIDENCE

IV: cadaveric study, case series.

non-arthroplasty iliopsoas impingement in athletes: a narrative literature review

INTRODUCTION

Iliopsoas impingement occurs secondary to a tight iliopsoas tendon that causes impingement during movement. This review presents current aspects regarding the diagnosis of iliopsoas impingement and also exposes the readers to the possible anatomic and clinical variations together with the available treatment options.

METHODS

We conducted a narrative literature review with regard to non-arthroplasty iliopsoas impingement.

RESULTS

Iliopsoas impingement is characterised by a distinct pattern of labral pathology, with anteriorly localised labral damage, that does not extend to the anterosuperior portion of the acetabulum. Anterior groin pain and intermittent catching, snapping or popping of the hip are common symptoms. Non-specific focal tenderness is often found over the iliopsoas tendon at the level of the anterior aspect of the joint. The 'C-sign' and Impingment test are usually positive. Dynamic ultrasonography is also useful for confirming the diagnosis. Initial management of painful iliopsoas impingement should be conservative. When patients continue to have pain, an ultrasound-guided injection can provide relief and predict the response to the surgical release. For patients who have recurrent pain after local injection of steroids, arthroscopic release has shown to achieve effective results.

CONCLUSIONS

Although different treatment options for iliopsoas impingement are emerging, the current standard of therapy is conservative followed by an arthroscopic tenotomy if necessary. Young adult hip surgeons should always keep this differential in mind in a patient presenting with groin pain and mechanical symptoms.

Morphological Distribution of the Anterior Inferior Iliac Spine in Patients With and Without Hip Impingement: Reliability, Validity, and Relationship to the Intraoperative Assessment

BACKGROUND

Subspinous impingement of the anterior inferior iliac spine (AIIS) on the femoral head-neck junction is increasingly recognized as a source of hip impingement. A classification system of AIIS morphology has previously been proposed that correlates with reduced hip motion and may predispose patients to subspinous hip impingement.

PURPOSE

To examine the morphological distribution of AIIS types in patients with and without diagnosed hip impingement and correlate AIIS morphology to intraoperative findings at the time of surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Three-dimensional reconstructed pelvic computed tomography scans were generated for a stratified sample of 449 hips in patients without a history of hip pain or hip impingement and 59 hips in patients with a diagnosis of hip impingement. Three blinded assessors classified the AIIS for each hip twice. The morphological distribution between symptomatic and asymptomatic patients was compared, controlling for age, sex, and affected side. Within the symptomatic cohort, AIIS morphology was compared with the intraoperative assessment of a low-lying AIIS using the Fisher exact test.

RESULTS

The intraobserver reliability of the classification system in our cohort was substantial (κ = 0.68-0.77). The interobserver reliability was moderate (κ = 0.50). The morphological distribution between symptomatic and asymptomatic patients was similar, with 75% of patients in the asymptomatic group and 80% of the patients in the symptomatic group having a type 2 or type 3 AIIS. When matched for age, sex, and affected side, there was no significant difference in the assessed classification type between the groups ( P = .55). Within the symptomatic group, there was no significant correlation between the surgeon assessment of a low-lying AIIS and a type 2 or type 3 radiographic classification ( P = .10). The positive predictive value of a type 2 or type 3 AIIS classification for hip impingement symptoms was 10%, and the negative predictive value was 91%.

CONCLUSION

These findings suggest that a high percentage of patients with AIIS morphology associated with subspinous impingement are, in fact, asymptomatic. The current radiographic classification scheme should not be used exclusively for clinical decision making.

Arthroscopic hip preservation surgery practice patterns: an international survey

To design and conduct a survey analyzing pre-, intra- and post- hip arthroscopy practice patterns among hip arthroscopists worldwide. A 21-question, IRB-exempt, HIPAA-compliant, cross-sectional survey was conducted via email using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. Seventy-five respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing AP pelvis, false profile and Dunn 45 were the most common radiographs utilized. CT scans were utilized by 54% of surgeons at least some of the time. Only 56% of participants recommended an arthrogram with MRI. Nearly all surgeons either never (40%) or infrequently (58%) performed arthroscopy in Tönnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51% never; 44% infrequently). Only 25% of participants perform a routine 'T' capsulotomy and 41% close the capsule if the patient is at risk for post-operative instability. Post-operatively, 52% never use a brace, 39% never use a continuous passive motion, 11% never recommended heterotopic ossification prophylaxis and 30% never recommended formal thromboembolic disease prophylaxis. Among a large number of high-volume experienced hip arthroscopists worldwide, pre-, intra- and post- hip arthroscopy practice patterns have been established and reported. Within this cohort of respondents, several areas of patient evaluation and management remain discordant and controversial without universal agreement. Future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Arthroscopic Decompression of a Type III Subspine Impingement

Extra-articular hip impingement refers to a variety of hip disorders causing pain and limited function in young, non-arthritic patients. Recently, there has been an increased focus on analyzing the degree of anterior inferior iliac spine (AIIS) dysmorphism and its correlation with subspine impingement (SSI), defined as abutment between a prominent distal aspect of the AIIS and the anterior aspect of the femoral head-neck junction. Arthroscopic decompression of the AIIS is recognized as an effective treatment for SSI. However, there may be some inherent risks of performing this procedure arthroscopically that require further investigation.

Understanding and Treating the Snapping Hip

Snapping hip, or coxa saltans is a palpable or auditory snapping with movement of the hip joint. Extra-articular snapping is divided into external and internal types, and is caused laterally by the iliotibial band and anteriorly by the iliopsoas tendon. Snapping of the iliopsoas usually requires contraction of the hip flexors and may be difficult to distinguish from intra-articular coxa saltans. Ultrasound can be a useful modality to dynamically detect tendon translation during hip movement to support the diagnosis of extra-articular snapping. Coxa saltans is typically treated with conservative measures including anti-inflammatories, stretching, and avoidance of inciting activities. Recalcitrant cases are treated with surgery to lengthen the iliopsoas or the iliotibial band.