Surgical correction of internal coxa saltans: a 20-year consecutive study

The peri-articular muscle envelope of the hip (PAME) shows atrophy in patients with refractory groin pain after iliopsoas tenotomy

BACKGROUND

Iliopsoas tenotomy is commonly used to address refractory groin pain resulting from iliopsoas tendinopathy. However, consensus and high-level research on its effectiveness are lacking, with concerns about poor outcomes and complications. Little is known of the effects of iliopsoas tenotomy on the peri-articular muscle envelope of the hip. As the iliopsoas loses its function as the most important hip flexor, the rectus femoris takes over its function, which makes the rectus prone to tendinopathy.

METHODS

A retrospective review of patients (n = 17) undergoing iliopsoas tenotomy between January 2016 and January 2021 was conducted. Pelvic MRI scans were evaluated for muscle quality and volume using a Quartile classification system and cross-sectional area (CSA) measurements. Reliability tests determined the most consistent reference points. Statistical analyses assessed changes between ipsilateral and contralateral sides.

RESULTS

Following iliopsoas tenotomy, significant reduced cross sectional area was seen in the psoas, iliacus, gluteus minimus, gluteus maximus, rectus femoris, piriformis, obturator internus and obturator externus. Significant increased fatty degeneration was seen in the psoas, iliacus, gluteus minimus, tensor fascia latae, piriformis, obturator internus and obturator externus. The gluteus medius was the only muscle where no difference was seen in the cross sectional area or the fatty degeneration. 15 patients (88%) presented with rectus tendinopathy and 8 of these patients had a surgical debridement of the rectus femoris.

CONCLUSIONS

Our findings reveal that patients with persistent groin pain following iliopsoas tenotomy exhibit changes in the peri-articular muscle envelope, displaying atrophy or fatty degeneration in all muscles except the gluteus medius. Awareness of potential risks is crucial when contemplating iliopsoas tenotomy. Persistent groin pain after iliopsoas tenotomy may be linked to secondary rectus femoris tendinopathy. Caution is recommended in the consideration of iliopsoas tenotomy for patients with pre-existing iliopsoas tendinopathy.

Anatomical Study of the Ultrasound-guided Percutaneous Tenotomy of the Iliopsoas Muscle Tendon in Cadavers: A Feasible Technique?

Objective  To evaluate the efficacy and safety of percutaneous tenotomy of the iliopsoas muscle tendon guided by ultrasound (US) in cadavers. Methods  We conducted an anatomical and descriptive study of the US-guided percutaneous tenotomy technique for the iliopsoas muscle tendon to review our experience performing it and its reproducibility in the clinical practice. Results  Of the 20 tenotomies, 17 were total, at the level of the upper edge of the acetabulum, while 3 were partial. One procedure resulted in a partial injury to the femoral nerve. We measured the distance between the place of blade introduction and the femoral nerve, a noble structure potentially at a higher risk during the procedure; the mean distance was of 8.4 mm. Conclusion  Iliopsoas tendon release procedures guided by US in a cadaveric model are feasible and consistently result in the total release of the tendon, except in cases of obesity, with minimal repercussions on adjacent structures, and their completion requires approximately 4 minutes.

Can we encourage the endoscopic treatment for external snapping hip (ESH)? A systematic review of current concepts

BACKGROUND

Snapping hip syndrome (SHS) is characterized by snapping sensation and pain and affects up to 10% of the general population. External snapping hip syndrome (ESHS), the most common form, is often due to repetitive movements in sports or anatomical predispositions. Conservative treatment includes physiotherapy and corticosteroid injections, while surgery is considered if conservative measures fail. Open surgical techniques carry several risks, while modern arthroscopic techniques offer less invasive options, such as endoscopic iliotibial band release (ITB) and gluteus maximus tenotomy.

MATERIALS AND METHODS

A systematic review was conducted adhering to the PRISMA guidelines. Relevant studies were searched in four databases: Pubmed, Scopus, Embase, and Medline. The selected articles were evaluated according to the criteria of levels of evidence. The Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) was used to analyze the retrospective studies. This paper was registered in the International Prospective Registry of Systematic Reviews (PROSPERO).

RESULTS

Out of 9 included studies, 403 patients with 689 hips underwent endoscopic treatment. ITB release and his variations were the main surgical techniques. Gluteus maximus tenotomy was also used in some studies. Postoperative rehabilitation protocols varied. Patients generally experienced significant improvements in symptoms and functional outcomes, with low rates of recurrence (1.02%) and revision (0.15%). Complications were minimal.

CONCLUSIONS

Endoscopic treatment of ESH shows favorable results, improving functional outcomes and returning patients to pre-injury activity levels. Long-term efficacy and costeffectiveness need to be evaluated, emphasizing the importance of large-scale prospective randomized trials to clarify surgery's benefits in refractory ESH cases.

Arthroscopic Fractional Lengthening After Total Hip Arthroplasty Results in Improved Patient-Reported Outcomes and Low Rates of Revision Total Hip Arthroplasty

Purpose

To report the clinical outcomes and reoperation rates of arthroscopic and endoscopic iliopsoas release at short-term follow-up after ipsilateral total hip arthroplasty (THA) at 2 separate medical institutions and to evaluate whether demographic and radiographic parameters are associated with postoperative patient-reported outcomes (PROs).

Methods

Patients with iliopsoas tendinitis in the setting of prior THA who underwent arthroscopic iliopsoas fractional lengthening from 1988 to 2023 at 2 academic institutions were reviewed. Patients were included if they had 12 months of follow-up and underwent evaluation of preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score, Single Assessment Numeric Evaluation score, Tegner activity scale score, visual analog scale (VAS) score, and revision hip arthroplasty.

Results

Sixty hips in 58 patients (19 male and 39 female patients) were followed up for a mean of 39.3 months (range, 12.0-105.9 months) postoperatively. Of the patients, 77% reported feeling "much better" or "slightly better," 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. The surgery satisfaction rating was 7.2 ± 3.3 (scale of 0 to 10). The mean postoperative modified Harris Hip Score, VAS score for pain at rest, VAS score for pain with use, and Single Assessment Numeric Evaluation score were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9, respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and did not significantly correlate with postoperative PROs (P ≥ .45). The Tegner score improved from 2.5 ± 1.7 preoperatively to 2.9 ± 1.4 postoperatively (P = .0253). Three patients underwent revision arthroplasty at a mean of 25.3 months (range, 11.6-40.4 months) postoperatively, with an acetabular component revision rate of 3.3%.

Conclusions

Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening after THA. There was no statistically significant relation between anterior acetabular component overhang and final PROs.

Level of Evidence

Level IV, therapeutic case series.

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.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Iliopsoas Release: A Systematic Review of Clinical Efficacy and Associated Complications

OBJECTIVE

To perform a systematic review of the findings of iliopsoas release as it relates to resolution of snapping, improvement of groin pain, and associated complications.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases PubMed/MEDLINE, EMBASE, CINAHL, and Web of Science were searched, identifying all literature pertaining to surgical treatment of a snapping hip/coxa saltans, iliopsoas impingement, or iliopsoas tendinitis. A total of 818 studies were identified. Two reviewers independently screened the titles, abstracts, and full-text articles for eligibility.

ELIGIBILITY CRITERIA

All studies published in English that reported on iliopsoas release for snapping hip/coxa saltans, iliopsoas impingement, or iliopsoas tendinitis reporting outcomes or associated complications were eligible.

RESULTS

A total of 48 articles were included in this review. Three surgical indications were identified for iliopsoas release, internal snapping hip, labral tear secondary to iliopsoas impingement, and iliopsoas tendinopathy after total hip arthroplasty. Arthroscopic techniques seemed to be superior to open techniques with regards to reoccurrence of snapping (5.1% vs 21.7%) and groin pain relief (89.1% vs 85.6%) with fewer complications (4.2% vs 21.1%) overall.

CONCLUSIONS

Both open and arthroscopic iliopsoas releases have been shown to be successful treatment options regardless of the surgical indications identified in this review. Arthroscopic release demonstrated a decreased failure rate, fewer complications, and improved outcomes when compared with open procedures.

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.

Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Postoperative Outcomes

BACKGROUND

Arthroscopic iliopsoas tendon release is a surgical treatment option for painful snapping hips, although it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy.

PURPOSE

To systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopic surgery as an intervention for painful snapping hips.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A total of 3 online databases (Embase, PubMed, and MEDLINE) were searched from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopic surgery. Studies were screened by 2 reviewers independently and in duplicate, and studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all included studies.

RESULTS

Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824), with a mean age of 28.1 years (range, 12-62 years) and mean follow-up of 32.1 months (range, 3-73 months). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) or the lesser trochanter in 64 hips (7.3%). The overall reported success rate of the procedure in resolving snapping hips was 93.0% (266/286), and all studies reported an improvement in functional outcome scores. Only 6 studies (93 hips) discussed postoperative hip flexion strength, with complete recovery of strength reported in 4 studies (47 hips) and mild decreases reported in the other 2 studies (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies; 66 hips) and was found postoperatively in 92.4% (61/66) of hips. No major complications were reported.

CONCLUSION

Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. Although patients demonstrated some early postoperative weakness and iliopsoas atrophy on radiological imaging, the results from studies to date showed satisfactory clinical function and return to sports/activities. High-quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release to determine the optimal technique and location of tendon release.

An Iliopsoas Impingement Lesion in the Absence of Painful Internal Snapping May Not Require Iliopsoas Fractional Lengthening

BACKGROUND

Iliopsoas impingement (IPI) has been associated with a distinct lesion on the anterior labrum. Iliopsoas fractional lengthening (IFL) can treat IPI in instances of painful internal snapping (PIS) and mechanical groin pain.

PURPOSE

To report minimum 2-year outcomes of patients without PIS who had an IPI lesion diagnosed intraoperatively that did not undergo IFL (+IPI -PIS -IFL) as compared with a matched group of patients with PIS and an IPI lesion that was treated with IFL (+IPI +PIS +IFL).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data on all patients who underwent primary hip arthroscopy between May 2009 and June 2017 were retrospectively reviewed. Patients were included if they underwent hip arthroscopy for femoroacetabular impingement-related pathology, an IPI lesion was diagnosed intraoperatively, and they had minimum 2-year postoperative scores for the following: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), iHOT-12 (International Hip Outcome Tool-12), patient satisfaction, and visual analog score (VAS) for pain. Patients were propensity score matched based on the following criteria: age, body mass index, follow-up time, sex, labral treatment, femoroplasty, and acetabuloplasty.

RESULTS

A total of 412 hips were eligible for the current study, of which 336 (81.6%) had 2-year follow-up. The matching process established 37 hips in the +IPI -PIS -IFL group and 87 hips in the +IPI +PIS +IFL group. Both groups experienced significant improvements from presurgery to latest follow-up for all recorded patient-reported outcomes (PROs). The +IPI -PIS -IFL group compared favorably with the +IPI +PIS +IFL group for mHHS (86.0 vs 86.1; P = .53), NAHS (83.0 vs 84.7; P = .40), and HOS-SSS (78.1 vs 76.5; P = .87). Additionally, iHOT-12, VAS, patient satisfaction, and rates of achieving the minimal clinically important difference for mHHS, NAHS, and HOS-SSS were similar between groups at the latest follow-up.

CONCLUSION

Patients without PIS who were diagnosed with an IPI lesion intraoperatively and did not undergo IFL had similar and favorable improvements in PROs, VAS, and satisfaction to a matched cohort with PIS who had IFL performed. Thus, an IPI lesion in the absence of PIS may not require IFL.

Ultrasound-Guided Iliopsoas Tendon Release: A Cadaveric Investigation

BACKGROUND

The iliopsoas is a common source of anterior hip pain. Refractory cases may require surgical intervention, with reported complication rates ranging from 3% to 50%. Development of a minimally invasive, outpatient method of iliopsoas tendon release is desirable and may reduce costs, lower complications, and improve recovery time.

OBJECTIVE

To describe and evaluate the safety and reproducibility of an ultrasound-guided (USG) iliopsoas tendon release using a spinal needle in a cadaveric model.

DESIGN

Prospective, cadaveric laboratory investigation.

SETTING

Academic Institution Procedural Skills Laboratory.

PARTICIPANTS

Five unembalmed cadaveric specimens (three female, two male), 69 to 93 years of age (mean 83.2 years), with a mean body mass index (BMI) of 24.5 kg/m² (range 19.2 to 30.3 kg/m² ).

INTERVENTIONS

Two operators each performed five USG iliopsoas tendon releases. Three additional investigators dissected the pelves to assess completeness of tendon release and damage to adjacent structures.

MAIN OUTCOME MEASURES

Successful transection, completeness (%) of the tendon transection, damage to adjacent structures, and procedural time.

RESULTS

Nine of 10 releases achieved the target release of ≥75% tendon transection. One procedure achieved 50% tendon release. No injury to adjacent structures was identified. The mean duration of the procedure was 6.19 minutes.

CONCLUSIONS

USG iliopsoas tendon release can be performed in a cadaveric model, consistently achieve the desired percentage of tendon release, does not result in injury to adjacent neurovascular structures, and takes approximately 6 minutes to perform. Although results cannot be generalized to a clinical setting, due to the minimally invasive nature of the procedure, it is likely that this procedure can be performed safely in an outpatient setting under local anesthesia, will cost less, and will facilitate a more rapid recovery when compared to standard surgical procedures. Further research is warranted for clinical application.

Iliopsoas snapping hip: improving the diagnostic value of magnetic resonance imaging with a novel parameter

OBJECTIVE

To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome.

METHODS

This retrospective cohort study reviewed hip MRI images of all patients seen by a single surgeon between January 2015 and March 2016. The comparison group included all patients with clinical internal hip snapping, versus the control group that did not. MRI images were processed using minimum intensity projection. Measurements obtained of the pelvis and course of the iliopsoas tendon included: pelvic incidence, coronal angle, and sagittal opening angle (SOA). Comparison of measurements between the groups was performed with Mann-Whitney U analysis and receiver operator curve (ROC) plotting, with a significance cutoff of p = 0.05.

RESULTS

The control group (n = 85) and comparison group (n = 48) demonstrated no difference in age or gender. Pelvic incidence was similar [51.3 (± 10.7) degrees control versus 52.2 (± 7.7) degrees comparison (p = 0.36)], as was coronal angle [13.9 (± 4.6) degrees control versus 14.8 (±4.8) degrees comparison (p = 0.15)]. There was a significant difference in SOA [137.0 (± 5.9) degrees control versus 141.9 (± 6.5) degrees comparison (p < 0.01)]. ROC analysis revealed SOA threshold of 140 degrees for clinical IP hip snapping (p < 0.01), with odds ratio 5.2 (2.4-11.3) for SOA > 140 degrees.

CONCLUSIONS

Iliopsoas hip snapping is often part of a more complex disease process. While challenging to diagnose, advanced imaging parameters, like the sagittal opening angle, relate with clinical pathology. The SOA offers diagnostic value, with a threshold of greater than 140 degrees significantly correlating with clinical presentation.

Midterm Outcomes of Iliopsoas Fractional Lengthening for Internal Snapping as a Part of Hip Arthroscopy for Femoroacetabular Impingement and Labral Tear: A Matched Control Study

PURPOSE

To report minimum 5-year outcomes and rate of painful snapping resolution for patients who underwent iliopsoas fractional lengthening (IFL) as a part of hip arthroscopy for femoroacetabular impingement (FAI) and labral tear. In addition, to match this group to a group of patients who underwent hip arthroscopy for FAI and labral tear without internal snapping.

METHODS

Patients were eligible for inclusion if they underwent hip arthroscopy for treatment of FAI and labral tear with concomitant IFL for painful snapping and had preoperative baseline scores for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Subscale, and visual analog scale for pain. The exclusion criteria for this study were preoperative Tönnis grade >0, active workers' compensation claims, or previous ipsilateral hip conditions. These patients were matched to a control group of patients who did not have snapping or undergo IFL but who otherwise satisfied the same inclusion and exclusion criteria.

RESULTS

There were 57 eligible cases (80.3% follow-up). Mean follow-up time was 69.3 months (from 60.0 to 91.9). All patient-reported outcomes measures demonstrated statistically significant improvements between preoperative and latest follow-up scores for the following measures (P < .001): modified Harris Hip Score (from 64.3 to 84.9), Nonarthritic Hip Score (from 61.7 to 85.2), Hip Outcome Score-Sports Subscale (from 47.0 to 75.0), and visual analog scale (from 6.5 to 2.2). Mean satisfaction was 8.1 out of 10. Painful snapping was resolved in 80.7% of cases. Ten hips (17.5%) required secondary arthroscopy at a mean of 30.5 months. Three hips (5.3%) required total hip arthroplasty at a mean of 57.5 months. One case (1.8%) had minor postoperative complications. There were no statistically significant differences between the groups in outcomes, complications, and secondary surgeries.

CONCLUSIONS

IFL as part of hip arthroscopy for treatment of FAI and labral tears demonstrated similar favorable improvement, complication rates, and secondary surgeries, when compared with a control group that did not undergo IFL.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Iliopsoas tendonitis after hip arthroscopy: prevalence, risk factors and treatment algorithm

The incidence of iliopsoas tendonitis (IPT) has not previously reported following hip arthroscopy for femoroacetabular impingement with or without labral tears. (i) What is the incidence of IPT following hip arthroscopy; (ii) are there any demographic risk factors and (iii) are there any operative techniques that are risk for IPT? Retrospective study. Hip arthroscopy patients from 2005 to 2012 were included. Patients were diagnosed via physical examination findings and were excluded if they had pre-operative IPT. Records were reviewed for demographics, operative reports and operative procedures. All patients received either labral debridement, labral repair, osteoplasty or a combination of those procedures. A standardized rehabilitation protocol was used. Of 252 patients, 60 (24%) had IPT. Twenty-eight (47%) had symptom resolution with activity modification, physical therapy and NSAIDs. Thirty-two (53%) required corticosteroid injection at a mean of 25 weeks after surgery. Seven (12%) required revision arthroscopy and iliopsoas release to resolve the symptoms. There were no patient-specific risk factors, differences based on surgical technique, and number of portals did not matter. Patients should minimize exercises that activate the iliopsoas after hip arthroscopy. The cause of IPT could be related to unaddressed abnormal mechanics, tendon scarring or improper physical therapy. Further studies are needed to investigate the reasons for this, as well as specific techniques to lower its incidence. The incidence of IPT after hip arthroscopy has an incidence of 24%. Additionally, we provide readers with a rehabilitation protocol to minimize this complication.

Does Iliopsoas Lengthening Adversely Affect Clinical Outcomes After Hip Arthroscopy? A Multicenter Comparative Study

BACKGROUND

Iliopsoas fractional lengthening (IFL) continues to be a controversial procedure in hip arthroscopy.

HYPOTHESIS

Patients who underwent arthroscopic surgery for femoroacetabular impingement (FAI) and a labral tear either with or without IFL would experience favorable outcomes, and there would be no difference in postoperative patient-reported outcomes (PROs) between the 2 groups at minimum 2-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from July 2009 and April 2015 were retrospectively reviewed. Patients were eligible if they had hip arthroscopy for both FAI and labral tear treatment with IFL and without IFL. IFL was indicated for painful internal snapping. Minimum postoperative follow-up was set to 2 years. The authors calculated the modified Harris Hip Score, International Hip Outcome Tool-12, Hip Outcome Score-Activity of Daily Living Score, Hip Outcome Score-Sports Specific Subscale, Non-Arthritic Hip Score, visual analog scale for pain, patient satisfaction, minimal clinically important difference (MCID), and the percentage of patients who achieved patient acceptable symptomatic state (PASS). Revision surgeries and conversions to total hip arthroplasty (THA) were documented.

RESULTS

351 hips (307 patients) met the necessary inclusion criteria in the IFL cohort, with a mean ± SD follow-up time of 42.5 ± 18.1 months. For the control cohort, 392 hips (354 patients) were included, with a mean ± SD follow-up time of 43.9 ± 19.6 months. Both groups showed significant postoperative improvement in 2-year follow-up PROs. The group with iliopsoas lengthening showed comparable results to the control group with respect to PRO improvement, MCID, PASS, and rates of revision or THA conversion.

CONCLUSION

This comparative cohort study demonstrated that treatment of painful internal snapping syndrome with arthroscopic IFL, in the setting of FAI and a labral tear, is a safe procedure with good short- to mid-term follow-up results and associated improvement in PROs. Patients who underwent IFL showed similar outcomes compared with a control group treated for FAI and labral tear without IFL. In appropriately selected patients, arthroscopic IFL did not adversely affect clinical outcomes compared with patients who did not need IFL.

Arthroscopic Technique for Iliopsoas Fractional Lengthening for Symptomatic Internal Snapping of the Hip, Iliopsoas Impingement Lesion, or Both

Pathology of the iliopsoas may cause painful internal snapping of the hip or labral damage from soft impingement. Favorable outcomes have been reported after arthroscopic release or fractional lengthening of the iliopsoas. In patients with risk factors for instability, restoration of other soft-tissue constraints such as the labrum and capsule should be performed if iliopsoas fractional lengthening is undertaken. The purpose of this article is to detail the step-by-step surgical technique of arthroscopic iliopsoas fractional lengthening, in addition to the indications, pearls, and pitfalls of the technique.

In Search of the Spherical Femoroplasty: Cam Overresection Leads to Inferior Functional Scores Before and After Revision Hip Arthroscopic Surgery

BACKGROUND

Femoroplasty performed for the treatment of cam-type femoroacetabular impingement (FAI) has become a common procedure. Underresection may result in residual FAI. Conversely, overresection may disrupt the labral seal, which is responsible for chondroprotective fluid dynamics of the hip. Hypothesis/Purpose: It was hypothesized that cam overresection negatively affects hip function. The purpose was to examine the effect of the accuracy of previous femoroplasty on hips presenting for revision hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients presenting for revision hip arthroscopic surgery between June 2010 and August 2014. On the basis of measurements on Dunn view radiographs, cases were divided into 3 groups: overresection (OR group) in which overresection measured over 5% of the diameter of the femoral head, underresection (UR group) in which there was a residual cam lesion (alpha angle >60°), and neutral resection (neutral group). Data collection included the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale, and visual analog scale at presentation and at a minimum 2-year follow-up after revision hip arthroscopic surgery and rates of conversion to total hip arthroplasty (THA).

RESULTS

One hundred thirty hips (120 patients) were included. Twenty hips (15.4%) were classified as the OR group, 16 (12.3%) as the UR group, and 94 (72.3%) as the neutral group. The mean follow-up was 39.6 ± 15.9 months. The mHHS and NAHS values at presentation were lower in the OR group compared with the UR group (50.2 ± 15.5 vs 64.7 ± 19.4 [ P = .033] and 48.5 ± 18.6 vs 63.0 ± 19.1 [ P = .044], respectively). The mHHS value at a minimum 2-year follow-up after revision was lower for the OR group (66.7 ± 19.8) than for the UR group (81.0 ± 14.5) ( P = .031). Conversion to THA was more common in the OR group than in the UR group (30% vs 0%, respectively; P = .024). Fifty percent of cases in the OR group, 69.9% in the neutral group, and 75% in the UR group met the minimal clinically important difference for the mHHS (Δ). The latest mHHS value reached the patient acceptable symptomatic state (PASS) in 35% of the cases in the OR group, 53.2% in the neutral group, and 75% in the UR group. Hips in the OR group had a significantly lower chance of reaching the PASS than the UR group (odds ratio, 0.1795 [95% CI, 0.0418-0.7711]; P = .0209).

CONCLUSION

Cam overresection of more than 5% of the diameter of the femoral head on the Dunn view predicts inferior clinical outcomes compared with cam underresection in this population. Furthermore, overresection predicts inferior outcomes after revision hip arthroscopic surgery and higher rates of conversion to THA.

Arthroscopic Treatment of Iliopsoas Snapping in Patients With Radiographic Acetabular Dysplasia Using Iliopsoas Fractional Lengthening and Capsular Plication

PURPOSE

The purpose of this study was to evaluate the greater than 2-year patient-reported outcomes (PROs) and patient satisfaction of patients who were treated with hip arthroscopy for snapping iliopsoas tendons that were painful with concomitant acetabular dysplasia and who underwent iliopsoas lengthening for symptomatic iliopsoas tendon snapping with concomitant capsular plication and treatment of hip impingement. Secondary measures included observation of the change in the Tönnis grade at greater than 2 years' follow-up.

METHODS

Between July 2009 and December 2011, data on patients with a lateral center-edge angle (LCEA) of less than 25° (range, 19°-24°) who underwent hip arthroscopy with central-compartment iliopsoas fractional lengthening and capsular plication were prospectively collected and retrospectively reviewed. Interportal capsular repair was performed using between 2 and 5 simple sutures. Patients also underwent procedures to treat hip impingement pathology. All patients had preoperative and minimum 2-year postoperative PRO measures: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score. The visual analog scale score and patient satisfaction with surgery (from 0 to 10) were also collected. Radiographs were analyzed preoperatively and at latest follow-up to assess progression of the Tönnis grade.

RESULTS

We analyzed 32 patients who met the inclusion criteria (30 female and 2 male patients; mean age, 25 years). The mean LCEA and anterior center-edge angle were 21.6° and 25.5°, respectively. Four patients required revision arthroscopy for labral retears. Among the 28 patients who did not undergo revision surgery, the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score improved from 68.7 to 83.5, from 64.9 to 86.6, from 71.6 to 86.7, and from 52.6 to 75.8, respectively (P < .001). The visual analog scale score improved from 5.6 preoperatively to 1.9 at latest follow-up (P < .001). The mean patient satisfaction rating was 8.0. There was no radiographic progression of the Tönnis grade at final follow-up.

CONCLUSIONS

This study showed that patients with an LCEA of less than 25° and associated painful iliopsoas snapping can be treated by addressing concomitant pathology and performing central-compartment fractional lengthening of the iliopsoas tendon with concomitant capsular plication and have high satisfaction, improvement in PROs, and improved pain scores, without significant progression of osteoarthritis.

LEVEL OF EVIDENCE

Level IV, case series.

Imaging of impingement syndromes around the hip joint

Impingement syndromes are increasingly recognised as significant causes of hip pain and dysfunction. A broad spectrum of intraarticular and extraarticular conditions has been implicated in their pathophysiology. Physical examination is often inconclusive as clinical findings may be unclear or misleading, often simulating other disorders. With current improvements in imaging techniques and better understanding of hip impingement related pathomechanisms, these entities can be accurately diagnosed. In addition, preoperative imaging has allowed for targeted treatment planning. This article provides an overview of the various types of hip impingement, including femoroacetabular impingement, ischiofemoral impingement, snapping hip syndrome, greater trochanteric-pelvic and subspine impingement. Current literature data regarding their pathogenesis, clinical manifestation and imaging work-up are discussed.

Magnetic Resonance Imaging Appearance of the Hip Musculature After Arthroscopic Labral-Level Iliopsoas Tenotomies

BACKGROUND

Iliopsoas (IP) muscle atrophy is a known consequence of open IP tenotomy, but the severity of IP muscle atrophy that occurs after arthroscopic labral-level IP tenotomies has not been documented.

PURPOSE

To document the severity of muscle atrophy that occurs in the iliacus, psoas, and adjacent hip musculature after arthroscopic labral-level IP tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-eight patients who had magnetic resonance arthrograms (MRAs) obtained prior to and 3 months to 5 years after arthroscopic labral-level IP tenotomies are the basis of this report. The pre- and postoperative MRAs of each patient were examined in consensus by 2 musculoskeletal radiologists who graded the postoperative muscle atrophy from 0 (no fatty infiltration) to 4 (>75% fatty infiltration) and noted any compensatory muscle hypertrophy or abnormal IP tendon morphology. Patients also were assessed with the Byrd 100-point modified Harris Hip Scoring system (MHHS) preoperatively and at the time of their postoperative MRA.

RESULTS

Postoperative MRAs were obtained on average 1.7 years (range, 3 months to 5 years) after hip arthroscopy. None of the patients had muscle atrophy on their preoperative MRAs. In contrast, 89% of patients had iliacus and psoas muscle atrophy on their postoperative MRAs, but only 2 (7%) developed grade 4 atrophy, and the majority (64%) had either grade 1 (n = 15) or no atrophy (n = 3). In addition, there were no significant differences in the MHHS of the patients with mild (grades 0-1), moderate (grades 2-3), or severe (grade 4) postoperative atrophy. Postoperative MRAs also demonstrated low-grade atrophy (grades 1-2) in the quadratus femoris (n = 5) and rectus femoris (n = 1) muscles, and 16 patients (57%) had distortion of the tendon, but none had a gap in their tendon.

CONCLUSION

A majority of patients (89%) developed IP muscle atrophy after arthroscopic labral-level IP tenotomies, and although this percentage was similar (89% vs 90%) to that reported with lesser trochanteric IP tenotomies, the patients did not (1) develop atrophy of the gluteus maximus and vastus lateralis muscles, (2) have chronic IP tendon disruption, or (3) develop the severity of IP atrophy (55% grade 4 vs 7% grade 4) that has been reported after arthroscopic lesser trochanteric IP tenotomies.

Snapping hip syndrome: systematic review of surgical treatment

The snapping hip (SH) syndrome is characterised by an audible snapping, often accompanied by pain, which usually occurs with the flexion and extension of the hip during exercise or ordinary daily activities.The causes of SH can be classified as external, internal and intraarticular. The prevalence of asymptomatic SH in the population is unknown and the incidence of symptomatic cases is not well-defined. The painless snapping in the hip is common in the general population; the symptomatic SH with debilitating pain and weakness is often seen in those who take part in activities such as ballet and running hurdles.The clinician's goal is to determine the cause and treat patients who have symptomatic SH so that they may return to their activities or to athletic peak performance.Most patients with SH can be treated conservatively. However, surgery may be indicated if the condition becomes chronically symptomatic. Arthroscopy may prove useful in the treatment of intraarticular lesions that are causing discomfort. Various techniques have been described with different grades of success. The aim is to achieve the least invasive procedure with the lowest potential complications that corrects the painful snapping, according to the patient's characteristics.The purpose of this systematic review is to clarify the results of the surgical treatment of SH, after the failure of the conservative treatment.

Arthroscopic Psoas Management: Techniques for Psoas Preservation and Psoas Tenotomy

The iliopsoas tendon is an important dynamic stabilizer of the hip joint, and it should be carefully identified and preserved during routine hip arthroscopy. However, it may also be a source of hip pain manifesting as iliopsoas tendinitis or a snapping hip or contributing to the development of labral pathology caused by psoas impingement. In the appropriately indicated, refractory cases of iliopsoas-related hip pain, surgical intervention in the form of an iliopsoas tenotomy at the level of the labrum can result in reliable pain relief. We describe a method to identify and protect the iliopsoas tendon during routine hip arthroscopy when preservation is desired. In addition, we detail how to deepen the psoas tunnel if psoas impingement is present but psoas tenotomy is contraindicated. We also describe a reproducible technique of arthroscopic iliopsoas tenotomy using standard portals and minimal equipment when indicated.

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.

Arthroscopic release of iliopsoas tendon in patients with femoro-acetabular impingement: clinical results at mid-term follow-up

BACKGROUND

The iliopsoas tendon is a recognized cause of extra-articular hip pain, and tenotomy has been described as an effective treatment in patients who do not respond to conservative treatments. Endoscopic release showed higher success rate, lower recurrence, fewer complications compared to open surgery. The aim of the study is to report the results at a mean of 4 years follow-up of a series of patients affected by femoroacetabular impingement (FAI) and an associated iliopsoas tendinopathy, treated with hip arthroscopy and transcapsular tendon release.

METHODS

Fifteen patients were retrospectively reviewed. Assessment of radiographic signs of FAI was performed, the alpha angle, the femoral head-neck offset and the lateral center edge angle (LCEA) were collected. Osteoarthritis was assessed from the AP pelvic and graded according to the Tönnis classification. Modified Harris Hip Score (mHHS), VAIL score and VAS score were administered to all patients before surgery, at follow-up at 1 year (T1) and final follow-up (T2).

RESULTS

We found a statistical significant improvement in functional scores (mHHS and VAIL score) from the baseline to T2. According to VAS score, a statistical significant improvement was also found from T0 to T2, from a median of 5.5 (range 3-7) to 0 (range 0-5) (P<0.001). Two patients referred a recurrence of pain one year after surgery who were treated conservatively. No other complications have been reported.

CONCLUSION

Iliopsoas tendinopathy can be associated to FAI in some patients, and failure in diagnosing and treating may be the reason of poor results and a revision surgery. Arthroscopic iliopsoas tendon release seems to produce good clinical outcome, reducing pain and the rate of a revision surgeries. Level of evidence: IV case series.

Endoscopic release of internal snapping hip: a review of literature

BACKGROUND

Internal snapping hip is a common clinical condition, characterized by an audible or palpable snap of the medial compartment of the hip. In most cases it is asymptomatic, while in a few patients, mostly in athletes who participate in activities requiring extremes of hip range of motion, the snap may become painful (internal snapping hip syndrome - ISHS).

MATERIALS AND METHODS

This is a review of current literature, focused on the pathogenesis, diagnosis and treatment of ISHS.

CONCLUSION

The pathogenesis of ISHS is multifactorial, and it is traditionally believed to be caused by the tendon snapping over the anterior femoral head or the iliopectineal ridge. Most cases of ISHS resolve with conservative treatment, which includes avoidance of aggravating activities, stretching, and NSAIDs. In recalcitrant cases, surgery may be indicated. Better results have been reported with endoscopic iliopsoas tendon release compared with open techniques, which may be related to the treatment of concomitant intra-articular pathologies. Furthermore, endoscopic treatment showed fewer complications, decreased failure rate and postop erative pain. It is important to remember that in most cases, a multiple iliopsoas tendon may exist, and that the incomplete release of the iliopsoas tendon can be a reason for refractory pain and poor results. Then, even if of not clinical relevance at long term follow-up, patients should be told about the inevitable loss of flexion strength after iliopsoas tenotomy.

LEVEL OF EVIDENCE

II.

Arthroscopic Treatment of Symptomatic Internal Snapping Hip with Combined Pathologies

Background

Arthroscopic iliopsoas tendon release was introduced in 2000. The purpose of this study was to evaluate clinical outcomes of arthroscopic iliopsoas tendon release for painful internal snapping hip with concomitant hip pathologies.

Methods

Between January 2009 and December 2011, we performed arthroscopic iliopsoas tendon release and related surgeries in 25 patients (20 men and 5 women; mean age, 32 years; range, 17 to 53 years) with combined intraarticular hip pathologies. The patients were followed for a minimum of 2 years postoperatively. Clinical and radiological evaluations were performed.

Results

Snapping sounds had disappeared by the 2-year follow-up in 24 of the 25 patients. All patients who had presented with loss of flexion strength postoperatively showed recovery at postoperative week 6 to 10. Harris hip score improved from 65 points (range, 46 to 86 points) preoperatively to 84 points (range, 67 to 98 points) postoperatively (p < 0.001). Seven hips (28%) had an excellent score, 15 hips (60%) a good score, 2 hips (8%) a fair score, and one hip (4%) a poor score (p < 0.001). The Tonnis grade of osteoarthritis did not change in any of the patients at the last follow-up.

Conclusions

Patients with painful internal snapping hip have combined hip pathologies. Therefore, the surgeon should keep in mind that painful internal snapping hips are frequently combined with concomitant intraarticular pathologies.

Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip: Clinical Outcomes With a Minimum 2-Year Follow-up

BACKGROUND

Internal snapping of the hip is caused by the iliopsoas (IP) tendon sliding over the iliopectineal eminence or the femoral head. In many cases that require hip arthroscopic surgery, there is coexistent painful internal snapping. In such cases, fractional lengthening of the IP tendon has been suggested as an adjunctive procedure.

PURPOSE

To examine the outcomes and effectiveness of arthroscopic IP tendon fractional lengthening as a solution to coexistent internal hip snapping in patients undergoing hip arthroscopic surgery for a labral tear and/or femoroacetabular impingement.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between June 2010 and June 2011, data were prospectively collected for all patients with internal snapping of the hip who underwent primary arthroscopic IP tendon fractional lengthening, with a minimum 2-year follow-up. All patients were interviewed by telephone with specific questions regarding the resolution or persistence of snapping. Patients were assessed preoperatively and postoperatively using the following patient-reported outcome (PRO) measures: Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activity of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS). Pain was recorded on a visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10.

RESULTS

A total of 55 patients were included, with all PROs showing statistically significant improvement postoperatively (NAHS: 57.6 ± 20.6 preoperatively vs. 80.2 ± 19.2 at 2 years; HOS-ADL: 60.9 ± 21.4 preoperatively vs. 81.8 ± 20.6 at 2 years; HOS-SSS: 43.4 ± 24.6 preoperatively vs. 70.0 ± 26.7 at 2 years; and mHHS: 62.3 ± 16.4 preoperatively vs. 80.5 ± 18.3 at 2 years) (P < .001 for all). Forty-five patients (81.8%) reported good/excellent satisfaction (≥7). Overall, 45 patients (81.8%) reported resolution of painful snapping. Patients who had resolution of snapping had statistically significant superior outcomes compared with those with persistent snapping using the change in the NAHS value (25.8 ± 16.1 vs. 8.0 ± 22.5, respectively; P = .005), change in the HOS-ADL value (23.6 ± 18.0 vs. 8.5 ± 15.2, respectively; P = .017), change in the HOS-SSS value (30.7 ± 26.9 vs. 8.7 ± 23.6, respectively; P = .021), and change in the mHHS value (23.3 ± 20.1 vs. 4.4 ± 9.9, respectively; P = .005).

CONCLUSION

A majority of patients reported resolution of painful snapping and improvement in symptoms. Nonetheless, the rate of persistence of internal snapping at a minimum 2 years postoperatively was higher than that reported in previous studies.

Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of labral impingement

PURPOSE

To document the clinical results of arthroscopic iliopsoas tenotomies performed at the level of the labrum to treat labral injuries caused by iliopsoas impingement.

METHODS

From a review of the database of the senior author (J.S.K.) of 300 hip arthroscopies that were performed between September 2009 and May 2011, 30 patients who had an arthroscopic release of the iliopsoas tendon at the level of the labrum and at least 2 years' follow-up were identified. In all cases the release was performed to treat a tight psoas tendon that was found at arthroscopy to be impinging on a torn or inflamed labrum. The results of hip arthroscopy in these patients were assessed with Byrd's 100-point modified Harris Hip Score system before arthroscopy and at 3, 6, 12, and 24 months after surgery.

RESULTS

The mean age of the 30 patients was 35 years, and their preoperative scores averaged 43 points. After surgery, the patients had 6-month scores that averaged 73 points and 12-month scores that averaged 84 points (range, 40 to 100 points). Over the first postoperative year, in 3 of the 5 patients whose preoperative ultrasound imaging showed snapping of the tendon, recurrent painful snapping developed in the hip. All 3 had iliopsoas bursa injections and had immediate relief of their hip pain. In 2 patients the relief was temporary and an arthroscopic release of the tendon at the lesser trochanter was performed. The 2-year scores of the remaining 28 patients who did not have a second iliopsoas tenotomy averaged 88 points, and 23 of these patients had good or excellent results (scores ≥80 points).

CONCLUSIONS

An arthroscopic release of the iliopsoas tendon at the level of the labrum was effective for alleviating hip pain from labral lesions caused by impingement of the tendon in 23 of 30 patients (77%). The remaining 7 patients had persistent hip pain and hip scores lower than 80 points because of recurrent snapping of the tendon (3), development of avascular necrosis (1), progression of degenerative joint disease (1), or chronic greater trochanteric bursitis (2).

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Medium-term and long-term outcomes of interventions for primary psoas tendinopathy

OBJECTIVE

To assess medium- and long-term outcomes of psoas tendinopathy to psoas tenotomy and image-guided steroid injections.

DESIGN

This is a 14-year retrospective case-control study to identify the efficacy of psoas tenotomy and image-guided steroid injections.

SETTING

This study was undertaken in a secondary care setting.

PATIENTS

Patients with confirmed psoas tendinopathy were followed up by postal questionnaire, which included a nonarthritic hip score (NAHS) and a study patient satisfaction questionnaire.

INTERVENTIONS

Patients underwent image-guided steroid injections. Depending on the analgesic or symptomatic relief, some patients proceeded to psoas tenotomy.

MAIN OUTCOME MEASURES

Response to steroid injection. Pain relief and symptomatic relief after the surgery.

RESULTS

Twenty-three patients were reviewed with a 70% follow-up over a time of 49 months for surgery (range, 13-144 months) and 77 months for injection (range, 14-160 months). Eight patients had a lasting response to injection and required no further intervention, and 15 patients proceeded to psoas tenotomy using a medial Ludloff approach. The average NAHS scores after the surgery and injection were 66.15 and 76.08, respectively. Ten patients reported pain relief after their tenotomy, and 5 patients reported no change in pain. All 8 patients, who only underwent injection, reported lasting pain relief.

CONCLUSIONS

Local steroid injections can provide long-term relief for patients presenting with psoas tendinopathy. For those patients with only temporary relief from injection, psoas tenotomy can provide good long-term pain relief.

Anatomic variance of the iliopsoas tendon

BACKGROUND

The iliopsoas tendon has been implicated as a generator of hip pain and a cause of labral injury due to impingement. Arthroscopic release of the iliopsoas tendon has become a preferred treatment for internal snapping hips. Traditionally, the iliopsoas tendon has been considered the conjoint tendon of the psoas major and iliacus muscles, although anatomic variance has been reported.

HYPOTHESIS

The iliopsoas tendon consists of 2 discrete tendons in the majority of cases, arising from both the psoas major and iliacus muscles.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Fifty-three nonmatched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62 years; range, 47-70 years; 29 male and 24 female) were used in this study. The iliopsoas muscle was exposed via a Smith-Petersen approach. A transverse incision across the entire iliopsoas musculotendinous unit was made at the level of the hip joint. Each distinctly identifiable tendon was recorded, and the distance from the lesser trochanter was recorded.

RESULTS

The prevalence of a single-, double-, and triple-banded iliopsoas tendon was 28.3%, 64.2%, and 7.5%, respectively. The psoas major tendon was consistently the most medial tendinous structure, and the primary iliacus tendon was found immediately lateral to the psoas major tendon within the belly of the iliacus muscle. When present, an accessory iliacus tendon was located adjacent to the primary iliacus tendon, lateral to the primary iliacus tendon.

CONCLUSION

Once considered a rare anatomic variant, the finding of ≥2 distinct tendinous components to the iliacus and psoas major muscle groups is an important discovery. It is essential to be cognizant of the possibility that more than 1 tendon may exist to ensure complete release during endoscopy.

CLINICAL SIGNIFICANCE

Arthroscopic release of the iliopsoas tendon is a well-accepted surgical treatment for iliopsoas impingement. The most widely used site for tendon release is at the level of the anterior hip joint. The findings of this novel cadaveric anatomy study suggest that surgeons should be mindful that more than 1 tendon may be present and require release for curative treatment.

Hip pathology in the adolescent athlete

Hip injuries in young athletes are being diagnosed with increasing frequency. Improvements in diagnostic imaging and surgical technologies have helped facilitate the diagnosis of intra- and extra-articular derangements that were previously untreated in this age group. Athletic injuries of the hip in the young athlete encompass both osseous and soft-tissue etiologies, which can be the result of a single traumatic event or repetitive microtrauma or may be associated with an underlying pediatric hip disorder. Without accurate diagnosis and management, these injuries may result in debilitating consequences. This article will review the more common causes of hip and groin pain in the adolescent athlete, as well as advances in diagnostic and therapeutic interventions.

Regrowth of the psoas tendon after arthroscopic tenotomy: a magnetic resonance imaging study

PURPOSE

The purpose of this study was to evaluate whether the psoas tendon regenerates after arthroscopic tenotomy through the central compartment of the hip in patients with internal snapping hip.

METHODS

Twenty-seven patients with a snapping hip, aged 18 to 54 years (mean, 37.47 years), underwent arthroscopic tenotomy through the central compartment of the hip; all patients had symptomatic femoroacetabular impingement as well. The degree of regeneration was evaluated by preoperative and postoperative measurements of the tendon perimeter with a magnetic resonance imaging protocol in patients with more than 6 months' follow-up. In addition, function was assessed preoperatively and postoperatively with the Western Ontario and McMaster Universities Osteoarthritis Index score. Postoperative active flexion force was graded clinically between 1 and 5 with the Medical Research Council score.

RESULTS

Eight patients had less than 6 months' follow-up, and they were excluded. The remaining 19 patients were evaluated after a mean follow-up period of 23.16 months (SD, 12.95 months). Tendon regeneration occurred in all patients. Compared with preoperative measurement, the psoas tendon circumference had recovered by 84.3% on average (55.44 ± 5.68 mm v 46.71 ± 6.05 mm, P < .001). Pain improved in all patients, and the mean Western Ontario and McMaster Universities Osteoarthritis Index score fell from 49 ± 15.9 points to 10.74 ± 11.35 points (P < .001). Muscle force recovered completely in all cases.

CONCLUSIONS

There is a process of tissular repair after psoas tenotomy, and the findings on magnetic resonance imaging suggest that tendon tissue regrowth occurs.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Peri-articular diseases of the hip: emerging frontiers in arthroscopic and endoscopic treatments

The precise diagnosis of both intra and extra-capsular disease of the hip is now possible because of commonly available advanced diagnostic imaging techniques. An increasing number of reports in the orthopedic literature describe new endoscopic and arthroscopic techniques to address peri-articular pathology of the hip. The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.

MR imaging of the hip: pathologies and morphologies of the hip joint, what the surgeon wants to know

MR imaging of the hip is frequently used in symptomatic patients before hip preservation surgery; it is used as a decision-making tool and as a planning tool. The MRI can confirm the preliminary working diagnosis, identify other possible sources of pain, and highlight anatomic areas that are not routinely viewed during surgery. In addition, MR imaging is capable of illustrating normal and abnormal bony morphology of the femur and pelvis; and in the case that arthrography is used, diagnostic injection can be administrated concurrently. This article highlights a surgeon's perspective on the use of MR imaging in the patient with nonarthritic hip pain.

Iliopsoas tendon reformation after psoas tendon release

Internal snapping hip syndrome, or psoas tendonitis, is a recognised cause of nonarthritic hip pain. The majority of patients are treated conservatively; however, occasionally patients require surgical intervention. The two surgical options for iliopsoas tendinopathy are step lengthening of the iliopsoas tendon or releasing the tendon at the lesser trochanter. Although unusual, refractory snapping usually occurs soon after tenotomy. We report a case of a 47-year-old active female with internal snapping and pain following an open psoas tenotomy. Postoperatively she was symptom free for 13 years. An MRI arthrogram revealed reformation of a pseudo iliopsoas tendon reinserting into the lesser trochanter. The pain and snapping resolved after repeat iliopsoas tendon release. Reformation of tendons is an uncommon sequela of tenotomies. However the lack of long-term studies makes it difficult to calculate prevalence rates. Tendon reformation should be included in the differential diagnosis of failed tenotomy procedures after a period of symptom relief.

Surgical management of internal snapping hip syndrome: a systematic review evaluating open and arthroscopic approaches

PURPOSE

This systematic review explored reported outcomes addressing internal snapping hip as well as comparing outcomes between open and arthroscopic management of internal snapping hip syndrome.

METHODS

Two databases (Embase and Medline) were screened for clinical studies involving the surgical management of internal snapping hip syndrome. Two reviewers conducted a full-text review of eligible studies and the references of these studies. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies.

RESULTS

We identified 11 eligible studies involving 248 patients. The mean age of the participants was 26.5 years (range, 14 to 62 years). The 2 most commonly reported standardized outcome measures were the modified Harris Hip Score (27%) and the Western Ontario and McMaster Universities Osteoarthritis Index (18%). Six studies (54%) presented return to the same level of competition or activities of daily living as an outcome. Among patients undergoing arthroscopic management for this condition, postoperative improvements in the modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score were greater in the studies involving transection at the lesser trochanter compared with the transcapsular technique. Standardized outcome measures were not reported among patients undergoing open procedures. Resolution of snapping was seen in 100% of patients who underwent arthroscopic release and 77% of open procedure patients. Complication rates were higher in patients undergoing an open procedure (21%) compared with an arthroscopic procedure (2.3%).

CONCLUSIONS

This review shows a decreased failure rate, fewer complications, and decreased postoperative pain with arthroscopic management of internal snapping hip syndrome in comparison with open management. However, given the lack of high-quality evidence or direct comparison data, these results should be interpreted with caution. This review also highlights the need for the development of a standardized outcome tool for consistent reporting of clinical outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Extra-articular hip endoscopy: A review of the literature

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

Accessibility of extra-articular pathologies of iliopsoas tendon and bursitis of greater trochanter in hip arthroscopy

PURPOSE

Different pathologies leading to psoas tendon pain and chronic bursitis of the greater trochanter are well known. The purpose of the study was to underline the accessibility of the psoas tendon at lesser trochanter, reproduce the results and measure the distances to anatomical landmarks.

METHODS

Twelve hips of six human cadavers underwent hip arthroscopy. The accessibility of the iliopsoas tendon at the lesser trochanter and the bursa at the greater trochanter was documented with the camera. In addition to the usual access portals, alternative ventral ports were analysed concerning accessibility of the lesser trochanter. Afterwards, arthroscopy needles were placed along the extra-articular portals followed by dissection. The distances of the portals in relation to important anatomical landmarks were analysed.

RESULTS

The accessibility to the iliopsoas tendon at the lesser trochanter and to the bursa at the greater trochanter throughout the conventional portals was reproducible. Sufficient distances to the important anatomical landmarks could be shown. The mean distance of the distal ventro-lateral and the wide distal ventro-lateral portal to the nervous cutaneous femoris lateralis was 26.8 ± 5.4 mm and 32.2 ± 3.9 mm. The mean distance from the more ventral located portals to the nervous arteria and vena femoralis was 28.3 ± 2.1 mm.

CONCLUSION

This is the first study known to us that describes in detail the accessibility of the extra-articular structures underlined by anatomical preparation. In addition, it was demonstrated that a more ventrally located portal had sufficient distance to the important neurovascular structures of the ventral femur and can also be used in addendum if necessary.

Extra-articular Snapping Hip: A Literature Review

CONTEXT

Snapping hip, or coxa saltans, is a vague term used to describe palpable or auditory snapping with hip movements. As increasing attention is paid to intra-articular hip pathologies such as acetabular labral tears, it is important to be able to identify and understand the extra-articular causes of snapping hip.

EVIDENCE ACQUISITION

The search terms snapping hip and coxa sultans were used in PubMed to locate suitable studies of any publication date (ending date, November 2008).

RESULTS

Extra-articular snapping may be caused laterally by the iliotibial band or anteriorly by the iliopsoas tendon. Snapping of the iliopsoas tendon usually requires contraction of the hip flexors and may be difficult to differentiate from intra-articular causes of snapping. Dynamic ultrasound can help detect abrupt tendon translation during movement, noninvasively supporting the diagnosis of extra-articular snapping hip. The majority of cases of snapping hip resolve with conservative treatment, which includes avoidance of aggravating activities, stretching, and anti-inflammatory medication. In recalcitrant cases, surgery to lengthen the iliotibial band or the iliopsoas tendon has produced symptom relief but may result in prolonged weakness.

CONCLUSIONS

In treating active patients with snapping soft tissues around the hip, clinicians should recognize that the majority of cases resolve without surgical intervention, while being mindful of the potential for concomitant intra-articular and internal snapping hips.

Clinical outcomes after arthroscopic psoas lengthening: the effect of femoral version

PURPOSE

The purpose of this study was to examine the association between femoral anteversion and clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon in young patients.

METHODS

Sixty-seven consecutive patients with symptomatic coxa saltans underwent arthroscopic psoas tendon lengthening through a transcapsular approach during a 3-year period by a single arthroscopic hip surgeon. Demographic and clinical variables were collected. Patients were divided into low/normal femoral version and high femoral version groups and analyzed for association of femoral version with clinical outcomes as measured by the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) preoperatively and postoperatively with a minimum of 6 months' follow-up (range, 6 to 24 months). Two-sample t tests were used for data analysis, with P < .05 defined as significant.

RESULTS

Preoperative evaluation showed excessive anteversion (>25°) associated with worse HOS sports subscale scores (26.6 v 50.0 for excessive v low/normal anteversion, P = .013) and no difference in mHHS and HOS activities-of-daily living subscale scores. Postoperative mHHS scores were significantly different (76.9 v 86.1 for excessive v low/normal anteversion, P = .031). No association was noted between clinical outcome measures and any other clinical or demographic variable (P > .05).

CONCLUSIONS

Patients with increased femoral anteversion may be at greater risk for inferior clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon. The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities, particularly terminal extension and external rotation when the tendon is typically at its highest tension. These results may help surgeons identify which patients may be at risk for inferior clinical outcome after psoas lengthening.

Disappointing short-term results with the DePuy ASR XL metal-on-metal total hip arthroplasty

Outcomes of ultralarge-diameter femoral heads used in metal-on-metal (MOM) total hip arthroplasty (THA) are relatively unknown. This study reports on early failures of the ASR XL (Depuy, Warsaw, Ind) and assesses whether a correlation with cup positioning exists. A retrospective review of 70 consecutive MOM THAs with ultralarge-diameter femoral head and monoblock acetabular component was conducted. Minimum follow-up was 24 months. Of 70 THAs, 12 (17.1%) required revision within 3 years for pain (7), loosening (3), and squeaking (2). Three additional THAs noted squeaking, 2 noted grinding, and 3 additional hips had persistent pain. In total, 20 (28.6%) of 70 demonstrated implant dysfunction. Acetabular components for all symptomatic hips were in acceptable range of cup abduction and anteversion. The failures noted with this design do not correlate to cup placement. The high rate of implant dysfunction at early follow-up suggests serious concerns with the concept of MOM THA with an ultralarge-diameter femoral head paired with a monoblock acetabular cup.

Iliopsoas impingement: a newly identified cause of labral pathology in the hip

Labral tears typically occur anterosuperiorly in association with femoroacetabular impingement or dysplasia. Less commonly, labral pathology may occur in an atypical direct anterior location adjacent to the iliopsoas tendon in the absence of bony abnormalities. We hypothesize that this pattern of injury is related to compression or traction on the anterior capsulo-labral complex by the iliopsoas tendon where it crosses the acetabular rim. In a retrospective review of prospectively collected data, we identified 25 patients that underwent isolated, primary, unilateral iliopsoas release and presented for at least 1 year follow-up (mean 21 months). Pre-operative demographics, clinical presentation, intra-operative findings, and outcome questionnaires were analyzed. The injury was treated with a tenotomy of the iliopsoas tendon at the level of the joint line and either labral debridement or repair. Mean post-operative outcome scores were 87.17, 92.46, and 78.8 for the modified Harris Hip Score, activities of daily living Hip Outcome Score, and sports-related score, respectively. The atypical labral injury identified in this study appears to represent a distinct pathological entity, psoas impingement, with an etiology which has not been previously described.

Cross-sectional analysis of iliopsoas muscle-tendon units at the sites of arthroscopic tenotomies: an anatomic study

BACKGROUND

Arthroscopic iliopsoas tenotomies are performed at the level of the labrum, femoral neck, and lesser trochanter. The composition and percentage of the iliopsoas muscle-tendon unit (MTU) that is released when the tendon is cut at these sites has not been reported to date.

HYPOTHESIS

Cutting the iliopsoas tendon at the 3 common sites of arthroscopic tenotomies does not release the entire iliopsoas MTU.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Forty iliopsoas MTUs from 20 embalmed cadavers were isolated at the level of the hip joint and released from their insertion on the lesser trochanter. Circumferential measurements of the composite MTU and the isolated iliopsoas tendon were then made at (1) the MTU's insertion on the lesser trochanter, (2) the Wettstein et al site of transcapsular release, and (3) the Alpert et al release site at the level of the labrum. Single proportion testing was performed using the Student t test to determine if significant differences existed between the average circumference of the iliopsoas MTUs or the isolated tendons at the 3 levels at which they were measured.

RESULTS

The average circumference of the iliopsoas-muscle belly complex at the level of the labrum, the transcapsular release site, and the lesser trochanter was 68, 58, and 46 mm, respectively. The average circumference of the iliopsoas tendon at these same levels was 27, 31, and 27 mm, respectively. Thus, at the level of the labrum, transcapsular release site, and lesser trochanter, the iliopsoas MTU is composed of 40% tendon/60% muscle belly, 53% tendon/47% muscle belly, and 60% tendon/40% muscle belly, respectively.

CONCLUSION

Cutting the iliopsoas tendon at the labrum, head-neck junction, or lesser trochanter does not result in a release of the entire iliopsoas MTU.

CLINICAL RELEVANCE

The results of this study document that releasing the iliopsoas tendon at the lesser trochanter preserves 40% of the MTU and does not result in a complete detachment of the iliopsoas MTU.

Case report: Bifid iliopsoas tendon causing refractory internal snapping hip

BACKGROUND

Treatment of painful internal snapping hip (coxa saltans) via arthroscopic lengthening or release of the iliopsoas tendon is becoming preferred over open techniques because of the benefits of minimal dissection, the ability to address concomitant intraarticular disorders, and a low complication rate. Persistent snapping after release is uncommon, especially when performed arthroscopically. Reported causes include incomplete release, intraarticular disorders, and incorrect diagnosis. Anatomic variants are not discussed in the orthopaedic literature.

CASE DESCRIPTION

We report a case of an 18-year-old softball player with internal snapping hip treated with arthroscopic iliopsoas release in the peripheral compartment. Postoperatively, the athlete continued to have painful snapping. Repeat arthroscopy with a larger capsulotomy revealed a bifid iliopsoas tendon causing refractory internal snapping hip, which resolved after revision arthroscopic release.

LITERATURE REVIEW

Bifid iliopsoas tendon as a cause of persistent snapping of the hip has not been reported in the orthopaedic literature. Prior sonographic and anatomic studies suggest the bifid iliopsoas tendon exists but is uncommon.

PURPOSE AND CLINICAL RELEVANCE

Recognition that a bifid iliopsoas tendon may be the source of painful internal snapping hip is important to prevent clinical failure of surgical management of the internal snapping hip. The differential diagnosis of failed iliopsoas lengthening surgery should include the consideration of an incompletely lengthened tendon attributable to bifid iliopsoas tendon anatomy. Prevention of this complication includes making a large enough capsulotomy to identify the tendon and to ensure it is not bifid.

Arthroscopic treatment of the snapping iliopsoas tendon through the central compartment of the hip: a pilot study

We undertook a prospective pilot study to determine whether arthroscopic surgery through the central compartment of the hip was effective in the management of a snapping iliopsoas tendon. Seven patients were assessed pre-operatively and at three, six, 12 and 24 months after operation. This included the assessment of pain on a visual analogue scale (VAS) and function using the modified Harris hip score. All the patients had resolution of snapping post-operatively and this persisted at follow-up at two years. The mean VAS score for pain fell from 7.7 (6 to 10) pre-operatively to 4.3 (0 to 10) by three months (p = 0.051), and to 3.6 (1 to 8) (p = 0.015), 2.4 (0 to 8) (p = 0.011) and 2.4 (0 to 8) (p = 0.011) by six, 12 and 24 months, respectively. The mean modified Harris hip score increased from 56.1 (13.2 to 84.7) pre-operatively to 88.4 (57.2 to 100) at one year (p = 0.018) and to 87.9 (49.5 to 100) at two years (p = 0.02). There were no complications and no weakness occurred in the musculature around the hip. Our findings suggest that this treatment is effective and would support the undertaking of a larger study comparing this procedure with other methods of treatment.

Arthrodiatasis for the treatment of Perthes' disease

It is hypothesized that the interruption of the blood supply is an important factor causing femoral head osteonecrosis in the early stages of Legg-Calvé-Perthes disease. Currently, treatment by containment is recommended to direct and guide remodeling of the softened femoral head as it evolves from fragmentation through ossification. The goal of this study was to show the results of arthrodiatasis to induce height recovery of the femoral head and to achieve true ambulatory nonweight-bearing containment. Forty-two patients younger than 8 years with a diagnosis of Perthes' disease were studied. Twenty-three patients (9 class B and 14 class C according to Herring's classification) were treated with an articulated distraction technique and 19 patients (11 class B and 8 class C) were treated conservatively as a control group. Arthrodiatasis or articulated distraction of the hip combines off-loading of muscles and body forces with distraction of the joint space by means of an external fixator that crosses the hip joint. Radiologically, 21 patients (91%) had satisfactory results and 2 (9%) had unsatisfactory results. Clinically, the results were good in 21 patients (92%), fair in 1 (4%), and poor in 1 (4%). In patients treated conservatively, 14 patients (72%) had satisfactory results and 5 (28%) had unsatisfactory results. Clinically, 71% had good results, 17% had fair, and 12% had poor. We conclude that hip joint containment by articulated arthrodiatasis (plus adductors and psoas minimal tenotomy surgery) is an effective method in the management of Perthes' disease in patients younger than 8 years, classified B and C, and associated with a highly reduced range of abduction. Restoration of clinical abnormalities and satisfactory radiological parameters are achieved in high percentages.

Cross-sectional analysis of the iliopsoas tendon and its relationship to the acetabular labrum: an anatomic study

BACKGROUND

Hip pain in patients with normal bony anatomy and anterior labral injury may be related to compression of the iliopsoas tendon across the anterior capsulolabral complex. No attempts to characterize the 3-dimensional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum have been reported to date.

HYPOTHESIS

The iliopsoas tendon directly overlies the capsulolabral complex. Contribution of the muscle belly and tendon to the overall circumference at the level of the labrum is approximately the same.

STUDY DESIGN

Descriptive laboratory study.

MATERIALS AND METHODS

Eight hip joints were dissected and cross-sectional measurements of the iliopsoas muscle-tendon complex were performed using digital calipers and image analysis software.

RESULTS

The iliopsoas tendon in all specimens was located directly anterior to the anterosuperior capsulolabral complex at the 2 to 3 o'clock position. The overall length of the iliopsoas tendon from the lesser trochanter to the acetabular labrum was 75.4 +/- 0.9 mm. The circumference of the iliopsoas tendon at the lesser trochanter was 25.5 +/- 2.6 mm, the iliopsoas tendon at the level of the labrum was 28.4 +/- 2.8 mm, and the iliopsoas tendon-muscle belly complex at the level of the labrum was 63.8 +/- 7.4 mm. At the level of the labrum, the iliopsoas is composed of 44.5% tendon and 55.5% muscle belly.

CONCLUSION

The close anatomic relationship of the iliopsoas tendon to the anterior capsulolabral complex suggests that iliopsoas pathologic changes at this level may lead to labral injury. Additionally, these data suggest that at the level of the labrum, 45% of the tendon-muscle belly complex should be released to release the entire tendinous portion.

CLINICAL RELEVANCE

Knowledge of the cross-sectional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum will better assist surgeons in treating lesions associated with iliopsoas injury.

Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes

BACKGROUND

An arthroscopic iliopsoas tendon release will alleviate painful snapping of the tendon. One question that remains is whether athletes can return to sports after this procedure. This study presents the results of 5 competitive and 10 recreational athletes who had an arthroscopic release of their iliopsoas tendon.

HYPOTHESIS

Athletes can return to full participation in their sport after an arthroscopic iliopsoas tendon release.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifteen athletes (2 college, 3 high school, 10 recreational) with painful snapping hips and no pain relief after anesthetic magnetic resonance arthrography had an ultrasound evaluation of their iliopsoas tendon and an anesthetic injection into the psoas bursa. In all 15 patients, the injection relieved their hip pain, and in 10 patients, real-time imaging demonstrated snapping of the tendon. All hips were assessed with Byrd's 100-point hip scoring system before the release and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

Preoperative hip scores averaged 41 and 44 points for the competitive and recreational athletes, respectively. After surgery, the 2 groups used crutches for 4 weeks, and had 6-week scores that averaged 87 and 63 points. At 6 months, their scores averaged 94 and 98 points, and at 12 months, 96 and 97 points, and none had recurrence of their snapping or pain. All 15 athletes returned to full participation in their sport at an average of 9 months after surgery.

CONCLUSION

A return to college, high school, and recreational sports can be expected after an arthroscopic release of the iliopsoas tendon.