External snapping hip: a systematic review of outcomes following surgical intervention: External snapping hip systematic review

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.

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique

PURPOSE

External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique.

METHODS

An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated.

RESULTS

The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€).

CONCLUSION

This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.

The effect of iliotibial band surgery at the hip: a systematic review

BACKGROUND

Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases.

PURPOSE

The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery.

METHODS

The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed.

RESULTS

A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery.

CONCLUSION

ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

Endoscopic Treatment of Recurred External Snapping Hip After Endoscopic Iliotibial Band Release

External snapping hip is caused by snapping of the thickening of the posterior portion of the iliotibial band or the anterior border of the gluteus maximus over the greater trochanter. Surgery is considered for patients who are refractory to conservative treatment. The endoscopic release of the iliotibial band or the endoscopic release of the femoral insertion of the gluteus maximus tendon is the most popular technique. There is a recurrence rate of 7-29% after endoscopic surgery. Although recurrence is often painless, revision surgery may be indicated for symptomatic recurrence. In this Technical Note, the technical details of endoscopic treatment of recurred external snapping hip after endoscopic iliotibial band release. The key to success is adequate release of the iliotibial band, gluteus maximus tendon, and the fibrosis underneath the iliotibial band.

External snapping hip: classification based on magnetic resonance imaging features and clinical correlation

BACKGROUND

With the increasing sport population, the number of patients with external snapping hip (ESH) has also increased. To detect and visualise pathological soft tissue changes, magnetic resonance imaging (MRI) has been 1 of the most useful modalities. However, only limited studies have investigated MRI and its clinical value in the treatment of ESH in the past.

MATERIALS AND METHODS

Between May 2017 and November 2018, 104 patients were diagnosed with ESH at our institution. We excluded patients who did not undergo an MRI (n = 11), had complaint of bilateral symptom (n = 17), were not diagnosed hip problems previously (n = 2), and were lost-follow-up within 6 months (n = 19). After applying the exclusion criteria, 55 patients remained. We classified the patients into 2 groups according-MRI findings: tensed iliotibial band (ITB) and hypertrophied gluteus maximus (GM). We investigated the clinical findings, such as mean age, symptom duration, pain score, grading based on symptom severity, and other radiological findings such as soft tissue signal change and ITB thickness. The variables were compared between the groups.

RESULTS

Between the 2 groups defined by MRI findings, the group characterised by tense ITB showed a relatively short symptom duration than the hypertrophied GM group (p < 0.001). No significant differences in the other variables were found between the groups.

CONCLUSIONS

ESH has 2 types of MRI features. Compared with the hypertrophied GM group, the tense ITB group showed a shorter symptom duration and a more reversible status.

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.

Ultrasound-Guided Percutaneous Iliotibial Band Release for External Coxa Saltans: A Cadaveric Study

The surgical treatment of external coxa saltans is not standardized. Many techniques for iliotibial release have been described, both open and arthroscopic. No technique describes ultrasound release. In this cadaveric study, we describe a minimally invasive technique for percutaneous iliotibial release with ultrasound guidance, designed to be performed under local anesthesia. The future objective would be to perform an active intraoperative test of the snapping hip to confirm adequate release, thus reducing the risk of recurrence.

External snapping hip syndrome is associated with an increased femoral offset

Background

External snapping hip syndrome (ESH) is postulated to be one of the causes of greater trochanteric pain syndrome, which also includes greater trochanteric bursitis and tendinopathy or tears of the hip abductor mechanism. However, it was not yet described what kind of bony morphology can cause the snapping and whether symptomatic and asymptomatic individuals have different imaging features.

Purpose

It was the purpose of this study to look for predisposing morphological factors for ESH and to differentiate between painful and asymptomatic snapping.

Methods

A consecutive cohort with ESH and available magnetic resonance imaging (MRI) between 2014 and 2019 was identified. The control group consisted of patients that underwent corrective osteotomies around the knee for mechanical axis correction and never complained of hip symptoms nor had undergone previous hip procedures. The following parameters were blindly assessed for determination of risk factors for ESH: CCD (corpus collum diaphysis) angle; femoral and global offset; femoral antetorsion; functional femoral antetorsion; translation of the greater trochanter (GT); posterior tilt of the GT; pelvic width/anterior pelvic length; intertrochanteric width. Hip and pelvic offset indexes were calculated as ratios of femoral/global offset and intertrochanteric/pelvic width, respectively. For the comparison of symptomatic and asymptomatic snapping, the following soft-tissue signs were investigated: presence of trochanteric bursitis or gluteal tendinopathy; presence of surface bony irregularities on trochanter major and ITB (Iliotibial band) thickness.

Results

A total of 31 hips with ESH were identified. The control group (n = 29) consisted of patients matched on both age (± 1) and gender. Multiple regression analysis determined an increased hip offset index to be independent predictor of ESH (r =  + 0.283, p = 0.025), most likely due to the higher femoral offset in the ESH group (p = 0.031). Pearson correlation analysis could not identify any significant secondary factors. No differences were found between painful and asymptomatic snapping on MRI.

Conclusions

A high hip offset index was found as an independent predictor for external snapping hip in our cohort, mainly due to increased femoral offset. No imaging soft-tissue related differences could be outlined between symptomatic and asymptomatic external snapping.

Level of evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00590.

Mid- to long-term clinical outcomes of arthroscopic surgery for external snapping hip syndrome

This study evaluated the outcomes of arthroscopic surgery for the treatment of external snapping hip at 2- to 10-year follow-ups. Eighteen patients with refractory external snapping hip treated by arthroscopic surgery were enrolled in this prospective study. All patients underwent unsuccessful conservative treatment for more than 3 months before surgery. We made diamond-shaped defects on the iliotibial band and resected peripheral fibrosis tissues for iliotibial band release with an arthroscopic approach. The visual analog scale (VAS), modified Harris hip score and return to previous level of activity were evaluated as functional outcomes. In addition, residual discomfort or the presentation of complications was also investigated. The average follow up period was 7 years. The modified Harris hip score increased from 70.08 preoperatively to 93.14 postoperatively, and the VAS score decreased from 3.67 preoperatively to 1.17 2 weeks after the operation and declined to 0.33 at the last follow-up. Neither recurrence of snaps nor complications were recorded. Two patients complained of a tight sensation with tenderness after exertion. Our clinical outcomes were compatible with those of previous studies, and no long-term complications were noted, even with a relatively longer follow-up period than what was reported in previous studies. Arthroscopic surgery is a safe and effective treatment that can provide promising long-term clinical outcomes for patients with refractory external snapping hip.

Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with External Snapping Hip: A Comparison Study of Matched Case Series

OBJECTIVE

To determine the effectiveness of hip arthroscopy combined with endoscopic iliotibial band (ITB) release in patients with both femoroacetabular impingement (FAI) syndrome and external snapping hip (ESH).

METHODS

Retrospectively review the preoperative and minimum of 2-year follow-up data of patients with both FAI syndrome and ESH who underwent endoscopic ITB release during hip arthroscopy (FAI + ESH group) from January 2014 to December 2018. The same number of age- and gender-matched FAI syndrome patients without ESH undergoing hip arthroscopy were enrolled in the control group (FAI group). Patient-reported outcomes (PROs) including international Hip Outcome Tool (iHOT-33), modified Harris Hip Score (mHHS), visual analog scale for pain (VAS-pain), and abductive force of affected hip at 3 month and 2 years postoperatively were comparatively analyzed. The VAS-satisfaction score of two groups at 2 years postoperatively were also analyzed.

RESULTS

The prevalence of ESH in FAI syndrome patients undergoing hip arthroscopy in our institution was 5.5% (39 of 715 hips), including nine males (10 hips) and 29 females (29 hips). The mean age at the time of surgery was 32.1 ± 6.9 years (range, 22-48 years). According to inclusion and exclusion criteria, 23 patients were enrolled in FAI + ITB group. Twenty-three age- and sex-matched FAI syndrome patients were enrolled in FAI group. At 24 months postoperatively, no patient still suffered ESH symptoms and painful palpation at lateral region in FAI + ITB group. The iHOT-33, mHHS, and VAS-pain score of patients in FAI + ESH group were significantly severer than patients in FAI group preoperatively (41.6 ± 7.5 vs 48.8 ± 7.2, 54.8 ± 7.2 vs 59.2 ± 6.9, 5.5 ± 0.9 vs 4.7 ± 1.0; P < 0.05), while there was no significant difference in these scores between the patients in FAI + ESH group and FAI group at 3-month and 24-month follow-up (73.6 ± 8.5 vs 76.1 ± 6.9, 85.3 ± 7.8 vs 84.2 ± 6.6, 0.8 ± 0.9 vs 0.6 ± 0.9; P > 0.05). At 3 months after surgery, the abductive force of operated hip was significantly smaller than that in FAI group (82.4 ± 12.4 N vs 91.9 ± 16.1 N, P < 0.05), whereas there was no significant difference at 24 months after surgery (101.6 ± 14.9 N vs 106.5 ± 13.7 N, P > 0.05). The VAS-satisfaction scores of patients in the two groups were at a similarly high level (90.5 ± 6.8 vs 88.8 ± 7.3, P > 0.05). There was no complication and no arthroscopic revision in either group until 2-year follow-up.

CONCLUSION

Although abductive force recovery of the hip was delayed, hip arthroscopy combined with endoscopic ITB release addressed hip snapping in patients with both FAI syndrome and ESH, and could get similar functional improvement, pain relief, recovery speed, as well as patient satisfaction compared with the pure hip arthroscopy in FAI syndrome patients without ESH.

Endoscopic Iliotibial Band Release During Hip Arthroscopy for Femoroacetabular Impingement Syndrome and External Snapping Hip Had Better Patient-Reported Outcomes: A Retrospective Comparative Study

PURPOSE

To compare patient-reported outcomes (PROs) in patients with femoroacetabular impingement (FAI) syndrome and external snapping hip (ESH) treated with hip arthroscopy with or without endoscopic iliotibial band (ITB) release.

METHODS

Retrospective review case series with both FAI syndrome and ESH who underwent surgical treatment under same indications. According to the primary operation that was determined by patients themselves, the patients undergoing ITB release during hip arthroscopy for FAI syndrome were enrolled in the ITB-R group, and patients undergoing hip arthroscopy without ITB release were enrolled in non-ITB-R group. Patients with dysplasia, severe osteoarthritis, revision, and bilateral surgery were excluded. PROs including international Hip Outcome Tool (iHOT-33), modified Harris Hip Score (mHHS), visual analog scale for pain (VAS-pain) and VAS-satisfaction, and the rates of achieving minimal clinically important difference, patient acceptable symptomatic state (PASS), and substantial clinical benefit for the PROs at 2 years operatively were comparative analyzed.

RESULTS

The prevalence of ESH in patients with FAI syndrome who underwent hip arthroscopy in our institution was 4.9% (30 of 612 hips). The mean age at the time of surgery was 33.1 ± 6.9 years (range 22-48 years). After exclusion, 16 patients (16 hips) were enrolled into ITB-R group and 11 patients (11 hips) enrolled into non-ITB-R group. PROs including iHOT-33, mHHS, VAS-pain, and VAS-satisfaction in patients in ITB-R group were better than that in non-ITB-R group at 2 years postoperatively (P = .013, .016, .002, and .005, respectively). The rates of achieving PASS for mHHS, PASS for VAS-pain, and substantial clinical benefit for iHOT-33 of patients in ITB-R group were significantly better than that in non-ITB-R group (P = .009, .006, and .027, respectively).

CONCLUSIONS

Patients with both FAI syndrome and ESH undergoing ITB release during hip arthroscopy had better PROs than those undergoing hip arthroscopy without ITB release.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Hip Abductor and Peritrochanteric Space Conditions

The hip trochanteric bursa, tendinous insertions of the gluteal muscles, and the origin vastus lateralis make up the main structures of the peritrochanteric space. Greater trochanteric pain syndrome (GTPS) refers to pain generated by one or multiple disorders of the peritrochanteric space, such as trochanteric bursitis, gluteus medius and minimus tendinopathy or tear, and disorders of the proximal iliotibial band. Patients with GTPS might present with associated intra-articular hip pathology, which requires further investigation and appropriate management. Successful midterm outcomes have been reported in patients undergoing surgical treatment of GTPS using an open or endoscopic approach.

Surgical interventions for external snapping hip syndrome

PURPOSE

Snapping hip is a common clinical condition, characterized by an audible or palpable snap of the hip joint. When the snap is perceived at the lateral side of the hip, this condition is known as external snapping hip or lateral coxa saltans, which is usually asymptomatic. Snapping hip syndrome (SHS) refers to a painful snap, which is more common in athletes who require increased hip range of motion. The aim of this article is to review the most common endoscopic techniques for the treatment of ESHS, as well as their results and limitations.

METHODS

This is a review of the current literature of endoscopic surgical procedures and of the results of the treatment of external snapping hip syndrome.

RESULTS

The pathogenesis of SHS is mechanical. The initial treatment attempt is conservative, and usually provides good results. Patients who do not respond to conservative management are candidate for surgery. The endoscopic release of the ilio-tibial band or the endoscopic release of the femoral insertion of the gluteus maximum tendon is the most popular technique.

CONCLUSION

Endoscopic techniques provide fewer complications compared to open surgery, a lower recurrence rate and good clinical outcomes. More comparative studies with a longer follow-up are required to adequate evaluate the full role of endoscopic techniques in periarticular hip surgery.

LEVEL OF EVIDENCE

Level V.

Is progressive resistance training feasible in patients with symptomatic external snapping hip?

BACKGROUND

Little is known about the feasibility of applying progressive resistance training (PRT) to patients with symptomatic external snapping hip (SESH).

PURPOSE

To investigate whether PRT is feasible in patients with SESH and to report changes to hip function, awareness of the hip joint and muscle strength following PRT.

METHODS

Feasibility was measured by drop-out rate, adverse events, pain exacerbation (VAS) and adherence to PRT. At baseline and the end of treatment, patients completed the Copenhagen Hip and Groin Outcome Score (HAGOS), the Forgotten Joint Score (FJS), maximal voluntary isometric (MVC) and dynamic hip muscle strength and a loaded stair test (LST).

RESULTS

Three out of nine included female patients (33%) dropped out. Pain scores were acceptable (VAS ≤ 50 mm) in 76% of all training sessions, and an overall decrease in pain during PRT was found (-10 mm, 95% CI [-3; -18]). For those who completed the intervention, training adherence was 97 ± 4%. Paired analyzes showed improvements in all HAGOS subscales, FJS, muscle strength and the LST.

CONCLUSION

Progressive resistance training seems feasible in a subset of patients with SESH despite a high drop-out rate. The present study suggests large effect sizes for hip pain, function, awareness and muscle strength.