Iliopectineal Eminence Research Articles

Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip

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.

Pubic ramus convexity or ballooning: a sentinel sign for severe periacetabular osteolysis in total hip arthroplasty

Osteolysis is a significant long-term problem in hip arthroplasty. Plain radiographs are the routine investigation of choice for monitoring hip arthroplasty patients; however, the recognition of clinically significant osteolysis can be challenging. We present two case reports of arthroplasty patients with ballooning and expansion of the superior pubic ramus with loss of the normal concavity of the ilio-pectineal line. Both patients subsequently displayed massive pubic osteolysis at the time of revision surgery. We suggest that the presence of convexity of the ilio-pectineal line/superior pubic ramus indicates established pelvic osteolysis.

MR Appearance and Clinical Significance of Changes in the Hip Muscles and Iliopsoas Tendon After Arthroscopic Iliopsoas Tenotomy in Symptomatic Patients

Iliopsoas tenotomy is a treatment for snapping hip. Does this surgical procedure change the surrounding muscle and tendon anatomy? This study seeks to evaluate the changes in the MR appearance of the hip muscles and iliopsoas tendon in patients following arthroscopic iliopsoas tenotomy. One hundred sixty-nine consecutive adults were evaluated after iliopsoas tenotomy at the lesser trochanter. Each MR exam was evaluated independently by three radiologists for muscle edema, atrophy (grade 0-4), compensatory hypertrophy, signal within the iliopsoas tendon (increased on T1 or T2 sequences), and iliopsoas tendon morphology (distorted or disrupted) above, at, and below the iliopectineal eminence. A finding was considered positive if reported by two or three of the radiologists. Twenty subjects met the inclusion criteria. Muscle edema was present in 15% (3/20) of subjects within the iliacus, psoas, and quadratus femoris. Atrophy was observed in the following muscles: iliacus 85% (17/20), psoas 75% (15/20), quadratus femoris 10% (2/20), rectus femoris 5% (1/20), vastus lateralis 5% (1/20), and gluteus maximus 25% (5/20). There was no compensatory hypertrophy. Ninety percent (18/20) had increased T1 and 10% (2/20) had increased T2 signal within the iliopsoas tendon. Thirty-five percent (7/20) of the iliopsoas tendons was disrupted and 85% (17/20) was distorted, most commonly below the iliopectineal eminence. The majority of postoperative symptomatic patients has atrophy of the iliacus and psoas muscles and distortion and disruption of the iliopsoas tendon and should be recognized as a normal imaging appearance following iliopsoas tendon release.

English

Psoas minor (PM) muscle belongs to the category of vestigial muscles. It is large in size in all those quadrupeds that brachiate and leap or run at very fast speed. None of these functions being required in bipedal, plantigrade man the muscle has receded during evolution; hence it is present only in 40-60% population. Apart from racial variations, a large number of morphological variations of this muscle have been described in the literature. The present study has been conducted in 20 cadavers. Psoas minor muscle was present bilaterally in 35% cases and unilaterally in 5% cases; overall incidence being 40%. Average length of fleshy belly was 7.85 cm that of tendon was 13.13 cm. Average maximum width of fleshy belly was 1.93 cm, and that of the tendon was 0.77cm. In most of the cases, muscle originated from the sides of bodies of T12 & L1 vertebrae & their intervening intervertebral disc. In few of them, origin extended to the sub diaphragmatic fascia & the medial arcuate ligament (Fig.1a). Tendon of PM flattened out at insertion on iliopectineal line & blended with iliopsoas fascia (Fig.2a, 3a). The expansion of tendon into this fascia might be serving some special functions, hitherto fore unappreciated. We also found Psoas accessorius (PA) muscle which was described for the first time by Joshi et al. (2010) 1 , in 15% cases unilaterally only on the left side. In one case, PA showed a bilamellar arrangement of muscle fibres.

Superior border of the arcuate line: Three dimension reconstruction and digital measurements of the fixation route for pelvic and acetabular fractures

To obtain a series of parameters describing the shape and bone thickness of the fixation route along the superior border of the arcuate line, so as to provide references for pelvic and acetabular surgery and design pelvic anatomic internal fixators. A total of 175 complete pelvic computed tomography (CT) scans of normal adult pelvises were collected. Each person's CT scans were reconstructed to create a three-dimensional pelvic model. A curve of the fixation route was delineated and divided into 11 equal parts. The total length of the curve, the radius of curvature, and the bone thickness at each decile point were all measured. The position of the pelvic inlet, the anterior and posterior sagittal diameter were measured. The radius of curvature at each decile point were 29.18 ± 15.53, 55.27 ± 29.48, 43.04 ± 14.42, 59.62 ± 21.02, 91.67 ± 52.01, 78.9 ± 38.66, 75.76 ± 25.87, 61.75 ± 16.68, 54.62 ± 14.88, and 43.61 ± 19.10mm, respectively. The anterior and posterior sagittal diameter of the pelvic inlet was 66.01 ± 9.15 and 41.36 ± 8.19mm, respectively. For all groups divided by the ratio of the posterior and the anterior sagittal diameter, the decile points 1, 3, and 10 had smaller radii of curvature than the before and after points, respectively. The curve of the fixation route along superior border of arcuate line has a relatively greater bending degree at the pubic tubercle, iliopubic eminence and close to the sacroiliac joint. With the transition of the pelvic inlet shape from android to gynecoid and platypelloid type, the bone surface at the iliopubic eminence becomes flatter. Pelvic and acetabular surgery could be more accurate by referring to the previous key bending points and the change of the pelvic inlet shape.

Screw placement in percutaneous acetabular surgery: gender differences of anatomical landmarks in a cadaveric study

Percutaneous reduction and periarticular screw implantation techniques have been successfully introduced in acetabular surgery. The advantages of this less invasive approach are attenuated by higher risks of screw misplacement. Anatomical landmarks are strongly needed to prevent malplacement. This cadaver study was designed to identify reliable anatomical osseous landmarks in the pelvic region for screw placement in acetabular surgery. Gender differences were specifically addressed. Twenty-seven embalmed cadaveric hemipelvic specimens (13 male, 14 female) were used. After soft-tissue removal, anterior and posterior column acetabular screw placement was conducted by one orthopaedic trauma surgeon under direct vision. Each column was addressed by antegrade and retrograde screw insertion. Radiographic verification of ideal screw placement was followed by assessment of the distance from the different entry points to adjoining anatomical osseous structures. For anterior column screw positioning, the posterior superior iliac spine (PSIS), posterior inferior iliac spine (PIIS), iliopectineal eminence and centre of the symphysis were most reliable regarding gender differences. For posterior column screw positioning, the distance to the anterior superior iliac spine (ASIS) and the ischial tuberosity showed the lowest deviation between the different gender specimens. Highest gender differences were seen in relation to the cranial rim of the superior pubic ramus in retrograde anterior column screw positioning (p = 0.002). Most landmarks could be targeted within a 2.5-cm range in all specimens. The findings emphasise the relevance of osseous landmarks in acetabular surgery. By adhering to easily identifiable structures, screw placement can be safely performed. Significant gender differences must be taken into consideration during preoperative planning.

In-out-in technique for acetabular fractures: is it really good?

Dear Editor, We would like to thank Meena et al. for showing their interest in our article [1]. We believe that the explanations given below should be sufficient respond to their queries. The lateral femoral cutaneous nerve usually passes beneath the inguinal ligament to supply the lateral part of the thigh. During iliofemoral exposure, the skin incision along the anterolateral part of the thigh should be slightly lateral and over the anterior aspect of the tensor muscle belly. This minimises the cutaneous sensory loss by reducing the number of branches of the lateral cutaneous nerve of the thigh which have to be sacrificed for the exposure. The tensor muscle is retracted laterally and the medial sheath of the tensor fascia along with the sartorius attachment on the anterior superior iliac spine is retracted medially protecting the major trunk(s) of the lateral femoral cutaneous nerve [2]. None of our patients had any symptoms of lateral femoral cutaneous nerve injury. Transverse fractures of the acetabulum can be fixed with screws or plates depending on their fracture pattern. Simple transverse fractures without any comminution can be fixed with screws alone. In comminuted fractures, plate fixation is needed for better stability. We have treated all of our patients based on this principle and did not notice loss of reduction in any case. The ‘in-out-in technique’ of anterior column lag screw fixation avoids the middle danger zone of the anterior column. The conventional anterior column lag screw fixation is strictly intraosseous and thus the minimal diameter of the anterior column should be taken into consideration for screw fixation. The reason why Hong et al. [3] and Chen et al. [4] warn orthopaedic surgeons about anterior column lag screw fixation is because of the minimal bone stock of the anterior column at the centre of the hip joint. Our screw fixation technique selectively avoids this narrow path and remains extraosseous. Shiramizu et al. measured the bone stock of the anterior column at different points. They found the thickness of the anterior column (pelvic brim to the margin of the hip joint) to be 14.0 ± 3.6 mm at the centre of the hip joint, compared to 18.5 ± 4.6 mm in the posterior and 17.2 ± 3.5 mm in the anterior half of the hip joint [5]. The final purchase of the lag screw using our technique remains in a thick strut of bone anteriorly. We could safely place two screws of 4.5 mm diameter in some of our cases because of this thicker bone stock at the anterior part of the anterior column. The post-operative rehabilitation protocol was based on the fracture pattern, severity of comminution and other associated injuries. In simple uncomminuted fractures, immediate toe-touch weight-bearing was started the next day and continued for 12 weeks. However, in patients with comminuted fractures and associated pelvis or other musculoskeletal injuries, mobilisation was delayed. Rarely the surgeon has to drill a second time for the screw track while inserting the anterior column lag screw using the in-out-in technique. However, the surgeon must be familiar with the iliofemoral approach before attempting fixation of the screw. Drilling and fixing the screw in the anterior column in our described technique is performed under direct visualisation and the iliopectineal eminence provides the best guide and fulcrum (for the drill) to locate the site of the anterior insertion of the screw. The indications for the proposed screw fixation technique have been clearly described in the article. To achieve a good purchase of fixation, there should not be comminution in the iliopectineal eminence. In comminuted fractures, an additional pelvic brim plate is needed. Fixation of the osteotomised anterosuperior iliac spine to its position is usually performed with two vertically directed 3.5-mm screws. However, in Fig. 5b, only one screw was used because it was fixed from an anterior to posterior direction and was found to be stable. In osteoporotic individuals, the screw purchase may not be adequate alone and additional fixation should be provided with plates, cables or wires.

Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

Comminuted quadrilateral plate fracture with medial displacement is a technically difficult fracture to treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difficulty in obtaining a stable fixation at this area, contribute to the surgical challenge of open reduction and internal fixation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are fixed to the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the infrapectineal reconstruction plate. The standard ilioinguinal approach and modified Stoppa approach have been described for the surgical access to the quadrilateral plate. Both the approaches have some limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive dissection and mobilisation of inguinal neurovascular bundle. The modified Stoppa approach does not permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe the fixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined with a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at right angle to the infrapectineal buttress plate (90°–90° plate construct). The vertical limb of the T-plate is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate. Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.

Acute inguinal pain associated with iliopectineal bursitis in four professional soccer players

Four professional soccer players were investigated for acute or subacute pain in the inguinal region. Clinical tests were negative for an inguinal hernia or adductor tendinitis. Resisted hip flexion caused pain. MRI in these four patients showed the onset of iliopectineal bursitis, with signal abnormalities predominantly at the periphery of the psoas tendon in contact with the iliopectineal eminence. Ultrasound-guided steroid injection allowed the two players injected to continue their sporting activity. The two other players were treated by 3 and 7 days rest and oral anti-inflammatory treatment.

A safe technique of anterior column lag screw fixation in acetabular fractures

Conventional anterior column lag screw fixation in acetabular fracture is a difficult technique that has potential risks of vascular injury, hip joint penetration and excessive radiation exposure. We propose a safe technique of anterior column lag screw fixation (in-out-in technique) and present the outcome. Twenty-seven acetabular fractures were operated through an iliofemoral approach, where the 'in-out-in technique' of lag screw fixation was a part of the surgical procedure. The technique involved insertion of a malleolar screw (4.5 mm) or 6.5 mm partially threaded cancellous screw from the outer side of the iliac wing, 0.5-1 cm posterior and inferior to the anteroinferior iliac spine. The screw comes out of the bone surface to re-enter into the anterior part of iliopectineal eminence, and finally gains purchase in the lateral part of superior pubic ramus. The screw fixation procedure was under direct visualization without resorting to an image intensifier. The average follow-up of the patients was at 18.6 months (range 12-36 months). No loss of reduction, joint penetration or visceral and neurovascular injury were documented. The average duration of surgery was 70 min and blood loss was 290 ml. All fractures were united after an average period of 2.8 months. Excellent to good functional outcome was observed in 24 patients (88 %), on evaluation with Merle D'Aubigne and Postel score at the latest follow-up. We conclude that the 'in-out-in technique' is a safe and effective method of anterior column lag screw fixation in acetabular fractures. It provides rigid stability and minimizes surgical duration, radiation exposure and intra-operative complications.

Les lésions de la jonction myotendineuse du psoas-iliaque en traumatologie du sport

The psoas muscle, the main flexor of the hip joint, is highly solicited in sports activities. Sports injuries are however rarely encountered and described. We report a retrospective series of 33 cases of psoas musculotendinous tears at the point where the muscle changes direction over the iliopectineal eminence. History taking is essential to identify anterior hip pain with rapid or progressive onset. The physical examination searches for pain at hip flexion against resistance, observed in 78% of our cases, and a less sensitive sign, pain at muscle stretching. The morphology should be explored with ultrasound, which is highly contributive in the acute phase. MRI can provide complementary information if the injury is older or recurrent. If there is doubt about the diagnosis, the examination should be able to rule out other hypotheses: traumatic injury to the lower tendons, associated or not with bone detachment, abscess formation, or the more widely encountered psoas hematoma. Early management should focus on puncture aspiration of a hematoma associated with selective rest then rehabilitation over 4 to 6weeks. Chronic and recurrent injuries may require local injections. An analysis of the sports movement should enable a specific management for each sport.

Arthroscopic Iliopsoas Tendon Release in the Treatment of Internal Snapping Hip (SS-44)

Introduction: Internal hip snapping produced by the iliopsoas tendon moving over the iliopectineal eminence or over the femoral head can cause significant pain in the hip joint. The purpose of this study was to examine the outcomes and effectiveness of arthroscopic iliopsoas tendon lengthening as a solution to internal hip snapping. Methods: Data was prospectively collected between 2009-2011 on all patients undergoing arthroscopic iliopsoas lengthening for a diagnosis of painful internal snapping hip. The exclusion criteria were revision surgeries and previous hip conditions such as LCPD, SCFE or AVN. The surgical approach used to lengthen the iliopsoas tendon involved releasing the tendinous portion at the joint level, while leaving the anterior muscular portion intact. Surgical outcome was measured according to the improvement in four hip specific scores (modified Harris Hip Score, NonArthritic Hip Score, and the two Hip Outcome Score subscales: the Sport Specific and the Activities of Daily Living), visual analog pain score (VAS), and satisfaction with surgery on a scale of 0 10. Results: A total of 28 cases met our inclusion/exclusion criteria. At the time of surgery, patient age ranged from 14 to 51, with an average age of 25. At an average follow-up of 15.4 months, 20 of the 28 cases resulted in a complete resolution of hip snapping. On average, patients showed an improvement of more than 19 points in all four hip specific scores. The pain level reduced by 3.2 points on average. All patients but six reported to have ‘good’ to ‘excellent’ (7 to 10 out of 10) level of satisfaction. One report of weakness in flexion was noted two weeks after the tendon lengthening and was found to be resolved at the three month clinical follow-up visit. Conclusion: Arthroscopic fractional lengthening of the iliopsoas tendon at the level of the joint in patients showing pre-operative internal hip snapping resulted in limited recurrence of the snapping post-operatively, no cases of unresolved weakness in flexion, as well as an overall good to excellent satisfaction and clinical improvement. Hip Arthroscopy in the Older patient (SS-45) MICHAEL MULDOON, M.D., PRESENTING AUTHOR CHRISTOPHER R. GOODING M.D. F.R.C.S.(TR&ORTH) GLENNIS MULDOON RICHARD SANTORE, M.D.

Internal fixation for fractures of the acetabular anterior column or pubic rami through minimally invasive ilioinguinal approach

Objective To explore the clinical effect of internal fixation for fractures of the acetabular anterior column or pubic rami through minimally invasive ilioinguinal approach.Methods From June 2008 to June 2011,26 patients were surgically fixed with reconstructive plates through minimally invasive ilioinguinal approach.Sixteen cases were diagnosed as fractures of the acetabular anterior column,and ten as fractures of the pubic rami.The patient was positioned supine or lateral floating.The incision included two parts.The lateral part along the anterior one-third of the iliac crest about 3-5 cm.The insertion of the abdominal muscles and the origin of the iliacus were sharply incised from the crest.By subperiosteal dissection,the iliacus was elevated from the internal iliac fossa as far medially as to expose the anterior inferior iliac spine,iliopubic eminence and acetabular anterior column.The medial part of the incision was from the pubic tubercle transverse lateral extend 2-3 cm.Subperiosteal dissection to expose the superior pubic ramus.Two windows were dissected subperiosteal to connect through a tunnel along the anterior column of the acetabulum and pubic ramus.Fractures were reduced,and reconstruction plates were contoured and placed through the tunnel.Two or three screws were used at each window to fix the fractures.Results According to Matta evaluation system,anatomic reductions of the hip were in 13 cases,good in 11 and fair in 2 cases.Twenty-three patients were followed up from 6 to 30 months (mean,15.6 months).Hip functions were excellent in 13 patients,good in 6,and fair in 4 patients according to the D'Aubigne scores system.Pelvic functional results showed 12 were excellent,9 were good and 2 were fair according to Majeed scores system.No complications such as infection or deep venous thrombosis occurred.Conclusion This modified ilioinguinal approach,with less operation time and low rate of complications,is simple and minimally invasive.It is easy for surgeons to perform plate moulding and could provide firm fixation. Key words: Pelvis; Acetabulum; Fracture fixation, internal; Surgical procedures, minimally invasive

Snapping of the Proximal Hamstring Origin: A Rare Cause of Coxa Saltans

Scillia, Anthony MD1; Choo, Andrew MD1; Milman, Edward MD1; McInerney, Vincent MD1; Festa, Anthony MD1 Author Information

Endoscopic Release of the Iliopsoas Tendon and Iliotibial Band

Indications for endoscopic surgery of the hip have expanded recently. The technique has found a clear indication in the management of snapping hip syndromes, both the external snapping hip and the internal snapping hip. Even though the snapping hips (external and internal) share a common name, they are very different in origin. The external snapping hip is produced by the iliotibial band snapping over the prominence of the greater trochanter during flexion and extension. Indication for surgical treatment is painful snapping with failure of conservative treatment. The endoscopic technique is designed to release the iliotibial band, producing a diamond shape defect on the iliotibial band lateral to the greater trochanter. The defect allows the greater trochanter to move freely without snapping. The greater trochanteric bursa is resected through the defect, and the abductor tendons are inspected. This procedure is performed without traction, and usually only the peritrochanteric space is accessed. If necessary, hip arthroscopy can also be performed. There is limited literature regarding the results of endoscopic treatment for the external snapping hip syndrome, but early reports are encouraging. The internal snapping hip syndrome is produced by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. The snapping phenomenon usually occurs with extension of the hip from a flexed position of more that 90°. Two different endoscopic techniques have been described to treat this condition. The iliopsoas tendon is released at the level of the hip joint; with this technique, the iliopsoas bursa is accessed through an anterior hip capsulotomy and is frequently referred to as a transcapsular release. The second technique is a release at the insertion of the iliopsoas tendon on the lesser trochanter; with this technique, the iliospaos bursa is accessed directly. In every report, the iliopsoas tendon release has been combined with arthroscopy of the hip joint. It has been documented that more than half of the patients with internal snapping hip syndrome have intra-articular hip pathology. The results of endoscopic release of the iliopsoas tendon in the treatment of internal snapping hip syndrome are encouraging and seem to be better than those reported for open procedures.

2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries - a case series

BackgroundScrew fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system.MethodsBetween August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 ± 1.2 month.Results56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 ± 4 minutes, mean fluoroscopy time per screw 123 ± 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure.Conclusion2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.

Endoscopic Treatment of Snapping Hips, Iliotibial Band, and Iliopsoas Tendon

Indications for endoscopic surgery of the hip have expanded recently. The technique has found a clear indication in the management of snapping hip syndromes, both external snapping hip and internal snapping hip. Even though the snapping hips (external and internal) share a common name, they are very different in origin. The external snapping hip is produced by the iliotibial band snapping over the prominence of the greater trochanter during flexion and extension. Indication for surgical treatment is painful snapping with failure of conservative treatment. The endoscopic technique is designed to release the iliotibial band producing a diamond shape defect on the iliotibial band lateral to the greater trochanter. The defect allows the greater trochanter to move freely without snapping. The greater trochanteric bursa is resected through the defect and the abductor tendons inspected. This procedure is performed without traction and usually only the peritrochanteric space is accessed. If necessary, hip arthroscopy can also be performed. There is limited literature regarding the results of endoscopic treatment for the external snapping hip syndrome, but early reports are encouraging. The internal snapping hip syndrome is produced by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. The snapping phenomenon usually occurs with extension of the hip from a flexed position of more than 90 degree. Two different endoscopic techniques have been described to treat this condition. Iliopsoas tendon release at the level of the hip joint, with this technique the iliopsoas bursa is accessed through an anterior hip capsulotomy and is frequently referred to as a transcapsular release. The second technique is a release at the insertion of the iliopsoas tendon on the lesser trochanter, with this technique the iliospaos bursa is accessed directly. In every report the iliopsoas tendon release has been combined with arthroscopy of the hip joint. It has been documented that more than half of the patients with internal snapping hip syndrome have intra-articular hip pathology. The results of endoscopic release of the iliopsoas tendon in the treatment of internal snapping hip syndrome are encouraging and seem to be better than those reported for open procedures.

Morphology of Psoas Minor and Psoas Accessorius

Psoas minor muscle is considered to be a vestigial muscle like palmaris longus and plantaris. It lies anterior to the psoas major muscle. It has a small fleshy belly and a long flat tendon. This small muscle is the representative in man of a relatively large muscle which in most mammals plays an important part of flexing the lumbar part of vertebral column. In some lower mammals it is larger than psoas major and acts as a flexor of pelvis; this being utilized in running by the rabbit and the apes in brachiating. It begins to disappear in those primates which assume the erect posture. The presence of this muscle varies from person to person and on the two sides. It is present in about 40 to 60% of the population. In the majority it is inserted on the iliopubic eminence but may also be attached to the arcuate line of ilium and the iliac fascia. While going through the literature we did not come across any detailed study of the muscle in the population of this region. Hence, we have conducted a detailed study of psoas minor muscle in 30 cadavers bilaterally. In the present series this muscle was absent in 70%. Average length of fleshy belly was 8.23 cm and that of the tendon 15.48 cm. In some cases an unusual interesting feature observed was the origin of some fibers of psoas major from the deep surface of flattened tendon of Psoas minor muscle, which we have named as Psoas accessorius.

Case Report: Calcific Tendinitis of the Rectus Femoris

Internal snapping hip is a syndrome caused by recurrent subluxation of the iliopsoas tendon. There is little agreement regarding the impinging sites responsible for the jerky motion of the tendon. Thus far, the lesser trochanter, anterior capsule, and iliopectineal eminence are considered the most likely catching sites. We report an unusual case in which a calcific tendinitis of the rectus femoris direct head impinged against the overlying iliacus muscle, resulting in a painful coxa saltans. The exclusive involvement of the direct head hid the calcium deposit on standard radiographs, whereas MRI suggested but poorly showed the tendon disease. Dynamic ultrasonography and CT scanning allowed a precise diagnosis and subsequent treatment with CT-guided steroid injection. Calcific tendinitis of the rectus anterior direct head has not been reported as a possible cause of snapping hip; involvement of the direct head in rectus anterior calcific tendinitis was described in one case. Our case shows the rectus anterior direct head may be involved in the etiology of coxa saltans. Theoretically any thickening of the tendon might activate the same pathomechanism. Physicians should consider this possible new cause of internal snapping hip when the most common ones have been excluded, especially as it may be managed easily with steroid injection.

Low back pain associated with internal snapping hip syndrome in a competitive cyclist

Low back pain is a common complaint among cyclists. Here we present the case of a competitive master cyclist with low back pain and whose symptoms ultimately resolved when he...