Internal Snapping Research Articles

The role ofiliopsoas fractional lengthening inhip arthroscopy: a systematic review.

Arthroscopic iliopsoas fractional lengthening (IFL) is a surgical option for the treatment of internal snapping hip syndrome (ISHS) after failing conservative management. Systematic review. A search of PubMed central, National Library of Medicine (MEDLINE) and Scopus databases were performed by two individuals from the date of inception to April 2023. Inclusion criteria were ISHS treated with arthroscopy. Sample size, patient-reported outcomes and complications were recorded for 24 selected papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and registered on PROSPERO database for systematic reviews (CRD42023427466). Thirteen retrospective case series, ten retrospective comparative studies, and one randomized control trial from 2005 to 2022 were reported on 1021 patients who received an iliopsoas fractional lengthening. The extracted data included patient satisfaction, visual analogue scale, the modified Harris hip score and additional outcome measures. All 24 papers reported statistically significant improvements in post-operative patient-reported outcome measures after primary hip arthroscopy and iliopsoas fractional lengthening. However, none of the comparative studies found a statistical benefit in performing IFL. Existing studies lack conclusive evidence on the benefits of Iliopsoas Fractional Lengthening (IFL), especially for competitive athletes, individuals with Femoroacetabular Impingement (FAI), and borderline hip dysplasia. Some research suggests IFL may be a safe addition to hip arthroscopy for Internal Snapping Hip Syndrome, but more comprehensive investigations are needed. Future studies should distinguish between concurrent procedures and develop methods to determine if the psoas muscle is the source of pain, instead of solely attributing it to the joint.

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.

Competitive Athletes with Femoroacetabular Impingement and Painful Internal Snapping Treated Arthroscopically with Intrabursal Iliopsoas Fractional Lengthening: High Rate of Return to Sport and Favorable Midterm Functional Outcomes

Background: Athletes with femoroacetabular impingement syndrome (FAIS) who undergo hip arthroscopy with iliopsoas fractional lengthening (IFL) in the context of painful internal snapping have demonstrated favorable patient–reported outcomes (PROs), return to sport (RTS), and resolution of internal snapping symptoms at short term follow–up. Midterm outcomes have not been established. Purposes: (1) To report minimum 5–year PROs and RTS rate in competitive athletes who underwent primary hip arthroscopy for FAIS and intra–bursal IFL for painful internal snapping and (2) to compare these clinical results with those of a propensity score–matched control group of competitive athletes who underwent primary hip arthroscopy without painful internal snapping and IFL. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reviewed for consecutive surgeries performed by a single surgeon between February 2010 and December 2013. Patients were considered eligible if they were professional, collegiate, or high school athletes and received a primary hip arthroscopy for FAIS and intra–bursal IFL without extended capsulotomy for painful internal snapping. Indications for IFL were painful internal snapping on preoperative physical examination. Inclusion criteria were preoperative and minimum 5–year follow–up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sport Specific Subscale, and visual analog scale for pain. Rates of achieving the minimal clinically important difference were also reported. For comparison, athletes in the IFL group were propensity matched by age, sex, body mass index, lateral and anterior center–edge angles, and sports level to a control group of athletes without internal snapping who underwent primary hip arthroscopy for FAIS without IFL. Results: A total of 105 competitive athletes in the IFL group were included in the study with a follow–up of 66.8 ± 6.9 months (mean ± SD). The IFL cohort showed significant improvement in all recorded PROs at minimum 5–year follow–up (P < .001). Furthermore, they demonstrated favorable rates of achieving the minimal clinically important difference for the modified Harris Hip Score (82.0%), Nonarthritic Hip Score (85.4%), and Hip Outcome Score–Sport Specific Subscale (82.8%). Further, 89.5% of athletes in the IFL cohort successfully returned to sport. A total of 42 athletes in the IFL group were propensity matched to 54 control athletes. When groups were compared, they demonstrated similar improvement in PROs and rates of RTS, revision arthroscopy, and achieving psychometric thresholds. Conclusion: Competitive athletes undergoing primary hip arthroscopy and intra–bursal IFL in the context of FAIS and painful internal snapping demonstrated favorable PROs and RTS rate at minimum 5–year follow–up. These results were comparable with those of a control group of athletes not requiring IFL.

One Bony Morphology, Two Pathologic Entities: Sex-Based Differences in Patients With Borderline Hip Dysplasia Undergoing Hip Arthroscopy

Background: Sex-based differences have been largely uncharacterized for patients with borderline hip dysplasia (BHD) undergoing hip arthroscopy. Purpose: To evaluate for sex-based differences in clinical and pathologic characteristics as well as surgical outcomes in patients with BHD undergoing hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Between January 2011 and December 2018, data were prospectively collected on all patients with BHD undergoing primary hip arthroscopy. Patients were included if they had preoperative and minimum 2-year postoperative scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain. Patients with previous ipsilateral hip conditions or surgery, Tönnis grade >1, lateral center-edge angle <18° or >25°, or workers’ compensation status were excluded. Patients were then divided by sex and propensity score matched in a 1:1 ratio for body mass index, age, and Tönnis grade. The rates of patients who achieved the minimal clinically important difference were recorded for the mHHS and NAHS. The rates of achieving the patient acceptable symptomatic state for the mHHS were calculated. Results: A total of 344 hips met the inclusion criteria, and 317 hips (92%) had adequate follow-up. Propensity score matching created cohorts of 109 male and 109 female patients. Male patients had significantly higher preoperative average alpha angles (69.79° vs 58.17°, P < .001), more often requiring a femoroplasty (97.2% vs 83.5%, P < .001), and had higher rates of complex labral tearing (50.5% vs 33.0%, P < .001). Male patients also had higher rates of grade 3 and 4 acetabular labral articular disruption (62.4% vs 19.3%, P < .001) and higher rates of grade 3 and 4 acetabular cartilage injury (59.6% vs 20.2%, P < .001) requiring a microfracture more frequently (32.1% vs 7.3%, P < .001). Female patients more typically had painful internal snapping requiring iliopsoas fractional lengthening (60.6% vs 32.1%, P < .001). Female patients also underwent capsular plication more regularly to address hip instability (79.8% vs 45.9%, P < .001). Male and female patients showed significant improvements in all outcome scores after surgery (P < .001). Female patients achieved the minimal clinically important difference for the NAHS at higher rates (85.3% vs 71.6%, P = .020). Conclusion: Female and male patients with BHD who underwent hip arthroscopy achieved favorable outcomes but had notably dissimilar pathology. Hence, although they share similar acetabular bony morphology, male and female patients with BHD may represent 2 very different pathologic entities.

Multiple iliopsoas tendons: a cadaveric study and treatment implications for internal snapping hip syndrome

PurposeThis cadaveric study aimed at describing the anatomical variations of the iliopsoas complex.MethodsThe iliopsoas complex was dissected unilaterally in 28 formalin-embalmed cadavers—13 males and 15 females with a mean age of 85.6 years. The number, courses and widths of the iliacus and psoas major tendons were determined. Patients with previous hip surgery were excluded. The following measurements were taken from the mid-inguinal point: the distance to the point of union of the psoas major and iliacus tendon; and the distance to the most distal insertion of iliopsoas.ResultsThe presence of single, double and triple tendon insertions of iliopsoas were found in 12, 12 and 4 of the 28 specimens, respectively. When present, double and triple tendons inserted separately onto the lesser trochanter. The average length of the iliopsoas tendon from the mid-inguinal point to the most distal attachment at the lesser trochanter was 122.3 ± 13.0 mm. The iliacus muscle bulk merged with psoas major at an average distance of 24.9 ± 17.9 mm proximal to the mid-inguinal point. In all cases, the lateral-most fibres of iliacus yielded a non-tendinous, muscular insertion on to the anterior surface of the lesser trochanter and the femoral shaft, rather than joining onto the main iliopsoas tendon(s). The average total width of the psoas major tendon decreased with an increasing number of tendons: 14.6 ± 2.2 mm (single tendon), 8.2 ± 3.0 mm (2 tendons present) and 5.9 ± 1.1 mm (3 tendons present) (P < 0.001).ConclusionsThe results of this study suggest that multiple tendinous insertions of iliopsoas are present as an anatomical variant in more than 50% of the population. The non-tendinous muscular insertion of the iliopsoas on to the anterior surface of the lesser trochanter and femoral shaft found represents a novel anatomical variant not previously described.Level of evidenceLevel V

Borderline Dysplastic Female Patients With Painful Internal Snapping Improve Clinical Outcomes At Minimum 2-Year Follow-Up Following Hip Arthroscopy With Femoroplasty, Labral Repair, Iliopsoas Fractional Lengthening, and Capsular Plication: A Propensity-Matched Controlled Comparison

To report minimum 2-year follow-up patient-reported outcome scores (PROs) in borderline dysplastic female patients who underwent primary hip arthroscopy with femoroplasty, labral repair, iliopsoas fractional lengthening, and plication of the capsule (FLIP procedure) for cam-type femoroacetabular impingement syndrome (FAIS), labral tear, and painful internal snapping and to compare these PROs to a propensity-matched borderline dysplastic control group without painful internal snapping. Data were retrospectively reviewed for patients who underwent primary hip arthroscopy for cam-type FAIS and labral tear between September 2008 and May 2017. Females with borderline dysplasia (lateral center-edge angle of ≥18° to ≤25°) and painful internal snapping, who underwent the FLIP procedure, with minimum 2-year PROs for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports-Specific Subscale, patient satisfaction, and visual analog scale (VAS) for pain were included. The group was matched 1:1 to a control group without painful internal snapping for age, sex, body-mass index (BMI), and surgical procedures. The minimal clinically important difference (MCID) was calculated. P-value was set at .05. Seventy-four hips were included. The mean was 26.82 ± 10.49 years and 23.62 ± 4.56 kg/m2 for age and BMI, respectively. Improvement was reported for all PROs and VAS (P < .0001). Twenty-nine patients were matched. At minimum 2-year follow-up, the FLIP procedure demonstrated comparable improvement in PROs and rate of achievement of MCID to the control group. After primary hip arthroscopy and FLIP procedure, females with borderline dysplasia and painful internal snapping demonstrated significant improvement in PROs at minimum 2 years' follow-up. When compared to a propensity-matched control group without painful internal snapping, the improvement between groups was comparable. III; Case-Control study.

Iliopsoas Pathology: Game-changing Findings from a Large Hip Arthroscopy Study Group

Report the prevalence, associated findings, rendered arthroscopic surgical procedures, and outcomes of hips with iliopsoas-related pathology. Enrolled patients that underwent isolated hip arthroscopy that reached 2-year minimum PRO follow-up were assigned to Iliopsoas group, defined as pre-operative diagnosis of iliopsoas tendonitis, internal snapping hip symptoms, history of psoas injection, and/or intra-operative anteroinferior labral bruising or tear or the control group. The prevalence of iliopsoas-related pathology, radiographic and intra-operative findings, and rendered procedures between study and control groups were compared using Chi square analysis. Minimum 2-year outcomes were compared using analysis of variance (a priori alpha set at 0.05). 629 patients met the inclusion criteria of which 69 patients (11%) comprised the iliopsoas group and 560 patients (89%), the control group. Iliopsoas tenotomy was performed in 5 patients, all via the transcapsular approach. Demographics did not differ between groups (p>0.05). There was no significant difference in the prevalence of cam deformity, global pincer deformity, or dysplasia between cohorts but there was a lower incidence of focal pincer impingement among patients with iliopsoas involvement (22 % vs 37%,p=0.001). Labral repair and debridement was more commonly performed in the group of patients without iliopsoas involvement and relatively more labral reconstructions in the iliopsoas group (p<0.05). Post-operative iHOT-12 scores similarly improved to 70.2 (SD:26.7) for the iliopsoas group and 73.0 (SD:25.1) for the control group (p=0.68). Post-operative pain scores similarly reduced to 21.9 (SD 23.0) for the iliopsoas group and 20.2 (SD: 22) for the control group (p=0.74). The most significant finding from this large multicenter study is the extremely low incidence of arthroscopic iliopsoas tenotomies despite the not uncommon prevalence of iliopsoas-related pathology. The incidence of iliopsoas tenotomy has significantly decreased in patients undergoing hip arthroscopy and the presence of iliopsoas–related pathology even untreated with tenotomy is not a predictor of poorer outcomes.

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.

Iliopsoas pathology, treatment, and outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement: Findings from the [redacted] study group

Paste abstract here and remove the remaining text. *For structured abstracts, begin each section under a separate, bolded subheading. Suggested subheadings are belowObjectives:The iliopsoas is a major hip flexor that provides anterior hip stability. Recent studies report significant compromise to these important functions with iliopsoas tenotomy. The purpose of this study is to report the prevalence, associated findings, rendered procedures, and outcomes of hips with iliopsoas involvement undergoing hip arthroscopy for FAI and/or chondrolabral pathology. The hypothesis is that there is a decrease in the incidence of tenotomy compared with historic controls and that tenotomy compromises patient-reported outcomes.Methods:Level of evidence 3 controlled study with prospectively-collected multicenter database from 7 centers. Enrolled patients that underwent isolated hip arthroscopy that reached 2-year minimum follow-up with iHOT-12 were assigned to Iliopsoas group defined as pre-operative diagnosis of iliopsoas tendonitis, internal snapping symptoms, intra-operative anteroinferior labral pathology (below 3 O’clock location) and/or preoperative psoas injection or the control group. The prevalence of iliopsoas pathology, radiographic and intra-operative findings, and rendered procedures between groups were compared using Chi square analysis. Minimum 2-year outcomes of Iliopsoas group versus control group were compared using analysis of variance (a priori alpha set at 0.05). Subanalysis within the Iliopsoas group was performed of patients with versus without tenotomy.Results:There were 97 study group subjects and 1053 control group subjects. There was no statistical difference in demographics between the groups (p>0.05) nor was there a difference in length of preoperative symptom duration (p=0.51). There were no significant differences in the incidence of cam impingement, pincer impingement or dysplasia between cohorts, nor were there significant differences between radiographic measures. There was a similar incidence of femoroplasty, acetabuloplasty, chondroplasty, microfracture, and synovectomy (p>0.05) regardless of iliopsoas involvement. There was not a significant effect on the surgical treatment of the labrum based on psoas involvement (p>0.16). Labral repair was performed in 55% of patients with iliopsoas involvement and 62% of patients without iliopsoas involvement. Although there was not a significant difference in capsular closure between cohorts (96% vs 93%, p=0.121), the overwhelming majority of patients with psoas involvement received capsular repair (87%) or plication (9%). Pre-operative iHOT-12 scores were similar 34 (SD: 18) for the iliopsoas group and 35 (SD 18) for the control group groups (p=0.51). Post-operative iHOT-12 scores improved to 72 for both the groups. The iliopsoas group achieved MCID, SCB, and PASS scores established for the iHOT-12 of 83%, 62%, and 58% which were similar to the control group. Ten subjects (10%) in the iliopsoas group received iliopsoas tenotomy. Subjects with tenotomy had lower 2-year post-op iHOT-12 scores compared to the non-tenotomy subgroup (55 vs 72, respectively; p=0.03) . This corresponded with lower achievement of MCID scores (60% vs 86%; p=0.03) and SCB scores (30% vs 70%, p=0.01) of patients with tenotomy compared to those without tenotomy.Conclusion:Iliopsoas tenotomy is rarely performed relative to its prevalence in patients undergoing hip arthroscopy by high volume surgeons for FAI and/or chondrolabral pathology. Surgical outcomes are not worsened with iliopsoas involvement but are worsened with tenotomy.

How has arthroscopic management of the iliopsoas evolved, and why? A survey of high-volume arthroscopic hip surgeons.

The rapid growth of hip preservation has left surgeons following trends based on limited, or even anecdotal, evidence in certain circumstances. A consensus as well as high-level research on how best to manage the iliopsoas is lacking. Arthroscopic treatment of the iliopsoas may be an example of how treatment patterns and trends can shift with limited evidence-based medicine. A cross-sectional survey of 16 high-volume hip preservation surgeons was conducted to gather perspectives and opinions on how and why the arthroscopic management of the iliopsoas has evolved. All participants completed the survey in person and anonymously. Of the surveyed surgeons, the mean career hip preservation volume was 1031.25 cases (250 to >3000) with an average annual volume of 162.08 cases (75–400). Of the surveyed surgeons’ caseload, 16.1% involved an iliopsoas tenotomy or fractional lengthening mostly commonly (75%) for recalcitrant internal snapping. Labral repair/reconstruction is performed concomitantly 87.5% of the time. Seventy-five percent of surgeons indicated a decrease in frequency of iliopsoas tenotomy over the course of their practice most commonly (56.3%) because of hip flexion weakness; however, 0% of the surgeons could cite literature evidence to support their practices. Perceived poor outcomes in individual practices was the most common (56.3%) source of this complication. Surgeons were less inclined to perform tenotomy on patients with borderline dysplasia (75%) or ligamentous laxity (56.3%).

The Femoral Head "Divot" Sign: A Useful Arthroscopic Sign of Hip Microinstability.

Background:A femoral head “divot” is a rare finding during hip arthroscopy. A linear chondral indentation can be observed on the femoral head, just lateral and parallel to the acetabular labrum.Purpose/Hypothesis:The purpose of this study was to describe a novel arthroscopic sign and retrospectively review patients with this finding. We hypothesized that this sign would be found in patients with characteristics consistent with hip microinstability.Study Design:Case series; Level of evidence, 4.Methods:Intraoperative images of patients undergoing primary hip arthroscopy between July 2017 and July 2019 were reviewed for evidence of a femoral head divot. Preoperative characteristics, physical examination findings, radiographic measurements, and magnetic resonance imaging (MRI) findings were described.Results:Of 690 available cases, 14 cases (13 patients; 2.0%) had evidence of a femoral head divot. The mean patient age was 29.1 years, and all but 1 patient (92.3%) were female. Ligamentous laxity was present in 81.8% of patients, anterior apprehension test was positive in 78.6%, and painful internal snapping was present in 50.0%. The mean lateral center-edge angle, anterior center-edge angle, and Tönnis angle were 19.2°, 20.3°, and 12.4°, respectively. The divot was identified in 5 of 12 available MRI scans, most commonly on axial proton density sequence. Intraoperatively, all hips had labral tears, iliopsoas bursitis was demonstrated in 78.6%, and the ligamentum teres was damaged in 42.9%. Labral repair was performed in 12 of the 14 hips, with 2 patients undergoing labral reconstruction. Iliopsoas fractional lengthening was performed in 50.0%, capsular plication was performed in 78.6%, and capsular repair was performed in the remainder.Conclusion:The femoral head divot sign is a rare arthroscopic finding during hip arthroscopy. The results of this study demonstrated that patients who have a divot also present with characteristic radiographic or physical examination findings of hip microinstability due to either acetabular dysplasia or ligamentous laxity. Recognition of a femoral head divot may be valuable for the diagnosis of microinstability during hip arthroscopy and may help guide appropriate management, such as capsular plication. Further studies are needed to determine the exact prevalence of the femoral head divot in patients with microinstability and to evaluate the effect of this finding on patient outcomes.

Mechanics of Psoas Tendon Snapping. A Virtual Population Study

Internal snapping of the psoas tendon is a frequently reported condition, especially in young adolescents involved in sports. It is defined as an increased tendon excursion over bony or soft tissue prominence causing local irritation and inflammation of the tendon leading to groin pain and often is accompanied by an audible snap. Due to the lack of detailed dynamic visualization means, the exact mechanism of the condition remains poorly understood and different theories have been postulated related to the etiology and its location about the hip. In the present study we simulated psoas tendon behavior in a virtual population of 40,000 anatomies and compared tendon movement during combined abduction, flexion and external rotation and back to neutral extension and adduction. At risk phenotyopes for tendon snapping were defined as the morphologies presenting with excess tendon movement. There were little differences in tendon movement between the male and female models. In both populations, abnormal tendon excursion correlated with changes in mainly the femoral anatomy (male r = 0.72, p < 0.001, female r = 0.66, p < 0.001): increased anteversion and valgus as well as a decreasing femoral offset and ischiofemoral distance. The observed combination of shape components correlating with excess tendon movement in essence presented with a medial positioning of the minor trochanter. This finding suggest that psoas snapping and ischiofemoral impingement are possibly two presentations of a similar underlying rotational dysplasia of the femur.

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

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. Systematic review. 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. 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. 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. 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.

Arthroscopy for patients with internal snapping hip and labral tear

Arthroscopy for patients with internal snapping hip and labral tear

Arthroscopie de hanche chez le sportif (hanche articulaire et abarticulaire)

For a long time of exceptional indication, arthroscopy of the hip knows for a decade a real explosion in connection with the dismemberment of new pathologies accessible to the arthroscopic treatment in particular in athletes. Arthroscopy of the hip allows the treatment of intra-articular lesions, in particular labral and cartilaginous lesions, as well as the correction of structural abnormalities, which are sources of femoro-acetabular impingement. More recently, arthroscopic treatment of the borderline forms of hip dysplasia responsible for chondrolabral lesions by microinstability has also been reported with encouraging results. The protective effect of these treatments on the occurrence of osteoarthritis seems to be confirmed although the scientific literature lacks long-term data. The extra-articular pathologies of the athlete's hip (external snapping of the fascia lata on the greater trochanter, internal snapping of the psoas, trochanteric bursitis) have also benefited from the recent advances in endoscopy and are now accessible to this minimally invasive treatment.

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

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. 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. There were 57 eligible cases (80.3% follow-up). Mean follow-up time was 69.3months (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 30.5months. Three hips (5.3%) required total hip arthroplasty at a mean of 57.5months. One case (1.8%) had minor postoperative complications. There were no statistically significant differences between the groups in outcomes, complications, and secondary surgeries. 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 III, retrospective comparative study.

Endoscopic release of internal snapping hip: a review of literature

Endoscopic release of internal snapping hip: a review of literature

Arthroscopic Iliopsoas Fractional Lengthening.

Iliopsoas fractional lengthening (IFL) is performed on patients with symptomatic internal snapping. This condition is defined as painful and sometimes audible snapping of the iliopsoas (IP) tendon over the femoral head or iliopectineal line. Arthroscopic IFL is performed if the snapping is unresponsive to conservative treatment1,2. Hip arthroscopy is performed with the patient in the supine position on a traction table. The portals used to access the joint capsule include standard anterolateral, mid-anterior, and distal anterolateral accessory (DALA) portals3. With a 70° arthroscope, diagnostic arthroscopy is conducted to assess the quality of labral tissue, acetabular and femoral cartilage surfaces, and the ligamentum teres. When indicated, supplementary procedures, such as acetabuloplasty, labral repair, or labral reconstruction4, are performed prior to IFL. With traction still applied, IFL is then performed from the central compartment at the level of the joint line. Exposure of the IP tendon is achieved with the use of a curved blade to extend the capsulotomy medially over the 3 o'clock position (right hip). Once the tendon can be appropriately visualized, a progressive and complete transverse cut is made in the tendinous portion, taking care to avoid the muscular portion. During this process, the anterolateral and mid-anterior portals serve as visualization and working portals, respectively5. Prior to arthroscopic IFL for painful internal snapping, nonsurgical options6,7 may include (1) physical therapy programs, (2) activity modification, (3) nonsteroidal anti-inflammatory drugs (NSAIDs), or (4) ultrasound-guided cortisone injections.

Arthroscopic treatment of internal snapping hip

Introduction:Internal snapping hip syndrome (ISHS) is caused by the iliopsoas tendon snapping over either the iliopectineal ridge or the anterior femoral head. Excellent results are achieved only with activity modification, rest, and stretching the iliopsoas muscle. The literature favors iliopsoas tendon release if conservative therapy fails. There is little evidence about the gold standard of this condition.Objective:Describe clinical results, complicactions and recurrence rate of arthroscopic treatment of ISHS.Methods:We included all patients who failed conservative treatment and were treated with arthroscopy for ISHS between March 2012 and March 2018. Patients with less than 2 years of follow up and previous surgery on the hip were excluded.We performed Ilizariturri´s technique with a transcapsular endoscopic release in central compartment.We registered modified Harris hip score (MHHS), Hip outcome score activity of daily living (EHOSDL), patients satisfaction, recurrence rate and complications.Results:Eight patients were included. Average follow up was 36 months (range 24-60 months). MMHS improved from preoperative average score of 70 (range 62-72) to postoperative average of 93 (range 92 to 96). Average EHOSDL improvement was 30% (from 55% preoperative to 85% postoperative). All patients had excellent results. Average patient satisfaction was 8 (range 7-9). We had no recurrence or complications.Conclusion:Arthroscopic treatment of ISHS allowed us to obtain very good clinical results with no complications or recurrences with a minimum 2 years follow up.

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

To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome. 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. 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 > 140degrees. 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.