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SPORTS HIP SURGERY


Hip arthroscopy is a newly emerging technique for diagnosing and treating hip problems which were not diagnosed until few years ago. Most people would be familiar with knee arthroscopy (key hole surgery) and is quite a common procedure done for treating knee problems like cartilage tear, ligament injuries etc., Knee arthroscopy is also relatively straightforward.

However, hip arthroscopy is a more specialized procedure and is less commonly done than a knee arthroscopy. It is also more difficult procedure than a knee arthroscopy (as it is much deeper than the knee joint) and only very few orthopaedic surgeons are trained in performing hip arthroscopy. As it is a relatively new procedure, the use of hip arthroscopy in diagnosing and treating hip problems is still evolving.

The procedure is usually done under general anaesthetic and often combined with a mini-open procedure depending on the condition being treated. The hip joint is distracted by a special traction table to introduce the camera into the hip joint.

Hip arthroscopy is used to treat various conditions of the hip joint as follows:

Labral tear: It is being increasingly recognized that groin pain and mechanical symptoms of the hip like painful clicking could be due to labral tear. This could be either trimmed or repaired depending on the pathology.

Hip impingement:

Femoroacetabular impingement (FAI) is also a recently recognised condition producing hip symptoms in young adults. This is essentially due to clearance problem between the ball and the cup of the hip joint. This condition is also now considered to lead to hip arthritis in young adults. The abnormal bumps of the bone could be either treated by arthroscopy are with in combination with a mini-open procedure.  

Loose bodies:

Very rarely loose bodies in the hip joint can lead to mechanical symptoms like locking or giving away and could be removed using hip arthroscopy.

Infection:

Acute infections of the hip joint could be treated by arthroscopic washout instead of a open procedure.

Biopsy:

Occasionally a sample of tissue could be taken from the hip joint for analysis. There are other emerging pathologies like ligamentum teres injury etc., which may be amenable to arthroscopic treatment.

Peri-trochanteric probelms:

Trochanteric bursitis is a common condition which is usually treated with steroid injections. However, it is now being recognized that in some cases, there may be a tear of the abductor muscles (similar to the rotator cuff tear in the shoulders). Arthroscopy can be used to diagnose and repair the abductor tear although the success rate is not universal.

Iliotibial band snapping syndrome: 

In this condition, the iliotibial band becomes thick and taut. As the hip is flexed and extended, the iliotibial band flips to the front and back of the greater trochanter resulting in a visible snapping. Usually the condition is pain free and the main line of treatment is conservative including physiotherapy. Very rarely if the snapping is painful and does not improve with conservative treatment, surgical treatment could be contemplated. In the past, the surgery involved a relatively big incision to release the tight iliotibial band. However, recent advances allow the release of the iliotibial band to be done through key hole surgery .

Complications:

One of the common complications is some numbness in the thigh or perineal area due to the traction applied. Usually they recover with time but sometimes it may persist. Very rarely, a more serious damage to the nerves or blood vessels can occur. Bleeding, infections etc., are very rare. Other complications like new bone formation, stiffness, femoral neck fracture etc., may rarely occur depending on the type of the procedure done.

Advances in hip arthroscopy is now allowing the surgeons to examine the hip joint in a much more detailed way compared to the past although still the technique is still evolving. Technically it is still a difficult procedure compared to for example a knee arthroscopy.

Initially, the arthroscopy allowed the surgeons to examine the articular part of the hip joint (joint surface). With increasing knowledge and understanding of hip pathologies like labral tear, impingement syndrome of the hip etc., surgeons have started using the arthroscopic technique to treat those hip joint conditions in addition to diagnosing them.

In addition, techniques are also being developed to access the peripheral compartment of the hip joint and treat pathologies like CAM impingement etc., (although many surgeons utilise a combination of hip arthroscopy and mini-open procedure for managing those conditions).

The following is a video demonstration of arthroscopic management of CAM impingement which has been kindly provided by Dr Lavigne and Dr Vendittoli, Consultant Orthopaedic Surgeons at the Rosemont Maisonneuve Hospital, Montreal,Canada where Mr.Ganapathi did his advanced adult lower limb fellowship.

What is it?

  • Recent concept. Common cause of hip pain in young adults.
  • Proposed to be one of the causes of arthritis of the hip at younger age.

What are the mechanisms?

  • Cam impingement (bony bump at the head neck junction damages the labrum and cartilage with flexion)
  • Pincer impingement (over-coverage of the acetabular wall – the labrum gets pinched between the acetabulum and femoral neck and gets damaged)

What are the symptoms?

  • FAI usually presents in active young adults with slow onset of deep groin pain that may start after a minor trauma. During the initial stages of the disease, the pain is intermittent and may be exacerbated by excessive demand on the hip, such as from athletic activities including deep flexion of the hip or prolonged walking. The pain also may present after sitting for a prolonged period.
  • Mechanical symptoms from the hip such as painful locking or giving way are common presenting feature if labral tear is present.

Whom does it affect?

  • Cam impingement – more common in young active males (M:F 14:1, age range 21-51, mean 32)
  • Pincer impingement – More common in middle-aged active females (M:F 1:3, age range 40-57, mean 40)

           (Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular Impingement: Radiographic                        Diagnosis—What the Radiologist Should Know AJR 2007; 188:1540-1552.)

  • Often many have mixed type of impingement

What are the clinical signs?

  • Anterior Impingement test – Hip is flexed to 90 degrees. Hip then passively flexed further, adducted and internal rotation – Positive if it reproduces the pain similar to that experienced by the patient.
  • Posterior impingement (uncommon) – The hip is passively hyperextended by hanging the leg over the end of the couch while keeping the opposite limb in neutral position. Pain is reproduced if passive external rotation of the extended leg.

 Differential diagnosis of hip pain in young adults

  • Acetabular dysplasia                                                   
  • Avascular necrosis
  • Snapping iliopsoas tendon
  • Arthritis
  • Non hip causes like inguinal hernia etc.,

How do we investigate?

  • Plain radiographs

Cam impingement: Bump over the anterolateral aspect of the femoral neck. Often obvious only in the horizontal beam lateral – hence the need to do both AP pelvis Xray and horizontal beam lateral when impingement syndrome is suspected. Various measurements like alpha angle etc.,

Pincer impingement: Cross over sign in standardised AP pelvis Xray – due to overcoverage of the anterior acetabular wall.

  • MRI arthrogram – evaluates cartilage damage and labral tear. Also may show pathology like avascular necrosis.

Management:

  • Nonsurgical:

An initial trial of nonsurgical treatment, which may include activity modification including restriction of athletic activities, and nonsteroidal anti-inflammatory medications. Physical therapy with an emphasis on improving passive range of motion or stretching may be counterproductive and exacerbate the symptoms.

  • Surgical treatment:

    1. Through open dislocation of the hip

    2. Combined arthroscopy and mini-open approach

    3. Arthroscopic treatment

Outcome?

  • Encouraging early results for symptomatic improvement in recent literature.
  • Less optimal result when there is large area of cartilage damage or presence of early arthritis
  • Still an evolving concept
  • No long term studies are available to show that surgical treatment can prevent the progression of arthritis

Hip impingement is a recently recognised condition which can cause hip pain in young adults. Essentially in this condition, the clearance between the ball (femoral head) and the cup (socket) of the hip joint is less than adequate. Often this is due to an abnormal shape of the ball of the hip joint (CAM impingement) or over coverage of the cup of the hip joint (Pincer impingement). Often it is due to a combination of both factors. Hip impingement can also occur if the socket is deeper than normal and also if there is joint laxity allowing abnormal movement. Hip impingement can lead to damage to labrum (could be considered like a soft tissue bumper for the hip joint) and subsequently the articular cartilage (surface lining of the hip joint) can get damaged leading to arthritis in young adults.

In a normal hip, the “ball” moves inside the cup without any restriction (impingement).

CAM impingement can occur when the shape of ball of the hip joint is not a sphere and more like a rugby ball on one side or with a “impingement bump” on one side. This leads to less clearance and with repetitive bending movements of the hip the labrum (a special cartilage at the rim of the cup of the hip joint) and the articular cartilage (surface lining of the hip joint) gradually get damaged.

Pincer impingement occurs when there is over coverage of the cup of the hip joint and this leads to impingement.  With repetitive bending movements of the hip, the labrum gets damaged initially followed by the articular cartilage.

Progressive damage to the cartilage can gradually lead to arthritis of the hip in young adults.

Symptoms:

The most common symptom in hip impingement is pain in the region of the groin (front of the hip joint). It may start following a minor injury or often without any injury. The pain increases with activities which involve bending of the hip joint. Activities which increase the pain include sitting for a prolonged period, getting up from a seated position, getting in and out of the car, walking up and down slopes, climbing stairs, getting in and out of the bath tub, squatting, heavy work including push/pull, carrying heavy objects, putting on shoes and socks, twisting etc., Sporting activities may also be affected. While many of the above symptoms can also be present in patients with hip arthritis, the arthritic pain also increases with activities like walking and sometimes there may be pain even at rest. The patients with impingement can also have a sensation of the hip coming out of the hip joint and also a feeling of clicking sensation. This can be due to a labral tear although in some patients this could be due to dysplasia (shallow cup).

Investigations:

While the preliminary diagnosis of hip impingement is based on the symptoms and the clinical finding on examination, further radiological investigation including plain x-rays and MRI scan and /or CT scan would be required.

X-rays showing CAM type impingement

X-rays showing the removal of the CAM (bump) from the femoral head

X-ray showing relatively normal looking hip but closer inspection
reveal calcification in the labral area and impingement cyst
suggesting possible impingement.

 

X-ray showing cross-over sign suggesting pincer impingement
(“figure of 8” sign, shaded area representing the overcoverage
of the acetabulum)

CT scan with 3 D reconstruction showing
CAM type impingement (shaded in green for
Illustration)

MR arthrogram showing labral tear
and impingement cyst

As the condition (hip impingement) is only being recently recognized as a cause of hip pain which can progress to hip arthritis  in young adults, the treatment strategies are still evolving. In the initial stages, it would be appropriate to consider conservative treatment including physiotherapy, painkillers and activity modification.

If the symptoms persist, it would be appropriate to consider surgical option. When Ganz initially suggested this condition as a cause of hip pain, he advised surgery using a technique known as “surgical dislocation” of the hip. In this exposure, the hip joint is completely exposed (see picture below). While this still may be needed in some cases, the  surgical exposure is extensive and carries certain morbidities including non-union of the trochanteric fragment.

Exposure of the femoral head with Ganz “surgical dislocation” of the hip
(the picture also shows the bony bump the so called “CAM  lesion” to be excised)

Hip arthroscopy is a technically more challenging procedure when compared with a knee arthroscopy.  However, with the advances in the technique of hip arthroscopy and instrumentation, treatment strategies are also evolving which makes it possible for at least some impingement pathologies to be treated entirely through hip arthroscopy.

CAM impingement resection through hip arthroscopy

Whatever the surgical technique may be, the treatment essentially entails creating better clearance for the ball of the hip joint.  The bump in the anterolateral aspect of the ball is removed and/or the over covered part of the acetabulum is excised.  The labral tear is often debrided but in some cases, the labrum could be repaired.

While studies have shown that many patients gain short term improvement in their symptoms, the symptom relief is not universal. One of the main negative predictors of symptoms relief is presence of arthritic changes or damage to the surface lining of the hip joint.  

At this stage, there is lack of data to say whether surgical treatment of hip impingement can delay or prevent the progression to hip arthritis.

The following are some relevant selected scientific references:

 

1.Femoroacetabular impingement syndrome: an under recognized cause of hip pain and premature osteoarthritis?

J Rheumatol. 2010 Jul;37(7):1395-404.

Reid GD, Reid CG, Widmer N, Munk PL.

Department of Medicine,University of British Columbia, Vancouver, British Columbia, Canada.

Abstract: Acetabular dysplasia is well recognized as a potential predisposing factor to the development of hip osteoarthritis (OA). In the orthopedic literature, other dysmorphic and orientation abnormalities of the femoral head, femoral head-neck junction, and the acetabulum have been reported, with increasing frequency in recent years, under the term femoroacetabular impingement syndrome (FAI). The studies have shown a clear association of these structural anomalies with patients’ symptoms and signs, radiographic and pathologic abnormalities, and the development of degenerative hip arthritis. FAI is now believed to be a very important predisposing factor for the development of degenerative hip arthritis, particularly in younger adults. Although the results of longterm studies are awaited, the hope is that early surgical intervention in patients with FAI will change the course or prevent the development of hip OA. It is well documented that early recognition of potential FAI surgical candidates, before OA is advanced, determines the postsurgical outcome. FAI has not been reported in the rheumatology literature, but since patients with FAI likely often initially present to rheumatology clinics for assessment of hip pain, it is important for rheumatologists to be aware of this condition and refer to orthopedics when appropriate. The objective of this review is to provide an outline of the basic concepts of FAI, including clinical presentation and radiographic findings, so that rheumatologists become more familiar with this important emerging entity.

 

2. Efficacy of Surgery for Femoroacetabular Impingement: A Systematic Review.

Am J Sports Med. 2010 May 20. [Epub ahead of print]

Ng VY, Arora N, Best TM, Pan X, Ellis TJ.

The Ohio State University.

Abstract: BACKGROUND: Recent case studies on the surgical treatment of femoroacetabular impingement (FAI) have introduced a large amount of clinical data. However, there has been no clear consensus on its efficacy. HYPOTHESIS: The current literature can be clarified to address 4 questions: (1) Does treatment for FAI succeed in improving symptoms? (2) In which subset of patients should treatment for FAI be avoided? (3) Is labral refixation superior to simple resection? (4) Does treatment for FAI alter the natural progression of osteoarthritis in this group of typically young patients? STUDY DESIGN: Systematic review. METHODS: Twenty-three reports of case studies on the surgical treatment of FAI were identified and a systematic review was conducted. Data from each study were collected to answer each of the 4 focus questions. RESULTS: This review of 970 cases included 1 level II evidence trial, 2 level III studies, and 20 level IV studies. Based on patient outcome scores and effect size, all studies demonstrated improvement of patient symptoms. Up to 30% of patients will eventually require total hip arthroplasty; those patients with Outerbridge grade III or IV cartilage damage seen intraoperatively or with preoperative radiographs showing greater than Tonnis grade I osteoarthritis will have worse outcomes with treatment for FAI. Only 2 studies directly compared labral refixation with labral debridement. Several studies reported postoperative osteoarthritis findings; only a minority of these patients had progression of their osteoarthritis. CONCLUSION: Surgical treatment for FAI reliably improves patient symptoms in the majority of patients without advanced osteoarthritis or chondral damage. Early evidence supports labral refixation. It is too soon to predict whether progression of osteoarthritis is delayed. CLINICAL RELEVANCE: These results may be used to help predict the outcome of surgical treatment of FAI in different patient populations and to assess the need for labral refixation.

 

3. Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement.

J Bone Joint Surg Am. 2010 Jul;92(8):1697-706.

Clohisy JC, Zebala LP, Nepple JJ, Pashos G.

Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO 63110, USA.  

Abstract: BACKGROUND: A variety of surgical techniques have been introduced for the treatment of femoroacetabular impingement, but clinical outcome studies of less-invasive treatment with a minimum duration of follow-up of two years are limited. The purpose of this study was to evaluate the early clinical and radiographic outcomes of combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction for the treatment of cam femoroacetabular impingement. METHODS: We performed a retrospective review of our first thirty-five patients (thirty-five hips) in whom cam femoroacetabular impingement had been treated with combined hip arthroscopy and limited open osteochondroplasty. Thirty-five patients (twenty-eight men and seven women) with an average age of thirty-four years and a minimum duration of follow-up of two years were analyzed. The modified Harris hip score was utilized to assess hip function. The Tönnis osteoarthritis grade and the alpha angle were determined to assess osteoarthritis progression and deformity correction, respectively. RESULTS: The average modified Harris hip score improved from 63.8 points preoperatively to 87.4 points at the time of the last follow-up. Twenty-nine (83%) of the thirty-five patients had at least a 10-point improvement in the Harris hip score, and 71% had a score of >80 points. The average alpha angle was reduced from 58.6 degrees preoperatively to 37.1 degrees at the time of follow-up when measured on cross-table lateral radiographs, from 63.9 degrees to 37.8 degrees when measured on frog-leg lateral radiographs, and from 63.1 degrees to 44.8 degrees when measured on anteroposterior radiographs. Two patients had osteoarthritis progression from Tönnis grade 0 to grade 1. Minor complications included one superficial wound infection, one deep vein thrombosis, and four cases of asymptomatic Brooker grade-I heterotopic ossification. There were no femoral neck fractures or cases of femoral head osteonecrosis, and no hip was converted to an arthroplasty. CONCLUSIONS: Early results indicate that combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction is a safe and effective treatment for femoroacetabular impingement. In our small series, most patients had symptomatic relief, improved hip function, and enhanced activity after two years of follow-up.

 

4. Open treatment of femoroacetabular impingement is associated with clinical improvement and low complication rate at short-term followup.

Clin Orthop Relat Res. 2010 Feb;468(2):504-10.

Peters CL, Schabel K, Anderson L, Erickson J.

Department of Orthopaedic Surgery, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT 84108, USA.

Abstract: BACKGROUND: Since the modern description of femoroacetabular impingement (FAI) a decade ago, surgical treatment has become increasingly common. Although the ability of open treatment of FAI to relieve pain and improve function has been demonstrated in a number of retrospective studies, questions remain regarding predictability of clinical outcome, the factors associated with clinical failure, and the complications associated with treatment. QUESTIONS/PURPOSES: We therefore described the change in clinical pain and function after open treatment, determined whether failure of treatment and progression of osteoarthritis was associated with Outerbridge Grade IV hyaline cartilage injury, and described the associated complications. METHODS: We retrospectively reviewed all 94 patients (96 hips) (55 males and 39 females; mean age, 28 years) who underwent surgical dislocation for femoroacetabular impingement between 2000 and 2008. Seventy-two of the 96 hips had acetabular articular cartilage lesions treated with a variety of methods, most commonly resection of damaged hyaline cartilage and labral advancement. Patients were followed for a minimum of 18 months (mean, 26 months; range, 18-96 months). RESULTS: Mean Harris hip scores improved from 67 to 91 at final followup. Six of the 96 hips (6%) were converted to arthroplasty or had worse Harris hip score after surgical recovery. Four of these six had Outerbridge Grade IV acetabular cartilage lesions and two had Legg-Calvé-Perthes disease or slipped capital epiphysis deformities. Two hips (2%) had refixation of the greater trochanter. CONCLUSIONS: At short-term followup, open treatment for femoroacetabular impingement in hips without substantial acetabular hyaline cartilage damage reduced pain and improved function with a low complication rate. Treatment of Outerbridge Grade IV acetabular cartilage delamination remains the major challenge. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

 

5. Combined arthroscopic and modified open approach for cam femoroacetabular impingement: a preliminary experience.

Arthroscopy. 2009 Apr;25(4):392-9.

Lincoln M, Johnston K, Muldoon M, Santore R.

Orthopedic Medical Group, San Diego, California 92123, USA.

Abstract: PURPOSE: We report our case series of patients undergoing surgical treatment (femoral osteoplasty) for symptomatic cam femoroacetabular impingement (FAI). Clinical results using a modified Heuter anterior approach combined with adjunctive hip arthroscopy are presented. METHODS: A chart review of 16 hips (14 consecutive patients) was conducted. Radiographic parameters (alpha angle, head-neck offset, and Tönnis grade) were compared preoperatively and postoperatively. Clinical features (range of motion, provocative testing, and Harris hip score) were assessed. RESULTS: At 2.0 years, mean hip flexion improved from 94.1 degrees to 110.0 degrees (P < .01) and internal rotation from 7.1 degrees to 12.3 degrees (P = .02). The mean alpha angle improved from 64.5 degrees to 43.3 degrees (P < .01), whereas the mean femoral head-neck offset improved from 1.9 to 9.6 mm (P < .01). The mean Harris hip score improved from 63.8 to 76.1 (P = .01). No deterioration in overall radiographic Tönnis grades was present at last follow-up. CONCLUSIONS: The combination of hip arthroscopy with a limited anterior approach (Heuter) is a useful technique for patients with cam or cam-dominant FAI lesions. We believe the limited anterior approach with open osteoplasty presents a reasonable alternative to arthroscopic methods of osteoplasty with minimal drawbacks in the event that total hip arthroplasty is indicated in the future. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

 

6. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement.

Clin Orthop Relat Res. 2009 Mar;467(3):739-46. Byrd JW, Jones KS.

Nashville Sports Medicine Foundation, 2011 Church Street, Suite 100, Nashville, TN 37203, USA.

Abstract: Cam-type femoroacetabular impingement is a recognized cause of intraarticular pathology and secondary osteoarthritis in young adults. Arthroscopy is reportedly useful to treat selected hip abnormalities and has been proposed as a method of correcting underlying impingement. We report the outcomes of arthroscopic management of cam-type femoroacetabular impingement. We prospectively assessed all 200 patients (207 hips) who underwent arthroscopic correction of cam impingement from December 2003 to October 2007, using a modified Harris hip score. The minimum followup was 12 months (mean, 16 months; range, 12-24 months); no patients were lost to followup. The average age was 33 years with 138 men and 62 women. One hundred and fifty-eight patients (163 hips) underwent correction of cam impingement (femoroplasty) alone while 42 patients (44 hips) underwent concomitant correction of pincer impingement. The average increase in Harris hip score was 20 points; 0.5% converted to THA. We had a 1.5% complication rate. The short-term outcomes of arthroscopic treatment of cam-type femoroacetabular impingement are comparable to published reports for open methods with the advantage of a less invasive approach.

 

7. Femoroacetabular impingement treatment using arthroscopy and anterior approach.

Clin Orthop Relat Res. 2009 Mar;467(3):747-52. Laude F, Sariali E, Nogier A.

CMC Paris V, 36 boulevard saint Marcel, 75005, Paris, France.

Abstract: Femoroacetabular impingement (FAI) has been identified as a common cause of hip pain in young adults. However, treatment is not well standardized. We retrospectively reviewed 97 patients (100 hips) who underwent osteochondroplasty of the femoral head-neck for FAI using a mini-open anterior Hueter approach with arthroscopic assistance. The mean age of the patients was 33.4 years. The labrum was refixed in 40 hips, partially excised in 39 cases, completely excised in 14 cases, and left intact in seven. Six patients were lost to followup, leaving 91 (94 hips) with a minimum followup of 28.6 months (mean, 58.3 months; range, 28.6-104.4 months). We assessed patients clinically using the nonarthritic hip score (NAHS). One patient had a femoral neck fracture 3 weeks postoperatively. At the last followup, the mean NAHS score increased by 29.1 points (54.8 +/- 12 preoperatively to 83.9 +/- 16 points at last followup). Eleven hips developed osteoarthritis and subsequently had total hip arthroplasty. The best results were obtained in patients younger than 40 years old with a 0 Tönnis grade. Refixation of the labrum did not correlate with a higher NAHS score (87 +/- 11 with refixation versus 82 +/- 19 points without) at the last followup. The technique for FAI treatment allowed direct visualization of the anterior femoral head-neck junction while avoiding surgical dislocation, had a low complication rate, and improved functional scores.

While mechanical symptoms of the hips are uncommon (unlike the knee joint), in some patients it can be one of the presenting symptoms. These include clicking sensation (which may be palpable or audible), a feeling of the hip coming out of the joint, locking or as a visible snapping (as in iliotibial band). As long as the mechanical symptoms are not painful, it is probably best to leave things alone.

There are a number of causes which can produce mechanical hip symptoms. They may be due to extra-articular causes (outside the hip joint) or intra-articular (inside the hip joint). With the advances in hip arthroscopy, a number of causes for mechanical symptoms are being recognised.

Extra-articular causes:

  • Snapping iliotibial band syndrome
  • Snapping iliopsoas tendon syndrome

Intra-articular causes:

  • Labral tears
  • Loose bodies
  • Synovial chondramatosis

Snapping iliotibial band syndrome:

In this condition, the iliotibial band (a thickened tissue over the outer aspect of the hip and thigh) becomes taut and produces an obvious (often visible) snapping as it slides over the greater trochanter (outer prominence of the hip) with flexion and extension of the hip. This is one of the commonest causes of snapping hip. Asymptomatic snapping hip should be considered benign and normal occurrence particularly in athletes. Even when the snapping becomes symptomatic and painful, the mainline of treatment is an extended period of non-operative treatment including stretching exercises, physiotherapy, activity modification and anti-inflammatories. In rare cases, where conservative treatment has not helped, surgical treatment could be considered. A number of surgical procedures have been described in the literature and majority involves a large scar including Z plasty of the iliotibial tendon.  With recent advances in hip arthroscopy, it is now possible to do the release of the taut iliotibial band through keyhole surgery thus minimising the scar over the outer aspect of the hip. However, it is important to understand that the results of the surgical procedures are variable and not always successful and hence the emphasis that non-operative treatment should be considered as the mainline of treatment.

(The following video shows Mr.Ganapathi performing an arthroscopic release of the snapping iliotibial band)


Snapping iliopsoas tendon syndrome:

In this condition, the  iliopsoas tendon (a muscle which originates in the spine and pelvis and attaches to the thigh bone) rubs over the iliopectineal eminence (a bony prominence on the front of the pelvis) or over the femoral head. This can produce a snapping sensation when the patient extends the hip from a flexed position. The snapping may be painful and may be related to sports or exercise activity. The treatment in majority of cases is non-operative with physiotherapy, activity modification, pain killers, anti-inflammatories etc.,  Further investigations include either a dynamic ultrasound or MRI scan. If there is clinical suspicion of psoas tendonitis, ultrasound guided steroid injection could be done which can improve the symptoms. If the symptoms do no improve with non-operative treatment, then surgical release could be considered but the results are not always successful.

Labral tears:

With recent advances in hip arthroscopy, intra-articular causes of painful snapping are being recognised including labral tears. The labral tears are in a way similar to the cartilage tears in the knee producing pain and mechanical symptoms but usually caused by repetitive injury (impingement syndrome) rather than due to an acute injury.

Pain over the lateral aspect of the hip (outer aspect) is quite a common clinical problem. It could be due to a number of reasons, including pain from the lower back as well as hip arthritis. One of the common causes is trochanteric bursitis and is usually treated by pain killers and local steroid injections.

It is now being recognised that in a small proportion of the cases, the pain may be due to tear in the abductor muscles of the hip (gluteus minimus/gluteus medius – the muscle which hold the pelvis level during single-leg stance) at their insertion into the greater trochanter. This is now considered to be similar to the “rotator cuff tear” of the shoulder and occurs due to chronic attrition. While the shoulder rotator cuff problems have been well recognised for a long time and the treatment is well evolved, the diagnosis and management of the “hip abductor problem” is still evolving.

The clinical diagnosis is based on the location of pain, temporary response to steroid injection, weakness of abductors, positive Trendelenberg test, pain during passive abduction etc., although not all signs may be present.

When a clinical diagnosis is suspected, further investigation is required to evaluate the problem. Either ultrasound or MRI scan can be done. MRI scan is probably better as the ultrasound interpretation is dependant on the person who does the ultrasound.

The management depends on the symptoms and the MRI findings. Although the long term results of repairing such an abductor tear is not known (as the condition is being recognised as a cause of hip pain only recently and the awareness about this condition among health professionals including orthopaedic surgeons is still scarce), recent studies have shown favourable short term results following surgical repair of the abductor tear. However, if there is significant fatty degenerative changes and wasting of the muscles, the results are likely to be less than optimal. Hence it is important to understand that the results may not be always successful.

The surgical treatment involves a open repair procedure although with advances in key hole surgery it is also possible to do the repair through key hole procedure. After the surgery, the repair should be protected with partial weight bearing with crutches for about 6 weeks.


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MRI scan showing trochanteric bursitis and partial tear of the abductors in left hip.

The following video shows Mr.Ganapathi performing an arthroscopic assessment of an abductor tear and mini-open repair of the abductor tear using suture anchors

The following are some relevant selected scientific references:

1. Surgical repair of chronic tears of the hip abductor mechanism.

Hip Int. 2009 Oct-Dec;19(4):372-6.
Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G.
Avon Orthopaedic Centre, Bristol, UK.

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn’t settle and warrants further investigation and treatment. We present a series of 28 patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors. There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5 (p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

2. Advanced techniques in hip arthroscopy.

Instr Course Lect. 2009;58:423-36.
Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS.
Twin Cities Orthopaedics, Minneapolis, Minnesota, USA.

The indications for hip arthroscopy are expanding as the understanding of hip disease increases. Improved instrumentation and technical skills also have facilitated the ability to treat some hip disorders arthroscopically. Femoroacetabular impingement (FAI) is increasingly recognized as a disorder that can lead to progressive intra-articular chondral and labral injury. Although FAI is usually treated through an open approach, limited-open and all-arthroscopic approaches have been described. Various arthroscopic techniques allow treatment of labral and acetabular rim pathology as well as peripheral compartment femoral head-neck abnormalities. Early outcomes of limited-open and all-arthroscopic treatment of FAI are only beginning to be reported but appear to compare favorably with those of open dislocation procedures. Although labral tears traditionally have been treated with simple débridement, concerns have been raised about the consequences of removing the labrum. Modified portal placement and hip-specific suture anchors are now being used in an effort to repair some labral tears. Snapping hip disorders typically are treated nonsurgically. For persistent symptoms, arthroscopic release is successful, compared with open release, and allows additional evaluation of the hip joint during surgery. Diagnosis and management of traumatic and atraumatic hip instability continue to be challenging. Hip arthroscopy has been shown to be effective in the treatment of hip instability in some patients. The extra-articular peritrochanteric space is receiving increased attention. The arthroscopic anatomy has been well defined, but the treatment of greater trochanteric pain syndrome and arthroscopic repair of abductor tendon tears are only beginning to be reported. Improved techniques and longer-term outcomes studies will further define the optimal role of hip arthroscopy.

3. Endoscopic repair of gluteus medius tendon tears of the hip.

Am J Sports Med. 2009 Apr;37(4):743-7.
Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT.
Hospital for Special Surgery, New York, NY 10021, USA.

BACKGROUND: Tears of the gluteus medius tendon at the greater trochanter have been termed “rotator cuff tears of the hip.” Previous reports have described the open repair of these lesions. HYPOTHESIS: Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys. RESULTS: At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal. CONCLUSION: With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

4. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip.

Arthroscopy. 2007 Nov;23(11):1246.e1-5.
Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.
Hospital for Special Surgery, New York, New York 10021, USA.

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

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