Exposure of the Iliopsoas tendon requires capsulotomy to the level of the Psoas notch.&nbsp; A small portion of the Iliopsoas tendon is then released to correct internal snapping of the tendon.&nbsp;

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Gregor Möckel, MD, (Berlin, Germany) discusses the threedifferent types of snapping hip syndrome and how to address them surgically inthis informative presentation. Dr. Mockel describes the symptoms and treatments associated with intra-articular, internaland external snapping hip and provides an overview of the etiology of eachsyndrome.

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Snapping Hip Release

I'm speaking now about the first three compartments. Philip talked about the fourth, and I'm speaking about the first three compartments. So the snapping hip can be classified into an intra-articular intra-articular snapping hip, where the source of the snapping is inside the hip joint, first second in the so-called internal snapping hip. That means a snapping of the psoas tendon and the so-called external snapping hip. This is a snapping of the IT band or a hypertrophic bursitis. So first of all, the intra articular snapping the source of the snapping is inside the hip joint. And quite often it's a cartilage flap like this. You see it typically in cam impingement patients where the Cam lesion peels off the cartilage, the labrum stays intact for a long time and the cartilage is peeled off. Or we can have as a source for the intra articular snapping, a torn labrum room, or a torn ligament, or loose bodies in the central or in the peripheral compartment. The so-called internal snapping hip is a clinical diagnosis. Patients come and complain about a loud snapping and clicking in the groin, and if you do your investigation, you take the hip from a 90 degrees of flexion into an extension, and then you feel and can hear in the groin, in the groin, a snapping of the iliopsoas tendon. You can quite often see it in the MRI as you can see it here. And first of all, you should try a conservative treatment. And for instance ultrasound. Ultrasound guided injections to the tendon. The internal snapping hip occurs as well in patients after total hip replacement. And you can typically have it in two positions either at the femoral and at the femoral neck, especially in patients with prosthesis with a large collar like this with an overhanging collar. There you can have a snapping. You see the arthroscopic view here or in a tabular cup which is too large or which is retroverted, and then you have a snapping over the cup. So I come back to the non replaced hip. And there you can do the release of the tendon on different levels. The first level you can do is at the level of the lesser trochanter. This is more or less a complete tenotomy and you have even quite a lot retraction of the tendon. And there are some concerns in the literature about deficits in function. So to leave more of the tendon muscle complex intact is more suitable to release the tendon more proximal, for instance, at the level of the medial synovial fold in the peripheral Compartment or at the level of the acetabular notch in the central compartment. In patients with dysplastic hips or borderline dysplasia, let's say with a lateral center of edge wrinkle of below 25 degrees, you should be careful in releasing this tendon, because in this patient, the tendon plays an important role in stability of the hip. So there is recommended to make a bony decompression of the medial aspect of the inferior iliac spine, or a decompression of the eminence, the iliopectineal. So this is a view into a left hip, into the peripheral compartment of a left hip. You see here the femoral head. You see the capsule above. You see the zona orbicularis right here. You see the medial synovial fold in the middle. And there you can open up the capsule just in front of the medial synovial fold. Make a little hole into the capsule. So. And if you do not see immediately the psoas tendon, then you can stretch and extend the leg, rotate the leg until the psoas tendon comes across the window. And then you can do a release with your radiofrequency probe. It is not recommended to cut it with hand instruments because ossifications can occur if you don't use radiofrequency. So the external snapping hip is a clinical diagnosis. Again, mostly young females come to your office and say, okay, my hip is dislocating and then you watch them and you see the hip is not dislocating, but the IT band is snapping over the greater trochanter. And of course, this is the first line treatment in these patients is conservative as well. But if this fails as surgical release can be done and there are different options. I like to perform it from a subcutaneous way to remove the subcutaneous soft tissue, with the fat and then goes straight to the IT band and then make a little cut into the IT band. And then in a lateral position, you can very easily try to to, to feel this effect to, to produce the snapping or not. And, and then you can continue release or not. So for conclusion, ladies and gentlemen, for the intra-articular snapping, it is essential that you look for the source of the pain, for the source of the snapping inside the hip joint, in the central and in the peripheral compartment. For the internal snapping hip hip you can do a psoas tendon release. It is recommended to do it more proximal, more between the muscle tendon junction and for the external snapping hip, it is recommended to do an IT band release. Thank you very much.

BenjaminDomb, MD, (Chicago, IL) discusses his technique for the surgical correction ofinternal snapping hip syndrome through the fractional lengthening of the iliopsoastendon. In this live surgery demonstration, Dr. Domb describes relevant anatomyand the technique used to partially release the symptomatic tendon.

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Iliopsoas Fractional Lengthening

The hip is in distraction at this point, and the arthroscope is in the central compartment using a beaver blade. We extend the capsulotomy a little bit anteriorly, staying distal away from the acetabular rim to allow for subsequent capsular closure or plication using sutures at the completion of the surgery. We'll use the shaver to debride the iliopsoas Bursa with care not to debride the capsule at all. This is a very important point. We'd like to repair the capsule at the conclusion of the surgery, so it is important not to debris the capsule with the shaver, but to debride only the iliopsoas Bursa and stay between the capsule and the iliopsoas in performing this exposure. The iliopsoas crosses the joint at about the 3:00 position when it is missed. It is frequently because the rectus femoris tendon or part of the capsule is mistaken for the iliopsoas, and the psoas is often more inferomedial than expected. So one must clearly identify the tendinous fibers as seen here by debriding the Bursa, and identify the medial and lateral borders of the iliopsoas. That's absolutely critical. At this point we introduce a beaver blade which will be used for the actual fractional lengthening. Now at the level of the joint the iliopsoas is approximately 50% tendon, 50% muscle. So when we cut through the tendinous portion we'll see it snap open. And boom, there it snaps open. You see behind it the red muscle fibers. Those stay intact. We don't cut through the red muscle fibers. So this allows a lengthening of the iliopsoas by about one centimeter. And it will subsequently heal but about a centimeter longer. This has been very predictably shown to alleviate internal snapping of the hip.

Excalibur, Curved, HL, 4.2 mm x 19 cm

Terminal de artroscopia Excalibur, curvado, longitud decadera, Ø 4.2 mm

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PUNSOR, PONTA MÉDIA RETA, EIXO DE Ø3.4 M

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Medium Punch, 220 mm, Ø 3.4 mm, Schaft gerade, Maul gerade

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Pinza sacabocados, mediana, punta recta, vástago recto, Ø3.4 mm, 220 mm

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Iliopsoas Release

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