Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes

Iliopsoas Tenotomy Does Not Negatively Affect Hip Flexion Strength in Crowe 3 and 4 Hips Undergoing Total Hip Arthroplasty

BACKGROUND

In total hip arthroplasty (THA), even if there is a dislocated hip, restoring the anatomical center of rotation increases long-term survival and hip function. Even with a shortening osteotomy, the procedure is still challenging due to soft-tissue tension. Therefore, soft tissue releases such as iliopsoas tenotomy may be necessary. In our study, we aimed to examine the effects of iliopsoas tenotomy on hip flexion and abduction strength in patients who underwent THA with shortening osteotomy for Crowe 3 and 4 hip dysplasia by using a hand dynamometer for measurement.

METHODS

The present study examined 27 patients who underwent THA with shortening osteotomy in unilateral Crowe 3 and 4 hips. The patients' hip flexion and abduction strengths were measured with a hand dynamometer preoperatively and in the first year postoperatively.

RESULTS

The average flexion strength of the operated side was less than the nonoperated side before surgery. It also decreased further in the first six weeks. But the strength increased in the 12th week and reached the same level as the non-operated side in the sixth month. The average abduction strength was less than the nonoperated side before the surgery, and it decreased further in the 6th week after surgery. However, the strength increased during follow-ups and reached the non-operated side strengths in the twelfth week.

CONCLUSIONS

In conclusion, during THA procedures for highly dislocated hips, releasing the iliopsoas tendon at the level of the minor trochanter to facilitate distalization of the hip center of rotation does not adversely affect hip flexion and abduction strengths.

LEVEL OF EVIDENCE

Level II.

Assessment of function and muscle strength after endoscopic iliopsoas tenotomy to treat iliopsoas impingement after total hip arthroplasty

PURPOSE

The objective of this study was to evaluate the functional outcome during follow-up (FU) after endoscopic tenotomy for iliopsoas (IP)-cup impingement and to quantitatively analyze the hip flexion strength.

METHODS

This was a monocentric, retrospective cohort study of a single surgeon series. Functional assessment was based on the modified Harris score, the Oxford score and the visual analog scale score. Strength was measured with a handheld dynamometer in the sitting and lying position.

RESULTS

Thirty-six IP tenotomies for cup impingement were performed between May 2013 and November 2021. Seven (19%) patients were lost to FU. At the time of tenotomy, the mean (standard deviation) age was 62,6 (12,2) and BMI was 26,5 (4,1). The mean FU time after tenotomy to the last FU was 3,6 (0,8) years. All three outcome scores improved from preoperatively to six months postoperatively (p < 0.001). There were no significant change from six months to last FU. The minimal clinically important difference (MCID) of the modified Harris score was set at 25. 20 (69%) patients had values that exceeded the threshold at one month and six months and neutral 19 (65.5%) had values that exceeded the threshold at the last FU. The limp symmetry index concerning hip flexion strength was 63% at 90° and 40% at 30° at the last FU.

CONCLUSION

Most patients significantly improved their outcome scores after endoscopic iliopsoas tenotomy, with results remaining consistently stable over time. Despite a significant loss in hip flexion strength, the majority of patients did not report any impairment of their quality of life.

STUDY DESIGN

Level III, Retrospective cohort study.

Arthroscopic and endoscopic techniques for iliopsoas release in THA are safe and effective: a systematic review of the literature

BACKGROUND

Hip replacement surgery is highly effective in relieving pain and improving mobility in patients with various hip conditions. However, some patients develop groin pain after surgery, often due to iliopsoas impingement (IPI), which can be challenging to diagnose. Conservative treatments are initially recommended, but when these are not effective, surgical options may be considered. This study aims to evaluate the clinical outcomes, success and failure rates, revision rates, and complications associated with arthroscopic and endoscopic surgery for IPI, thereby providing a comprehensive understanding of the effectiveness and risks of these surgical interventions.

MATERIALS AND METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including a thorough search of five main databases: PubMed, Scopus, Embase, Medline, and Cochrane. Eligible articles were meticulously evaluated according to predefined criteria for levels of evidence (LoE), with retrospective studies assessed using the Coleman Methodology Score (mCMS). This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO).

RESULTS

Among the 16 included studies, 431 patients with 434 hips underwent either endoscopic or arthroscopic tenotomy. Both techniques showed favorable outcomes, with arthroscopic tenotomy demonstrating slightly higher success rates than endoscopic tenotomy. Common complications included mild pain and occasional infections, with recurrence observed in some cases. Both techniques offer direct visualization of prosthetic components and potential preservation of psoas function.

CONCLUSIONS

Arthroscopic and endoscopic iliopsoas tenotomy are effective treatments for alleviating symptoms and improving hip function in patients with IPI post-total hip arthroplasty (THA).

LEVEL OF EVIDENCE

IV.

Arthroscopic Fractional Lengthening After Total Hip Arthroplasty Results in Improved Patient-Reported Outcomes and Low Rates of Revision Total Hip Arthroplasty

Purpose

To report the clinical outcomes and reoperation rates of arthroscopic and endoscopic iliopsoas release at short-term follow-up after ipsilateral total hip arthroplasty (THA) at 2 separate medical institutions and to evaluate whether demographic and radiographic parameters are associated with postoperative patient-reported outcomes (PROs).

Methods

Patients with iliopsoas tendinitis in the setting of prior THA who underwent arthroscopic iliopsoas fractional lengthening from 1988 to 2023 at 2 academic institutions were reviewed. Patients were included if they had 12 months of follow-up and underwent evaluation of preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score, Single Assessment Numeric Evaluation score, Tegner activity scale score, visual analog scale (VAS) score, and revision hip arthroplasty.

Results

Sixty hips in 58 patients (19 male and 39 female patients) were followed up for a mean of 39.3 months (range, 12.0-105.9 months) postoperatively. Of the patients, 77% reported feeling "much better" or "slightly better," 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. The surgery satisfaction rating was 7.2 ± 3.3 (scale of 0 to 10). The mean postoperative modified Harris Hip Score, VAS score for pain at rest, VAS score for pain with use, and Single Assessment Numeric Evaluation score were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9, respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and did not significantly correlate with postoperative PROs (P ≥ .45). The Tegner score improved from 2.5 ± 1.7 preoperatively to 2.9 ± 1.4 postoperatively (P = .0253). Three patients underwent revision arthroplasty at a mean of 25.3 months (range, 11.6-40.4 months) postoperatively, with an acetabular component revision rate of 3.3%.

Conclusions

Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening after THA. There was no statistically significant relation between anterior acetabular component overhang and final PROs.

Level of Evidence

Level IV, therapeutic case series.

The role of iliopsoas fractional lengthening in hip 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.

Bilateral psoas release for long standing hip-spine syndrome: surgical technique and case report

Background

Severe positive sagittal malalignment can potentially lead to shortening and contracture of the psoas and joint capsule in a flexed spinopelvic position. The utilization of bilateral psoas release to supplement sagittal spinal deformity correction in the same hospitalization was not reported in the literature.

Case presentation

A 66-year-old patient presented with a 5-year history of severe global spinal deformity (sagittal vertical axis 220 mm, 60° spinopelvic mismatch) that did not improve on supine radiographs, and a modified Thomas test with more than 30° flexion contracture of bilateral hips. A 3-stage operation utilizing posterior spinal column osteotomies, anterior lumbar interbody fusion, and bilateral psoas releases was performed.

Outcome

Her postoperative alignment significantly improved and she was pleased with her new posture and the ability to stand up straight.

Conclusions

This report is the first to demonstrate safe and substantial correction of severe spinal deformities associated with bilateral hip flexion contracture in 1 hospitalization.

Hearing and Seeing Nerve/Tendon Snapping: A Systematic Review on Dynamic Ultrasound Examination

Nerve/tendon snapping can occur due to their sudden displacement during the movement of an adjacent joint, and the clinical condition can really be painful. It can actually be challenging to determine the specific anatomic structure causing the snapping in various body regions. In this sense, ultrasound examination, with all its advantages (especially providing dynamic imaging), appears to be quite promising. To date, there are no comprehensive reviews reporting on the use of dynamic ultrasound examination in the diagnosis of nerve/tendon snapping. Accordingly, this article aims to provide a substantial discussion as to how US examination would contribute to 'seeing' and 'hearing' these pathologies' different maneuvers/movements.

Favorable Patient-Reported Outcomes and High Return to Sport Rates Following Hip Arthroscopy in Adolescent Athletes: A Systematic Review

PURPOSE

The purpose of this systematic review is to synthesize the existing literature surrounding hip arthroscopy in the adolescent athlete population to determine patient-reported outcomes, return to sport rates, complications, and reoperations associated with this intervention.

METHODS

A systematic literature review was performed using PubMed (MEDLINE), Cochrane Library, and Embase according to PRISMA guidelines. Studies were included if they were published in English with greater than 2 participants, contained patients aged 10-19 years old or classified as "high school athletes" or "middle school athletes," and reported postoperative patient-reported outcomes and return to sport. Patient-reported outcomes (PROs) and their associated P values were recorded. Finally, return-to-sport outcomes and sports played were also extracted from the included studies. Weighted kappa was used to assess inter-reviewer agreement.

RESULTS

Eleven studies included in the final analysis, resulting in 344 patients and 408 hips were analyzed by this review. Patient-reported outcomes (PROs) were reported in all studies. The modified Harris Hip Score (mHHS) was used in all but 1 study. Six of the 11 studies reported a 100% return-to-sport rate, for a total of 98/98 athletes returning to sport. Fabricant et al. did note that a majority of athletes who returned to sport were able to do so at a subjective "nearly normal" level. Only 4 of the studies reported complications, with the majority being transient neuropraxias.

CONCLUSIONS

Adolescent athletes who undergo hip arthroscopy demonstrate favorable postoperative patient-reported outcome scores, high rates of return to sport, and an overall low complication rate. The heterogeneity in both surgical methodology and outcome measures used for evaluation and treatment leads to continued ambiguity with regard to the optimal method for managing adolescent athletes with hip pathology.

LEVEL OF EVIDENCE

V, systematic review of Level II-V studies.

Arthroscopic resection as a rapid recovery treatment for Os acetabuli in soccer players who had undergone hip arthroscopy: a case series with 1-year follow-up

INTRODUCTION

Os acetabuli (OSA) is defined as a radiopaque structure located around the acetabular rim highly related to Femoroacetabular Impingement (FAI). Its treatment depends on the perspective of post-surgical joint instability. Ossicle resection is recommended if the femoral head is covered enough by the labrum. Previous research has described the results of this technique in general population. The aim of this study is to describe the outcomes and the time and rate of return to play (RTP) after hip arthroscopy and OSA removal in soccer players.

METHODS

This study is a retrospective analysis of a prospective database containing all the consecutive soccer players who had undergone hip arthroscopy between 2018 and 2019. The subjects diagnosed with OSA and a center-edge angle (CEA) > 25 ° were included in the analysis. All the patients were treated with arthroscopic removal of the OSA and femoral osteoplasty. Hip function was assessed using the Modified Harris Hip Score (MHHS) before and at 3 and 12 months after surgery. Rate of RTP and competitive level at RTP were assessed at a 1-year follow-up.

RESULTS

Between 2018 and 2019, 90 soccer players were treated with hip arthroscopy in our facilities. Six of them (6.6%) were diagnosed with OSA. Mean (SD) MHHS values were 69.7 (12.1) before the surgery, 89.7 (6.7) at 3 months post-surgery and 95.7 (5.1) at 12 months post-surgery. All the subjects reported significant improvements in their MHHS scores at 3 and 12 months post-surgery compared with pre-surgery levels (p < 0.01). Non-significant differences were found between 3 and 12 months post-surgery (p > 0.05). All the subjects (100%) returned to previous competitive levels.

CONCLUSIONS

After surgery, all the soccer players returned to previous competitive level. Preoperative MHHS improved significantly at 3 months maintained for up to 12 months.

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.

Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: A Comprehensive 5-Phase Patient-Guided Program

Background:

Many of the current rehabilitation programs for patients undergoing hip arthroscopy fail to consider the progression of soft tissue healing and inflammation that can be heightened due to aggressive therapy to the operative hip in the immediate postoperative period.

Hypothesis:

It was hypothesized that introducing conservative physical therapy (PT) preoperatively along with a slow progression to return to activity using a structured, patient-guided postoperative program would improve patient outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors conducted a retrospective review of patients who received a hip arthroscopy, were at least 18 years old, and who had completed the following patient-reported outcomes (PROs) at 1-year follow-up: modified Harris Hip Score (mHHS), Hip Outcome Score, Nonarthritic Hip Score, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. Patients who underwent previous surgery on the ipsilateral hip and those with cartilage erosion down to exposed subchondral bone (Outerbridge grade 4) were excluded. Paired-samples t tests were used to compare the change in PRO scores at 3-month, 6-month, and 1-year follow-up, and the percentage of patients who achieved minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds on the mHHS were stratified according to their Outerbridge grade (0-3).

Results:

Overall, 202 patients (53% female, 47% male) were included in the analysis. Significant improvement was seen from 3 to 6 months on all PRO measures and from 6 months to 1 year on all but the mHHS (P < .05 for all except the mHHS). A significantly smaller percentage of patients with Outerbridge grade 3 cartilage damage achieved the MCID and SCB on the mHHS compared with those with grade 0, both at 6 months (grade 3 vs 0: 20% vs 63.2% [MCID]; 18.0% vs 52.6% [SCB]; both P = .03) and 1 year (grade 3 vs 0: 22.0% vs 57.9% [MCID]; 14.0% vs 52.6% [SCB]; both P < .05).

Conclusion:

A structured, patient-guided PT protocol after arthroscopic acetabular labral repair can significantly improve postoperative outcomes.

Arthroscopic iliopsoas tenotomies: a systematic review of surgical technique and outcomes

PURPOSE

To evaluate the technique, results and complications of arthroscopic iliopsoas tenotomies either on native hips or total hip arthroplasty (THA).

METHODS

A systematic review was performed using 3 databases: PubMed, EMBASE and the Cochrane library from January 2000 to December 2018 in accordance with the PRISMA procedure. The literature search, data extraction and quality assessment were conducted by 2 independent reviewers. Surgical technique, clinical outcomes, recurrences and complication rate were evaluated.

RESULTS

Out of 115 articles reviewed, 20 articles concerned native hips and 8 articles THA. 3 levels of release were described. For native hips, the recurrence rate was higher for central compartment than peripheral or lesser trochanter releases. Complication rates were similar for hip arthroscopy but remained low in all series. Loss of strength was evaluated mainly using the MRC muscle scale. Most studies noted strength recovery. MRI analysis of muscle atrophy was greater for lesser trochanter than for central compartment release but unrelated to loss of strength. The complication rate was low for tenotomy after THA, heterotopic ossification being the most common complication.

CONCLUSIONS

Central compartment releases lead to the highest rate of recurrence due to incomplete release. Peripheral releases have a potential risk of vascular injury. The lesser trochanteric approach has the disadvantage of not having direct access to the joint. The main difficulty with THA lies in the diagnosis of cup/iliopsoas impingement. Diagnostic tests with infiltration should be made before iliopsoas release to prevent its failure. Cup protrusion of over 8mm is a potential indication for acetabular revision.

Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy in High-Level Athletes With a Propensity-Matched Benchmarking Against a Unilateral Control Group

BACKGROUND

Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established.

PURPOSE

(1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery/conditions. Rates of achieving the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. These athletes were then propensity matched in a 1:3 ratio to high-level athletes who underwent unilateral arthroscopy for comparison. Outcomes were compared among the first hip of the study group, the second hip of the study group, and the control group.

RESULTS

A total of 74 high-level athletes who underwent bilateral hip arthroscopy met the inclusion criteria, and follow-up was available for 68 (91.9%) at 58.9 ± 24.5 months (mean ± SD). Athletes undergoing bilateral hip arthroscopy returned to sports at a high rate (81.7%), demonstrated significant improvements in all recorded PROs, and achieved the MCID and PASS for the HOS-SSS at rates of 80.9% and 64.7%, respectively. PROs, RTS rate, and rates of achieving the MCID and PASS for the HOS-SSS were similar when the bilateral study group was compared with the unilateral control group (P > .05).

CONCLUSION

High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

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

OBJECTIVE

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.

DESIGN

Systematic review.

DATA SOURCES

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.

ELIGIBILITY CRITERIA

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.

RESULTS

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.

CONCLUSIONS

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.

Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated with Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement

PURPOSE

The purpose of this article was to report prevalence of iliopsoas pathology in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI), incidence of rendered tenotomy, and outcomes of hips with iliopsoas involvement compared with those with primary FAI.

METHODS

A cohort study from a hip arthroscopy study group using a prospectively-collected multicenter database was performed. Patients who underwent isolated hip arthroscopy for FAI from January 2016 to March 2017 were assigned to the Iliopsoas group (defined as preoperative diagnosis of coxa saltans internus, intraoperative anteroinferior labral bruising or tear, and preoperative positive psoas injection) or control group. The prevalence of iliopsoas pathology, radiographic and intraoperative findings, and rendered procedures between groups were compared. Mean 2-year (minimum 1.8 year) outcomes of iliopsoas groups with and without rendered tenotomy and a control group were compared.

RESULTS

There were 1393 subjects, of which 92 (7%) comprised the iliopsoas study group with 1301 subjects control subjects. Sixteen subjects in the iliopsoas group received tenotomy (17% of iliopsoas group, 1% of all subjects), whereas 76 subjects (83% of iliopsoas group) with iliopsoas involvement did not. There was significant effect on postoperative International Hip Outcome Tool-12 (iHOT-12) scores based on iliopsoas involvement and treatment, F(2,1390) = 3.74, P = .02. Compared with the control group (M = 73, standard deviation [SD] = 24), the non-tenotomized iliopsoas group (M = 69, SD = 32) had similar postoperative scores (P = .46), whereas the tenotomized iliopsoas group (M = 57, SD = 28) averaged lower postoperative scores (P = .03). In the tenotomy group, 25% achieved the iHOT-12 substantial clinical benefit and patient acceptable symptomatic state value for normal function and 100% satisfaction, compared to 49% and 41% for the without tenotomy and control groups.

CONCLUSIONS

Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for FAI is infrequently performed and is associated with poorer outcomes. Co-afflicted patients treated without tenotomy have similar successful outcomes to patients with primary FAI. Indiscriminate tenotomy for iliopsoas pathology in this setting should be cautiously considered.

LEVEL OF EVIDENCE

Level III, cohort study.

Meditation Monologue can Reduce Clinical Injection-Related Anxiety: Randomized Controlled Trial

Background.

Strategies to reduce anxiety prior to injection procedures are not well understood. The purpose is to determine the effect of a meditation monologue intervention delivered via phone/mobile application on pre-injection anxiety levels among patients undergoing a clinical injection. The following hypothesis was tested: patients who listened to a meditation monologue via phone/mobile application prior to clinical injection would experience less anxiety compared to those who did not.

Methods.

A prospective, randomized controlled trial was performed at an orthopedics and sports medicine clinic of a tertiary level medical center in the New England region, USA. Thirty patients scheduled for intra- or peri-articular injections were randomly allocated to intervention (meditation monologue) or placebo (nature sounds) group. Main outcome variables were state and trait anxiety inventory (STAI) scores and blood pressure (BP), heart rate, and respiratory rate.

Results.

There were 16 participants who were allocated to intervention (meditation monologue) while 14 participants were assigned to placebo (nature sounds). There was no interaction effect. However, a main time effect was found. Both state anxiety (STAI-S) and trait anxiety (STAI-T) scores were significantly reduced post-intervention compared to pre-intervention (STAI-S: p = 0.04, STAI-T: p = 0.04). Also, a statistically significant main group effect was detected. The pre- and post- STAI-S score reduction was greater in the intervention group (p = 0.028). Also, a significant diastolic BP increase between pre- and post-intervention was recorded in the intervention group (p = 0.028), but not in the placebo group (p = 0.999).

Conclusion.

Listening to a meditation monologue via phone/mobile application prior to clinical injection can reduce anxiety in adult patients receiving intra- and peri-articular injections. Registration:ClinicalTrials.gov NCT02690194

The Limited Reliability of Physical Examination and Imaging for Diagnosis of Iliopsoas Tendinitis

PURPOSE

To determine if any association exists between physical examination, imaging findings [ultrasound (US) and magnetic resonance imaging (MRI)], and iliopsoas tendinitis (IPT) to characterize the reliability of these diagnostic modalities.

METHODS

Patients who had undergone US-guided iliopsoas tendon sheath injection (of lidocaine and a corticosteroid agent) as well as MRI performed within 1 year of injection from 2014 to 2019 were retrospectively reviewed. Demographic data, response to physical exam maneuvers, and response to injection were queried from patient records. US and MRI were reviewed by 2 independent musculoskeletal-trained radiologists. Response to injection was considered positive if the patient improved by >2 points on a 0- to 10-point VAS score. Chi-squared and Fisher exact testing were used to assess for any associations. Sensitivities, specificities, positive predictive values, and negative predictive values were calculated.

RESULTS

Sixty-three patients, age 52.3 ± 17.3 years (mean ± standard deviation), body mass index 27.4 ± 4.3 kg/m², and follow-up 33.6 ± 20.6 months, met inclusion criteria. No physical exam maneuvers, sonographic features, or MRI findings were significantly associated with response to iliopsoas tendon injection (P > .05). Groin pain had a sensitivity of 100% but a specificity of 7%. Snapping hip had a specificity of 82% but a sensitivity of 24%. Pain with resisted straight leg raise (SLR) (sensitivity 62%, specificity 25%) and weakness with resisted SLR (sensitivity 15%, specificity 71%) both were nonreliable. Sonographic bursal distension and tendinosis had low sensitivities (67% and 63%, respectively) and specificities (35% and 32%). Bursal distension on MRI had sensitivity and specificity of 64% and 45%, respectively. Tendon thickening had sensitivity and specificity of 55% and 60%, respectively, and heterogeneity had sensitivity and specificity of 52% and 65%.

CONCLUSION

Neither physical examination nor US or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected IPT.

LEVEL OF EVIDENCE

III, retrospective comparative trial limited by lack of a reference standard for iliopsoas tendonitis diagnosis.

Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Postoperative Outcomes

BACKGROUND

Arthroscopic iliopsoas tendon release is a surgical treatment option for painful snapping hips, although it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy.

PURPOSE

To systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopic surgery as an intervention for painful snapping hips.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A total of 3 online databases (Embase, PubMed, and MEDLINE) were searched from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopic surgery. Studies were screened by 2 reviewers independently and in duplicate, and studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all included studies.

RESULTS

Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824), with a mean age of 28.1 years (range, 12-62 years) and mean follow-up of 32.1 months (range, 3-73 months). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) or the lesser trochanter in 64 hips (7.3%). The overall reported success rate of the procedure in resolving snapping hips was 93.0% (266/286), and all studies reported an improvement in functional outcome scores. Only 6 studies (93 hips) discussed postoperative hip flexion strength, with complete recovery of strength reported in 4 studies (47 hips) and mild decreases reported in the other 2 studies (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies; 66 hips) and was found postoperatively in 92.4% (61/66) of hips. No major complications were reported.

CONCLUSION

Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. Although patients demonstrated some early postoperative weakness and iliopsoas atrophy on radiological imaging, the results from studies to date showed satisfactory clinical function and return to sports/activities. High-quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release to determine the optimal technique and location of tendon release.

Hip Flexor Injuries in the Athlete

Athletic injuries to the hip flexors and iliopsoas have been described in populations across all levels of competitive sports. Overall estimates of hip flexor pathology have ranged from 5% to 28% of injuries among high-risk sport specific groups. Although most of these injuries are successfully treated with conservative management, and high rates of return to play are observed, significant rehabilitation time can be involved. As the understanding of hip pathology with imaging modalities such as MRI has advanced, greater importance has been placed on accurately diagnosing hip flexor injuries and initiating rehabilitation protocols early to minimize time loss from sport.

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%).

Severe Weakness of Hip Flexor after Iliopsoas Tenotomy: Two Case Reports

Hip arthroscopies are becoming a standard surgical technique, with psoas tenotomy being a relatively common procedure during this operation. A 37-year-old male and a 42-year-old female with internal hip snapping came to our department. Arthroscopic partial psoas tenotomy of the iliopsoas portion of the conjoint tendon was performed, but its results were bad. Patients reported preoperative unilateral low-back pain and weakness when flexing the hip. Unilateral atrophy of the lumbar psoas and fatty multifidus were detected in both cases. Patients at risk of unsatisfactory outcomes after psoas tenotomy should be ideally identified prior to surgery. Warning symptoms, physical examination, and imaging studies should be considered to avoid unsatisfactory results.

Ultrasound-Guided Iliopsoas Tendon Release: A Cadaveric Investigation

BACKGROUND

The iliopsoas is a common source of anterior hip pain. Refractory cases may require surgical intervention, with reported complication rates ranging from 3% to 50%. Development of a minimally invasive, outpatient method of iliopsoas tendon release is desirable and may reduce costs, lower complications, and improve recovery time.

OBJECTIVE

To describe and evaluate the safety and reproducibility of an ultrasound-guided (USG) iliopsoas tendon release using a spinal needle in a cadaveric model.

DESIGN

Prospective, cadaveric laboratory investigation.

SETTING

Academic Institution Procedural Skills Laboratory.

PARTICIPANTS

Five unembalmed cadaveric specimens (three female, two male), 69 to 93 years of age (mean 83.2 years), with a mean body mass index (BMI) of 24.5 kg/m² (range 19.2 to 30.3 kg/m² ).

INTERVENTIONS

Two operators each performed five USG iliopsoas tendon releases. Three additional investigators dissected the pelves to assess completeness of tendon release and damage to adjacent structures.

MAIN OUTCOME MEASURES

Successful transection, completeness (%) of the tendon transection, damage to adjacent structures, and procedural time.

RESULTS

Nine of 10 releases achieved the target release of ≥75% tendon transection. One procedure achieved 50% tendon release. No injury to adjacent structures was identified. The mean duration of the procedure was 6.19 minutes.

CONCLUSIONS

USG iliopsoas tendon release can be performed in a cadaveric model, consistently achieve the desired percentage of tendon release, does not result in injury to adjacent neurovascular structures, and takes approximately 6 minutes to perform. Although results cannot be generalized to a clinical setting, due to the minimally invasive nature of the procedure, it is likely that this procedure can be performed safely in an outpatient setting under local anesthesia, will cost less, and will facilitate a more rapid recovery when compared to standard surgical procedures. Further research is warranted for clinical application.

Iliopsoas Release in Hip Arthroscopy: Assessment of Muscle Atrophy

Iliopsoas release is a common procedure for coxa saltans interna of the hip. The possible sequelae from this surgery have not been well studied. The purpose of this study was to determine postoperative atrophy and morphology of the cut tendon. This retrospective review included patients who underwent arthroscopic iliopsoas release and had magnetic resonance imaging of the ipsilateral hip before and after surgical intervention. Cross-sectional area measurements were obtained of the iliopsoas muscle at the level of the distal anterior inferior iliac spine as well as at the L5 vertebral pedicle in patients who had imaging that included the lower lumbar spine. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and the Hip Outcome Score subscales for activities of daily living (HOS ADL) and sport (HOS Sport). A total of 44 patients met inclusion criteria for this study; 26 patients had additional advanced imaging that included the lumbar spine. The cross-sectional area of the iliopsoas at the level of the anterior inferior iliac spine decreased postoperatively by a mean of 191.4 mm²;, this difference was statistically significant (P<.0001). Mean area at the L5 pedicle was 628.9 mm² on the released side and 1216.2 mm² on the nonoperative side (P<.05). Mean Goutallier-Fuchs score of the released iliopsoas at the L5 pedicle was 1.3 (SD, 0.7). Mean mHHS, HOS ADL, and HOS Sport scores for patients at least 1 year postoperatively were 51, 56, and 42, respectively. [Orthopedics. 2020;43(3):e171-e176.].

Rate of Return to Sport and Functional Outcomes After Bilateral Hip Arthroscopy in High-Level Athletes

BACKGROUND

Bilateral hip symptoms are common in athletes, and athletes may require treatment with bilateral hip arthroscopy. Return-to-sport (RTS) rates in competitive athletes after unilateral procedures have been reported at 74% to 93%; however, RTS rates after bilateral hip arthroscopy are still unknown.

PURPOSE/HYPOTHESIS

The purpose was to determine rate of RTS in competitive athletes undergoing bilateral hip arthroscopy and report minimum 1-year patient-reported outcomes (PROs) for this cohort. We hypothesized that after bilateral hip arthroscopy, the RTS rate would be similar to the square of the probability of returning after unilateral hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected on patients undergoing hip arthroscopy at our institution from November 2011 to July 2018. Patients were included if they underwent bilateral hip arthroscopy and were a high school, collegiate, or professional athlete before their first surgery. A patient's RTS was defined as return to competitive participation in one's sport at a level the same as or higher than the preoperative level. Additionally, minimum 1-year PROs, including modified Harris Hip Score (mHHS), nonarthritic hip score, and Hip Outcome Score-Sports Specific Subscale (HOS-SSS), as well as complication rates and future surgery were compared for all patients. Rates of reaching the minimal clinically importance difference (MCID) and patient acceptable symptomatic state (PASS) for the mHHS (8 and 74, respectively) and HOS-SSS (6 and 75, respectively) were also recorded.

RESULTS

A total of 87 patients met inclusion criteria, for which follow-up was available for 82 (94.3%). At latest follow-up, 100% of professional athletes had returned to their sport, while 53.7% of the entire cohort returned to their sport, with 75.8% of male patients returning versus 38.8% of female patients (P < .001). Of patients returning, 56% did so at the same ability or higher. The most common reason for not returning was graduation or lifestyle change (47.4%). Patients returning to sport had significantly higher PROs at latest follow-up relative to those who did not return, including mHHS (93.7 vs 87.5), nonarthritic hip score (94.4 vs 88.2), and HOS-SSS (90.9 vs 78.2) (P < .05). Rates of achieving the PASS and MCID for the mHHS were not significantly different. However, for the HOS-SSS, patients who returned had significantly higher rates of achieving the MCID and PASS thresholds.

CONCLUSION

The rate of RTS among competitive athletes after bilateral hip arthroscopy was similar to the square of published RTS rates after unilateral hip arthroscopy. Both those who returned to play and those who did not showed significant improvement in PROs after surgery. However, those who returned to sports achieved significantly higher scores in all outcome measures. Additionally, patients returning to sports showed a significantly higher rate of attaining the MCID and PASS scores for the HOS-SSS.

Indications for hip arthroscopy in pediatric patients a systematic review

The purpose of this study was to evaluate the current available literature on hip arthroscopy and determine the clinical indications in the pediatric patient population (age ≤ 18). In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a comprehensive literature search was performed on the 23 October 2018 using PubMed, Cochrane Library, Embase and e-books to identify research surrounding the use of hip arthroscopy in the pediatrics. Exclusion criteria were studies that described joints other than the hip, animal studies, systematic reviews, open procedures and those that reported solely on patients aged 19-year-old and older. From 232 studies, 57 were reviewed in detail; 17 articles were removed as their indication fell into a category of ‘diagnostic hip arthroscopy for pain’ or no clear separation between the data on the adult and pediatric population could be made in a full text review of the paper. Eleven categories were identified as indications for hip arthroscopy in the pediatric population. At best a Grade C recommendation can be made to support the use of hip arthroscopy in the pediatric population. Our results support our hypothesis. Despite the exponential increase in hip arthroscopy over the last decade, limited evidence exists in support of its use in the pediatric (≤18) population. Our findings support the need for further research in delineating the indications for its use, as clearly arthroscopy may be advantageous in many situations, particularly in light of the alternatives.

Short-term Effect of Ultrasound-Guided Iliopsoas Peritendinous Corticosteroid Injection

OBJECTIVES

Treatment for iliopsoas tendinopathy includes ultrasound (US)-guided iliopsoas peritendinous corticosteroid injection. Evidence is lacking regarding US-guided iliopsoas injection efficacy in patients with iliopsoas tendinopathy and intra-articular (IA) hip abnormalities. The purpose of this study was to examine the efficacy of US-guided iliopsoas corticosteroid injection for iliopsoas tendinopathy in patients with and without IA hip abnormalities.

METHODS

This work was a prospective study evaluating patients aged 12 to 50 years with iliopsoas tendinopathy. Participants completed a Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire before and 6 weeks after injection. The main outcome measure was the change in HOOS subcategory scores. Independent variables included time and hip status. Normal hips were compared to abnormal hips with IA abnormalities. A 2-way repeated measures analysis of covariance with effect size (η² ) was used to determine injection effects on HOOS scores before and 6 weeks after injection.

RESULTS

A total of 178 patients (154 female and 24 male) were analyzed. Time effects were found for both normal and abnormal hips in all HOOS subcategories: symptoms (P = .041; η²  = 0.050), pain (P = .001; η²  = 0.184), activities of daily living (P = .011; η²  = 0.076), function in sports and recreation (P = .001; η²  = 0.151), and quality of life (QOL; P = .001; η²  = 0.193). Significant differences between normal versus abnormal hips were found in the sports and recreation (P = .032; η²  = 0.056) and QOL scores (P = .001; η²  = 0.135).

CONCLUSIONS

In patients with iliopsoas tendinopathy, US-guided iliopsoas corticosteroid injection improved outcomes regardless of coexisting IA hip abnormalities. Patients without IA hip abnormalities showed greater improvement in sports and recreation and QOL scores compared to patients with IA hip abnormalities. Ultrasound-guided iliopsoas injection for iliopsoas tendinopathy may advance short-term care and help continue with nonsurgical treatment regimens.

Editorial Commentary: Iliopsoas Fractional Lengthening: Treating a Disease or a Symptom?

Arthroscopic iliopsoas fractional lengthening requires careful patient selection, specifically reproducible symptoms, confirmatory physical examination, suggestive imaging findings, and evaluation for microinstability. Resolution of hip snapping is expected in about 80% of cases, but there is a possibility of weakness and pain, presumably from microinstability from the loss of a dynamic anterior hip stabilizer.

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

PURPOSE

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.

METHODS

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.

RESULTS

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

CONCLUSIONS

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 OF EVIDENCE

Level III, retrospective comparative study.

Iliopsoas tendonitis after hip arthroscopy: prevalence, risk factors and treatment algorithm

The incidence of iliopsoas tendonitis (IPT) has not previously reported following hip arthroscopy for femoroacetabular impingement with or without labral tears. (i) What is the incidence of IPT following hip arthroscopy; (ii) are there any demographic risk factors and (iii) are there any operative techniques that are risk for IPT? Retrospective study. Hip arthroscopy patients from 2005 to 2012 were included. Patients were diagnosed via physical examination findings and were excluded if they had pre-operative IPT. Records were reviewed for demographics, operative reports and operative procedures. All patients received either labral debridement, labral repair, osteoplasty or a combination of those procedures. A standardized rehabilitation protocol was used. Of 252 patients, 60 (24%) had IPT. Twenty-eight (47%) had symptom resolution with activity modification, physical therapy and NSAIDs. Thirty-two (53%) required corticosteroid injection at a mean of 25 weeks after surgery. Seven (12%) required revision arthroscopy and iliopsoas release to resolve the symptoms. There were no patient-specific risk factors, differences based on surgical technique, and number of portals did not matter. Patients should minimize exercises that activate the iliopsoas after hip arthroscopy. The cause of IPT could be related to unaddressed abnormal mechanics, tendon scarring or improper physical therapy. Further studies are needed to investigate the reasons for this, as well as specific techniques to lower its incidence. The incidence of IPT after hip arthroscopy has an incidence of 24%. Additionally, we provide readers with a rehabilitation protocol to minimize this complication.

Does Iliopsoas Lengthening Adversely Affect Clinical Outcomes After Hip Arthroscopy? A Multicenter Comparative Study

BACKGROUND

Iliopsoas fractional lengthening (IFL) continues to be a controversial procedure in hip arthroscopy.

HYPOTHESIS

Patients who underwent arthroscopic surgery for femoroacetabular impingement (FAI) and a labral tear either with or without IFL would experience favorable outcomes, and there would be no difference in postoperative patient-reported outcomes (PROs) between the 2 groups at minimum 2-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from July 2009 and April 2015 were retrospectively reviewed. Patients were eligible if they had hip arthroscopy for both FAI and labral tear treatment with IFL and without IFL. IFL was indicated for painful internal snapping. Minimum postoperative follow-up was set to 2 years. The authors calculated the modified Harris Hip Score, International Hip Outcome Tool-12, Hip Outcome Score-Activity of Daily Living Score, Hip Outcome Score-Sports Specific Subscale, Non-Arthritic Hip Score, visual analog scale for pain, patient satisfaction, minimal clinically important difference (MCID), and the percentage of patients who achieved patient acceptable symptomatic state (PASS). Revision surgeries and conversions to total hip arthroplasty (THA) were documented.

RESULTS

351 hips (307 patients) met the necessary inclusion criteria in the IFL cohort, with a mean ± SD follow-up time of 42.5 ± 18.1 months. For the control cohort, 392 hips (354 patients) were included, with a mean ± SD follow-up time of 43.9 ± 19.6 months. Both groups showed significant postoperative improvement in 2-year follow-up PROs. The group with iliopsoas lengthening showed comparable results to the control group with respect to PRO improvement, MCID, PASS, and rates of revision or THA conversion.

CONCLUSION

This comparative cohort study demonstrated that treatment of painful internal snapping syndrome with arthroscopic IFL, in the setting of FAI and a labral tear, is a safe procedure with good short- to mid-term follow-up results and associated improvement in PROs. Patients who underwent IFL showed similar outcomes compared with a control group treated for FAI and labral tear without IFL. In appropriately selected patients, arthroscopic IFL did not adversely affect clinical outcomes compared with patients who did not need IFL.

Return to Play After Hip Arthroscopy: A Systematic Review and Meta-analysis

BACKGROUND

The use of arthroscopic treatment for intra-articular hip pathology has demonstrated improved patient-reported outcomes (PROs) with a lower rate of complications, reoperation, and patient morbidity as compared with traditional methods. Although the use of this minimally invasive approach has increased in prevalence, no evidence-based return-to-play (RTP) criteria have been developed to ensure an athlete's preparedness for sporting activities.

PURPOSE

To determine if there exists sufficient evidence in the literature to support an RTP protocol and functional assessment after hip arthroscopy, as well as to assess the mean rate and duration of RTP.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The search terms "hip arthroscopy," "return to play," and 10 related terms were searched in PubMed, Cochrane Library, Scopus, and Web of Science, yielding 263 articles. After screening, 22 articles were included. RTP timeline, rehabilitation protocols, and conditional criteria measures were assessed with previously established criteria. Pooled estimates were calculated for RTP rate and duration, and weighted mean scores were determined for PROs.

RESULTS

A total of 1296 patients with 1442 total hips were identified. Although 54.5% (12 of 22) of studies did not provide a guideline for RTP duration after hip arthroscopy, 36.4% (8 of 22) recommended a duration of 4 months, while 9.1% (2 of 22) recommended 3 months. The most frequently described postoperative rehabilitation protocols were weightbearing guidelines (15 studies) and passive motion exercises (9 studies). Only 2 studies satisfied the criteria for a sufficient RTP protocol, and 3 provided a specific replicable test for RTP. The mean RTP duration was 7.4 months (95% CI, 6.1-8.8 months), and the return rate was 84.6% (95% CI, 80.4%-88.8%; P = .008) at a mean ± SD follow-up of 25.8 ± 2.4 months. Mean modified Harris Hip Score (mHHS) improved from 63.1 to 84.1 postoperatively (+33.3%), while Non-arthritic Hip Score improved from 61.7 to 86.8 (+40.7%). A lower preoperative mHHS was significantly associated with a higher postoperative improvement ( r = -0.95, P = .0003).

CONCLUSION

Significant variability exists in RTP protocols among institutions owing to a lack of standardization. Despite a high overall rate of RTP and improvement in PROs after hip arthroscopy, the majority of rehabilitation protocols are not evidence based and rely on expert opinion. No validated functional test currently exists to assess RTP.

Outcomes of Joint Preservation Procedures for Cartilage Injuries in the Hip: A Systematic Review and Meta-analysis

Background:

The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy.

Purpose:

To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs).

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was performed using the terms “hip arthroscopy,” “microfracture,” “autologous chondrocyte implantation,” “fibrin glue,” “osteochondral transfer,” and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis.

Results:

A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm² (95% CI, 1.9-3.0 cm²). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score–Activities of Daily Living and Hip Outcome Score–Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% (P < .05).

Conclusion:

Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.

Arthroscopic Treatment of Iliopsoas Snapping in Patients With Radiographic Acetabular Dysplasia Using Iliopsoas Fractional Lengthening and Capsular Plication

PURPOSE

The purpose of this study was to evaluate the greater than 2-year patient-reported outcomes (PROs) and patient satisfaction of patients who were treated with hip arthroscopy for snapping iliopsoas tendons that were painful with concomitant acetabular dysplasia and who underwent iliopsoas lengthening for symptomatic iliopsoas tendon snapping with concomitant capsular plication and treatment of hip impingement. Secondary measures included observation of the change in the Tönnis grade at greater than 2 years' follow-up.

METHODS

Between July 2009 and December 2011, data on patients with a lateral center-edge angle (LCEA) of less than 25° (range, 19°-24°) who underwent hip arthroscopy with central-compartment iliopsoas fractional lengthening and capsular plication were prospectively collected and retrospectively reviewed. Interportal capsular repair was performed using between 2 and 5 simple sutures. Patients also underwent procedures to treat hip impingement pathology. All patients had preoperative and minimum 2-year postoperative PRO measures: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score. The visual analog scale score and patient satisfaction with surgery (from 0 to 10) were also collected. Radiographs were analyzed preoperatively and at latest follow-up to assess progression of the Tönnis grade.

RESULTS

We analyzed 32 patients who met the inclusion criteria (30 female and 2 male patients; mean age, 25 years). The mean LCEA and anterior center-edge angle were 21.6° and 25.5°, respectively. Four patients required revision arthroscopy for labral retears. Among the 28 patients who did not undergo revision surgery, the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score improved from 68.7 to 83.5, from 64.9 to 86.6, from 71.6 to 86.7, and from 52.6 to 75.8, respectively (P < .001). The visual analog scale score improved from 5.6 preoperatively to 1.9 at latest follow-up (P < .001). The mean patient satisfaction rating was 8.0. There was no radiographic progression of the Tönnis grade at final follow-up.

CONCLUSIONS

This study showed that patients with an LCEA of less than 25° and associated painful iliopsoas snapping can be treated by addressing concomitant pathology and performing central-compartment fractional lengthening of the iliopsoas tendon with concomitant capsular plication and have high satisfaction, improvement in PROs, and improved pain scores, without significant progression of osteoarthritis.

LEVEL OF EVIDENCE

Level IV, case series.

[Arthroscopic treatment of psoas impingement]

OBJECTIVE

Tenotomy of the psoas tendon in symptomatic internal coxa saltans or psoas impingement should relieve pain.

INDICATIONS

Indicated in conservative treatment-resistant internal coxa saltans and in psoas impingement.

CONTRAINDICATIONS

Contraindications are symptomatic psoas pathologies in hip dysplasia patients.

SURGICAL TECHNIQUE

Three different procedures exist with the arthroscopic technique, in which the psoas tenotomy can be performed at one of three different levels. These are the arthroscopic transcapsular, the endoscopic extra-articular, and the arthroscopic central techniques.

POSTOPERATIVE MANAGEMENT

Forearm crutches are recommended for approximately 2-4 weeks as well as physiotherapy to strengthen the hip flexors.

RESULTS

A literature-based comparison could reveal no difference between the extra-articular and transcapsular techniques. Particularly in the long term was no loss of strength evident. Various different authors describe the techniques as good, finding neither complications nor recurrence of internal snapping hip.

Clinical Outcomes and Return to Sport in Competitive Athletes Undergoing Arthroscopic Iliopsoas Fractional Lengthening Compared With a Matched Control Group Without Iliopsoas Fractional Lengthening

PURPOSE

To compare the minimum 2-year outcomes and return to sports in competitive athletes after arthroscopic iliopsoas fractional lengthening (IFL) and treatment for femoroacetabular impingement (FAI) to competitive athletes treated for FAI who did not undergo IFL.

METHODS

Data were prospectively collected and retrospectively reviewed between November 2009 and April 2014. Included patients were high school, collegiate, or professional athletes who underwent arthroscopic IFL, treatment for FAI, and preoperative modified Harris Hip Score, Non-Arthritic Athletic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Exclusion criteria were patients younger than 16 years, Tönnis grade >1, microfracture, abductor pathology, and previous hip conditions. A subgroup of athletes were matched to athletes who did not undergo IFL by age ± 5 years, sex, and body mass index ± 5.

RESULTS

There were 75 athletes eligible for inclusion, 60 (80.0%) of whom had minimum 2-year follow-up. All patient-reported outcome (PRO) scores demonstrated significant improvements at latest follow-up (P < .001). Mean satisfaction was 7.9. No patients converted to arthroplasty. Painful snapping was resolved in 55 athletes (91.7%). Nine athletes (15.0%) had nonpainful snapping at follow-up. Thirty-nine (65%) returned to their sport. Forty (66.7%) maintained or improved their competitive abilities. There was one case (1.6%) of temporary postoperative numbness. There were no complaints of weakness in hip flexion. Forty-one IFL athletes were matched to 41 controls. No differences were detected in demographics, follow-up time, intraoperative findings, procedures, mean magnitudes of improvement, or return to sports.

CONCLUSIONS

In competitive athletes, IFL during hip arthroscopy is safe and demonstrates favorable improvements in PROs and VAS, high satisfaction, and high rate of symptom resolution at a minimum of 2 years postoperatively. Most patients were able to return to sports and maintain or improve their competitive levels. These results were similar to a control group of athletes not requiring IFL.

LEVEL OF EVIDENCE

Level III, case-control study.

Sports Injuries about the Hip: What the Radiologist Should Know

Injuries of the hip and surrounding structures represent a complex and commonly encountered scenario in athletes, with improper diagnosis serving as a cause of delayed return to play or progression to a more serious injury. As such, radiologists play an essential role in guiding management of athletic injuries. Familiarity with hip anatomy and the advantages and limitations of various imaging modalities is of paramount importance for accurate and timely diagnosis. Magnetic resonance (MR) imaging is often the modality of choice for evaluating many of the injuries discussed, although preliminary evaluation with conventional radiography and use of other imaging modalities such as ultrasonography (US), computed tomography, and bone scintigraphy may be supplementary or preferred in certain situations. Stress fractures, thigh splints, and posterior hip dislocations are important structural injuries to consider in the athlete, initially imaged with radiographs and often best diagnosed with MR imaging. Apophyseal injuries are particularly important to consider in young athletes and may be acute or related to chronic repetitive microtrauma. Femoroacetabular impingement has been implicated in development of labral tears and cartilage abnormalities. Tear of the ligamentum teres is now recognized as a potential cause of hip pain and instability, best evaluated with MR arthrography. Greater trochanteric pain syndrome encompasses a group of conditions leading to lateral hip pain, with US playing an increasingly important role for both evaluation and image-guided treatment. Muscle injuries and athletic pubalgia are common in athletes. Lastly, snapping hip syndrome and Morel-Lavallée lesions are two less common but nonetheless important considerations. ^©RSNA, 2016.

Return to Sport and Clinical Outcomes After Hip Arthroscopic Labral Repair in Young Amateur Athletes: Minimum 2-Year Follow-Up

PURPOSE

To determine the rate of return of young amateur athletes to sport after hip arthroscopy, their clinical outcomes, and pathologic risk factors for worse outcomes 2 years after surgery.

METHODS

This study included all patients between age 13 and 23 who participated in a sport prior to surgery with intent to return who underwent hip arthroscopy after failure of comprehensive nonoperative management for whom 2-year outcome scores were available. Outcomes collected retrospectively included modified Harris Hip Score (mHHS) and the Hip Outcome Scores (HOS) subscales for activities of daily living (ADL) and sport (HOS Sport). In addition, sport played, return to sport rates, and Tegner Scores were measured preinjury and postoperatively. Descriptive statistics were used to present demographic data. A priori analysis was used to determine the sample size needed to show minimal clinically important differences for mHHS, HOS ADL, and HOS Sport.

RESULTS

The study population included 50 patients with a mean age of 17.8 years. Athletes returned to sport at a rate of 92% (46/50). At a mean follow-up of 34 months, the mean mHHS, HOS ADL, and HOS Sport outcome scores were 85, 91, and 80 for the entire study group; 87, 92, and 84 for the group that returned to sport; and 67, 82, and 41 for the group that did not return to sport, respectively. Median preinjury and postoperative Tegner levels were 8 and 7, respectively. Labral takedown and reattachment was associated with lower HOS ADL (P = .01) and HOS Sport scores (P = .02).

CONCLUSIONS

Athletes returned to sport at a high rate (92%; 46/50) after hip arthroscopy and perform activities at near preinjury levels. In this group of athletes, arthroscopic labral repair with chondrolabral preservation, which reflected less severe chondrolabral pathology, performed better than labral repair with takedown and reattachment.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Musculoskeletal Approach to Pelvic Pain

Visceral and somatic causes of pelvic pain are often inter-related, and a musculoskeletal examination should always be considered for the successful diagnosis and treatment of pelvic pain. For the diverse etiologies of hip pain, there are many unique considerations for the diagnosis and treatment of these various disorders. Pelvic pain is often multidimensional due to the overlap between lumbo-hip-pelvic diagnoses and may require a multidisciplinary approach to evaluation and management.

Magnetic Resonance Imaging Appearance of the Hip Musculature After Arthroscopic Labral-Level Iliopsoas Tenotomies

BACKGROUND

Iliopsoas (IP) muscle atrophy is a known consequence of open IP tenotomy, but the severity of IP muscle atrophy that occurs after arthroscopic labral-level IP tenotomies has not been documented.

PURPOSE

To document the severity of muscle atrophy that occurs in the iliacus, psoas, and adjacent hip musculature after arthroscopic labral-level IP tenotomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-eight patients who had magnetic resonance arthrograms (MRAs) obtained prior to and 3 months to 5 years after arthroscopic labral-level IP tenotomies are the basis of this report. The pre- and postoperative MRAs of each patient were examined in consensus by 2 musculoskeletal radiologists who graded the postoperative muscle atrophy from 0 (no fatty infiltration) to 4 (>75% fatty infiltration) and noted any compensatory muscle hypertrophy or abnormal IP tendon morphology. Patients also were assessed with the Byrd 100-point modified Harris Hip Scoring system (MHHS) preoperatively and at the time of their postoperative MRA.

RESULTS

Postoperative MRAs were obtained on average 1.7 years (range, 3 months to 5 years) after hip arthroscopy. None of the patients had muscle atrophy on their preoperative MRAs. In contrast, 89% of patients had iliacus and psoas muscle atrophy on their postoperative MRAs, but only 2 (7%) developed grade 4 atrophy, and the majority (64%) had either grade 1 (n = 15) or no atrophy (n = 3). In addition, there were no significant differences in the MHHS of the patients with mild (grades 0-1), moderate (grades 2-3), or severe (grade 4) postoperative atrophy. Postoperative MRAs also demonstrated low-grade atrophy (grades 1-2) in the quadratus femoris (n = 5) and rectus femoris (n = 1) muscles, and 16 patients (57%) had distortion of the tendon, but none had a gap in their tendon.

CONCLUSION

A majority of patients (89%) developed IP muscle atrophy after arthroscopic labral-level IP tenotomies, and although this percentage was similar (89% vs 90%) to that reported with lesser trochanteric IP tenotomies, the patients did not (1) develop atrophy of the gluteus maximus and vastus lateralis muscles, (2) have chronic IP tendon disruption, or (3) develop the severity of IP atrophy (55% grade 4 vs 7% grade 4) that has been reported after arthroscopic lesser trochanteric IP tenotomies.

Snapping hip syndrome: systematic review of surgical treatment

The snapping hip (SH) syndrome is characterised by an audible snapping, often accompanied by pain, which usually occurs with the flexion and extension of the hip during exercise or ordinary daily activities.The causes of SH can be classified as external, internal and intraarticular. The prevalence of asymptomatic SH in the population is unknown and the incidence of symptomatic cases is not well-defined. The painless snapping in the hip is common in the general population; the symptomatic SH with debilitating pain and weakness is often seen in those who take part in activities such as ballet and running hurdles.The clinician's goal is to determine the cause and treat patients who have symptomatic SH so that they may return to their activities or to athletic peak performance.Most patients with SH can be treated conservatively. However, surgery may be indicated if the condition becomes chronically symptomatic. Arthroscopy may prove useful in the treatment of intraarticular lesions that are causing discomfort. Various techniques have been described with different grades of success. The aim is to achieve the least invasive procedure with the lowest potential complications that corrects the painful snapping, according to the patient's characteristics.The purpose of this systematic review is to clarify the results of the surgical treatment of SH, after the failure of the conservative treatment.

Arthroscopic Psoas Management: Techniques for Psoas Preservation and Psoas Tenotomy

The iliopsoas tendon is an important dynamic stabilizer of the hip joint, and it should be carefully identified and preserved during routine hip arthroscopy. However, it may also be a source of hip pain manifesting as iliopsoas tendinitis or a snapping hip or contributing to the development of labral pathology caused by psoas impingement. In the appropriately indicated, refractory cases of iliopsoas-related hip pain, surgical intervention in the form of an iliopsoas tenotomy at the level of the labrum can result in reliable pain relief. We describe a method to identify and protect the iliopsoas tendon during routine hip arthroscopy when preservation is desired. In addition, we detail how to deepen the psoas tunnel if psoas impingement is present but psoas tenotomy is contraindicated. We also describe a reproducible technique of arthroscopic iliopsoas tenotomy using standard portals and minimal equipment when indicated.

Endoscopic release of internal snapping hip: a review of literature

BACKGROUND

Internal snapping hip is a common clinical condition, characterized by an audible or palpable snap of the medial compartment of the hip. In most cases it is asymptomatic, while in a few patients, mostly in athletes who participate in activities requiring extremes of hip range of motion, the snap may become painful (internal snapping hip syndrome - ISHS).

MATERIALS AND METHODS

This is a review of current literature, focused on the pathogenesis, diagnosis and treatment of ISHS.

CONCLUSION

The pathogenesis of ISHS is multifactorial, and it is traditionally believed to be caused by the tendon snapping over the anterior femoral head or the iliopectineal ridge. Most cases of ISHS resolve with conservative treatment, which includes avoidance of aggravating activities, stretching, and NSAIDs. In recalcitrant cases, surgery may be indicated. Better results have been reported with endoscopic iliopsoas tendon release compared with open techniques, which may be related to the treatment of concomitant intra-articular pathologies. Furthermore, endoscopic treatment showed fewer complications, decreased failure rate and postop erative pain. It is important to remember that in most cases, a multiple iliopsoas tendon may exist, and that the incomplete release of the iliopsoas tendon can be a reason for refractory pain and poor results. Then, even if of not clinical relevance at long term follow-up, patients should be told about the inevitable loss of flexion strength after iliopsoas tenotomy.

LEVEL OF EVIDENCE

II.

Hip Dislocation or Subluxation After Hip Arthroscopy: A Systematic Review

PURPOSE

To determine patient- and surgery-specific characteristics of patients sustaining postarthroscopic hip dislocation or subluxation.

METHODS

A systematic review of multiple medical databases was registered with PROSPERO and performed using Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines. Level I to IV clinical outcome studies reporting the presence of hip dislocation or subluxation after hip arthroscopy were eligible. Length of follow-up was not an exclusion criterion. All patient- and surgery-specific variables were extracted from each, specifically evaluating osseous morphology and resection details; labral, iliopsoas, ligamentum teres, and capsular management; generalized ligamentous laxity; instability direction and mechanism; management; and outcome. Study authors were individually contacted to assess most recent outcome.

RESULTS

Ten articles with 11 patients were analyzed (mean patient age: 36.6 ± 12.3 years). There were 9 hip dislocations and 2 subluxations. Mean time between surgery and dislocation was 3.2 ± 4.0 months (range: recovery room to 14 months). Anterior was the most frequent dislocation direction (8 cases). Acetabular undercoverage (preoperative dysplasia or iatrogenic rim over-resection) was observed in 5 cases. Labral debridement was performed in 5 cases, iliopsoas tenotomy in 3 cases, and ligamentum teres debridement in 1 case. A "T" capsulotomy was created in 1 case (isolated interportal in other 10 cases). Capsular closure was performed in 2 cases (both interportal). Generalized ligamentous laxity was diagnosed in 1 case. A combination of external rotation and extension was observed in 5 of the 6 cases reporting the mechanism of anterior dislocation. Four cases were successfully treated with closed reduction; 4 required total hip arthroplasty; and 3 required revision capsulorrhaphy.

CONCLUSIONS

Postarthroscopic hip instability was observed in patients with acetabular undercoverage (including iatrogenic resection), labral debridement, capsular insufficiency, or iliopsoas tenotomy. Most dislocations were anterior, occurring with hip extension and external rotation.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment

Introduction

Athletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. This systematic review aims to identify the most common causes of groin pain in athletes requiring surgery. Additionally, it aims to further characterise their susceptible athlete profiles, common physical examination and imaging techniques, and surgical procedures performed. This will enable the orthopaedic sports medicine clinician/surgeon to best treat these patients.

Materials and methods

The electronic databases MEDLINE, PubMed and EMBASE were searched from database inception to 13 August 2014 for studies in the English language that addressed athletic groin pain necessitating surgery. The search was updated on 4 August 2015 to find any articles published after the original search. The studies were systematically screened and data were abstracted in duplicate, with descriptive data presented.

Results

A total of 73 articles were included within our study, with data from 4655 patients abstracted. Overall, intra-articular and extra-articular causes of groin pain in athletes requiring surgery were equal. The top five causes for pain were: femoroacetabular impingement (FAI) (32%), athletic pubalgia (24%), adductor-related pathology (12%), inguinal pathology (10%) and labral pathology (5%), with 35% of this labral pathology specifically attributed to FAI.

Conclusions

Given the complex anatomy, equal intra-articular and extra-articular contribution, and potential for overlap of clinical entities causing groin pain leading to surgery in athletes, further studies are required to ascertain the finer details regarding specific exam manoeuvres, imaging views and surgical outcomes to best treat this patient population.

The Functional and Structural Outcomes of Arthroscopic Iliopsoas Release

BACKGROUND

Arthroscopic release of the iliopsoas tendon may alleviate pain associated with internal snapping hip, but previous reports of physical function, hip strength, and muscle atrophy after surgery are mixed.

HYPOTHESIS

The hips of patients who underwent arthroscopic iliopsoas release would demonstrate significantly reduced hip flexion strength and iliopsoas muscle volume when compared with their contralateral hips and the hips of patients who underwent hip arthroscopy without psoas release.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Eighteen patients who underwent hip arthroscopy with iliopsoas release for symptomatic internal snapping hip and concomitant femoroacetabular impingement (FAI) and/or chondrolabral damage (release group) and 18 patients who underwent arthroscopy for FAI and/or chondrolabral damage without iliopsoas release (control group) were evaluated at a mean of 21 months (range, 16-30 months) postoperatively. Magnetic resonance images were performed and segmented to calculate iliopsoas volume. Isometric hip flexion strength was evaluated in the supine and seated positions with a custom testing apparatus. Differences between groups and differences between the operative and nonoperative limbs within groups were compared with unpaired and paired t tests, respectively.

RESULTS

In the release group, the iliopsoas muscle of the surgical limb was significantly smaller (288 ± 98 vs 384 ± 113 cm(3), P < .001) and weaker in the seated position (13 ± 4.7 vs 17 ± 5.8 kg, P < .001) than the contralateral limb. Compared with the control group, the release group demonstrated a greater percentage decrease in iliopsoas volume on magnetic resonance imaging (-25% ± 9.1% vs -0.6% ± 4.6%, P < .001) and seated hip flexion strength (-19% ± 16% vs -3.9% ± 20%, P = .018) between the operative and contralateral limbs. There were no significant differences in supine strength between limbs or groups (all P > .168).

CONCLUSION

Arthroscopic iliopsoas release results in iliopsoas atrophy with a 25% volume loss and a 19% reduction in seated hip flexion strength.

A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications

PURPOSE

This systematic review examines outcomes and risk profiles of the hip arthroscopy in the supine versus lateral decubitus positions to elucidate any superiority of one approach over the other.

METHODS

Three databases (Embase, PubMed, and Medline) were searched for studies that addressed hip arthroscopy performed in either position, and were subsequently screened by two reviewers with data abstracted in duplicate.

RESULTS

Similar outcomes were observed. Supine studies showed a greater mean postoperative improvement for modified Harris hip score (33.74), visual analog scale (-3.99), nonarthritic hip score (29.61), Harris hip score (35.73), and hip outcome score (31.4). Lateral decubitus studies showed greater improvement using the Western Ontario and McMaster University Osteoarthritis (14.76) score. Supine studies reported more neuropraxic injuries (2.06% v 0.47%), labral penetration (0.65% v 0%), and heterotopic ossification (0.21% v 0%). Lateral decubitus studies reported more fluid extravasation (0.21% v 0.05%) and missed loose bodies (0.08% v 0.01%). Similar rates of revision (1.8% lateral, 1.4% supine) and conversion to open procedures (2.6% in lateral, 2.0% in supine) were also identified.

CONCLUSIONS

Because of quality of evidence, direct comparisons are currently limited; however, the supine position is associated with more neuropraxic injuries, labral penetration, and heterotopic ossification, whereas lateral decubitus has increased risk of fluid extravasation and missed loose bodies. At this time, no evidence exists to establish superiority of one position.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Internal Snapping Hip Syndrome: Incidence of Multiple-Tendon Existence and Outcome After Endoscopic Transcapsular Release

PURPOSE

To report the frequency of presentation of bifid or multiple iliopsoas tendons in patients who underwent endoscopic release for internal snapping hip syndrome (ISHS) and to compare both groups.

METHODS

A consecutive series of patients with ISHS were treated with endoscopic transcapsular release of the iliopsoas tendon at the central compartment and prospectively followed up. The inclusion criteria were patients with a diagnosis of ISHS with failure of conservative treatment. During the procedure, the presence of a bifid tendon was intentionally looked for. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at last follow-up. Four patients presented with a bifid tendon and one patient had 3 tendons. At a minimum of 12 months' follow-up, the presence of snapping recurrence was evaluated and the WOMAC scores were compared between both groups.

RESULTS

Among 279 hip arthroscopies, 28 patients underwent central transcapsular iliopsoas tendon release. The mean age was 29.25 years (range, 16 to 65 years; 6 left and 22 right hips). Group 1 included 5 patients with multiple tendons; the remaining patients formed group 2 (n = 23). None of the patients presented with ISHS recurrence. The mean WOMAC score in group 1 was 39 points (95% confidence interval [CI], 26.2 to 55.4 points) preoperatively and 73.6 points (95% CI, 68.4 to 79.6 points) at last follow-up. In group 2 the mean WOMAC score was 47.21 points (95% CI, 44.4 to 58.2 points) preoperatively and 77.91 points (95% CI, 67.8 to 83.4 points) at last follow-up. We identified a bifid tendon retrospectively on magnetic resonance arthrograms in 3 of the 5 cases that were found to have multiple tendons during surgery. None of these were recognized before the procedures.

CONCLUSIONS

In this series the surgeon intentionally looked for multiple tendons, which were found in 17.85% of the cases. Clinical results in patients with single- and multiple-tendon snapping seem to be similarly adequate. However, the possibility of a type II error should be considered given the small number of patients.

LEVEL OF EVIDENCE

Level IV.