**4. Discussion**

An iliopsoas tenotomy has shown good to excellent postoperative outcomes in indicated patients with iliopsoas snapping/impingement. The systematic reviews of 11 eligible studies (248 patients), level IV studies revealed 'the resolution of snapping' as seen in 100% of patients who underwent an arthroscopic release and 77% of those who underwent open procedures. The complication rates

**49**

*Arthroscopic and Endoscopic Management of the Internal Snapping Hip Syndrome*

were higher in patients undergoing an open procedure (21%) compared with an arthroscopic procedure (2.3%). The analysis of the open procedure; either open transection of the iliopsoas tendon at the level of the lesser trochanter (14 patients) or open tendon lengthening of the iliopsoas tendon (105 patients) has shown 27 of 119 patients with recurrence of snapping and 4 of 119 experienced snapping with pain, 6 patients needed a second surgical intervention. There was an increased prevalence of recurrent snapping with open transection of the iliopsoas tendon as compared to patients with iliopsoas tendon lengthening (43% vs. 20%). The complications of the open procedure are postoperative pain (11–36%) and the hip flexion weakness (8–14%). In the arthroscopic group with transection at the lesser trochanter and transcapsular release, 3 of 37 (8%) patients of the group with transection at lesser trochanter reported complications including 2 cases of ischial bursitis and 1 case of greater trochanteric bursitis. No reported complications from the transcapsular release group. No hip flexion weakness was reported in the arthroscopic groups. None of the arthroscopically treated patients

A study of 25 patients with 2-year follow up following transcapsular release with intra-articular procedures in the internal snapping hip with combined pathologies revealed 88% of patients with good to excellent results without serious complications [10]. A comparative case-series with 20 patients, including 6 patients with a release at the lesser trochanter level vs. 14 central compartment release patients revealed the same favorable results based-on WOMAC scores. Just 1 of 14 patient with central compartment release had a recurrence of snapping that required surgi-

The iliopsoas release/tenotomy is the treatment option for iliopsoas tendinopathy or impingement following a total hip replacement. A systematic review of level IV studies in 18 studies (11 case series, 6 case reports and 1 prospective cohort) of 171 patients who underwent hip arthroscopy after an arthroplasty revealed the pathology, including 35.8% of iliopsoas tendinopathy, 24.6% of symptomatic hips with no clear diagnosis, 6.4% of periprosthetic infection, and 3.5% of intra-articular loose bodies. Almost all patients who underwent hip arthroscopy experienced positive outcomes from the procedure [12]. A systematic review of 11 studies, 280 hips treated for iliopsoas impingement, following a total hip replacement, showed improved outcome scores in all three treatment groups including: 1. conservative treatment group (54 patients using local injections and physical therapy), 2. Iliopsoas tenotomy group (133 patients using either arthroscopic, endoscopic or an open approach), and 3. Revision arthroplasty (93 patients by exchange of the acetabular component). The tenotomy group reported 5 (3.76%) complications that included 1 patient with a 13-mm acetabular prominence with continuing groin pain and subsequently needed component revision, 1 patient with a heterotrophic ossification, 1 anterior dislocation, 1 compressive hematoma affecting the peroneal nerve, and 1 periprosthetic ossification. The revision arthroplasty group reported 18 (19.4%) complications including 5 developing trochanteric bursitis, 4 with recurrent groin pain, 2 revision surgeries, 2 dislocations, 1 DVT, 1 deep infection, 1 trochanteric nonunion, 1 superfi-

A retrospective review of 49 patients [6] who had been treated for iliopsoas impingement after a primary total hip arthroplasty with 4 years of mean followup show 50% (10 patients) in the nonoperative group had groin pain resolution as compared to 76% (22 patients) in the operative group (p = 0.06). The patients with <8 mm of component prominent tenotomy stated 100% resolution of groin pain (5 patients) but patients with ≥8 mm of prominent tenotomy led to groin pain resolution at only 33% (3 patients). Acetabular revision in patients with ≥8 mm of prominence had groin pain resolution in 92% (12 of 13 patients) (p = 0.07). Thus, it

cal intervention. No complications were reported in both groups [11].

*DOI: http://dx.doi.org/10.5772/intechopen.91919*

required a second surgical intervention [9].

cial wound infection, and 1 disarticulation [13].

#### *Arthroscopic and Endoscopic Management of the Internal Snapping Hip Syndrome DOI: http://dx.doi.org/10.5772/intechopen.91919*

were higher in patients undergoing an open procedure (21%) compared with an arthroscopic procedure (2.3%). The analysis of the open procedure; either open transection of the iliopsoas tendon at the level of the lesser trochanter (14 patients) or open tendon lengthening of the iliopsoas tendon (105 patients) has shown 27 of 119 patients with recurrence of snapping and 4 of 119 experienced snapping with pain, 6 patients needed a second surgical intervention. There was an increased prevalence of recurrent snapping with open transection of the iliopsoas tendon as compared to patients with iliopsoas tendon lengthening (43% vs. 20%). The complications of the open procedure are postoperative pain (11–36%) and the hip flexion weakness (8–14%). In the arthroscopic group with transection at the lesser trochanter and transcapsular release, 3 of 37 (8%) patients of the group with transection at lesser trochanter reported complications including 2 cases of ischial bursitis and 1 case of greater trochanteric bursitis. No reported complications from the transcapsular release group. No hip flexion weakness was reported in the arthroscopic groups. None of the arthroscopically treated patients required a second surgical intervention [9].

A study of 25 patients with 2-year follow up following transcapsular release with intra-articular procedures in the internal snapping hip with combined pathologies revealed 88% of patients with good to excellent results without serious complications [10]. A comparative case-series with 20 patients, including 6 patients with a release at the lesser trochanter level vs. 14 central compartment release patients revealed the same favorable results based-on WOMAC scores. Just 1 of 14 patient with central compartment release had a recurrence of snapping that required surgical intervention. No complications were reported in both groups [11].

The iliopsoas release/tenotomy is the treatment option for iliopsoas tendinopathy or impingement following a total hip replacement. A systematic review of level IV studies in 18 studies (11 case series, 6 case reports and 1 prospective cohort) of 171 patients who underwent hip arthroscopy after an arthroplasty revealed the pathology, including 35.8% of iliopsoas tendinopathy, 24.6% of symptomatic hips with no clear diagnosis, 6.4% of periprosthetic infection, and 3.5% of intra-articular loose bodies. Almost all patients who underwent hip arthroscopy experienced positive outcomes from the procedure [12]. A systematic review of 11 studies, 280 hips treated for iliopsoas impingement, following a total hip replacement, showed improved outcome scores in all three treatment groups including: 1. conservative treatment group (54 patients using local injections and physical therapy), 2. Iliopsoas tenotomy group (133 patients using either arthroscopic, endoscopic or an open approach), and 3. Revision arthroplasty (93 patients by exchange of the acetabular component). The tenotomy group reported 5 (3.76%) complications that included 1 patient with a 13-mm acetabular prominence with continuing groin pain and subsequently needed component revision, 1 patient with a heterotrophic ossification, 1 anterior dislocation, 1 compressive hematoma affecting the peroneal nerve, and 1 periprosthetic ossification. The revision arthroplasty group reported 18 (19.4%) complications including 5 developing trochanteric bursitis, 4 with recurrent groin pain, 2 revision surgeries, 2 dislocations, 1 DVT, 1 deep infection, 1 trochanteric nonunion, 1 superficial wound infection, and 1 disarticulation [13].

A retrospective review of 49 patients [6] who had been treated for iliopsoas impingement after a primary total hip arthroplasty with 4 years of mean followup show 50% (10 patients) in the nonoperative group had groin pain resolution as compared to 76% (22 patients) in the operative group (p = 0.06). The patients with <8 mm of component prominent tenotomy stated 100% resolution of groin pain (5 patients) but patients with ≥8 mm of prominent tenotomy led to groin pain resolution at only 33% (3 patients). Acetabular revision in patients with ≥8 mm of prominence had groin pain resolution in 92% (12 of 13 patients) (p = 0.07). Thus, it

*Essentials in Hip and Ankle*

**Figure 11.**

*iliopsoas tendon release.*

**3.4 Postoperative rehabilitation**

*Endoscopic view from the anterolateral portal of the left hip; right is the proximal aspect and left is the distal aspect of the proximal femur: (A) and (B) identification of the anterior femoral cortex, iliopsoas bursa (IP bursa) and lessor trochanter (LT) using the distal anterolateral working portal; (C) identification of the iliopsoas tendon (IP) which attaches to the lessor trochanter; (D) peeled-off iliopsoas tendon from the lessor trochanter using radiofrequency; and (E) and (F) lessor trochanter and the surrounding tissue after the* 

portal using a needle and guidewire under fluoroscopy. The 4.5-mm, cannulated switching stick is inserted through the guidewire under endoscopic control. The iliopsoas tendon is identified at the lesser trochanteric insertion then, the radiofrequency or an arthroscopic shaver is used via the distal anterolateral portal to remove the iliopsoas bursa surrounding the tendon and to obtain adequate visualization of the tendon. The iliopsoas tendon is 'peeled' from the lesser trochanter using radiofrequency under direct vision (**Figure 11**). After completion of the tenotomy, the portals are simply sutured, and the wounds are closed in standard fashion.

Active hip range of motion exercises are allowed immediately following surgery.

An iliopsoas tenotomy has shown good to excellent postoperative outcomes in indicated patients with iliopsoas snapping/impingement. The systematic reviews of 11 eligible studies (248 patients), level IV studies revealed 'the resolution of snapping' as seen in 100% of patients who underwent an arthroscopic release and 77% of those who underwent open procedures. The complication rates

Hip flexion strength may decrease in the first 6–8 weeks and usually returns to baseline after 8 weeks. Active hip flexor strengthening exercises are allowed after 6 weeks postoperative. The patients progress to full weight bearing as soon as possible, postoperatively. Return to normal activities is allowed 6–8 weeks after

**48**

surgery.

**4. Discussion**

is suggested that use of tenotomy in patients with <8 mm of component prominence and acetabular revision in patients with ≥8 mm of prominence is indicated.
