**3.3 Surgical technique**

The endoscopic portals are marked as seen in **Figure 9**. The anterolateral portal (1–2 cm anterior to level of tip of greater trochanter) and distal anterolateral portal (5–7 cm distal to anterolateral portal) are identified. The direction of the instrument and arthroscope can be aligned under fluoroscopic control toward the tip of the lesser trochanter (**Figure 10**). The needle and guidewire are inserted through the anterolateral portal with the designed trajectory toward the lesser trochanter. A 4.5-mm cannulated switching-stick (Smith and Nephew, MA, USA) is inserted then changed to a 5.0-mm cannula and an obturator. Blunt dissection using the cannula is performed above the lesser trochanter in a superior-inferior direction to create more working space anteriorly under fluoroscopic guidance. A 70° arthroscope is inserted via this anterolateral portal and the distal anterolateral portal is created as a second

#### **Figure 8.**

*Patient positioned for the endoscopic iliopsoas release of the left hip. Supine on the radiolucent traction table. The surgical hip is in external rotation, fully stretched in full knee extension that brings the lessor trochanter further anteriorly.*

**47**

**Figure 10.**

**Figure 9.**

*trochanter.*

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

*Endoscopic portals of the left hip in supine position without traction. Left hand is patient's up and right is the legs. AL, anterolateral portal; DAL, distal anterolateral portal; ASIS, anterior superior iliac spine; GT, greater* 

*Demonstration of the direction of the instrument and endoscope under fluoroscopic control in a left, prosthetic hip: (A) both instruments aimed toward tip of the lessor trochanter in the convergence direction. (B) and (C) the endoscope is inserted from the AL portal and the radiofrequency abrasion is inserted from the DAL portal.*

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

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

#### **Figure 9.**

*Essentials in Hip and Ankle*

**3.2 Patient position**

further anteriorly (**Figure 8**).

**3.3 Surgical technique**

ruled out.

**46**

**Figure 8.**

*further anteriorly.*

*Patient positioned for the endoscopic iliopsoas release of the left hip. Supine on the radiolucent traction table. The surgical hip is in external rotation, fully stretched in full knee extension that brings the lessor trochanter* 

Preoperative physical examination, blood analysis for white blood cell count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), hip X-rays, and CT assessment are needed to evaluate possible other causes of hip/groin pain in total hip replacement patients. Infection and prosthesis loosening need to be

The author's preferred patient position is supine on a radiolucent traction table (Maquet, Rastatt, Germany) similar for the patient with an arthroscopic proximal release. Both legs and feet are well padded, wrapped with soft cotton and hung to the footplate. A large, well-padded perineal post is used to prevent complications from pudendal nerve compression. The C-arm is placed at the non-operative side and positioned horizontally to check the anteroposterior view of the affected hip. Traction of the prosthetic component is not a requirement and the release is performed at the lesser trochanter level. The affected leg is placed in an externally rotated position of the hip in full knee extension. This moves the lesser trochanter

The endoscopic portals are marked as seen in **Figure 9**. The anterolateral portal (1–2 cm anterior to level of tip of greater trochanter) and distal anterolateral portal (5–7 cm distal to anterolateral portal) are identified. The direction of the instrument and arthroscope can be aligned under fluoroscopic control toward the tip of the lesser trochanter (**Figure 10**). The needle and guidewire are inserted through the anterolateral portal with the designed trajectory toward the lesser trochanter. A 4.5-mm cannulated switching-stick (Smith and Nephew, MA, USA) is inserted then changed to a 5.0-mm cannula and an obturator. Blunt dissection using the cannula is performed above the lesser trochanter in a superior-inferior direction to create more working space anteriorly under fluoroscopic guidance. A 70° arthroscope is inserted via this anterolateral portal and the distal anterolateral portal is created as a second

*Endoscopic portals of the left hip in supine position without traction. Left hand is patient's up and right is the legs. AL, anterolateral portal; DAL, distal anterolateral portal; ASIS, anterior superior iliac spine; GT, greater trochanter.*

#### **Figure 10.**

*Demonstration of the direction of the instrument and endoscope under fluoroscopic control in a left, prosthetic hip: (A) both instruments aimed toward tip of the lessor trochanter in the convergence direction. (B) and (C) the endoscope is inserted from the AL portal and the radiofrequency abrasion is inserted from the DAL portal.*

#### **Figure 11.**

*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 iliopsoas tendon release.*

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.
