**2.3 Surgical technique**

The peripheral compartment approach is introduced in hip flexion of 20–30° using a proximal anterolateral portal (PAL). Peripheral compartment examination and synovectomy are performed using an anterior working portal (**Figure 6**). Following the peripheral compartment work that includes synovectomy and cam resection, the central compartment is assessed under traction of the hip in a full extension position. Intra-articular examination and surgical procedures are completely performed. These include; debridement, acetabuloplasty, and labral surgery.

The arthroscopic iliopsoas tenotomy can performed by two methods: (1) central compartment approach under traction and (2) peripheral compartment approach with hip flexion of 20–30°.

In a central compartment approach. After performing the intra-articular procedures, the arthroscope is retracted to the peripheral compartment to assess under traction the anterior hip capsule at approximately the 3 O'clock position of the anterior labrum. This step uses the anterolateral viewing portal and the anterior portal for the procedure. Inflammation of the anterior labrum may represent evidence of iliopsoas impingement. The iliopsoas tendon is located near the anteromedial aspect of the anterior hip capsule. The anterior capsule at this area is thin and some patients have an anterior capsular hole directly connected to the iliopsoas tendon [8]. A capsulotomy of approximately 1–2 cm is performed to the 3 O'clock position of the right hip. After capsulotomy, the synovial tissue around the iliopsoas tendon is identified and resected using an arthroscopic shaver or electrocautery. The iliopsoas tendon is identified and released until the iliacus muscle can be observed beneath the released portion of the tendon. Keeping this portion of the iliacus muscle may decrease of the risk of hip flexion weakness, postoperatively (**Figure 7**).

#### **Figure 6.**

*The portals used in peripheral compartment approach of the right hip. Proximal anterolateral portal (PAL) is the start and viewing portal. Anterior (A) and anterolateral (AL) portals are shown. GT, greater trochanter; ASIS, anterior superior iliac spine.*

In the peripheral compartment approach, following the intra-articular work, the traction is released to reduce the hip joint. The arthroscope is inserted via the same AL viewing portal or re-inserted from the PAL portal in the hip at 20–30° in a flexion position. Then, the zona orbicularis, medial synovial fold, and the anterior labrum are identified. The medial synovial fold is the landmark for the most inferomedial head–neck area, also known as, the 6 O'clock position. The 1–2 cm capsulotomy is performed at the capsular space between the anterior labrum and the zona orbicularis close to the proximal attachment of the medial synovial fold. After capsulotomy, the synovial tissue around the iliopsoas tendon is resected as previously described and the iliopsoas tendon is released while preserving the iliacus muscle.

It is not necessary to perform the capsular closure if the capsulotomy is less than 1–2 cm. With complete tenotomy of the iliopsoas, either in the central or peripheral approach, the portals are sutured simple and the wounds are closed in standard fashion.

#### **2.4 Post-operative rehabilitation**

Active hip range of motion is allowed immediately post operatively. The hip flexion strength may decrease in the first 6 to 8 weeks and usually restores after 8 weeks. Active hip flexor strengthening exercises are allowed after 6 weeks postoperatively.

Weight bearing is dependent on the intra-articular conditions. The patients apply partial weight bearing for 6 weeks if the cartilage or the labral lesions were repaired/fixated, or if osteochondroplasty of the cam lesion is done. In the isolated iliopsoas release patients, there is no need to protect weight bearing after post operatively. Return to sport activities are allowed after 3 months.

**45**

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

**3. Endoscopic iliopsoas release at the lesser trochanteric level** 

• No evidence of prosthesis loosening or infection.

• Painful iliopsoas impingement following a total hip replacement, no obvious malposition of the acetabular cup and the anterior overhang is <8 mm.

*Arthroscopic view of the central compartment transcapsular iliopsoas tenotomy of the right hip. (A and B) Peripheral compartment first approach using the proximal anterolateral (PAL) viewing portal and anterior working portal. (C and D) Approach to the central compartment by direct visualization and inserting the switching stick through the anterior portal. (E and F) Examination in the central compartment. (G) Create the anterolateral (AL) portal under direct visualization using anterior viewing portal. (H and I) Switch the scope to the AL viewing portal and working from the anterior portal. (J to L) After a small anterior capsulotomy to about the 3 O'clock position, the iliopsoas tendon (IP) is cut using electrocautery. The iliacus muscle (\*) is preserved. [L-labrum, FH-femoral head, FN-femoral neck, A-acetabulum, C-capsule].*

• Failed conservative more than 4–6 months with positive iliopsoas injection test.

**(distal endoscopic release)**

**3.1 Indications**

**Figure 7.**

*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 7.**

*Essentials in Hip and Ankle*

In the peripheral compartment approach, following the intra-articular work, the traction is released to reduce the hip joint. The arthroscope is inserted via the same AL viewing portal or re-inserted from the PAL portal in the hip at 20–30° in a flexion position. Then, the zona orbicularis, medial synovial fold, and the anterior labrum are identified. The medial synovial fold is the landmark for the most inferomedial head–neck area, also known as, the 6 O'clock position. The 1–2 cm capsulotomy is performed at the capsular space between the anterior labrum and the zona orbicularis close to the proximal attachment of the medial synovial fold. After capsulotomy, the synovial tissue around the iliopsoas tendon is resected as previously described and the iliopsoas tendon is released while preserving the iliacus muscle. It is not necessary to perform the capsular closure if the capsulotomy is less than 1–2 cm. With complete tenotomy of the iliopsoas, either in the central or peripheral approach, the portals are sutured simple and the wounds are closed in standard

*The portals used in peripheral compartment approach of the right hip. Proximal anterolateral portal (PAL) is the start and viewing portal. Anterior (A) and anterolateral (AL) portals are shown. GT, greater trochanter;* 

Active hip range of motion is allowed immediately post operatively. The hip flexion strength may decrease in the first 6 to 8 weeks and usually restores after 8 weeks. Active hip flexor strengthening exercises are allowed after 6 weeks

Weight bearing is dependent on the intra-articular conditions. The patients apply partial weight bearing for 6 weeks if the cartilage or the labral lesions were repaired/fixated, or if osteochondroplasty of the cam lesion is done. In the isolated iliopsoas release patients, there is no need to protect weight bearing after post

operatively. Return to sport activities are allowed after 3 months.

**44**

fashion.

**Figure 6.**

*ASIS, anterior superior iliac spine.*

postoperatively.

**2.4 Post-operative rehabilitation**

*Arthroscopic view of the central compartment transcapsular iliopsoas tenotomy of the right hip. (A and B) Peripheral compartment first approach using the proximal anterolateral (PAL) viewing portal and anterior working portal. (C and D) Approach to the central compartment by direct visualization and inserting the switching stick through the anterior portal. (E and F) Examination in the central compartment. (G) Create the anterolateral (AL) portal under direct visualization using anterior viewing portal. (H and I) Switch the scope to the AL viewing portal and working from the anterior portal. (J to L) After a small anterior capsulotomy to about the 3 O'clock position, the iliopsoas tendon (IP) is cut using electrocautery. The iliacus muscle (\*) is preserved. [L-labrum, FH-femoral head, FN-femoral neck, A-acetabulum, C-capsule].*
