New arthroscopic tendon release relieves snapping hip pain

Anesthetic injection of the psoas bursa confirms the diagnosis - investigators said that led to their success with the technique.

In this fluoroscopic view, the 5 mm trochar and cannula are shown after the surgeon advanced them over the nitinol wire to a position over the proximal aspect of the lesser trochanter. Also visible is the position of the spinal needle. Surgeons used it to create the second portal by placing the second 5 mm cannula medial to, but in contact with, the proximal cannula.

This fluoroscopic image shows the proximal cannula in an optimal position, containing the 30º arthroscope used for the iliopsoas tendon release. Also seen is the position of the inferior cannula with a thermal probe inserted in it. The surgeon advances the probe just until it is visualized at the cannula’s tip.

COURTESY MARK E. FLANUM

KEYSTONE, Colo. — University of Wisconsin physicians have developed a new arthroscopic iliopsoas tendon release technique that effectively treats painful internal snapping hips in athletes. They used it successfully in conjunction with a magnetic resonance arthrography protocol they also devised.

“Arthroscopic release of the tendon is a safe procedure that will avoid complications over open procedures and provide safe, long-term relief from pain,” said Mark E. Flanum, MD. He presented the group’s initial results using the technique at the American Orthopaedic Society for Sports Medicine 2005 Annual Meeting, here.

Hip snapping can be painful, yet some patients are asymptomatic. The condition may stem from internal, external or intra-articular causes, like traumatic labral tears. “Distinguishing between the internal and intra-articular causes is difficult because the two conditions have similar clinical findings,” Flanum said.

Evaluating the psoas tendon with ultrasound and injecting an anesthetic into the psoas bursa before surgery helped investigators definitively diagnose the condition, he noted.

Small series

Flanum’s series involved two men and four women (mean age 41 years) who were taken from 45 patients who initially presented with painful snapping hips. Their hip snapping lasted for 12 months, mean.

To identify patients with an internal painful snapping hip, all 45 hips had an MR arthrogram, which included injection of bupivicaine (0.5%), 5-cc each of saline and a nonionic radiographic contrast medium (Omnipaque), and 1 cc of gadolinium.

Twenty-three of these patients ultimately had an ultrasound evaluation of their iliopsoas tendon when the anesthetic hip injection did not relieve the pain. Six patients who eventually had arthroscopic surgery had complete but transient pain relief following the psoas bursal injection, and in four of these six patients, real-time imaging demonstrated snapping of the iliopsoas tendon when they experienced their hip pain, Flanum noted.

The surgeons’ arthroscopic technique involved placing the patients supine on a fracture table with both feet in traction boots and the involved hip in maximal external rotation to expose the lesser trochanter. They flexed the hip to 30º to keep tension on, but allow access to, the psoas tendon. Surgeons then used two arthroscopic portals — one for a 30º arthroscope and one for a thermal probe. Both were passed through a 5-mm cannula. They introduced a 17-gauge, six inch, stylet enclosed spinal needle under fluoroscopic guidance and advanced it along the anterior surface of the femur to the lesser trochanter. This step was followed by advancing the trochar and cannula in the same site over a nitanol wire that had been passed through and replaced the spinal needle.

Surgeons used a similar technique to create the second portal.

Harris hip scores improved

The physical therapists doing the patients’ postop care used the same protocol in all cases, and were told to expect postop hip flexor muscle weakness in the group for four to six weeks. Surgeons removed the sutures at seven days postop, and patients used crutches for at least four weeks.

Harris hip scores (HHS) averaged 54 points preop and increased postoperatively to 75 and 82 points at six and 12 weeks, respectively. “However, unlike hip arthroscopy scores, which plateau at three months, their scores continued to improve, averaging 94 points at six and 12 months. Thus, on average, the HHS improved 40 points,” Flanum said.

Return to work was consistently good. “One woman started walking five miles a day four months after surgery. She had been unable to walk more than two blocks prior to surgery,” he said.

Complications rates as high as 51% have been reported in patients who undergo open surgery. Although few patients were treated with the new arthroscopic technique, there were no complications and “at the one-year follow-up visit, none of the patients had hip flexor weakness, portal problems or recurrent snapping,” Flanum noted.

For more information:
Flanum ME, Keene JS, Blankenbaker DG, DeSmet AA. Arthroscopic treatment of the painful “internal” snapping hip: Results of a new endoscopic technique and imaging protocol. Presented at the American Orthopaedic Society for Sports Medicine 2005 Annual Meeting. July 14-17, 2005. Keystone, Colo.