Hip arthroscopy for treatment of peri-articular disorders Focus On

Focus On
Hip arthroscopy for treatment
of peri-articular disorders
The evolving scope of minimally invasive surgery has driven the
gradual increase in the application of hip arthroscopy for periarticular problems of the hip. There is a greater understanding
of various disorders of the hip, such as greater trochanteric pain
syndrome,1-3 internal snapping hip syndrome,4-6 deep gluteal
syndrome7-9 and ischiofemoral impingement.10-13 These can now
potentially be treated by endoscopic means.
Greater trochanteric pain syndrome
Greater trochanteric pain syndrome includes a constellation of
hip disorders such as recalcitrant trochanteric bursitis, external
snapping iliotibial band (ITB), and gluteus medius and minimus
tears.1-5,14-16 It is quoted at 1.8/1000 head of population.17 All
these present as chronic pain over the lateral aspect of the hip.
The diagnosis of trochanteric bursitis is confirmed by the history,
examination and response to a possible injection. Although
MRI is not necessary to make the diagnosis, fluid-sensitive
images may reveal increased signal intensity of the trochanteric
bursa. External snapping hip or coxa saltans may occur when a
thickened portion of the posterior margin of the iliotibial band
or the anterior fibres of the gluteus maximus tendon slide over
the greater trochanter.3,18 This band lies posterior to the greater
trochanter when the hip is extended and slides anteriorly over
it during flexion. Dynamic ultrasound may display the real-time
images of the ITB snapping over the greater trochanter.
Tears in the gluteus medius and minimus tendons are often
misdiagnosed as trochanteric bursitis.16 They share similarities
to the rotator cuff tendon injuries in the shoulder16 and are
associated with increasing age.19,20 These may be intrasubstance,
partial or complete;19 with partial thickness undersurface tear
being more common.16,21 Physical examination may reveal pain
and weakness with resisted abduction of the hip with slight
Trendelenburg gait. The combination of abductor weakness,
persistence of symptoms after conservative treatment, and a
positive MRI result that shows increased signal in the tendon
confirms the diagnosis.16
It has been proposed that patients with persistent symptoms
after two corticosteroid injections for trochanteric bursitis may
require operative intervention.22 The endoscopic release of the
ITB for the treatment of external snapping and trochanteric
bursitis is an effective and reproducible procedure and may
lead to 100% resolution of pain and 91% resolution of snapping
symptoms.3 Similarly satisfactory outcome after surgical repair
of the gluteus medius and minimus tears and release of the ITB
has been reported.16,22-24
Internal snapping hip syndrome
The iliopsoas tendon slipping either over the femoral head
©2012 British Editorial Society of Bone and Joint Surgery
or the iliopectineal eminence causes internal snapping hip
syndrome.25,26 The patients present with pain and sensation of
snapping in the groin particularly on hip extension.4 Endoscopic
release of the iliopsoas tendon can lead to effective relief of pain
and snapping.4-6,27 The results of endoscopic release seem to be
better than those reported for open procedures.2
Deep gluteal syndrome
Deep gluteal syndrome is a term given to pain in the buttock
caused by sciatic nerve entrapment from any of the structures
in the gluteal region.7-9 This may be piriformis syndrome, which
is associated with buttock pain that is exacerbated by hip flexion
movements combined with internal or external rotation of the
affected leg. It often occurs after blunt trauma to the buttock
with resultant haematoma formation and subsequent scarring
between the sciatic nerve and external rotators.28 The proximal
origin of the hamstrings has an intimate relation with the sciatic
nerve and scarring of the hamstring tendons by trauma or
avulsion of the hamstring29 may be a cause. Similarly, irritation
of the structures of the obturator internus/gemellus complex
may cause sciatica-like discomfort.30,31 Pre-operative bilateral
dynamic EMG testing, MRI myelogram of the lumbar spine,
a piriformis injection test, intra-operative nerve monitoring
and elimination of the other sources of posterior hip pain are
integral to the correct diagnosis.8 Arthroscopic techniques for
treating piriformis syndrome32 and release of sciatic nerve have
been demonstrated to be effective in diminishing extra-articular
posterior hip pain and return to normal activities.8
Ischiofemoral impingement
Ischiofemoral impingement has been described in the past after
total hip replacement, and also lately in the native hip.10-13,33 It
is caused by abnormal contact between the lesser trochanter
and ischium. The quadratus femoris muscle occupies this
space and may theoretically be compressed between these
two bony structures. The patients present with chronic pain in
the groin and/or the buttock. This may radiate distally along
the leg. The differential diagnoses have included a snapping
iliopsoas tendon, sciatica, chronic hamstring injury and adductor
tendonitis. Clinically the symptoms may be reproduced by a
combination of hip extension, adduction and external rotation.
MRI is the imaging method of choice, with special attention paid
to the ischiofemoral space.
Radiologically guided infiltration of corticosteroid into the
ischiofemoral space has been reported to be useful.10,34 The
definitive treatment for ischiofemoral impingement is not yet
clear as it has not been widely recognised. However, arthroscopic
debridement of the quadratus femoris tendon with removal of
the impingement lesion is an option that can be explored.
Portal placement and procedure
Portal placement for the peri-trochanteric space has been
previously described.18 It is a matter of individual preference
and depends on the pathology being treated, although the same
portals used to access the central and peripheral compartment
can be used to gain access to the peri-trochanteric space. For
sciatic nerve decompression an auxillary posterolateral portal
may be useful.8
A 30° arthroscope is ordinarily used. Balloon dissection
has been shown to be superior to blunt dissection in terms
of access, safety and haemostasis.35 Voos et al36 recommend
that the arthroscope should be first orientated towards the
gluteus maximus insertion into the linea aspera, as well as
the vastus lateralis. A step-wise examination of various parts
of the peritrochanteric area should be performed including the
gluteus maximus insertion (Figure 1 and 2), vastus lateralis,
fibres of gluteus medius and minimus inserting onto the greater
trochanter and the ITB. A thorough knowledge of the normal
anatomy of the tendon insertions, the bursae, and the bony
facets of the greater trochanter is essential.36 The fibres of
the gluteus medius lie posterior to the minimus and should be
thoroughly probed and inspected to identify the presence of fullthickness tears of the tendon insertion. The posterior one-third
of the ITB is implicated in external snapping hip syndrome and
may be causing direct abrasive wear of the greater trochanter.36
Assessment for abductor tendon tear should be performed
in cases in which there is no clinical concern of an external
snapping hip.
The ITB can be approached either from the peritrochanteric
space where the deep surface of the ITB is visualised first37 or
by the subcutaneous approach where the superficial surface
is initially visible (Figure 3).3 Release of ITB is performed along
the posterolateral portion of the greater trochanter, beginning
at the insertion of the vastus lateralis at the vastus tubercle,
extending to the tip of the greater trochanter in a V-Y type release
(Figure 4), which is the senior author’s preferred technique. The
ITB is fully released until it no longer rubs, causing impingement
over the greater trochanter; and this is confirmed by hip rotation
under arthroscopic view.22 There may be a requirement for slight
variation depending on the particular fibres under the greatest
amount of tension. A repair of the V-Y plasty can be performed
(Figure 5). Alternatively, excision of a diamond shaped area from
the ITB has been described.3 Prominent bone over the lateral
aspect of the greater trochanter may need to be debrided along
with a formal bursectomy (Figure 6).
Martin et al8 have described the endoscopic approach to
identifying and dealing with DGS. After examining the peritrochanteric space to look for the various causes of hip pain they
would proceed to a stepwise examination of the sciatic nerve
(Figure 7). This would include an arthroscopic assessment of the
excursion of the sciatic nerve with the leg in flexion and internal/
external rotation and full extension with internal/external
rotation. Inspection of the sciatic nerve would begin distally
beneath the femoral insertion of the tendon of gluteus maximus
and proceed upwards to the sciatic notch. A blunt probe can
be used to assess sciatic nerve entrapment by the quadratus
Fig. 1.
Arthroscopic picture with vastus lateralis to left and above
and insertion of gluteus maximus tendon to the right.
Fig. 2.
Arthroscopic debridement of the trochanteric area
adjacent to the gluteus maximum tendon insertion.
Fig. 3.
Inflamed ITB visible from the superficial side.
Fig. 4.
V-Y plasty of the ITB being performed from the superficial
femoris, gemelli, fibrovascular scar bands and the piriformis.
Any impinging structures on the sciatic nerve can be released by
delicate dissection and the range of movement of the hip can be
repeated to ensure adequate mobility of the sciatic nerve.
The iliopsoas tendon can be exposed after an anterior
capsulotomy while examining the peripheral compartment of the
hip. The tendon can be located by identifying the medial synovial
fold that lies slightly medially underneath the anteromedial
capsule at the level of the psoas tendon.5 A fluoroscopic
assessment of the position of the tip of the arthroscope and
the instruments along the probable track of the iliopsoas as it
inserts into the lesser trochanter is helpful. The site of release of
the iliopsoas tendon is critical. To release it proximally, through
the capsule at the level of the hip joint, leaves the muscular part
of iliopsoas intact. This minimises any reduction in the strength
of hip flexion and allows the surgeon to directly view tendon
excursion during the procedure.4 Anteriorly located branches
of the femoral nerve can theoretically be damaged at surgery
although the risk is reduced if iliopsoas is released distally, at
the lesser trochanter. Here, the iliopsoas tendon can be easily
seen and is separated from the femoral nerve by a bursal wall
and vastus intermedius.4 It has been shown that iliopsoas
tendon release at the level of the lesser trochanter or at the level
of the hip joint using a transcapsular technique is both effective
and reproducible and leads to similar clinical results.38
Recalcitrant trochanteric bursitis, external snapping hip
syndrome, and focal, isolated tears of the gluteus medius
and minimus tendons may now be successfully treated
arthroscopically. As the arthroscopic anatomy of the hip
becomes more clearly defined and surgical indications clarified,
the range of available treatment options for disease entities of
the peri-articular space of the hip will undoubtedly increase. This
is clearly a rapidly developing frontier of modern-day hip surgery.
Fig. 5.
Repair of the V-Y plasty of ITB underway.
Fig. 6.
Prominent trochanteric bone being debrided.
A. Malviya FRCS Ed (Tr & Orth)
G. H. Stafford FRCS (Tr & Orth)
R. N. Villar FRCS (Tr & Orth)
The Richard Villar Practice
Spire Cambridge Lea Hospital
30 New Road, Impington
Cambridge CB24 9EL
Fig. 7.
Sciatic nerve decompression underway.
E-mail: [email protected]
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