Internal snapping hip
Tendon impingement at the level of iliopectineal eminence
Iliopsoas impingement with the acetabular component in a THA
Tendon snap at the level of the upper branch of the pubic bone
Conflict with the anterior acetabular margin
Conflict between two components of a bifid tendon
Impingement of the tendon at the level of the anterior inferior iliac spine
External snapping hip
Thickening of the posterior ITB or the gluteus maximus
Big offsets in THA
Intra-articular snapping hip
Osteochondromatosis, fragment results of articular fractures, loose bodies
9.2 External Snapping Hip
The most common cause of snapping hip syndrome is irritation of the greater trochanter by the ITB. The ITB is a large flat tendinous structure that originates on the anterior superior portion of the iliac crest, crosses over the greater trochanter of the femur, and inserts onto the lateral condyle of the tibia.
When the hip is extended, the ITB is posterior to the greater trochanter. As the hip moves into flexion, the ITB moves anterior to the greater trochanter. Ordinarily, it glides smoothly over the greater trochanter with assistance from the underlying bursae . When the posterior portion of the iliotibial tract or the anterior border of the gluteus maximus becomes thickened, however, this results in snapping of the tendon over the greater trochanter. The bursae can then become inflamed and further exacerbate the condition . Coxa vara may predispose to a snapping hip. Other predisposing factors are hyperplasia of the trochanteric bursa, narrower bi-iliac width, prominent greater trochanters, and increased distance between the greater trochanters. A case of snapping hip secondary to fibrosis of the band/muscle related to multiple intramuscular injections has also been reported .
9.2.1 Physical Examination
External snapping hip is seen in athletes who undergo repetitive knee flexion, such as runners, dancers, and cyclists. Athletes will have pain over the greater trochanter of the femur, the lateral thigh, or radiating pain down to the knee. Patients often report hip instability symptoms. If severe enough, the snapping sensation will occur during normal ambulation. Once this area becomes inflamed, running or rising from a seated position may hurt continuously. On physical examination, in addition to evidence of the shot, which is often caused voluntarily by the patient, it can consist of tenderness upon insertion of IBD or the greater trochanter, with occasional painful side irradiation in the thigh. Patients may demonstrate a positive Ober test because of increased tension of the ITB.
Diagnosis of snapping hip is a clinical one. Although dynamic ultrasound best demonstrates the snapping hip, cross-sectional imaging with MRI can demonstrate findings associated with external snapping hip, namely, the thickened iliotibial band or the muscle, and the associated secondary change of atrophy of the rest of the gluteus maximus muscle. Both signs should be looked for to confirm the diagnosis. Any intra-articular pathologies should be investigated with plain X-rays and MRI which could also reveal a trochanteric bursitis or a tear of the gluteus medius or minimus.
This condition can be asymptomatic and however in some patients can cause pain and disability. Conservative therapy is, in most cases, decisive; physical therapy, with emphasis on stretching, strengthening, and alignment, can often help. Sometimes, treatment with a corticosteroid injection to the area can relieve inflammation. However, when the remission of symptoms is unsatisfactory, a surgical approach is indicated. A pioneer in this field was James Glick, who described the lateral approach and was also key to the development of specialized instrumentation required for this procedure. In 2006 Ilizaliturri was the first to underline comparable results between endoscopic and open procedures (Picture 9.1). We have recently published a modified endoscopic iliotibial band release with excellent results in terms of snapping phenomenon resolution, patient satisfaction, and return to previous level of activity [6, 7].
The Ilizaliturri technique
9.2.4 Surgical Technique
Both lateral and supine position can be used for the treatment of the external snapping hip. We usually prefer the supine position when a concomitant hip arthroscopy is performed (Picture 9.2). When using the lateral decubitus position, prepping and draping of the operating area and the leg is carried out in the standard fashion. The leg is draped so that the hip can be moved during surgery. With the operating area ready, the greater trochanter (GT) is outlined, and a spine needle is used to locate and to mark the apex of GT. Two portals, one anterior and one posterior, are created at the level of the snapping tract of the ITB. The 30° 4-mm scope is then introduced through the posterior portal, and water inflow with an arthroscopy pump at low pressure is started to develop a space between the subcutaneous tissue and the ITB. The space superficial to the ITB is further developed with the shaver until the ITB can be easily identified. A hooked radiofrequency (RF) probe is introduced trough the anterior portal, and hemostasis is carried out on the subcutaneous tissue if necessary. A horizontal cut is made into the ITB and a defect is created into the ITB. The trochanteric bursa, if inflamed, can easily be resected through the defect using a shaver and a RF ablator (Picture 9.3). The snapping should be tested at different times during the procedure so that adequate resection is obtained. It is appropriate at the end of the procedure to perform a coagulation of small vessels and cut and place a drain for about 12 h [8, 9].
Left: the supine position can be easily used to perform the ITB release. Right: personal technique with horizontal section of the fibers
From left to right: an horizontal cut is made and a defect is created into the ITB
Physicians agree that, in the majority of patients, a conservative approach will be successful; only a select few patients will require operative intervention. The endoscopic approach allows to reach the same or better results in terms of snapping and pain resolution with lower incidence of local complication. The most frequently reported complication in the literature has been the incomplete relief of symptoms after operative intervention. This can be minimized with an accurate preoperative diagnosis; it also is fundamental to test the snap with provocative maneuvers at different times during the procedure so that an adequate resection could be obtained with particular attention to detect any focal thickening at the anterior edge of the gluteus maximus. In case of pain association, a complete bursectomy should be performed. There is limited literature regarding the results of endoscopic treatment for the external snapping hip syndrome, but early reports are encouraging. Ilizaliturri et al. created a diamond-shaped resection and release; after which, the trochanteric bursa was debrided. Ten of 11 hips (10 patients) were relieved of their snapping, and all were relieved of pain at a minimum of 1-year follow-up. No patient required revision surgery, and all patients returned to preoperative levels of activity . Polesello et al. performed a gluteus maximus tenotomy to decrease tension on the iliotibial band. Seven of 9 hips (8 patients) were relieved of pain and snapping postoperatively, with 1 patient requiring a revision operation. All patients returned to their preoperative level of activity, and no patients complained of weakness at a minimum follow-up of 22 months . We have published a study with 15 patients (3 men and 12 women) with symptomatic external snapping hip treated with an endoscopic release of the iliotibial band. The average age was 25 years (range 16–37 years). VAS score was significantly reduced with respect to the preoperative value with 60% of the patients pain-free. No revision procedures were indicated and all the patients returned to their previous level of activity .
9.3 Internal Snapping Hip
The treatment of the different pathologies of the iliopsoas tendon, in the case of relapsing tendonitis for conflict with adjacent structures or arising from problems such as those of patients with spasticity, has been traditionally performed by orthopedic surgery through an open approach. Continuous improvements in surgical techniques finally allowed using endoscopy to reach and treat the most common tendon disorders, ensuring better accuracy and greater respect of the anatomical structures.
The iliopsoas tendon is composed of the union of the great psoas muscle and iliac. These two, clearly separated proximally, come together on the femur at the level of the lesser trochanter.
The strong tendon lies in its course on the anterior portion of the capsule, at about 2 o’clock. It is at this level that a bursa can be found, which often have a direct communication with the coxofemoral joint.
The iliopsoas tendon injuries are frequently associated with pain, click, and strength reduction. This clinical condition, along with the anatomical and pathological findings described, is called internal snapping hip. It is noted that the snapping is present asymptomatically in approximately 10% of the population, and those most frequently affected by this clinical syndrome are athletes, especially dancer [11–13].