The surgical treatment of external coxa saltans (the snapping hip) by Z-plasty of the iliotibial band

PURPOSE: A snapping hip (coxa saltans) secondary to a tight iliotibial band rarely needs surgical intervention. The purpose of this study is to present the surgical results of refractory external-type snapping hip by Z-plasty of the iliotibial band. MATERIALS AND METHODS: Nine symptomatic snapping hips in 8 consecutive patients (1 bilateral) from August 1997 through March 2002 who underwent an iliotibial band Z-plasty were reviewed. RESULTS: Eight of the 9 hips were in active-duty military and 1 was a civilian, with an average age of 25.6 years (range, 21 to 38 years). Mean duration of symptoms prior to surgical intervention was 25.2 months (range, 16 to 39 months) with an average follow-up of 22.9 months (range, 7 to 38 months). All patients had complete resolution of the snapping hip, and all but 1 returned to full unrestricted activities. The 1 failure had persistent groin pain but no residual snapping. CONCLUSIONS: Patients with snapping hip of the iliotibial band refractory to conservative treatment are rare. The surgical results of Z-plasty are excellent and predictable. Careful screening is necessary to preclude other confounding diagnoses. Z-plasty is recommended as an effective surgical treatment of the refractory snapping hip secondary to iliotibial band tightness.     

Arthroscopic treatment of the painful "internal" snapping hip: results of a new endoscopic technique and imaging protocol

BACKGROUND: Traditional surgical treatment for a painful snapping iliopsoas tendon has been an open lengthening of the tendon. HYPOTHESIS: An endoscopic release will alleviate painful snapping of the tendon. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Six patients with painful snapping hips who had no pain relief after magnetic resonance arthrography, which included injection of bupivacaine into the hip joint, subsequently had an ultrasound evaluation of their iliopsoas tendons and an anesthetic injection into the psoas bursa. In all 6 patients, the injection relieved their hip pain, and in 4, real-time imaging demonstrated snapping of the tendon. All hips were evaluated with the 100-point Harris hip scoring system before and at 1.5, 3, 6, and 12 months after surgery. RESULTS: Preoperative hip scores averaged 58 points. After surgery, all patients had hip flexor weakness, used crutches for 5 weeks, and had 6-week scores that averaged 62 points. The patients continued to improve, and at 6 and 12 months, their scores averaged 90 and 96 points, respectively, and none had recurrence of their snapping or pain. CONCLUSION: Ultrasound-guided anesthetic injection of the psoas bursa is useful to confirm snapping of the iliopsoas tendon as the cause of a patient's hip pain. Endoscopic release of the tendon is a safe outpatient procedure that provides effective relief of the snapping and pain.     

Surgical correction of the snapping iliopsoas tendon

Eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this "internal" variety of snapping hip. We referred to the pathologic, painful snapping of the iliopsoas in the deep anterior groin as the "internal" snapping hip. This is in contrast to the more common and better-known "external" snapping that involves the greater trochanter and its overlying soft tissues. The results of our iliopsoas lengthening procedure are presented here. Lengthening of the iliopsoas tendon was accomplished by step cutting of the tendinous portion of the iliopsoas. The pathoanatomy of this poorly understood symptom complex was described in 1984 paper from this institution and is reviewed here. Iliopsoas bursography demonstrated a sudden jerking movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence, synchronous with the patient's pain and often accompanied by an audible snap. The average preoperative duration of symptoms was 2.9 years, and the average length of postoperative followup was 25 months. All patients, except one, had a marked reduction in the frequency of snapping after tendon lengthening, and 14 of 20 hips had no snapping postoperatively. Of the six patients who had recurrence of snapping, all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state. Two hips required reoperation. Postoperatively, only three patients complained of subjective weakness, and most patients were unlimited in physical activity with return to activities such as competitive football, pole vaulting, and long-distance running.(ABSTRACT TRUNCATED AT 250 WORDS)     

The surgical treatment of internal snapping hip

BACKGROUND: Internal snapping hip is an underdiagnosed cause of hip pain that sidelines many recreational and competitive athletes. It originates from a taut iliopsoas tendon that snaps across bony prominences when the hip is extended from a flexed position. When nonoperative treatment methods fail, fractional tendon-lengthening procedures may be used. HYPOTHESIS: Surgical tendon lengthening through a true ilioinguinal approach, which has not been previously reported, will achieve good results in patients with internal snapping hip. STUDY DESIGN: Retrospective cohort study. METHODS: In 30 patients with symptoms in their anterior hip, internal snapping hip was diagnosed by history and physical examination. All patients were initially treated nonoperatively; 19 (63%) improved and did not require further intervention. Eleven patients (12 hips) whose symptoms were recalcitrant to physical therapy were offered the surgical option of iliopsoas tendon lengthening. The procedure was performed via an ilioinguinal intrapelvic approach. Patients were followed up for an average of 3 years. RESULTS: All 11 surgically treated patients (100%) had complete postoperative mitigation of their snapping hip. Nine (82%) reported excellent pain relief. Moreover, nine patients thought that they had greatly benefited from the tendon lengthening and would repeat the surgery. CONCLUSION: Although nonoperative measures are usually successful in the treatment of internal snapping hip, surgical tendon lengthening is a viable approach in cases refractory to nonoperative therapy.     

A modified Z‐plasty technique for severe tightness of the gluteus maximus

The majority of reports concern external snapping hips caused by the iliotibial band. Comparatively, little information is available regarding snapping hips caused by a gluteus maximus. Here we show that hip problems caused by a tight gluteus maximus can be treated using a modified Z‐plasty technique. Fourteen hips in seven patients were diagnosed as snapping hips caused by a tight gluteus maximus. The main functional impairment is that when the hips were flexed, legs were abducted widely and could not be adducted. All had functional impairments irresponsive to conservative treatments besides snapping, whether painful or not, and all patients underwent surgery using a modified Z‐plasty technique on the iliotibial band. All patients were followed up and the mean follow‐up was 7 years. All patients had complete resolution of functional impairments, snapping, and pain after surgery. No patient needed revision surgery, and there were no complications, such as, abductor weakness, or irritation over the greater trochanter. We suggest that the intrinsic tendon contracture can cause serious functional impairment in patients with snapping due to a tight gluteus maximus. In this context, a modified Z‐plasty technique offers a good surgical approach.     

Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers

BACKGROUND: Although snapping hip syndrome is commonly reported in ballet dancers, the prevalence, impact, and underlying mechanism of this condition have not been formally studied within a cohort of dancers. PURPOSE: To determine the prevalence, associated factors, and mechanisms of snapping hip and to investigate self-reported snapping with physical and ultrasound examination. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A snapping hip questionnaire was completed by 87 unselected elite ballet dancers at 2 institutions. Twenty-six of the dancers (50 hips) who were able to voluntarily snap their hips were selected from this group for further physical examination by 2 clinicians to determine whether there was a palpable snap, and each underwent an ultrasound examination of his or her hips. RESULTS: Ninety-one percent of dancers reported snapping hip, of which most (80%) had bilateral symptoms. Fifty-eight percent had pain associated with the snap, and 7% had taken time off dance because of this condition. Sixty percent of the dancers could voluntarily snap their hip. One or more of 3 dance movements elicited the snapping in 81%. The clinicians could palpate 46 of the 50 self-reported snapping hips. Ultrasound showed a snapping iliopsoas tendon in 59% of the hips and the iliotibial band snapping in 4%. In one third of cases, ultrasound was not helpful in identifying the cause of the snapping. CONCLUSION: Snapping hip is extremely common in ballet dancers. Some dancers have significant pain, yet many are asymptomatic. Self-reported snapping is likely to be palpable by the clinician. Iliotibial band snapping is evident by physical examination and ultrasound. Iliopsoas snapping was most common and required ultrasonic confirmation.     

The snapping hip syndrome

The snapping hip syndrome is a symptom complex characterized by hip pain and an audible snapping of the hip with exercise typically seen in young individuals. "External" and "internal" etiologies have been described, although the "internal" etiology is poorly understood. A clinical, radiographic, and anatomical study of eight patients with this disorder, secondary to an internal etiology, was undertaken to aid in the diagnosis and surgical treatment. Iliopsoas bursography with cineradiography revealed subluxation of the iliopsoas tendon to be an apparent cause of the snapping hip. The anatomy of the hip in relationship to the iliopsoas tendon is defined with the anterior inferior iliac spine, iliopectineal eminence, and lesser trochanter assuming a significant role in the syndrome. An operative approach involving a partial release and lengthening of the iliopsoas tendon, with minimal resection of a lesser trochanteric bony ridge, if involved, is described.     

Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft recipients

The sensitivity of magnetic resonance (MR) imaging in the detection of avascular necrosis (AVN) of the hip and natural history of the MR findings were determined prospectively in renal allograft recipients, a group at risk for development of the disease. One hundred four patients were studied up to 24 months after transplantation. In 25 hips in 14 patients, MR findings were consistent with AVN. Pain developed in seven hips in four patients; in each hip, the MR images showed abnormality before the onset of symptoms. Plain radiographs showed abnormality in all hips that became painful; however, the plain radiographs of 17 of 18 asymptomatic hips in which MR imaging showed evidence of AVN showed no abnormality over a mean follow-up period of 16 months. All MR lesions in the symptomatic hips were larger than those in the asymptomatic cohort. MR lesions in seven hips (in five asymptomatic patients) regressed in size; in six hips, the MR images returned to normal. The findings suggest that some patients with MR evidence of AVN of the hip have spontaneous improvement.     

Eccentric hip abductor weakness in patients with symptomatic external snapping hip

Symptomatic external snapping hip can be a long‐standing condition affecting physical function in younger people between 15–40 years. Gluteal weakness has been suggested to be associated with the condition. The aim of this study was to investigate whether eccentric hip abduction strength is decreased in patients with external snapping hip compared with healthy matched controls, and to examine isometric hip abduction, adduction, extension, flexion, internal rotation, and external rotation in patients with external snapping hip and matched controls. Thirteen patients with external snapping hip were compared with 13 healthy matched controls in a cross‐sectional study design. The mean age of the patients was 25.5 ± 3.4 years and the mean age of the controls was 25.6 ± 2.6 years. Eccentric and isometric strength were assessed with a handheld dynamometer, using reliable test procedures. Eccentric hip abduction strength was 16% lower in patients with external snapping hip compared with healthy matched controls (1.50 ± 0.47 Nm/kg versus 1.82 ± 0.48 Nm/kg, P = 0.01). No other strength differences were measured between patients and controls (P > 0.05). Eccentric hip abductor weakness was present in patients with symptomatic external snapping hip compared with healthy matched controls.     

Extraarticular snapping hip: sonographic findings

OBJECTIVE. The aim of the study was to determine the sonographic findings of snapping hip and to correlate the findings with the presence or absence of pain. MATERIALS AND METHODS. Twenty patients with snapping hip were examined with sonography. Conventional and dynamic sonographic examinations of both hips were performed using a 5.0- or 7.0-MHz transducer. RESULTS. Conventional sonographic studies allowed identification of various structural abnormalities (tendinitis, bursitis, synovitis) and helped to document tenderness along the course of specific tendons. Dynamic sonographic studies revealed 26 cases of snapping hip. In 24 of these 26 cases, the underlying cause was clearly identified. Twenty-two snapping hips were caused by an abnormal movement of the iliopsoas tendon, and two were caused by iliotibial band friction over the greater trochanter. One patient reported a bilateral snapping sensation that could not be documented on sonography. Snapping hip was elicited by a wide variety of hip movements. Sonography established an immediate temporal correlation between the jerky tendon motion and the painful snap reported by the patient. Only 14 cases of snapping hip were painful. CONCLUSION. Conventional sonographic studies can identify signs of tendinitis, bursitis, or synovitis. Dynamic sonographic studies revealed the cause of snapping hip in most patients. Snapping hip is characterized on sonography by a sudden abnormal displacement of the snapping structure. In our study, a significant proportion of the cases of snapping hip were not painful.     

A new operative approach to snapping hip and refractory trochanteric bursitis in athletes

This report concerns seven patients that had a painful hip due to snapping of the iliotibial band over the greater trochanter and resultant trochanteric bursitis, and whose symptoms were refractory to nonoperative treatment. An operative procedure that has not been previously described was performed. It involved the excision of an ellipsoid-shaped portion of the iliotibial band overlying the greater trochanter and removal of the trochanteric bursa. Five of the seven patients were evaluated at the time this report was prepared; the average length of followup was 55 months. Four were significantly improved or relieved of their symptoms, and the fifth was an operative failure with complete recurrence. This final patient underwent a second, more extensive partial excision of the iliotibial band, and was asymptomatic 1 year later. A review of the clinic records of the remaining two patients that could not be contacted revealed that they both had been doing well at their 6 month evaluation. For those patients with a symptomatic snapping hip and trochanteric bursitis unresponsive to conservative therapy, the procedure described is an effective method of treatment.     

Clinical and radiographic "reankylosis" following hip surgery in ankylosing spondylitis.

Eleven patients with ankylosing spondylitis underwent reconstructive hip surgery (21 hips). In 10 of these hips multiple surgical procedures had been performed. The final procedure included total hip arthroplasties (16 hips), femoral cup arthroplasties (four hips) and an Austin-Moore prosthetic replacement (one hip). A clinical and radiographic evaluation in the postoperative period revealed a high incidence of decreased joint motion and heterotopic ossification. Clinically moderate to severe restriction of motion was noted in 12 hips, and in six of these "reankylosis" was present. Radiographically moderate to severe new bone formation was seen in 11 hips, and in nine of these "reankylosis" was suggested. An association of excessive ossification and multiple surgical procedures was evident. It would appear that when the prime indication for hip surgery in patients with ankylosing spondylitis is restricted motion, the operation may not be beneficial.     

Surgical correction of internal coxa saltans: a 20-year consecutive study

PURPOSE: To report the complications associated with surgical correction of internal snapping hip. STUDY DESIGN: Retrospective review. METHODS: A review of 92 cases of internal coxa saltans (12 bilateral) from 1982 to 2002 was performed to identify complications following primary surgical correction. An inguinal approach was used for iliopsoas tendon fractional lengthening. The average follow-up time per patient was 5.4 years. RESULTS: A total of 40 complications occurred in 32 patients. Complications included persistent hip pain (n = 6), sensory deficit (n = 8), and hip flexor weakness persisting longer than 1 month (n = 3). Additionally, painful bursa formation (n = 1), hematoma requiring reexploration (n = 1), and superficial infection (n = 1) were noted. Some patients developed recurrent snapping after a 3-month snapping-free interval (n = 9), and some patients never had complete resolution of snapping and were considered failures (n = 11). Of these failures/recurrences, 8 patients had a second tenotomy with 4 failures. Two had a third tenotomy, with 1 failure. CONCLUSIONS: In this series, primary iliopsoas tendon lengthening in patients with internal coxa saltans was without any complication in only 60% of patients; however, overall patient satisfaction was 89%.     

简化髂胫束Z延长术治疗弹响髋

采用局部麻醉下简化的髂胫束Z延长手术治疗了12例青少年及运动员的弹响髋,获得了满意效果。本方法切口小,手术简单,术后两周即可恢复训练。     

髋关节镜导向器引导下精准钻孔减压治疗早期股骨头坏死的近期临床疗效

 目的 分析髋关节镜导向器引导下精准钻孔减压治疗早期股骨头坏死的近期临床疗效。方法 选取2015-04至2018-08解放军总医院第三医学中心骨科60例(93髋)诊断为股骨头坏死的患者,均接受导向器引导下股骨头坏死区精准钻孔减压治疗。患者18～53岁,平均38.3岁,男44例,女16例。其中激素性股骨头坏死28例,酒精性股骨头坏死11例,8例为武警战士训练后所致,13例不明原因。术前采用Harris评分系统进行患髋评分,术后予以对症治疗,定期随访,拍片复查。结果 60例(93髋)获得随访,失访2例,平均随访13个月。Harris评分由术前[(74.19±12.19)分]提高到末次随访时的[(87.40±5.34)分]。其中2例病情进展股骨头发生塌陷。无感染及术中、术后股骨转子间或股骨颈骨折发生。结论 导向器引导下股骨头坏死区精准钻孔减压能将钻孔位置精准定位到股骨头坏死区域,提高了钻孔减压的准确性,手术效果好。     

Iliopsoas impingement on the acetabular component: radiologic and computed tomography findings of a rare hip prosthesis complication in eight cases

OBJECTIVE: To describe the radiographic and computed tomography (CT) scan features of iliopsoas impingement on the acetabular component (IPI) in total hip arthroplasty. METHOD: Eight cases of iliopsoas impingement were diagnosed and confirmed by surgical revision. The plain film radiograph findings and CT scan findings were compared with those of two control populations (8 patients with painless total hip prosthesis and 16 patients with other complications confirmed by surgical revision). RESULTS: An oversized cup was found in four hips with IPI (50%) and in one hip with another complication (6%). Coronal inclination of the acetabular cup was normal in the IPI group and in the two control groups, with a similar mean cup size. All patients with IPI had an acetabular cup overhang of more than 12 mm. Conversely, in the two control groups, the overhang, present in three and two cases, respectively, was always less than 8 mm. Iliopsoas bursal effusion was present in four hips with IPI and three hips with other complications and was never present in normal prostheses. CONCLUSION: More than a 12-mm overhang of the acetabular cup is a sensitive and specific parameter for diagnosing IPI.     

Case report: imaging and surgical treatment of a snapping hip due to ischiofemoral impingement

An association between hip pain and quadratus femoris MRI abnormality with concurrent narrowing of the ischiofemoral space has been reported in a number of patients to date, raising the possibility that the muscular damage observed is due to ischiofemoral impingement [1]. Possible impingement has been noted primarily in middle-aged females either with or without a history of trauma or surgery, and associated snapping of the hip is a rarely described feature [1–3]. We report here on a 17-year-old girl who presented with post-traumatic hip pain; she later developed evidence of ischiofemoral narrowing and quadratus femoris edema on MRI in addition to an audible snapping. Surgical resection of the lesser trochanter was performed, relieving both her hip pain and the snapping. To our knowledge, this is the first reported case of non-iatrogenic ischiofemoral impingement with surgical confirmation. The diagnosis of ischiofemoral impingement should be considered in patients complaining of a snapping hip.     

Arthroscopic treatment of the hip in early and midstage degenerative joint disease

The purpose of this study was to present the technique of arthroscopic capsule release in patients with early and midstage degenerative joint disease of the hip. In 22 patients we performed an arthroscopic capsular release of the hip joint capsule with simultaneous synovectomy and percutaneous drilling of areas of bone edema. The age of the patient ranged from 28 to 65 years (mean 52 years). There were 14 male and 8 female patients. All patients had suffered from a significant reduction of quality of life. In 15 of the 22 patients hip arthroplasty was already indicated in another institution. The preoperative Harris hip Score of 12 patients was below 69 points, 8 patients had a score between 70 and 79 points and 2 patients had a score between 80 and 89 points. At the time of follow-up (mean 26 months after surgery) 1 patient scored below 69 points, 3 patients scored between 70 and 79 points in the Harris hip score. Two patients scored between 80 and 89 points and 16 patients reached a score between 90 and 100 points. Subjective and objective 18 of 22 patients showed clinical relevant improvement. There was no complication in this series. Four patients underwent hip arthroplasty between 6 months and 2 years after the arthroscopic procedure. Minimal invasive arthroscopic treatments seem to decrease the subjective and objective complaints in early and midstage degenerative arthritis of the hip.     

Sonography of the iliopsoas tendon and injection of the iliopsoas Bursa for diagnosis and management of the painful snapping hip

Objective The purpose of this study was to compare sonographic evaluations of patients referred with suspected snapping of their iliopsoas tendon with the pain relief achieved from anesthetic injection of the iliopsoas bursa, and with the subsequent surgical outcome. This study also assessed the effectiveness of Kenalog injection into the iliopsoas bursa for long-term pain relief.Patients and methods Dynamic and static sonography was performed in 40 patients with clinically diagnosed snapping hips. The iliopsoas bursa was injected with Bupivicaine and Lidocaine in the first 22 patients, and an additional 1 ml Kenalog-40 was added to this mixture in the last 18 patients. We compared the static and dynamic sonographic findings with change in the patients’ level of pain at 2 days after anesthetic injection. The sonographic findings and response to anesthetic injection were also compared to the response to Kenalog injection and the results of any subsequent surgery.Results Static sonography of the iliopsoas tendon was normal in 38 patients, and detected iliopsoas bursitis in one patient and iliopsoas tendinopathy in another. Snapping of the iliopsoas tendon was observed using dynamic sonography in 9 of the 40 patients. Following anesthetic injection of the iliopsoas bursa, 29 patients had complete or partial pain relief, and 11 patients had no pain relief. Eight of the nine patients with a snapping iliopsoas tendon had complete or partial pain relief from the bursal injection. Twelve of the 29 patients with pain relief after anesthetic injection later had an arthroscopic iliopsoas tendon release, and all of these 12 patients had a good postoperative result. Of the 18 patients who had Kenalog-40 injected into the iliopsoas bursa and did not have iliopsoas surgery, 16 had sustained pain relief following the injection.Conclusions Patients with groin pain and a clinically suspected snapping iliopsoas tendon can benefit from injection into the iliopsoas bursa even if the snapping tendon is not visualized sonographically. The use of a corticosteroid may provide long-term pain relief, and pain relief after injection is a predictor of good outcome after surgical release of the iliopsoas tendon.     

The fate of the hip in spondylo-epi-metaphyseal dysplasia: clinical and radiological evaluation of adults with SEMD Handigodu type

Purpose

This study was undertaken to document the fate of the hip with reference to its structure and function in patients with spondylo-epi-metaphyseal dysplasia tarda Handigodu type (SEMD_HG).

Material and methods

Radiographs of 271 adult patients with SEMD_HG were studied to identify the pattern of long-term sequelae in the hips. Several measurements of the proximal femur and acetabulum were made to quantify morphological alterations in the hip. Fifty-four adult patients were examined and administered a questionnaire to evaluate the extent of disability attributable to the hips.

Results

Three patterns of changes in the hips were noted: 35% had acetabular protrusio, 33% had subluxation of the hip, and 32% had no protrusio or subluxation. Distinctly different anthropometric measurements and dimensional alterations around the hip were noted in these three patterns. Patients with protrusio were relatively tall while those with subluxation were the shortest. All the patients had developed degenerative arthritis of the hips by the fourth decade of life irrespective of the pattern of hip involvement. The reduction in the range of hip motion and fixed deformities were most severe in patients with protrusio. All the patients had significant disability and very low functional hip scores.

Conclusion

Degenerative arthritis of the hip develops in the majority of patients with SEMD_HG; the symptoms are severe enough to warrant reconstructive surgery by the fourth decade of life. Protrusio or subluxation develops in a third of the patients each; both these complications will influence the surgical approach if total hip arthroplasty is planned.