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The picture shows the Ilizaliturri's ITB release technique. A diamond-shaped defect is created over the greater trochanter to release the ilio-tibial band
Source publication
Purpose: Snapping hip is a common clinical condition, characterized by an audible or palpable snap of the hip joint. When the snap is perceived at the lateral side of the hip, this condition is known as external snapping hip or lateral coxa saltans, which is usually asymptomatic. Snapping hip syndrome (SHS) refers to a painful snap, which is more c...
Context in source publication
Context 1
... anterior and posterior direction. The posterior transverse cut is particularly important because the snapping area is mostly located on the posterior part of the ITB, and this cut should be carried out until the snapping is resolved with while manipulating the limb. Resection with a shaver results in 4 flaps and a diamondshape defect in the ITB (Fig. 1). Now, the hip movements are tested under direct endoscopic visualization, and the GT should move within the defect without snapping. Finally, the GTB can be easily removed through the diamond-shape defect and the abductor tendons are inspected for ...
Citations
... Various surgical techniques for the treatment of ESHS have been reported in the literature, including Z-or N-plasty lengthening of the ITB [2,6,7], release or resection of a portion of the ITB [2,[8][9][10][11][12], and release of the GM femoral insertion [1,13,14], all of which can be performed via either an open or endoscopic approach. A review by Randelli et al. reported endoscopic techniques, as compared to open surgery to have fewer complications, lower recurrence rates, and better clinical and cosmesis [15]. On the other hand, recent systematic review by Sugrañes et al., does not seem to prioritise endoscopic techniques in ESHS treatment [16]. ...
Purpose:
External snapping hip syndrome (ESHS) was historically attributed to isolated iliotibial band (ITB) contracture. However, the gluteus maximus complex (GMC) may also be involved. This study aimed to intraoperatively identify the ESHS origin and assess the outcomes of endoscopic treatment based on the identified aetiological type.
Methods:
From 2008-2014, 30 consecutive patients (34 hips) with symptomatic ESHS cases refractory to conservative treatment underwent endoscopic stepwise "fan-like" release, gradually addressing all known reasons of ESHS: from the isolated ITB, through the fascial part of the GMC until a partial release of gluteus maximus femoral attachment occurred. Snapping was assessed intra-operatively after each surgical step and prospectively recorded. Functional outcomes were assessed via the MAHORN Hip Outcome Tool (MHOT-14).
Results:
Twenty seven patients (31 hips) were available to follow-up at 24-56 months. In all cases, complete snapping resolution was achieved intra-operatively: in seven cases (22.6%) after isolated ITB release, in 22 cases (70.9%), after release of ITB + fascial part of the GMC, and in two cases (6.5%) after ITB + fascial GMC release + partial release of GM femoral insertion. At follow-up, there were no snapping recurrences and MHOT-14 score significantly increased from a pre-operative average of 46 to 93(p<0.001).
Conclusion:
Intraoperative identification and gradual addressing of all known causes of ESHS allows for maximum preservation of surrounding tissue during surgery while precisely targeting the directly involved structures. Endoscopic stepwise "fan-like" release of the ITB and GMC is an effective, tailor-made treatment option for ESHS regardless of the snapping origin in the patients with possibility to manually reproduce the snapping.
... Before surgical intervention, nonoperative care should be trialed for at least 6 months, including physical therapy, NSAIDs, and/or injections 5,39 . ...
... Regardless of the specific technique, the open approach has reported a success rate of over 75% in all registered series (ranging from 5 to 44 patients) with a recurrence of painless snapping and painful snapping of 19% and 14%, respectively 42,44,45,53,54,67 (Table IV). Z-plasty is the open procedure that has reported successful outcomes in over 83% of cases, with only 1 revision performed for recurrent painless snapping 40,46,53 The endoscopic approach for ESHS has been recently reviewed with different size patient series 39,51,55,56,68 (Table IV) ISHS is a frequent issue, and several risk factors have been recognized, including larger pelvic anatomy, chronic snapping, and hypertrophy of the psoas muscle (dancers, weight lifters, or HIIT athletes) 6,7 . Surgery is performed to relieve iliopsoas tension after conservative care has been tried and failed. ...
» Asymptomatic snapping hip affects 5% to 10% of the population; when pain becomes the primary symptom, it is classified as snapping hip syndrome (SHS).
» The snap can be felt on the lateral side of the hip (external snapping hip), often attributed to an iliotibial band interaction with the greater trochanter, or on the medial side (internal snapping hip), often attributed to the iliopsoas tendon snapping on the lesser trochanter.
» History and physical examination maneuvers can help distinguish the etiology, and imaging may help confirm diagnosis and rule out other pathologies.
» A nonoperative strategy is used initially; in the event of failure, several surgical procedures are discussed in this review along with their pertinent analyses and key points.
» Both open and arthroscopic procedures are based on the lengthening of the snapping structures. While open and endoscopic procedures both treat external SHS, endoscopic procedures typically have lower complication rates and better outcomes when treating internal SHS. This distinction does not appear to be as noticeable in the external SHS.
... BMC Musculoskeletal Disorders (2023) 24:75 LHP covers a variety of underlying pathologies, not always with clear diagnostic parameters, and are historically attributed mainly to greater trochanteric bursitis (GTB) and coxa saltans externa (CSE), and more recently hip abductor tendon pathology [50,51,67]. CSE is found as frequently as 10% in the young adult population [30,47]. Most often among athletes, females, and young adults [6, 25,44]. ...
... (Fig. 1). The reference lists of included studies and identified relevant reviews [20,21,26,38,47,48,50,56,58,67] were assessed for potentially relevant studies, not identified in the database search ("snowballing"). ...
... A narrative bias assessment of the methodological and clinical limitations for the included studies was performed with a focus on key study features; 1) patient cohort -in-and exclusion criteria; 2) follow-up -adequate defined as six months or more; 3) outcomesufficient use of validated scores for outcome [34]; and 4) intervention -clear description of surgical intervention and technique [47]. ...
Background
Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases.
Purpose
The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery.
Methods
The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed.
Results
A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery.
Conclusion
ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.
... Though arthroscopic techniques have advantages of minimally invasive ness and less soft tissue dissection, open Z plasty is still routinely used due to clear identification of landmarks and easy learning curve compared to arthroscopic technique. [7][8][9] Interpretations obtained are similar to those shown in previous studies. 6 Our patient showed good symptomatic relief following surgery with complete resolution of previous symptoms. ...
p>Coxa saltans commonly known as snapping hip is a nagging illness which can physically and mentally hinder patients life. A snapping hip (coxa saltans) secondary to a tight iliotibial band rarely needs surgical release since most cases respond well to conservative management. The purpose of this study is to present the surgical results of refractory external-type snapping hip by Z-plasty of the iliotibial band. We present a case report of 47-year-old lady who was diagnosed to have snapping hip of external type who was treated with Brignall and stainsby technique of Z plasty. The surgical results of Z-plasty are excellent and predictable. Careful examination is necessary to rule out other causes. Z-plasty is recommended as an effective surgical treatment of the refractory snapping hip.</p
... 1,[3][4][5] The endoscopic release of the iliotibial band or the endoscopic release of the femoral insertion of the gluteus maximus tendon is the most popular technique. 4,6 Endoscopic techniques, as compared to open surgery, provide fewer complications, lower recurrence rate, and good clinical outcomes. 6 However, there still is a recurrence rate of 7-29%. ...
... 4,6 Endoscopic techniques, as compared to open surgery, provide fewer complications, lower recurrence rate, and good clinical outcomes. 6 However, there still is a recurrence rate of 7-29%. 2,7 Although recurrence is often painless, revision surgery may be indicated for symptomatic recurrence. 2 The purpose of this Technical Note is to describe the details of endoscopic treatment of a recurrent external snapping hip after endoscopic iliotibial band release. ...
... The most common endoscopic techniques for the treatment of external snapping hip syndrome are diamond-shaped iliotibial band release over the greater trochanter and the release of the femoral insertion of the gluteus maximus tendon. 3,6 This reported technique basically follows the same approaches. Besides endoscopic release of the iliotibial band and gluteus maximus tendon, the fibrous band underneath the iliotibial band is also released. ...
External snapping hip is caused by snapping of the thickening of the posterior portion of the iliotibial band or the anterior border of the gluteus maximus over the greater trochanter. Surgery is considered for patients who are refractory to conservative treatment. The endoscopic release of the iliotibial band or the endoscopic release of the femoral insertion of the gluteus maximus tendon is the most popular technique. There is a recurrence rate of 7-29% after endoscopic surgery. Although recurrence is often painless, revision surgery may be indicated for symptomatic recurrence. In this Technical Note, the technical details of endoscopic treatment of recurred external snapping hip after endoscopic iliotibial band release. The key to success is adequate release of the iliotibial band, gluteus maximus tendon, and the fibrosis underneath the iliotibial band.
... 38 While the Polesello technique spares deformity of the lateral thigh, residual gluteal hypotrophy and asymmetry have been reported in a few studies using the Polesello technique. 42 For endoscopic release, Malinowski et al. described a fanlike technique that allows the surgeon to gradually incise structures intraoperatively until snapping is eliminated. 43 The aim is to avoid total release and tissue removal, except in the case of an inflamed trochanteric bursa. ...
... However, in comparing open to endoscopic surgical management, it is essential to note the limited sample size for endoscopic surgeries. 42,[53][54][55] EXTERNAL SNAPPING HIP SYNDROME Open surgical management of external SHS primarily targets the iliotibial band to prevent sliding over the greater trochanter. Various open surgical procedures have been described, including resection of the iliotibial band and lengthening of the iliotibial band (Z-plasty). ...
Purpose of review:
This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.
Recent findings:
Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.
Summary:
SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.
To assess the functional and clinical outcomes of patients who underwent either open or endoscopic Whiteside transfer of gluteus maximus and tensor fascia lata muscles in cases of massive rupture of gluteus medius tendon associated with muscle atrophy on a native hip
This retrospective, descriptive, single-centre study was conducted by a single operator with a minimum follow-up period of 12 months. All Whiteside palliative transfers performed on patients with Type 5 gluteus medius tendon rupture, according to Lall’s classification, resulting in painful and treatment-resistant Trendeleburg gait between 2017 and 2022 were included. Functional evaluation was based on modified Harris Hip Scores (mHHS), iHOT-12, Non-Arthritic Hip Score (NAHS), and the pain on a Visual Analog Scale (VAS). Muscle strength was clinically assessed using the MRC classification.
Between January 2017 and January 2022, a total of 15 Whiteside palliative transfers were identified, including nine (60%) open procedures and 6 (40%) endoscopic procedures, performed on 13 patients. One patient was excluded, and none were lost to follow-up. The median follow-up period was 41 (12; 59) months. The median age at the time of surgery was 74 (66; 76) years. The male-to-female sex ratio was 0.27. Functional results demonstrated a significant improvement in all scores: NAHS (45 vs. 72, p = 0.002), mHHS (22 vs. 55, p = 0.002), iHOT-12 (101 vs. 56, p = 0.002), and VAS (8 vs. 3, p = 0.002). Clinical outcomes also showed improvements in muscle strength (p = 0.003), single-leg stance (p = 0.01), and gait (p = 0.02). No significant differences were found in the various scores between the endoscopic and open techniques.
Whiteside transfer surgery, whether performed through open surgery or endoscopically, is a palliative surgical approach that should be considered for patients with irreparable gluteus medius tendon tears, where the main symptom is trochanteric pain. This procedure yields satisfactory clinical and functional outcomes, although the gains in abduction strength recovery and gait improvement are modest.
Purpose:
External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique.
Methods:
An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated.
Results:
The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€).
Conclusion:
This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.
Hip and groin injuries are common in ballet dancers, who often begin sport-specific training at a young age. The unique demands of ballet include extreme range of motion, with an emphasis on external rotation and abduction. This creates a distinctive constellation of hip symptoms and pathology in this cohort, which may differ from other flexibility sports. When managing hip symptoms in this cohort, orthopaedic surgeons should consider the unique factors associated with ballet, including ballet-specific movements, morphologic adaptations of the hip, and the culture of the sport. Three common etiologies of hip pain in ballet dancers include femoroacetabular impingement syndrome, hip instability, and extra-articular snapping hip syndrome. First-line treatment often consists of focused physical therapy to strengthen the core and periarticular hip musculature, with surgical management reserved for patients who fail to improve with conservative measures.
Résumé
Les lésions des tendons des muscles glutéaux sont une cause importante de syndrome douloureux du grand trochanter. Compte-tenu de signes cliniques et d’examens d’imagerie aspécifiques, leur diagnostic est parfois retardé ou méconnu. L’aspect lésionnel peut revêtir plusieurs formes : bursite trochantérienne, tendinopathie non rompue, rupture partielle ou complète, rétraction tendineuse et infiltration graisseuse. Les options thérapeutiques non chirurgicales associent réadaptation physique et modification d’activité, antalgiques, anti-inflammatoires, infiltrations péri-trochantériennes (corticostéroïdes, PRP). En cas de symptômes récalcitrants au traitement médical, un traitement chirurgical pourra être indiqué. Une classification en cinq stades selon des constatations per-opératoires et les éléments fournis par l’IRM permet d’orienter la technique : bursectomie isolée avec microperforations, réparation tendineuse simple ou double rang, chirurgie palliative type transfert musculaire (grand glutéal ± fascia lata). L’essor de la chirurgie conservatrice de la hanche permet aujourd’hui d’appréhender l’intégralité de ces techniques chirurgicales sous endoscopie, qui a démontré une amélioration significative des scores fonctionnels et de la douleur à court et moyen terme, avec un taux de complications moindre qu’avec une chirurgie mini-invasive. Cependant, la rétraction tendineuse et l’infiltration graisseuse ont été décrites comme des facteurs de mauvais pronostic des résultats fonctionnels et de la cicatrisation tendineuse et les transferts palliatifs donnent des résultats mitigés sur la récupération de la force. Il est donc préférable de ne pas attendre de voir apparaître une boiterie de Trendelenburg pour proposer une chirurgie de réparation du moyen glutéal à des patients douloureux avec une lésion sur l’IRM et en échec du traitement médical depuis plus de 6 mois. À partir d’un avis d’experts, cet article fait le point sur le diagnostic des lésions du tendon moyen glutéal, son traitement et notamment la place de l’endoscopie, ses indications et les résultats actuels.
Niveau de preuve
V.
