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Hip Videos: Extra-articular
Endoscopic Proximal Adductor Lengthening for Chronic Adductor-Related Groin Pain
Proximal adductor injuries are relatively common groin injuries in athletes. Various tenotomy techniques have been described including open, partial, and percutaneous approaches. Current techniques help most athletes return to sport; however, many develop adductor weakness. Moreover, the procedures lack full visualization of the tendon and do not allow for return to athletes' preinjury level of play. We describe an endoscopic z-lengthening of the proximal adductor tendon with the potential to minimize complications associated with open procedures such as incisional pain and neurovascular injury while affording a more complete tenotomy than current percutaneous techniques.Extra-articular Debridement of Hip Joint for Management of Anterior Hip Pain
Groin pain is a common problem that is known to be a complex issue. The wide variety of possible pathologies in numerous anatomical structures contributes to this complexity. For patients who have anterior hip pain in Patrick's test and tenderness at Scarpa's triangle, we perform periarticular debridement based on the hypothesis that rectus femoris tendinosis, subacute/chronic fibrosis of the anterior inferior iliac spine fat pad, and gluteal muscle adhesion are responsible for such anterior hip pain.Fresh Femoral Head Osteochondral Allograft Transplantation for Treating Osteochondritis Dissecans of the Femoral Head
Treatment options for the management of osteochondritis dissecans (OCD) lesions of the femoral head are limited. Although arthroscopic surgery of the hip can treat a variety of intra- and extra-articular pathologies, an OCD lesion located at the superior and medial zone of the femoral head is often difficult to access and cannot be adequately treated arthroscopically. The use of fresh-stored osteochondral allograft allows surgeons to both avoid donor-site morbidity and treat lesions of a larger surface area.Endoscopic Lesser Trochanter Resection With Refixation of the Iliopsoas Tendon for Treatment of Ischiofemoral Impingement
Ischiofemoral impingement is a source of hip pain derived from impingement between the lesser trochanter and the ischium. Lesser trochanter excision has been recommended for recalcitrant ischiofemoral impingement through either an anterior or posterior approach. However, neither of these approaches involves refixation of the iliopsoas tendon. We describe an endoscopic procedure involving anterior trochanter-plasty, minimizing the risk of sciatic complications, with refixation of the partially detached iliopsoas tendinous insertion, potentially minimizing compromise to hip flexion strength and anterior hip stability.Endoscopic Gluteus Medius and Minimus Repair With Allograft Augmentation Using Acellular Human Dermis
Recently, attention has been given to recalcitrant lateral hip pain, also known as greater trochanteric pain syndrome. Although, historically, this has been attributed to greater trochanteric bursitis, the literature has shown that many patients will have a lesion of the gluteus medius and minimus tendons. Endoscopic hip abductor tendon repair has been shown to provide good outcomes with decreasing overall morbidity and is becoming more popular. However, failure rates have been reported to be as high as 35%, likely due to the poor tissue quality in this older population.Lesser Trochanter Osteoplasty for Ischiofemoral Impingement
Ischiofemoral impingement is a newly recognized cause of extra-articular hip pain, and is caused by contact between the lesser trochanter and ischium. Surgical intervention has been proven successful for patients with persistent pain and disability after failure of nonoperative management. This technique article provides a reliable method for endoscopic lesser trochanter osteoplasty using an anterior approach.Imaging of Abductor Tears: Stepwise Technique for Accurate Diagnosis
This article presents the authors' technique for evaluation of possible abductor tears with magnetic resonance imaging (MRI). By using T2 fat-saturated coronal and axial slices of the hip and T1 coronal images of the pelvis, the authors show how to visualize all tears of the abductor tendons and signs of chronic abductor deficiency. After diagnosis has been made, signs that may help the surgeon determine if open or arthroscopic surgery would be best used are reviewed. Finally, the author reviews indications for a gluteus medius repair with concomitant gluteus maximus reconstruction.Arthroscopic Iliopsoas Release at the Level of the Lesser Trochanter Following Total Hip Arthroplasty
Iliopsoas impingement is an uncommon cause of pain after total hip arthroplasty. If pain persists after a trial of conservative treatment, surgical intervention can alleviate the patient's symptoms. Multiple advantages exist to release the iliopsoas tendon at the level of the lesser trochanter. The purpose of this Technical Note is to demonstrate a technique for arthroscopic release of the iliopsoas tendon at the lesser trochanter after total hip arthroplasty.Tenosuspension of the Reflected Head of the Rectus Femoris in Hip Arthroscopy: Description of a Portal and a Surgical Maneuver
Arthroscopy is a surgical technique useful in the treatment of intra- and extra-articular hip pathologies, including femoroacetabular impingement (FAI). In the arthroscopic treatment of pincer-type FAI, tendon interposition of the reflected head of the rectus femoris frequently hinders acetabular edge resection in the anterior-superior region (acetabuloplasty) and labrum repositioning, even causing tendon injury during the surgical procedure. Many surgeons do not give importance to the reflected head of the rectus femoris, and during the procedure they try to avoid it, giving 30° of flexion to the hip.Arthroscopic Piriformis Release—A Technique for Sciatic Nerve Decompression
Various techniques for piriformis muscle release have been published previously. However, it is imperative we continue to improve on existing techniques as well as develop new ones that may further optimize outcomes. Therefore, we aimed to describe an endoscopic technique for the release of the piriformis muscle in those with symptoms of sciatic nerve compression. Using the posterolateral portal, we are able to perform a complete release of the piriformis from the greater trochanter and the piriformis fossa with care to protect the external rotators and the sciatic nerve.Arthroscopic Psoas Management: Techniques for Psoas Preservation and Psoas Tenotomy
The iliopsoas tendon is an important dynamic stabilizer of the hip joint, and it should be carefully identified and preserved during routine hip arthroscopy. However, it may also be a source of hip pain manifesting as iliopsoas tendinitis or a snapping hip or contributing to the development of labral pathology caused by psoas impingement. In the appropriately indicated, refractory cases of iliopsoas-related hip pain, surgical intervention in the form of an iliopsoas tenotomy at the level of the labrum can result in reliable pain relief.Arthroscopic Fixation of Os Acetabuli Technique: When to Resect and When to Fix
Acetabular rim fractures, or os acetabuli, are hypothesized to occur as a result of an unfused ossification center or a stress fracture from repetitive impingement of an abnormally shaped femoral neck against the acetabular rim. When treated surgically, these fragments are typically excised as part of the correction for femoroacetabular impingement. However, in some patients, removal of these fragments can create symptoms of gross instability or microinstability of the hip. In these cases, internal fixation of the fragment is necessary.Endoscopic Trochanteric Bursectomy and Iliotibial Band Release for Persistent Trochanteric Bursitis
Lateral hip pain associated with trochanteric bursitis is a common orthopedic condition, and can be debilitating in chronic or recalcitrant situations. Conservative management is the most common initial treatment and often results in resolution of symptoms and improved patient outcomes. These modalities include rest, activity modification, physical therapy, anti-inflammatory medication, or corticosteroid injections. However, there is a subset of patients in which symptoms persist despite exhaustive conservative modalities.Diagnosis, Evaluation, and Endoscopic Repair of Partial Articular Gluteus Tendon Avulsion
In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT.All-Endoscopic Single-Row Repair of Full-Thickness Gluteus Medius Tears
Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness.Endoscopic Sciatic Neurolysis
Despite remaining a controversial diagnosis, piriformis syndrome continues to affect patients' quality of life with pain, sitting discomfort, and exercise intolerance. Open sciatic neurolysis has been noted by the senior author to often only bring temporary relief of the symptoms, with the recurrence presumably due to postoperative scar tissue. Minimally invasive techniques used to decompress the nerve have met with mixed results. This article describes a step-by-step surgical technique designed to maximize patient safety, as well as surgeon orientation, and achieve a thorough neurolysis.Endoscopic Surgical Removal of Calcific Tendinitis of the Rectus Femoris: Surgical Technique
Calcific tendinitis of the rectus femoris (CTRF) is an under-recognized condition and, because of its self-limiting nature, is usually managed conservatively. Nevertheless, when nonsurgical therapy fails, further invasive alternatives are required. At this point, arthroscopic resection provides a minimally invasive and interesting alternative to open surgery. The aim of this work is to report the surgical technique of endoscopic surgical removal in patients with CTRF at the periarticular region of the hip joint.Endoscopic Pubic Symphysectomy for Athletic Osteitis Pubis
Osteitis pubis is a common form of athletic pubalgia associated with femoroacetabular impingement. Endoscopic pubic symphysectomy was developed as a less invasive option than open surgical curettage for recalcitrant osteitis pubis. This technical note demonstrates the use of the anterior and suprapubic portals in the supine lithotomy position for endoscopic burr resection of pubic symphyseal fibrocartilage and hyaline endplates. Key steps include use of the suprapubic portal for burr resection of the posteroinferior symphysis and preservation of the posterior and arcuate ligaments.Dry Endoscopic-Assisted Mini-Open Approach With Neuromonitoring for Chronic Hamstring Avulsions and Ischial Tunnel Syndrome
Chronic hamstring origin avulsions and ischial tunnel syndrome are common causes of posterior hip pain. Although physical therapy has shown benefits in some cases, recent evidence has reported better outcomes with surgical treatment in appropriately selected patients. The full-open approach has been the classic procedure to address this problem. However, the complications related to extensive tissue exposure and the proximity of the incision to the perianal zone have led to the description of full-endoscopic techniques.Arthroscopic Capsule Reconstruction in the Hip Using Iliotibial Band Allograft
The hip capsule has been identified as an important static stabilizer of the hip joint. Despite the intrinsic bony stability of the hip socket, the capsule plays a key role in hip stability, particularly at the extremes of motion, and the iliofemoral ligament is the most important stabilizer in extension and external rotation. Patients who do not undergo capsular closure or plication may continue to complain of hip pain and dysfunction postoperatively, likely because of microinstability or muscle invagination into the capsular defect, and high-resolution magnetic resonance imaging or magnetic resonance arthrography will identify the capsular defect.Trochanteric Micropuncture: Treatment for Gluteus Medius Tendinopathy
Lateral hip pain along with tenderness of the greater trochanter has been associated with greater trochanteric pain syndrome. Radiographically, this has been associated with gluteus medius pathology on magnetic resonance imaging. This has led some surgeons to conclude that abductor pathology is a primary cause of lateral hip pain. Failure of conservative treatment in the setting of gluteus medius pathology may lead to surgical intervention. In some patients a focal tear of the gluteus medius cannot be visualized and likely represents more diffuse tendinopathy.Hip Capsulolabral Spacer Placement for the Treatment of Severe Capsulolabral Adhesions After Hip Arthroscopy
Recently, there has been a rapid increase in the number of hip arthroscopies performed. The increase in the number of primary surgeries has been associated with a similar increase in the number of revision procedures. The most frequent indications for revision hip arthroscopy are residual bony deformity (impingement), persistent labral pathology, and intra-articular adhesions. Our current understanding of capsulolabral adhesions is limited. Although adhesions between the capsule and labrum are common after hip arthroscopy, generally, they are mild and asymptomatic.Surgical Technique for Treatment of Recalcitrant Adductor Longus Tendinopathy
Chronic groin pain in the athlete can be a difficult problem to manage. Adductor dysfunction is the most common cause of groin pain in athletes, with the adductor longus being the tendon most commonly involved. The most reproducible finding for adductor longus tendinopathy is tenderness along the tendon with passive abduction and resisted hip adduction in extension. Magnetic resonance imaging and injection of a corticosteroid and anesthetic into the proximal muscle-tendon junction are both helpful in confirming the diagnosis.Endoscopic Transtendinous Repair for Partial-Thickness Proximal Hamstring Tendon Tears
Partial tears of the proximal hamstring tendon can successfully be managed with tendon repair in cases of failed conservative management. As in partial-thickness gluteus medius repair, a transtendinous technique can be used to repair partial-thickness undersurface tears of the hamstring origin. This report details an endoscopic transtendinous approach for the treatment of partial-thickness hamstring tendon tears.Hip Arthroscopy for Excision of Osteoid Osteoma of Femoral Neck
Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management.
