External Snapping Hip Syndrome

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CHAPTER 9 External Snapping Hip Syndrome

The snapping hip, or coxa saltans, is characterized by a snapping phenomenon that occurs around the hip in association with hip motion. It has been classified into three different types ¹:

1. External snapping hip syndrome was the earliest type described.² It is caused by the iliotibial band sliding over the greater trochanter.

2. The internal snapping hip syndrome. This is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head.

3. A third type, the so-called, intra-articular snapping hip, refers to intra-articular pathology causing mechanical hip symptoms (locking, catching, giving way). Because we are now more precise in the diagnosis and description of intraarticular hip pathology, the term intra-articular snapping hip is no longer used.³ This chapter focuses on the external snapping hip syndrome, or coxa saltans externa.

PATHOANATOMY

The external snapping hip syndrome is produced by a posterior thickening of the iliotibial band and an anterior thickening of fibers of the gluteus maximus. These fibers lie posterior to the greater trochanter. The thickened fibers snap on the greater trochanter with flexion and extension of the hip.

HISTORY AND PHYSICAL EXAMINATION

The snapping phenomenon in the case of the external snapping hip syndrome is always reported by patient at the lateral upper thigh, over the area of the greater trochanter.

In some cases, the snapping phenomenon may be visible under the skin and, in some other cases, it may be palpated over the area of the greater trochanter. In symptomatic patients, the snapping phenomenon is accompanied by pain in the area of the greater trochanter. The snapping phenomenon is always voluntary and the patient often volunteers to demonstrate it.¹ Asymptomatic snapping (snapping without pain) must always be considered a normal occurrence.⁴ Clinical diagnosis is evident; the snapping will occur with flexion and extension of the hip. The snapping phenomenon is also described by some patients as the ability to “dislocate the hip.” This is often demonstrated by actively rotating the affected hip while tilting the pelvis in standing position. The voluntary dislocators are more frequently painless and should only be treated with stretching exercises of the iliotibial band. Symptomatic external snapping hip syndrome is always accompanied with pain and tenderness in the posterior greater trochanteric region. The pain is often secondary to greater trochanteric bursitis and may also be related to tendinosis of the trochanteric insertion of the gluteus medius. When Trendelenburg gait is also found, an associated abductor muscle tear must be suspected; this is an indication for surgical treatment.

DIAGNOSTIC IMAGING

Anteroposterior pelvis x-rays should always be done to identify bony abnormalities, calcifications, or other pathology. The snapping phenomenon can be documented with dynamic ultrasonography and associated pathology such as tendinitis, bursitis or muscle tears can be detected.⁵^,⁶ Iliopsoas bursitis and abductor muscle tears can be diagnosed using magnetic resonance imaging (MRI).⁷^,⁸

TREATMENT OPTIONS

Conservative Treatment

Most symptomatic cases improve with stretching physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid infiltration of the greater trochanter bursa.¹ When conservative treatment fails, surgical release is indicated. Open iliotibial band release or lengthening has been the traditional surgical option to treat the external snapping hip syndrome.⁹^–¹² Recently, we have described a technique for endoscopic iliotibial band release for the treatment of external snapping hip syndrome¹³ that provides access to the peritrochanteric space.

Indications

Symptomatic external snapping hip syndrome is indicated in patients who have a snapping phenomenon over the area of the greater trochanter that occurs mainly with flexion and extension and is associated with pain and tenderness. Surgical release is indicated when conservative treatment fails.

Contraindications

Hip osteoarthritis requiring total hip replacement

Local soft tissue infections

Nonpainful snapping phenomenon over the greater trochanter

Success of conservative treatment

Medical contraindications for surgery

Arthroscopic Technique

The patient is positioned laterally, similar to the setup for total hip replacement. Surgical drapes must allow for free range of motion of the lower extremity so that the snapping phenomenon is reproduced with flexion and extension of the hip. Snapping usually occurs with flexion of more than 90 degrees. Reproduction of the snapping phenomenon during surgery is important to evaluate when the release of the iliotibial band is complete (Figs. 9-1 and 9-2). No traction is necessary to access the peritrochanteric space, greater trochanteric bursa, and iliotibial band. When there is a combination of periarticular pathology and hip joint pathology, arthroscopic access to the hip joint is necessary. The patient is positioned for hip arthroscopy, preparing for traction to access the central compartment and dynamic positioning for the hip periphery. I favor the lateral position for hip arthroscopy. When arthroscopy of the hip joint is complete, the foot is taken out of the traction device, the perineal post is lowered, and the peritrochanteric space is accessed. This allows for flexion and extension for reproduction of the snapping phenomenon. A more recent positioning method for hip arthroscopy is the Spider device (Tenet Medical, Calgary, Canada) which allows for full range of motion without releasing the foot for the traction device (Figs. 9-3 and 9-4).

FIGURE 9-1 Patient positioning similar to the position used for total hip replacement. This allows for full range of motion of the hip joint. In this photograph, the left hip is extended, with slight abduction and neutral rotation.

FIGURE 9-2 Hip flexion. It is necessary to flex the hip up to 90 degrees to reproduce the snapping phenomenon.

FIGURE 9-3 Patient positioned in lateral decubitus position for arthroscopy of the left hip. Note the horizontal perineal post and the traction device attached to the Spider positioner (Tenet Medical, Alberta, Canada). The image intensifier is horizontally positioned under the table to provide an anteroposterior view of the left hip.

FIGURE 9-4 By releasing the pressure of the Spider system, the hip can be flexed.

The greater trochanter is the main landmark for portal placement and is marked on the skin using a skin marker. I use two portals, a proximal trochanteric and distal trochanteric. The area of snapping should be between both portals to ensure that iliotibial band release will include the area that generates the problem. We also mark the area of snapping on the skin (Fig. 9-5). We start by infiltrating the space under the iliotibial band with 40 to 50 mL of saline. Next, the inferior trochanteric portal is established using a standard arthroscopic cannula that is introduced under the skin. It is directed proximally to the site of the superior trochanteric portal using the blunt obturator to develop a working space above the iliotibial band. The obturator is exchanged by a 4.0-mm 30-degree arthroscope and the inferior trochanteric portal used as the viewing portal. The site of the proximal trochanteric portal is identified arthroscopically using a needle inserted at the portal landmark (Fig. 9-6), the skin incision is made, and a shaver is introduced to dissect subcutaneous tissue from the iliotibial band situated between the portals (Fig. 9-7). Hemostasis is performed in this step to allow clear visualization of the iliotibial band. A radiofrequency hook probe is then introduced from the proximal trochanteric portal and a 4- to 6-cm vertical retrograde cut is made on the iliotibial band starting at the level of the inferior trochanteric portal and ending at the level of the superior trochanteric portal (Fig. 9-8). The pump pressure should be kept low while working on the subcutaneous space to avoid skin complications.

FIGURE 9-5 Illustration of portals. The anterior superior iliac spine (ASIS) and greater trochanter (GT) have been outlined. The proximal trochanteric portal is superior to the top of greater trochanter and the distal trochanteric portal is inferior to the tip of the greater trochanter. The snapping area must be between the portals. In this case, the snapping area is indicated by horizontal lines. Note how a transparent adhesive dressing has been used to prevent fluid from accessing the patient. A portion of the transparent adhesive dressing has been removed from the surgical area to prevent plastic material to be brought in through the portals.

FIGURE 9-6 A 4-mm 30-degree arthroscope is positioned above the iliotibial band at the subcutaneous space from the distal trochanteric portal. A needle is at the site of the proximal trochanteric portal. Insert, Arthroscopic photograph demonstrating endoscopic visualization of the needle at the proximal trochanteric portal.

FIGURE 9-7 The arthroscope is at the distal trochanteric portal and a mechanical shaver is at the proximal trochanteric portal.

FIGURE 9-8 Vertical cut of the iliotibial band (ITB) above the area of the greater trochanter on a left hip.

Once the vertical cut on the iliotibial band is complete, the pump pressure can be increased and a transverse anterior cut of 2 cm long is made, starting at the middle of the vertical cut (Fig. 9-9). The resulting superior and inferior anterior flaps are resected using a shaver to develop a triangular defect on the anterior iliotibial band that will provide access to the posterior iliotibial band (Figs. 9-10 and 9-11). Next, a transverse posterior cut is started at the same level of the transverse anterior cut. This is the most important release and should be carried out until the snapping phenomenon is eliminated. Finally, the superior and inferior posterior flaps are resected, which results in a diamond-shaped defect on the iliotibial band (Figs. 9-12 and 9-13). The greater trochanter will rotate freely within the defect without snapping. The greater trochanteric bursa should be removed through the defect on the iliotibial band and the abductor tendons inspected for tears (Fig. 9-14).

FIGURE 9-9 Anterior transverse cut at the midportion of the anterior margin of the vertical cut on the iliotibial band (ITB) on a left hip.

FIGURE 9-10 Anterior triangular defect of the iliotibial band (ITB) after the superior and inferior flaps of the anterior transverse cut are resected on a left hip.

FIGURE 9-11 Endoscopic sequence of an iliotibial band release for external snapping hip syndrome in a left hip, anterior release. A, Vertical release is performed, resulting in anterior and posterior margins of the iliotibial band (ITB). B, When the vertical release is complete the greater trochanteric bursa (GTB) is visible through the defect between the anterior margin of the iliotibial band (AITB) and the posterior margin of the iliotibial band (PITB). C, Direction of the anterior cut at the midportion of the vertical release on the anterior margin of the iliotibial band (arrow). The GTB and PITB are observed behind the radiofrequency hook. D, A mechanical shaver is used to resect the superior and inferior flaps after the anterior transverse release is completed. Note the triangular defect on the iliotibial band. The GTB is visible through the defect. To the right is the PITB.

FIGURE 9-12 Endoscopic sequence of an iliotibial band release for external snapping hip syndrome in a left hip, posterior release. A, Triangular defect is observed on the iliotibial band after the flaps forming the anterior transverse cut have been removed. The edges of the anterior release can be seen (arrows). The greater trochanteric bursa is visible through the defect and the posterior margin of the iliotibial band (PITB) is the base of the triangular defect. B, Radiofrequency hook probe used to perform the posterior transverse release at the midportion of the PITB. The direction of the cut is shown (arrow). The greater trochanteric bursa (GTB) and some fibers of the vastus lateralis (VL) are observed through the defect. C, The posterior transverse release of the PITB is complete. The greater trochanteric bursa is visible through the defect. D, Shaver is used to remove the superior and inferior flaps of the posterior transverse release on the PITB. The apex of the posterior release forming the posterior tip of the diamond-shaped defect can be seen (arrow). The GTB is observed through the defect.

FIGURE 9-13 Diamond-shaped defect on the iliotibial band (ITB) after release for external snapping hip syndrome. The greater trochanter (GT) is observed through the defect on a left hip.

FIGURE 9-14 Endoscopic photographs demonstrating a greater trochanteric bursectomy of a left hip. A, The greater trochanteric bursa is removed using a radiofrequency hook probe. The area is visualized and accessed though a diamond-shape released of the iliotibial band. The greater trochanter (GT) covered by the insertion of gluteus medius and vastus lateralis is at the bottom. Distal fibers of the gluteus medius (GM) are observed through the bursa at the top. B, After resection of the greater trochanteric bursa, the insertion of the GM is clearly observed on the GT. No tears are seen.

PEARLS& PITFALLS

PEARLS

• Hypotensive anesthesia control is critical for visualization in the subcutaneous and peritrochanteric space. Inform the anesthesiologist preoperatively that the systolic pressure should remain below 100 mm Hg.

• When doing an iliotibial band release for external snapping hip syndrome, it is very important to identify the snapping phenomenon with the patient anesthetized and in the surgical position. The snapping should be between the endoscopy portals for an adequate release.

• The snapping may be very apparent and visually identified though the skin, or identified only by palpation of the greater trochanteric region.

• The posterior aspect of the iliotibial band can be visualized endoscopically snapping over the posterior part of the greater trochanter once the anterior releases have been completed.

• The first step of this technique is performed in the subcutaneous space. To prevent complications, the pump pressure must be kept low (20 to 30 mm Hg). Use inflow only when carrying out the procedure; close inflow when changing instruments. Once the first vertical cut on the iliotibial band is completed, the pump pressure may be elevated to 50 mm Hg because the fluid will be accommodated in the thigh compartment or lost through leakage from the portals. It is important to close the inflow when changing instruments or evaluating snapping to make fluid management more efficient.

• Abduction of the hip may prevent injury to the abductor tendons while performing the first release. Infiltration of 60 mL of saline under the iliotibial band, before the procedure starts, may help increase the space between the iliotibial band and greater trochanter further.

• Visualization of the iliotibial band and the peritrochanteric space must be optimal. I prefer to use an ablation design radiofrequency device for hemostasis throughout the procedure. Careful hemostasis will also prevent the formation of postoperative hematomas.

• The radiofrequency hook probe, shaver, and ablation device are interchanged throughout the procedure; a slotted cannula may be used to facilitate the exchange.

• Aspirate the fluid from the peritrochanteric space when the procedure is finished.

PITFALLS

• The posterior transverse release of the iliotibial band treats the snapping phenomenon of the external snapping hip syndrome. Insufficient posterior release will result in recurrence. The most posterior part of the release should be performed under clear visualization from under the iliotibial band and in retrograde fashion using a radiofrequency hook probe. This technique will prevent damage to the sciatic nerve and structures within the paratrochanteric space.

• Resection of the greater trochanteric bursa should be performed carefully to protect the underlying gluteus medius tendon. Using the shaver with the cutting window oriented on its side, over the greater trochanteric bursa facing the camera, will protect the medius tendon.

RESULTS

Published literature on the results of surgical treatment of the external snapping hip syndrome is limited. Most reports have been about open releases of the iliotibial band and the evidence is anecdotal.⁹^–¹² Recently, our group reported the results of an endoscopic technique to release the iliotibial band with greater trochanteric bursectomy and examination of the abductor tendons.

A summary of the results of open and endoscopic techniques for iliotibial band release in the treatment of external snapping hip syndrome is presented in Table 9-1. There is little information about the results of the endoscopic technique, but they compare well with the reported results of open surgical procedures.

TABLE 9-1 Results of Surgical Treatment of External Snapping Hip Syndrome

REHABILITATION

Range of motion of the hip or knee joints is not restricted after an endoscopic release of the iliotibial band for the treatment of external snapping hip syndrome. The patient is instructed to walk with crutches or a walker for 3 weeks after the procedure, with the ipsilateral foot flat on the floor and with partial weight bearing to avoid postoperative pain secondary to the iliotibial band release. When a rupture of the gluteus medius or minimus is associated with the snapping phenomenon, crutches or walkers are also recommended, with foot-flat and partial weight bearing to protect the abductor repair.

In the absence of abductor muscle lesions, active range of motion and strength exercises are usually started 3 weeks after the procedure. Patients return to activities of daily living by the fourth week postoperative and participation in athletic activity is usually possible by 6 to 8 weeks. In the case of associated abductor tears, activities of daily living are usually possible at 6 to 8 weeks and the return to athletic activity depends on each patient.

CONCLUSIONS

Only recently has endoscopic management of symptomatic external snapping hip syndrome been reported.¹³ I have found this procedure to be safe and reproducible. Appropriate patient selection is an important factor for ensuring good results of surgical treatment.

REFERENCES

1. Allen WC, Cope R. Coxa saltans: the snapping hip revisited. J Am Acad Orthop Surg. 1995;3:303-308.

2. Binnie JF. Snapping hip (Hanche a resort; Schnellend Hefte). Ann Surg. 1913;58:59-66.

3. Byrd JWT. Evaluation and management of the snapping iliopsoas tendon. Tech Orthop. 2005;20:45-51.

4. Provencher MT, Hofmeister EP, Muldoon MP. The surgical treatment of external coxa saltans (the snapping hip) by Z-plasty of the iliotibial band. Am J Sports Med. 2004;32:470-476.

5. Pelsser V, Cardinal E, Hobden R, et al. Extra-articular snapping hip: sonographic findings. AJR Am J Roentgenol. 2001;176:67-73.

6. Choi YS, Lee SM, Song BY, Paik SH, Yoon YK. Dynamic sonography of external snapping hip syndrome. J Ultrasound Med. 2002;21:753-758.

7. Wunderbaldinger P, Bremer C, Schellenberger E, et al. Imaging features of iliopsoas bursitis. Eur Radiol. 2002;12:409-415.

8. Cvitanic O, Henzie G, Skezas N, et al. MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). AJR Am J Roentgenol. 2004;182:137-143.

9. White RA, Hughes MS, Burd T. A new operative approach in the correction of external coxa saltans. Am J Sports Med. 2004;32:1504-1508.

10. Faraj AA, Moulton A, Sirivastava VM. Snapping iliotibial band. Report of ten cases and review of the literature. Acta Orthop Belg. 2001;67:19-23.

11. Brignall CG, Stainsby GD. The snapping hip: Treatment by Z-plasty. J Bone Joint Surg Br. 1991;73:253-254.