External Snapping Hip Syndrome Endoscopic Treatment: "Fan-like" Technique as a Stepwise, Tailor-made Solution

Abstract

Classically, external snapping hip syndrome (ESHS) is considered to be caused by friction of a tight iliotibial band (ITB) over the greater trochanter (GT), which leads to pain, inflammation, and palpable or audible snapping. Surgical treatment remains a gold standard in patients resistant to conservative measures. Many surgical procedures addressing ESHS exist in the literature, but the vast majority of them involve only plasties of the ITB. However, observations led us to the conclusion that friction of the ITB over the GT may not be the only cause of ESHS and other structures like gluteal fascias or an anterior scarred part of gluteus maximus may be involved. The aim of this article is to provide a detailed description and video demonstration of an endoscopic surgical procedure using a "fan-like" cut to treat the ESHS. Its greatest advantage is the ability to gradually increase the extent of surgery based on intraoperative observations. It turns the procedure into a tailor-made surgery, which offers good and reproducible results.

Fig 1

The left hip of the patient in the lateral decubitus position. At the beginning of the procedure, the position of the STP 1 to 2 cm above the tip of the greater trochanter and inferior trochanteric portal 5 to 7 cm below the greater trochanter are marked. (GM, gluteus maximus; ITP, inferior trochanteric portal; STP, superior trochanteric portal.)

Fig 2

Arthroscopic view from the inferior trochanteric portal in the left hip in the lateral decubitus position. Formation of the superior trochanteric portal under direct visual control using an injection needle for proper position. (GT, greater trochanter.)

Fig 3

Arthroscopic view from the inferior trochanteric portal in the left hip in lateral decubitus position. An RF probe introduced through superior trochanteric portal is used to perform a longitudinal cut along the natural course of the fibers of the ITB over the greater trochanter. (ITB, iliotibial band; RF, radiofrequency.)

Fig 4

Arthroscopic view from the inferior trochanteric portal in the left hip in lateral decubitus position. (A) An RF probe introduced through superior trochanteric portal is used to perform a perpendicular incision to previous one as a second part of the “fan-like technique.” (B) The dissection is continued depends on the intraoperative “snapping” examination and is extended close to the posterior wall of GT until the snapping stops or red tissue of GM belly is reached. Black arrows: posterior wall of the longitudinal cut; red line: the direction of perpendicular cut. (GM, gluteus maximus; GT, greater trochanter; ITB, iliotibial band; RF, radiofrequency.)

Fig 5

Arthroscopic view from the inferior trochanteric portal in the left hip in lateral decubitus position. In some cases, Metzenbaum scissors can be used to carefully release some visible additional layers of fibrous adhesive tissue that cover tendinous insertions on the GT. (GT, greater trochanter.)

Fig 6

Arthroscopic view from the inferior trochanteric portal in the left hip in lateral decubitus position. The RF probe is used to perform an additional posterosuperior incision (red line). The cut is performed when longitudinal and perpendicular cuts were not enough for eliminate snapping. (GT, greater trochanter; RF, radiofrequency.)

Fig 7

Diagrammatic drawing of the idea of fan-like incision technique for external snapping hip syndrome. The left hip is presented.