Editorial Commentary: Indications for Concurrent Procedures During Hip Femoroacetabular Impingement Arthroscopic Treatment

In patients with femoroacetabular impingement (FAI), the underlying hip joint pathology often leads to an alteration of gait as well as core and pelvic muscular imbalance. Flexor, abductor, adductor, and hamstring tightness and pain are common patient-reported complaints at the time of evaluation for FAI and potential hip arthroscopy. Surgical interventions have been developed to target all of these potential issues, but the question remains whether these adjunct procedures are necessary or whether postoperative rehabilitation and other conservative measures may serve to better treat each condition.

An evolving challenge for the field of hip arthroscopy is determining and understanding which of these associated conditions are compensatory (i.e., will improve after the underlying hip pathology is addressed during FAI surgery), and which are pathologic (i.e., must separately be addressed at the time of surgery). As the indications and techniques for the arthroscopic treatment of FAI and associated conditions expand, the evidence base for our practices lags behind, leading us to make clinical decisions based on case reports, series, or anecdotal evidence based on personal experience. Yet, as the body of evidence grows surrounding each intervention, surgeon decision-making and practice changes. For example, we can learn much from our past experience with iliopsoas release. After several studies raised concerns about postoperative hip flexion weakness and microinstability in patients with increased anteversion, a recent survey of high-volume hip arthroscopists reported a nearly 50% decrease in the number of iliopsoas releases being performed in current-day practice as compared with earlier practice.

In this regard, the present study by Zhang, Dong, Li, Wang, Wei, Tong, and Li, entitled “Endoscopic Iliotibial Band Release During Hip Arthroscopy for Femoroacetabular Impingement Syndrome and External Snapping Hip Had Better Patient-Reported Outcomes: A Retrospective Comparative Study,” should be commended for continuing to add to the body of evidence supporting concurrent procedures performed during hip arthroscopy and should have an important impact on clinical practice. The authors report a 5% prevalence of external snapping hip (ESH) in patients with FAI undergoing hip arthroscopy in their practice, with 16 undergoing iliotibial band (ITB) release and 11 electing to forgo ITB release at the time of hip arthroscopy. The authors reported excellent outcomes in the ITB-release group at 2 years postoperatively, with no recurrence of ESH in that group. In contrast, only 1 of 11 (9.1%) of the patients with ESH had resolution of the snapping using conservative means postoperatively. Meanwhile, 10 of 11 (89.9%) patients in the conservative group still had ESH 3 months postoperatively, and this persisted until the 2-year follow-up time point unless the patient (60%) decided to undergo ITB release. Clearly, the results of Zhang et al. suggest that ESH associated with FAI is not a condition that will improve without surgical intervention, and the case is made that in patients with ESH and FAI, ITB release should be performed at the time of hip arthroscopy.

The authors describe their ITB release, which involved an endoscopic transverse 5- to 7-cm incision of the ITB from the anterior edge of the ITB at the insertion of the tensor fascia lata to the posterior edge of the ITB at the gluteus maximus insertion. A similar technique has been reported on previously in a small study of isolated ITB releases with good results overall, although 40% of patients complained of pain with strenuous sporting activities. Many techniques for ITB release, both endoscopic and open, have been described. Endoscopic treatment of isolated ESH has demonstrated excellent results, with release of the gluteus maximus tendon, transverse release, and cruciate release all considered safe and reproducible without clear support for one option over another.^{,,  ,}  Despite the limited available evidence, we are of the opinion that theoretically a large transverse release may lead to overstretching or weakness of the lateral hip stabilizers and increased strain across the abductors, but more research is required on the subject.

In their study, Zhang et al. reported that no patients developed Trendelenburg gait or weakness of hip abduction or extension following transverse release, although objective measurement of abductor strength was not performed. Our technique for addressing the ITB involves a cruciate release and has previously been described in the literature: through the anterolateral and distal anterolateral accessory portal, an endoscopic cruciate release of the ITB in the mid-portion of the tendon 2 cm in a longitudinal direction and 2 cm in a horizontal direction is performed. This is followed by shaver resection of the resulting flaps to create an ellipsoid or diamond-shaped defect, followed by a thorough endoscopic bursectomy.^,

Similar to the findings of the aforementioned study on iliopsoas release, I have found that I tend to perform concurrent ITB release during hip arthroscopy less and less over time. Unmistakably, lateral hip pain is a common problem in patients with FAI, but it is important to identify which patients develop this pain as a result of compensation due to their intra-articular pathology versus which patients have developed a separate pathology that won’t necessarily improve with hip arthroscopy alone. Previously in my practice, ITB release had been used for a number of indications: (1) to facilitate access to the bursal tissue in patients with lateral hip pain secondary to trochanteric bursitis, (2) a tight ITB with positive Ober’s test, and (3) patients with symptomatic snapping hip syndrome. Over time, my surgical indications have narrowed, as I have gained respect for violation of the ITB as a potential cause of postoperative pain and weakness. I believe that nonsurgical management with stretching, anti-inflammatory medications, and injections as an adjunct to operative intervention of FAI can resolve ITB tightness and pain in most patients. Currently, patients with nonsnapping extra-articular lateral hip pain are evaluated clinically and with magnetic resonance imaging for signs of trochanteric bursitis, abductor tendinosis or tearing, and ITB tightness. Patients with lateral hip pain that prevents them from lying on their side at night are candidates for endoscopic trochanteric bursectomy through a minimal longitudinal ITB incision. Patients with evidence of gluteus medius pathology including positive Trendelenburg test, Trendelenburg gait, or pain with resisted hip abduction are treated with either bioinductive patch gluteus medius tendon augmentation or endoscopic or open abductor repair. In those patients with trochanteric bursitis or abductor tendinosis or partial-thickness tearing, endoscopic bursectomy and/or abductor repair and augmentation are now performed through a minimal 1- to 2-cm longitudinal incision in the ITB. At the completion of the procedure, the ITB incision is closed endoscopically with absorbable sutures. Only patients with severe ITB tightness warrant a cruciate release, as often correction of the intra-articular pathology and targeted physical therapy with stretching can correct a tight ITB. Meanwhile, symptomatic ESH remains the main indication for formal cruciate ITB release in my practice.

Ultimately, we commend the authors of this study for making a compelling argument for the concurrent operative treatment of ESH at the time of hip arthroscopy. We use this commentary to call on all hip arthroscopists to continue to critically analyze and report on your successes and failures so that we may continue to build the body of evidence supporting our growing list of surgical interventions.