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Editorial Commentary: Indiscriminate Iliopsoas Tenotomy May Cause Complications–With Tight Indications and Transbursal Lengthening, We May Avoid Them

      Abstract

      Surgical management of iliopsoas pathology that fails conservative treatment is controversial. Potential complications following iliopsoas tenotomy include recurrent painful internal snapping, postoperative pain, and hip flexor weakness. Concerns are even greater in dysplastic patients, in whom the iliopsoas may play a role as an anteromedial hip stabilizer. Although data demonstrate arthroscopic iliopsoas tenotomy for painful internal snapping as safe and effective, its use has declined for the reasons stated above. On the other hand, procedures such as capsular plication with inferior shift and anatomic labral repair, augmentation, and reconstruction have made it possible to restore the primary stabilizers in many cases of hip instability. In these cases, iliopsoas fractional lengthening (IFL) with avoidance of collateral damage to the musculature or capsule can successfully treat painful internal snapping hip. We recommend iliopsoas lengthening when (1) there is painful internal snapping, (2) IFL can be performed without collateral damage, (3) the primary soft tissue stabilizers can be restored or augmented, and (4) there is no bony morphology likely to cause continued instability.
      Treatment of iliopsoas pathology with arthroscopic iliopsoas tenotomy in the setting of femoroacetabular impingement syndrome (FAIS) and chondrolabral pathology has been associated with controversy. At one time, there was a trend toward indiscriminate iliopsoas tenotomy. Furthermore, techniques for tenotomy were highly variable, were performed at varying levels, and often included extension of the capsulotomy or collateral damage to the surrounding musculature. Not surprisingly, these trends led to subsequent reports of complications such as decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy.
      • Gouveia K.
      • Shah A.
      • Kay J.
      • et al.
      Iliopsoas tenotomy during hip arthroscopy: A systematic review of postoperative outcomes.
      ,
      • Patel K.A.
      • Collins M.S.
      • Cazan B.A.
      • Krych A.J.
      • Levy B.A.
      • Hartigan D.E.
      Iliopsoas release in hip arthroscopy: Assessment of muscle atrophy.
      In the multicenter study, “Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated With Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement”
      • Matsuda D.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Tenotomy for iliopsoas pathology is infrequently performed and associated with poorer outcomes in hips undergoing arthroscopy for femoroacetabular impingement.
      by Matsuda, Kivlan, Nho, Wolff, Salvo, Christoforetti, Martin, and Carreira, the authors present a case-control investigation combining data of 7 high-volume hip arthroscopists, aiming to report the prevalence of iliopsoas pathology in patients undergoing hip arthroscopy for FAIS, the incidence of rendered tenotomy, and outcomes of hips with iliopsoas involvement compared with those with primary FAIS. Three groups were delineated: FAIS and iliopsoas pathology with tenotomy (n = 16), FAIS and iliopsoas pathology without tenotomy (n = 76), and a control group with just FAIS diagnosis (n = 1301). Iliopsoas-related pathology was found in 7% of patients undergoing primary hip arthroscopy for FAIS, with an iliopsoas tenotomy performed in 17% of those patients. In addition, the overall prevalence of iliopsoas tenotomy was 1%. All groups reported improvement on the International Hip Outcome Tool-12, but the tenotomized iliopsoas group had lower average postoperative scores. No statistically significant difference between groups was found for patient satisfaction.
      Conversely, judicious use of atraumatic iliopsoas fractional lengthening (IFL) through a transbursal approach has allowed for successful treatment of painful internal snapping hip, without extension of the capsulotomy or damage to the surrounding muscle fibers. In a multicenter study, surgeons from the American Hip Institute and the Mayo Clinic compared 307 subjects who underwent primary arthroscopy for FAIS with IFL for recalcitrant internal snapping to 354 control subjects.
      • Maldonado D.R.
      • Krych A.J.
      • Levy B.A.
      • Hartigan D.E.
      • Laseter J.R.
      • Domb B.G.
      Does iliopsoas lengthening adversely affect clinical outcomes after hip arthroscopy? A multicenter comparative study.
      Short- to midterm outcomes demonstrated that judicious IFL was successful as a treatment for internal snapping, without adverse effects.
      • Maldonado D.R.
      • Krych A.J.
      • Levy B.A.
      • Hartigan D.E.
      • Laseter J.R.
      • Domb B.G.
      Does iliopsoas lengthening adversely affect clinical outcomes after hip arthroscopy? A multicenter comparative study.
      Further, at midterm follow-up, IFL led to a high rate of resolution of internal snapping and favorable outcomes, with no increase in complication rate or secondary surgeries compared to a control group.
      • Perets I.
      • Chaharbakhshi E.O.
      • Mansor Y.
      • et al.
      Midterm outcomes of iliopsoas fractional lengthening for internal snapping as a part of hip arthroscopy for femoroacetabular impingement and labral tear: A matched control study.
      In another study, Gouveia et al.
      • Gouveia K.
      • Shah A.
      • Kay J.
      • et al.
      Iliopsoas tenotomy during hip arthroscopy: A systematic review of postoperative outcomes.
      systematically assessed the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopy for painful internal snapping. Arthroscopic release of the iliopsoas tendon was effective in alleviating painful snapping and reported satisfactory clinical function.
      • Gouveia K.
      • Shah A.
      • Kay J.
      • et al.
      Iliopsoas tenotomy during hip arthroscopy: A systematic review of postoperative outcomes.
      It is a cautionary tale that certain studies have demonstrated early postoperative weakness and iliopsoas atrophy on radiological imaging. Furthermore, the data in outcomes after hip arthroscopy in patients with painful snapping without IFL are scarce,
      • Meghpara M.B.
      • Bheem R.
      • Diulus S.C.
      • et al.
      An iliopsoas impingement lesion in the absence of painful internal snapping may not require iliopsoas fractional lengthening.
      which makes the current study presented by Matsuda et al.
      • Matsuda D.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Tenotomy for iliopsoas pathology is infrequently performed and associated with poorer outcomes in hips undergoing arthroscopy for femoroacetabular impingement.
      very valuable. The first line for the treatment of iliopsoas pathology should be conservative treatment.
      • Chen A.W.
      • Steffes M.J.
      • Laseter J.R.
      • et al.
      How has arthroscopic management of the iliopsoas evolved, and why? A survey of high-volume arthroscopic hip surgeons.
      Indiscriminate iliopsoas tenotomy in any scenario is inadvisable. We could not agree more with Matsuda et al.
      • Matsuda D.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Tenotomy for iliopsoas pathology is infrequently performed and associated with poorer outcomes in hips undergoing arthroscopy for femoroacetabular impingement.
      that indiscriminate tenotomy for iliopsoas pathology should be cautiously considered. It has also been our experience that an iliopsoas impingement lesion in the absence of painful internal snapping does not require IFL.
      • Meghpara M.B.
      • Bheem R.
      • Diulus S.C.
      • et al.
      An iliopsoas impingement lesion in the absence of painful internal snapping may not require iliopsoas fractional lengthening.
      Although performing an IFL using the transbursal approach is feasible, in our experience, there are key technical pearls to diminish the risk of complications and obtain favorable outcomes.
      • Perets I.
      • Hartigan D.E.
      • Chaharbakhshi E.O.
      • Ashberg L.
      • Mu B.
      • Domb B.G.
      Clinical outcomes and return to sport in competitive athletes undergoing arthroscopic iliopsoas fractional lengthening compared with a matched control group without iliopsoas fractional lengthening.
      In the setting of FAIS and labral tear, labral restoration and accurate bony morphology correction are important. Careful capsular management, by avoiding extension of the capsulotomy beyond the 3 o’clock position and performing a capsular plication, is critical,
      • Maldonado D.R.
      • Lall A.C.
      • Battaglia M.R.
      • Laseter J.R.
      • Chen J.W.
      • Domb B.G.
      Arthroscopic iliopsoas fractional lengthening.
      particularly in the high-risk patient population. With meticulous technique, IFL can be performed without collateral damage to the iliofemoral ligament or iliopsoas musculature.
      It may be that the iliopsoas acts as a secondary stabilizer only in a pathological situation when the primary stabilizers are compromised. The results presented by Matsuda et al.
      • Matsuda D.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Tenotomy for iliopsoas pathology is infrequently performed and associated with poorer outcomes in hips undergoing arthroscopy for femoroacetabular impingement.
      importantly demonstrate the deleterious effects of indiscriminate IFL, especially when the primary stabilizers cannot be restored. On the other hand, procedures such as capsular plication with inferior shift and anatomic labral repair, augmentation, and reconstruction have made it possible to restore the primary stabilizers in many cases of hip instability.
      • Domb B.G.
      • Philippon M.J.
      • Giordano B.D.
      Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: Relation to atraumatic instability.
      • Fry R.
      • Domb B.
      Labral base refixation in the hip: Rationale and technique for an anatomic approach to labral repair.
      • Domb B.G.
      • Kyin C.
      • Rosinsky P.J.
      • et al.
      Circumferential labral reconstruction for irreparable labral tears in the primary setting: Minimum 2-year outcomes with a nested matched-pair labral repair control group.
      • Domb B.G.
      • Kyin C.
      • Go C.C.
      • Shapira J.
      • Rosinsky P.J.
      • Lall A.C.
      • Maldonado D.R.
      Arthroscopic circumferential acetabular labral reconstruction for irreparable labra in the revision setting: Patient-reported outcome scores and rate of achieving the minimal clinically important difference at a minimum 2-year follow-up.
      In these cases, judicious IFL with meticulous avoidance of collateral damage to the musculature or capsule can successfully treat painful internal snapping hip.
      • Maldonado D.R.
      • Diulus S.C.
      • Annin S.
      • et al.
      Borderline dysplastic female patients with painful internal snapping improve clinical outcomes at minimum two-year follow-up following hip arthroscopy with femoroplasty, labral repair, iliopsoas fractional lengthening and capsular plication: A propensity-matched controlled comparison.
      For now, we recommend iliopsoas lengthening when (1) there is painful internal snapping, (2) the IFL can be lengthened without collateral damage, (3) the primary soft tissue stabilizers can be restored or augmented, and (4) there is no bony morphology likely to cause continued instability. Our field will benefit from further collaboration between centers to elucidate the indications and surgical techniques that are most likely to yield successful outcomes in the presence of painful internal snapping hip.

      Supplementary Data

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