Surgical Technique: Endoscopic Gluteus Maximus Tendon Release for External Snapping Hip Syndrome

Abstract

Background While many authors have recommended surgery for patients with persistent symptoms of external snapping hip, it is unclear which one best relieves symptoms. Concerns with iliotibial band (ITB)-modifying techniques include altering the shape of the lateral thigh and overload of the contralateral abduction mechanism. We describe a new endoscopic technique that decreases the tension of the ITB complex by releasing the femoral insertion of the gluteus maximus tendon (GMT). Description of Technique Via an endoscopic approach, we tenotomize the GMT near its insertion at the linea aspera through two trochanteric portals, developing a space beneath the ITB. Methods We reviewed eight patients (nine hips) with external snapping hip nonresponsive to nonoperative treatment treated by endoscopic GMT release. There were seven women (one bilateral) and one man, with a mean ± SD age of 35 ± 13.1 years (range, 18-55 years). Mean symptom duration was 36 ± 20.3 months (range, 16-84 months). Minimum followup was 22 months (mean, 32 ± 9.3 months; range, 22-45 months). Results Snapping and pain resolved in seven patients after the initial procedure. We performed one revision procedure with complete relief of symptoms. All eight patients returned to their previous level of activity. Average modified Harris hip score was 61 points (range, 45-70 points) preoperatively and 78 points (range, 62-93 points) at latest followup. We observed no neurovascular complications. Conclusions Our small series suggests endoscopic release of the GMT resolves pain and snapping symptoms in most patients. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis and Management of Snapping Hip Syndrome: A Comprehensive Review of Literature

“…Surgical treatment is indicated when patients do not respond to conservative treatments. Many surgical techniques have been reported in literature for the treatment both for ESHS and ISHS ( In order to preserve the abductor complex, Polesello et al [25] proposed the release of the gluteus maximum tendon (GMT), based on the hypothesis that the ITB, the gluteus maximum (GM) and the tensor fascia late (TFL) muscle work as a single complex. In fact, the ITB is pulled by the TFL anteriorly, and by the GM posteriorly, which work in synergy, and they are currently considered the main responsible of ESH [33].…”

“…The aim of surgery is to release the tendon to resolve the snapping. Different surgical procedures have been reported for treatment of ESH, including Zshaped ITB release, formal Z-lengthening, cross-shaped release, or the release of the gluteus maximus tendon insertion to the femur, which can be performed both open or endoscopically [21][22][23][24][25]. An open Zlengthening procedure was performed by Provencher, et al [21] they reported on 9 cases (8 patients) with a complete resolution of symptoms, and all but 1 returned back to active military duty.…”

“…In order to preserve the shape of the lateral thigh and the biomechanics of the ITB (Figure 6), Polesello et al [25] performed a gluteus maximus tenotomy to decrease tension on the ITB. With the patient in supine position on a traction table, the superior and inferior trochanteric portals are performed.…”

Hip arthroscopy for extra-articular hip disease

“…External coxa saltans or external snapping hip can occur as a result of a thickening of the posterior ITB, the TFL, or the gluteus maximus as they slide over the greater trochanter during hip flexion [31][32][33][34]. This frictional irritation may also lead to GTB [31].…”

“…Imaging consists of x-rays of the pelvis to exclude other pathologies causing hip pain [32,33,35]. Ultrasound and MRI may complement the history and physical exam but are probably unnecessary, except for cases in which there is concern for additional pathologies [35].…”