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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 97-100

The Surgical Treatment of Recalcitrant External Coxa Saltans by Ellipsoid-Shaped Segment Excision of the Iliotibial Band


Department of Orthopaedics, Patna Medical College, Patna, Bihar, India

Date of Submission05-Nov-2021
Date of Decision14-Nov-2021
Date of Acceptance14-Nov-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Rakesh Choudhary
H – 29, Doctors Colony, Kankarbagh, Patna - 800 020, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_30_21

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  Abstract 


Introduction: Snapping hip (coxa saltans) is an audible and sometimes painful disorder of the hip that occurs during activities that require repetitive flexion, extension, and abduction of the hip. Depending upon anatomic location of the offending structure, it may be external, internal, and intra-articular. The most common type is an external type in which structures external to the hip joint are primarily involved. This is usually the iliotibial band as it slides over the greater trochanter during repeated flexion and extension. Conservative therapy is the mainstay of treatment. For those cases who are refractory to conservative means, surgery can be considered. Materials and Methods: Only those patients undergoing operative intervention for symptoms refractory to conservative measures (>6 months) were included. Patients were excluded if they had concomitant diagnosis, prior fractures, childhood hip pathology, or prior surgical procedures. Ober test was performed to determine tightness of the iliotibial band. All patients underwent excision of an ellipsoid-shaped segment of iliotibial band over greater trochanter and removal of trochanteric bursae followed by Ober test. Results: Preoperative examination yielded an average hip flexion of 115.7°, extension of 7.14°, abduction of 43.6°, internal rotation of 16.4°, and external rotation of 34.3°. All seven hips demonstrated a palpable painful snap directly over the greater trochanter with flexion and extension with positive Ober test. Postoperative examination yielded an average flexion of 125.7°, extension of 13.6°, abduction of 52.1°, and internal and external rotation of 25° and 41.4°, respectively. The snap completely resolved and Ober tests were negative in all seven cases. Conclusion: We concluded that excision of an ellipsoid-shaped segment of iliotibial band over greater trochanter and removal of underlying trochanteric bursae as the primary surgical modality for relief in the refractory yet symptomatic snapping hip due to a tight iliotibial band.

Keywords: Coxa saltans, iliotibial band, snapping hip


How to cite this article:
Choudhary R, Ranjan P, Anand R. The Surgical Treatment of Recalcitrant External Coxa Saltans by Ellipsoid-Shaped Segment Excision of the Iliotibial Band. J Orthop Dis Traumatol 2021;4:97-100

How to cite this URL:
Choudhary R, Ranjan P, Anand R. The Surgical Treatment of Recalcitrant External Coxa Saltans by Ellipsoid-Shaped Segment Excision of the Iliotibial Band. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Aug 20];4:97-100. Available from: https://jodt.org/text.asp?2021/4/3/97/332947




  Introduction Top


Snapping hip (coxa saltans) is an audible and sometimes painful disorder of the hip that occurs during activities that require repetitive flexion, extension, and abduction of the hip. Depending upon anatomic location of the offending structure, it may be external, internal, and intra-articular.[1] The most common type is an external type in which structures external to the hip joint are primarily involved. This is usually the iliotibial band as it slides over the greater trochanter during repeated flexion and extension. Asymptomatic snapping hip should be considered a benign and normal occurrence, especially in athletes. Occasionally, a snapping hip attributable to the iliotibial band becomes symptomatic and limiting to a patient. The majority of these cases are amenable to stretching, physical therapy, activity modification, a course of nonsteroidal anti-inflammatory medications, and selective injections into the trochanteric bursa. Conservative therapy is the mainstay of treatment because most improve. For those cases who are refractory to conservative means, surgery can be considered.[1],[2],[3],[4],[5]


  Materials And Methods Top


This prospective study was in between October 2018 and September 2020. Seven symptomatic snapping hips due to a tight iliotibial band underwent surgery.

Only those patients undergoing operative intervention for symptoms refractory to conservative measures (>6 months) were included. Patients were excluded if they had concomitant diagnosis, prior fractures, childhood hip pathology, or prior surgical procedures. Physical examination consisted of hip and knee range of motion, gait abnormalities, and Trendelenburg evaluation. Presence of snapping was assessed by internally and externally rotating the extended and adducted hip. The hip was then flexed while palpating the greater trochanter. A positive test was elicited when there was an audible and palpable snap over this area.[3] Finally, the Ober test was performed to determine tightness of the iliotibial band. In the lateral decubitus position, the affected hip is up and then flexed, abducted, and hyperextended to catch the iliotibial band on the greater trochanter. Then, the limb is adducted. In a positive test with a tight iliotibial band, the limb is unable to be adducted down to the examining table or to the contralateral limb.

All patients underwent excision of an ellipsoid-shaped segment of iliotibial band over greater trochanter and removal of trochanteric bursae [Figure 1]. The patient is placed in lateral decubitus position. An Ober test is performed under anesthesia noting the palpable snap and the relative tightness of the extremity on adduction to the table. An incision, approximately 10 cm in length, is made over the greater trochanter, with two-thirds of the incision below the center of the trochanter [Figure 2]. After hemostasis is obtained, an ellipsoid-shaped segment of iliotibial band over greater trochanter is excised followed by removal of trochanteric bursae [Figure 3] and [Figure 4].
Figure 1: Ellipsoid-shaped segment excision of the iliotibial band over he greater trochanter described by Zoltan et al.[6]

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Figure 2: Skin incision marking

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Figure 3: Surgical planning of incision over greater trochanter (intraoperative image)

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Figure 4: Ellipsoid-shaped segment excision of iliotibial band over greater trochanter and removal of underlying trochanteric bursae

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Next, the hip is tested through a range of motion for palpable snap and Ober test is performed. The relative tightness in adduction is compared to the preoperative examination under anesthesia. Postoperatively, the patient is partial weight-bearing with crutches for 2 weeks and progressed to full weight-bearing over the next 4 weeks. Active abduction is discouraged for 6 weeks.


  Results Top


Five of the snapping hips were in males and two in females. The average duration of symptoms before surgical intervention was 16.4 months (range 10–24 months). Preoperative conservative modalities included activity modification, physical therapy and stretching program, and greater trochanter steroid injections. Pain with an audible snap was the principal complaint, followed by difficulty during running, climbing stairs, endurance training, pain and snap while carrying heavy loads, and difficulty in performing general household activities. Magnetic resonance imaging was done to exclude internal and intra-articular pathologies. Preoperative examination yielded an average hip flexion of 115.7° (range, 105°–135°), extension of 7.14° (range, 0°–10°), abduction of 43.6° (range, 35°–50°), internal rotation of 16.4° (range, 10°–20°), and external rotation of 34.3° (range, 30°–40°). All seven hips demonstrated a palpable snap directly over the greater trochanter with flexion and extension. The Ober test was positive in all seven hips, with associated pain. Postoperative examinations yielded an average flexion of 125.7°, extension of 13.6°, abduction of 52.1°, and internal and external rotation of 25° and 41.4°, respectively. The snap completely resolved and Ober tests were negative in all seven cases [Table 1].
Table 1: Pre/postoperative flexion, extension, abduction, internal rotation, and external rotation are in degrees

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  Discussion Top


Conservative treatment is the mainstay of therapy, and the vast majority of symptomatic snapping hips resolve. Activity modification, heat, nonsteroidal anti-inflammatory medications, and a supervised physical therapy program are the cornerstones of therapy.[1],[6] Steroid injections may complement the conservative regimen.

Gordon found that in a series of 51 patients, 49 had good or excellent results with an average of 1.5 (steroid and anesthetic) to 1.8 injections (anesthetic only).[7] In a few cases who are recalcitrant to conservative treatment, a surgical lengthening may be performed.

A simple release of the iliotibial band and the anterior edge of the gluteus maximus was first performed by Dickinson in 1929 with good results. Several authors have also described a transverse release of the iliotibial band with equally good results.[8]

In 1979, Brooker described excellent pain relief with a cruciate incision of the iliotibial band directly over the greater trochanter in patients with severe trochanteric bursitis.[5]

In 1981, Orlandi et al. performed an iliotibial band release with reattachment to the greater trochanter in 20 patients.[9] They reported complete relief in 16 patients, with preservation of hip function, whereas two had pain with activities that involved internal rotation of the hip, and two had recurrence of the snap.

Sarkis and Chicote-Campos performed an anterior transfer of the iliotibial band over the greater trochanter to produce an effective lengthening of the tract with resolution of snapping and pain in all four patients.[10]

Larsen and Johansen operated on 31 patients with a periarticular snapping hip for average of 2 years. They performed a resection of the posterior half of the iliotibial tract at the insertion of the gluteus maximus in 27 patients, and a posterior flap of the iliotibial band was sutured to the anterolateral surface of the fascia in 4 patients. In 8 of 31 patients, the trochanteric bursa was excised. They found that the iliotibial tract abnormally thickened in 30 of 31 hips, and at an average 4-year follow-up, 22 of 31 (71%) were symptom-free, 6 (19%) had snapping without pain, and 3 (10%) had snapping with pain.[11],[12]

A Z-plasty lengthening of the iliotibial band in eight patients was described by Brignall and Stainsby.[4] All patients reported resolution of the snap and were pain-free at an average of 3 years after the surgery. Three hips in two patients experienced occasional aching above the greater trochanter with exercise.

Zoltan et al.[6] described an approach to refractory trochanteric bursitis in athletes in 1986. The average age was 25 years, and all seven patients were symptomatic during respective sporting activities (track, cross-country, rowing, and recreational running) with duration of symptoms from 4 months to 4 years. Conservative modalities had failed, including an average of 1.7 steroid injections. All seven underwent an elliptical-shaped resection of the iliotibial band over the greater trochanter. All reported resolution of snapping and were back to sports at 6–8 weeks after the operation.

An alternative approach was described by Polesello et al.[13] where the gluteus maximus insertion onto the proximal femur was released arthroscopically. In nine hips with external snapping hip, pain and snapping resolved in seven patients after the initial procedure and eigth patients had resolution of symptoms after a revision procedure. All eight patients returned to their previous level of activity.

Endoscopic release of the iliopsoas tendon has become more common. However, these results may be confounded by a concomitant hip arthroscopy. Ilizaliturri et al. reported on endoscopic release of the iliopsoas tendon in six patients with complete resolution of symptoms, but significant loss of flexion strength until 8 weeks after surgery.[14]

Byrd also reported on endoscopic release at the lesser trochanter in nine cases with 100% resolution of symptoms, but more than half had intra-articular hip pathology.[15]


  Conclusion Top


When compared to other hip conditions, coxa saltans is considered an uncommon cause of hip pain and dysfunction. However, in active person, the snapping may become symptomatic, leading to debilitating pain and weakness. Although conservative therapy should be the mainstay of therapy for the pathologic iliotibial band in a snapping hip, the surgical results in refractory cases are predictable and satisfactory in a carefully screened population of individuals. We recommend excision of an ellipsoid-shaped segment of iliotibial band over greater trochanter and removal of underlying trochanteric bursae as the primary surgical modality for relief in the refractory yet symptomatic snapping hip due to a tight iliotibial band.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Allen WC, Cope R. Coxa saltans: The snapping hip revisited. J Am Acad Orthop Surg 1995;3:303-8.  Back to cited text no. 1
    
2.
Binnie JF. V. Snapping hip (Hanche a Ressort; Schnellende Hufte). Ann Surg 1913;58:59-66.  Back to cited text no. 2
    
3.
Brignall CG, Brown RM, Stainsby GD. Fibrosis of the gluteus maximus as a cause of snapping hip. A case report. J Bone Joint Surg Am 1993;75:909-10.  Back to cited text no. 3
    
4.
Brignall CG, Stainsby GD. The snapping hip. Treatment by Z-plasty. J Bone Joint Surg Br 1991;73:253-4.  Back to cited text no. 4
    
5.
Brooker AF Jr. The surgical approach to refractory trochanteric bursitis. Johns Hopkins Med J 1979;145:98-100.  Back to cited text no. 5
    
6.
Zoltan DJ, Clancy WG Jr., Keene JS. A new operative approach to snapping hip and refractory trochanteric bursitis in athletes. Am J Sports Med 1986;14:201-4.  Back to cited text no. 6
    
7.
Gordon EJ. Trochanteric bursitis and tendonitis. Clin Orthop. 1961;20:193-202.  Back to cited text no. 7
    
8.
Dickinson AM. Case reports by Dr. Arthur M. Dickinson: Bilateral snapping hip. Am J Surg 1929:6;97-101.  Back to cited text no. 8
    
9.
Orlandi S, Ossola A, Pellegrini F. The extra-articular snap hip.ArchSci Med 1981;138:599-602.  Back to cited text no. 9
    
10.
Sarkis F, Chicote-Campos F. The snapping hip. Orthop practice 1978;14:618-24.  Back to cited text no. 10
    
11.
De Paulis F, Cacchio A, Michelini O, Damiani A, Saggini R. Sportsinjuries in the pelvis and hip: diagnostic imaging. Eur J Radiol.1998;27(suppl 1):S49-S59.  Back to cited text no. 11
    
12.
Larsen E, Johansen J. Snapping hip. Acta Orthop Scand.1986;57:168-70.  Back to cited text no. 12
    
13.
Polesello GC, Queiroz MC, Domb BG, Ono NK, Honda EK. Surgical technique: Endoscopic gluteus maximus tendon release for external snapping hip syndrome. Clin Orthop Relat Res 2013;471:2471-6.  Back to cited text no. 13
    
14.
Ilizaliturri VM Jr., Villalobos FE Jr., Chaidez PA, Valero FS, Aguilera JM. Internal snapping hip syndrome: Treatment by endoscopic release of the iliopsoas tendon. Arthroscopy 2005;21:1375-80.  Back to cited text no. 14
    
15.
Byrd JW. Evaluation and management of the snapping iliopsoas tendon. Instr Course Lect 2006;55:347-55.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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