Clinical outcomes and return to sport in competitive athletes undergoing iliopsoas fractional lengthening

as a part of hip arthroscopy – minimum 2 year follow-up

Itay Perets, MD1 , David Hartigan, MD2, Edwin O. Chaharbakhshi, BS1,

Lyall Ashberg, MD3, Mary R. Close, BS1, Benjamin G. Domb, MD1,4

1. American Hip Institute 2. Mayo Clinic Arizona 3. Atlantis Orthopaedics 4. Hinsdale Orthopaedics

Purpose

Conclusions

Background

Methods

Results

• The iliopsoas is a hip flexor and stabilizer that may

be associated with internal snapping.

• Internal snapping is believed to be created by the

motion of the iliopsoas over the iliopectineal

eminence or over the femoral head.

• Treatment options for iliopsoas impingement are

both conservative and surgical.

• First line of treatment: lengthening the tendon and

reduce inflammation through stretching in

physical therapy, non-steroidal anti-inflammatory

drugs, or a direct corticosteroid injection to the

iliopsoas bursa.

• Second line of treatment: if conservative

measures fail to alleviate the pain, a minimally

invasive hip arthroscopic iliopsoas tenotomy or

iliopsoas fractional lengthening (IFL) has shown

to be safe and effective.

• Although flexion and stability are important in

competitive athletes, painful internal snapping may

be debilitating and may necessitate arthroscopic

iliopsoas fractional lengthening (IFL).

To report athletes’ patient-reported outcomes (PROs),

their returns to sports, and competitive abilities after

undergoing IFL as a part of hip arthroscopy at a

minimum of two years postoperatively.

• Data were prospectively collected and retrospectively

reviewed for patients undergoing hip arthroscopy

between November 2009 and April 2014.

• Inclusion criteria: high school, collegiate, or

professional athlete, who underwent arthroscopic IFL,

and agreed to complete preoperative modified Harris

Hip Score (mHHS), Non-Arthritic Athletic Hip Score

(NAHS), Hip Outcome Score – Sports Specific

Subscale (HOS-SSS), and Visual Analog Scale

(VAS).

• Exclusion criteria: patients <16 years old, Tönnis

grade >1, previous hip conditions, and previous

surgical intervention for either hip.

• Indications for an IFL:

• History of painful internal snapping of the hip

• Presence of an iliopsoas impingement lesion

defined as a labral tear at the 3:00 acetabular

clockface position associated with hyperemia at the

capsulolabral or chondrolabral junction (Fig 1)

• 80 athletes were eligible for

inclusion, 64 (80%) of which

had minimum two-year

follow-up.

• All PRO scores demonstrated

significant improvements at

latest follow-up (p < 0.0001).

• mHHS (65.2 – 82.5)

• NAHS (62.8 – 83.1)

• HOS-SSS (43.6 – 73.2)

• VAS (5.7 - 2.6)

• Mean satisfaction was 7.9.

• Painful snapping was

resolved in 49 patients (77%).

• 67.2% return to sport

Figure 1: Iliopsoas impingement lesion. This figure shows a labral tear (LT) and labral

hyperemia (*) at the 3:00 acetabular clockface. This lesion is thought to be a result of

internal snapping of the hip. L – Labrum. A – Acetabulum. FH – Femoral Head. P –

Probe.

Figure 2: Iliopsoas fractional lengthening. 2A) The iliopsoas tendon (IPT) after

performing an interportal capsulotomy to expose the tendon and before the fractional

lengthening. 2B) The IPT is split after cutting through it using a beaver blade (BB).

Medial to the split IPT is the intact iliopsoas muscle (IPM). L – Labrum. C – Capsule.

FH – Femoral Head.

In competitive athletes, IFL during hip arthroscopy is safe and demonstrates favorable improvements in

PROs and VAS, high satisfaction, and high rate of symptom resolution at a minimum of two years

postoperatively. The majority of patients were able to return to sports and maintain or improve their

competitive levels.

1 2A 2B

Strengths:

1.This is the first study examines

arthroscopic IFL in athletes.

2.We utilized three PRO measurements,

VAS, and patient satisfaction and had

an adequately powered study.

Limitations:

1.No control group.

2.Larger studies are warranted to

adequately assess the outcomes of

this procedure based on individual

sports and competitive levels.

Patient RTS and ability

based on preop

competitive level

RTS (n, %)

Ability remained the same

or increased regardless of

RTS (n, %)

Total (n = 64 patients) 43 (67.2%) 43 (67.2%)

High school 21 (58.3%) 24 (66.7%)

Collegiate 13 (72.2%) 14 (77.8%)

Professional 9 (90.0%) 5 (50.0%)

Patient Demographics (n = 64) n (%)/mean ± SD

Age at surgery (years) 19.6 ± 3.9

Gender

Male 13 (20.3%)

Female 51 (79.7%)

Hip laterality

Left 31 (48.4%)

Right 33 (51.6%)

Preoperative competitive sports level

High school 36 (56.3%)

Collegiate 18 (28.1%)

Professional 10 (15.6%)

BMI 22.4 ± 3.9

Follow-up

Time (months) 49.7 ± 19.5

Percentage of eligible patients 80.0%

Future secondary arthroscopy 10 (15.6%)

Time (months) 31.9 ± 27.9

Future total hip replacement 0 (0%)