A Simple Anteromedial Approach to the Lesser Trochanter of the Femur for the Release of the Iliopsoas Tendon

Background: Lesser trochanter avulsions are rare injuries in adolescents. Severe cases with relevant fragment displacement can be treated surgically. However, no standard approach is available in the literature. Operative techniques are presently limited to anterograde fixations. A new retrograde approach to reduce operative difficulty and postoperative morbidity has been proposed. So far, no biomechanical comparison of these techniques is available. Hypothesis: Retrograde repair of the lesser trochanter with a titanium cortical button will produce superior stability under load to failure and similar displacement under cyclic loading compared with anterograde fixation with titanium suture anchors. Study Design: Controlled laboratory study. Methods: Sixteen paired hemipelvic cadaveric specimens (mean age, 62.5 ± 10.7 years) were dissected to isolate the lesser trochanter and iliopsoas muscle. After repair of a simulated lesser trochanter avulsion, specimens were tested under cyclic loading between 10 and 125 N at 1 Hz for 1500 cycles before finally being loaded to failure at a rate of 120 mm/min in a material testing machine. Motion tracking was used to assess displacement at the superior and inferior aspects of the iliopsoas tendon under cyclic loading. Results: Load to failure was significantly greater for the retrograde repair compared with the anterograde repair (1075.24 ± 179.39 vs 321.85 ± 62.45 N; P = .012). Mean displacement at the superior repair aspect (retrograde vs anterograde: 3.29 ± 1.84 vs 4.39 ± 4.50 mm; P = .779) and mean displacement at the inferior aspect (3.54 ± 2.13 vs 4.22 ± 4.48 mm; P = .779) of the iliopsoas tendon did not significantly differ by the type of repair. Mode of failure was tendon tearing by the sutures for each retrograde repair and anchor pullout for each anterograde repair. Conclusion: Surgical repair of lesser trochanter avulsion fractures with retrograde fixation using a titanium cortical button demonstrated superior load to failure and similar displacement under cyclic loading compared with anterograde fixation using suture anchors. Clinical Relevance: The retrograde approach provides a biomechanically validated alternative to other surgical techniques for this injury.

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Multiple iliopsoas tendons: a cadaveric study and treatment implications for internal snapping hip syndrome

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-021-04009-5 ◽

2021 ◽

Author(s):

Benjamin Lin ◽

Jonathan Bartlett ◽

Thomas D. Lloyd ◽

Dimitris Challoumas ◽

Cecilia Brassett ◽

...

Keyword(s):

Average Length ◽

Average Distance ◽

Femoral Shaft ◽

Cadaveric Study ◽

Total Width ◽

Anterior Surface ◽

Anatomical Variant ◽

Iliopsoas Tendon ◽

Lesser Trochanter ◽

Psoas Major

Abstract Purpose This cadaveric study aimed at describing the anatomical variations of the iliopsoas complex. Methods The iliopsoas complex was dissected unilaterally in 28 formalin-embalmed cadavers—13 males and 15 females with a mean age of 85.6 years. The number, courses and widths of the iliacus and psoas major tendons were determined. Patients with previous hip surgery were excluded. The following measurements were taken from the mid-inguinal point: the distance to the point of union of the psoas major and iliacus tendon; and the distance to the most distal insertion of iliopsoas. Results The presence of single, double and triple tendon insertions of iliopsoas were found in 12, 12 and 4 of the 28 specimens, respectively. When present, double and triple tendons inserted separately onto the lesser trochanter. The average length of the iliopsoas tendon from the mid-inguinal point to the most distal attachment at the lesser trochanter was 122.3 ± 13.0 mm. The iliacus muscle bulk merged with psoas major at an average distance of 24.9 ± 17.9 mm proximal to the mid-inguinal point. In all cases, the lateral-most fibres of iliacus yielded a non-tendinous, muscular insertion on to the anterior surface of the lesser trochanter and the femoral shaft, rather than joining onto the main iliopsoas tendon(s). The average total width of the psoas major tendon decreased with an increasing number of tendons: 14.6 ± 2.2 mm (single tendon), 8.2 ± 3.0 mm (2 tendons present) and 5.9 ± 1.1 mm (3 tendons present) (P < 0.001). Conclusions The results of this study suggest that multiple tendinous insertions of iliopsoas are present as an anatomical variant in more than 50% of the population. The non-tendinous muscular insertion of the iliopsoas on to the anterior surface of the lesser trochanter and femoral shaft found represents a novel anatomical variant not previously described. Level of evidence Level V

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Iliopsoas Tendon Reformation after Psoas Tendon Release

Case Reports in Orthopedics ◽

10.1155/2013/361087 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

K. Garala ◽

R. A. Power

Keyword(s):

Surgical Intervention ◽

Symptom Relief ◽

Prevalence Rates ◽

Iliopsoas Tendon ◽

Lesser Trochanter ◽

Snapping Hip ◽

Surgical Options ◽

Snapping Hip Syndrome ◽

Long Term Studies

Internal snapping hip syndrome, or psoas tendonitis, is a recognised cause of nonarthritic hip pain. The majority of patients are treated conservatively; however, occasionally patients require surgical intervention. The two surgical options for iliopsoas tendinopathy are step lengthening of the iliopsoas tendon or releasing the tendon at the lesser trochanter. Although unusual, refractory snapping usually occurs soon after tenotomy. We report a case of a 47-year-old active female with internal snapping and pain following an open psoas tenotomy. Postoperatively she was symptom free for 13 years. An MRI arthrogram revealed reformation of a pseudo iliopsoas tendon reinserting into the lesser trochanter. The pain and snapping resolved after repeat iliopsoas tendon release. Reformation of tendons is an uncommon sequela of tenotomies. However the lack of long-term studies makes it difficult to calculate prevalence rates. Tendon reformation should be included in the differential diagnosis of failed tenotomy procedures after a period of symptom relief.

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Surgical Technique: Iliopsoas Tendon Release from Lesser Trochanter

10.1007/978-1-4614-7321-3_140-1 ◽

2021 ◽

pp. 1-7

Author(s):

Victor M. Ilizaliturri ◽

Carlos Suarez-Ahedo

Keyword(s):

Surgical Technique ◽

Iliopsoas Tendon ◽

Lesser Trochanter

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Spontaneous Isolated Iliopsoas Tendon Tear in Elderly—Case Report and Review of Literature

Indian Journal of Radiology and Imaging ◽

10.1055/s-0041-1735499 ◽

2021 ◽

Author(s):

Ramanan Rajakulasingam ◽

Christine Azzopardi ◽

Peter Dutton ◽

David Beale ◽

Rajesh Botchu

Keyword(s):

Case Report ◽

Full Thickness ◽

Review Of Literature ◽

Tendon Tear ◽

Avulsion Fractures ◽

Iliopsoas Tendon ◽

Lesser Trochanter ◽

Tendon Tears

AbstractIliopsoas tendon tears are rare. These typically occur in young and can be associated with avulsion fractures of lesser trochanter. We report a case of full thickness rupture of iliopsoas tendon in 87-year-old male without avulsion of the lesser trochanter.

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Cross-Sectional Analysis of the Iliopsoas Tendon and Its Relationship to the Acetabular Labrum

The American Journal of Sports Medicine ◽

10.1177/0363546509332817 ◽

2009 ◽

Vol 37 (8) ◽

pp. 1594-1598 ◽

Cited By ~ 60

Author(s):

Joshua M. Alpert ◽

Michal Kozanek ◽

Guoan Li ◽

Bryan T. Kelly ◽

Peter D. Asnis

Keyword(s):

Iliopsoas Muscle ◽

Acetabular Labrum ◽

Cross Sectional ◽

Iliopsoas Tendon ◽

Muscle Belly ◽

Lesser Trochanter ◽

3 Dimensional ◽

Bony Anatomy ◽

Sectional Analysis ◽

Labral Injury

Background Hip pain in patients with normal bony anatomy and anterior labral injury may be related to compression of the iliopsoas tendon across the anterior capsulolabral complex. No attempts to characterize the 3-dimensional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum have been reported to date. Hypothesis The iliopsoas tendon directly overlies the capsulolabral complex. Contribution of the muscle belly and tendon to the overall circumference at the level of the labrum is approximately the same. Study Design Descriptive laboratory study. Materials and Methods Eight hip joints were dissected and cross-sectional measurements of the iliopsoas muscle-tendon complex were performed using digital calipers and image analysis software. Results The iliopsoas tendon in all specimens was located directly anterior to the anterosuperior capsulolabral complex at the 2 to 3 o'clock position. The overall length of the iliopsoas tendon from the lesser trochanter to the acetabular labrum was 75.4 ± 0.9 mm. The circumference of the iliopsoas tendon at the lesser trochanter was 25.5 ± 2.6 mm, the iliopsoas tendon at the level of the labrum was 28.4 ± 2.8 mm, and the iliopsoas tendon–muscle belly complex at the level of the labrum was 63.8 ± 7.4 mm. At the level of the labrum, the iliopsoas is composed of 44.5% tendon and 55.5% muscle belly. Conclusion The close anatomic relationship of the iliopsoas tendon to the anterior capsulolabral complex suggests that iliopsoas pathologic changes at this level may lead to labral injury. Additionally, these data suggest that at the level of the labrum, 45% of the tendon–muscle belly complex should be released to release the entire tendinous portion. Clinical Relevance Knowledge of the cross-sectional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum will better assist surgeons in treating lesions associated with iliopsoas injury.

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Hip geometry in hip fracture patients in Greenland occurring over a 7.7-year period

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02482-7 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Inuuteq Fleischer ◽

Mogens Laursen ◽

Stig Andersen

Keyword(s):

Hip Fracture ◽

Femoral Neck ◽

Fracture Risk ◽

Cortical Thickness ◽

Geometric Analysis ◽

Osteoporotic Fractures ◽

Premature Death ◽

Neck Length ◽

Hip Geometry ◽

Lesser Trochanter

Abstract Background Hip geometry influences hip fracture risk. Hip fractures are common, and they are associated with pain, disability, premature death and marked costs on society. Osteoporotic fractures are frequent in Arctic populations and increase with advancing age in this society with a steep rise in life expectancy. Greenland Inuit is a distinct ethnic group, and data on hip geometry is missing. We thus aimed to describe hip geometry in 7.7 years of consecutive hip fracture patients in Greenland. Methods We evaluated collodiaphysial angle, femoral neck length, the outer and inner diameter of the femur at 2 and 5 centimetres below the centre of the lesser trochanter and the cortical thickness from pelvic and hip radiographs in all patients operated in Greenland over 7.7 years. We included all 84 patients with one non-fractured hip visible for geometric analysis. Analyses were conducted in duplicate. Results We found a collodiaphysial angle of 134.8/132.6o in men/women (p = 0.06) and a femoral neck length of 38.0/33.9 mm in men/women (p = 0.001). Cortical thickness was affected by sex in the adjusted analysis (p < 0.001). Cortical thickness index at 5 cm below the centre of the lesser trochanter decreased with age (p = 0.026) and may be influenced by height (2 cm below the centre of the lesser trochanter, p = 0.053). Conclusion Our findings differed from European data and suggest a delicate balance in hip geometry in Arctic populations. Ethnic peculiarities influence the structure of the hip and may influence fracture risk. A focus on hip geometry and risk factors for osteoporotic fractures in Arctic populations is warranted.

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A Novel Measurement Using Digital Radiography to Minimize Fluoroscopy in Total Hip Arthroplasty

The Journal of Hip Surgery ◽

10.1055/s-0041-1728760 ◽

2021 ◽

Author(s):

Andrew G. Yun ◽

Marilena Qutami ◽

Kory B. Dylan Pasko

Keyword(s):

Femoral Head ◽

Total Hip Arthroplasty ◽

Radiation Exposure ◽

Hip Arthroplasty ◽

Fluoroscopy Time ◽

Lesser Trochanter ◽

Total Hip ◽

Preoperative Templating ◽

The Mean ◽

Templating Technique

AbstractPreoperative templating for total hip arthroplasty (THA) is fraught with uncertainty. Specifically, the conventional measurement of the lesser trochanter to the center (LTC) of the femoral head used in preoperative planning is easily measured on a template but not measurable intraoperatively. The purpose of this study was to examine the utility of a novel measurement that is reproducible both on templating and in surgery as a more accurate and practical guide. We retrospectively reviewed 201 patients with a history of osteoarthritis who underwent primary THA. For preoperative templating, the distance from the top of the lesser trochanter to the equator (LeTE) of the femoral head was measured on a calibrated digital radiograph with a neutral pelvis. This measurement was used intraoperatively to guide the choice of the trial neck and head. As with any templating technique, the goal was to construct a stable, impingement-free THA with equivalent leg lengths and hip offset. In evaluating this novel templating technique, the primary outcomes measured were the number of trial reductions and the amount of fluoroscopic time, exposures, and radiation required to obtain a balanced THA reconstruction. Using the LeTE measurement, the mean number of trial reductions was 1.21, the mean number of intraoperative fluoroscopy images taken was 2.63, the mean dose of radiation exposure from fluoroscopy was 0.02 mGy, and the mean fluoroscopy time per procedure was 0.6 seconds. In hips templated with the conventional LTC prior to the LeTE, the mean fluoroscopy time was 0.9 seconds. There was a statistically significant difference in fluoroscopy time (p < 0.001). The LeTE is a reproducible measurement that transfers reliably from digital templating to surgery. This novel preoperative templating metric reduces the fluoroscopy time and consequent radiation exposure to the surgical team and may minimize the number of trial reductions.

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