Good morning. My name is Andrea Herzga. It's a pleasure to be here this morning. I'll be talking about the ileo psoas and how to manage in 2023. I have no disclosures. Ileo psoas pathology is common and it comes in several flavors. It can be difficult to distinguish from intraarticular hip pathology. Ileo psoas bursitis and tendonitis often coexist and are lumped together and termed collectively psoas syndrome. Painful internal snapping hip syndrome is a painful, palpable, and often audible snap as the hip is actively brought from favor to extension. This snap reproduces the patient's pain. Ileo psoas impingement refers to repetitive friction between the ileo psoas tendon and the anterior labrum that creates the outside and anteroinferior labral lesion seen at 9 o'clock or 3 o'clock. Traditional treatment for psoas pathology is nonoperative, the workhorse being physical therapy, focusing on manual therapy, correction of lumbar lordosis, and gradual strengthening. Results of physical therapy are generally good, although the literature is scant. In patients with painful internal snapping, refractory to physical therapy, candidacy for ileo psoas tenotomy can be carefully considered. In order to do this, we must first understand the risks. Early case reports of anterior hip dislocation following tenotomy raised extreme concern over iatrogenic instability. Additionally, persistent weakness and atrophy were noted. In this study out of the University of Utah, patients were matched with and without tenotomy. A 19% decreased seated hip flexion strength was noted in those patients who underwent tenotomy, and that was ranging 16 to 32 months postoperatively. Additionally, a 25% ileo psoas volume loss was seen on MRI in these patients. So that brings us to our question paramount to this talk. We know that some patients can have persistent weakness and atrophy following tenotomy, but we also know some patients can get excellent relief of this really refractory painful snapping. So then the decision becomes to cut or not to cut. That is the question. Cut not for femoral anteversion greater than 25 degrees. This study out of HSS demonstrates worse tenotomy postoperative outcomes in patients with femoral aversion greater than 25 degrees. Cut not if it doesn't hurt. This study out of the American Hip Institute compared intraop incidental ileo psoas impingement without tenotomy to symptomatic painful internal snapping with tenotomy. Outcomes between groups were equal and statistically significant. The authors conclude that tenotomy is not needed in patients with incidental finding of ileo psoas impingement without painful snapping. Done in the right way in the right patient, ileo psoas fractional lengthening can provide great relief even in cases with borderline hip dysplasia. It is important to understand the nuances that contributed to the success of these patients. To start with, the senior author is very experienced and highly skilled. Strict inclusion and exclusion criteria were used to avoid surgery in patients at risk for excessive instability. These patients were referred for PAO consultation. In addition, the labral seal was recreated and meticulous capsular management was done with plication in patients who had dysplasia. Postoperative bracing and a physical therapy protocol focusing on elimination of instability was utilized. All these ingredients are necessary for success. In the end, it is not clear whether the psoas tenotomy derives the improvement seen in some studies or whether many of these patients ultimately battle their way into a minimally clinically important difference despite the psoas tenotomy. A prospective randomized trial of PIS patients with and without tenotomy is needed to answer that question. This multicenter study compares FAI surgical outcomes in patients with ileo psoas pathology treated with or without tenotomy and control patients with FAI. Although it did not reach statistical significance, the tenotomy group trended towards inferior results with lower scores. Additionally, the ileo psoas pathology patients without tenotomy had scores similar to the control group. The authors conclude that indiscriminate tenotomy for ileo psoas pathology should be avoided. In summary, potential indications for tenotomy include painful internal snapping as a chief complaint that is refractory to skilled PT plus or minus injection, no dysplasia, clinical instability or hypermobility, and femoral version less than 25. Pearls for successful tenotomy, screen for variant anatomy, Drs. Lin and Dr. Philippon have demonstrated that bifid tendon variant is extremely common and even trifit in some cases. Perform tenotomy at the end of the central compartment work and use low pump pressure to avoid abdominal compartment syndrome. Preserve, reconstruct, recreate that labral seal. And pay attention to the capsule with meticulous work. I like to do my first two sutures and then bring the leg into extension to make sure that there's not excess tension and then bring it up to about 30 degrees and finish it. And then if you do a tenotomy brace post-op, limit extension and external rotation in the early post-operative phase and be sure that your patient is working with a very skilled therapist who can progress them gradually. Relative contraindications to tenotomy include dancers, inflection-dependent athletes, femoral version greater than 25, hypermobility, anterior instability preoperatively. For me, a ligamentum teres tear is a big worrisome finding and those patients should not undergo tenotomy or dysplasia. Those patients are prone to severe instability. It is my personal opinion that the painful internal snapping hip is the baker's cyst of the hip. It is symptomatic when something is wrong. Effusion, dysplasia, instability, muscular imbalance, glute shutdown. It subsides with correction of the problem. Most often it is merely the messenger and not the source. Thank you.

ileo psoas pathology

internal snapping hip syndrome

ileo psoas tenotomy

prospective randomized trial

indications