Clinical Outcomes After Arthroscopic Psoas Lengthening: The Effect of Femoral Version

doi:10.1016/j.arthro.2011.11.028

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 7, July 2012, Pages 965-971

https://doi.org/10.1016/j.arthro.2011.11.028 Get rights and content

Purpose

The purpose of this study was to examine the association between femoral anteversion and clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon in young patients.

Methods

Sixty-seven consecutive patients with symptomatic coxa saltans underwent arthroscopic psoas tendon lengthening through a transcapsular approach during a 3-year period by a single arthroscopic hip surgeon. Demographic and clinical variables were collected. Patients were divided into low/normal femoral version and high femoral version groups and analyzed for association of femoral version with clinical outcomes as measured by the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) preoperatively and postoperatively with a minimum of 6 months' follow-up (range, 6 to 24 months). Two-sample t tests were used for data analysis, with P < .05 defined as significant.

Results

Preoperative evaluation showed excessive anteversion (>25°) associated with worse HOS sports subscale scores (26.6 v 50.0 for excessive v low/normal anteversion, P = .013) and no difference in mHHS and HOS activities–of–daily living subscale scores. Postoperative mHHS scores were significantly different (76.9 v 86.1 for excessive v low/normal anteversion, P = .031). No association was noted between clinical outcome measures and any other clinical or demographic variable (P > .05).

Conclusions

Patients with increased femoral anteversion may be at greater risk for inferior clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon. The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities, particularly terminal extension and external rotation when the tendon is typically at its highest tension. These results may help surgeons identify which patients may be at risk for inferior clinical outcome after psoas lengthening.

Level of Evidence

Level IV, therapeutic, case series.

Section snippets

Patient Selection

An institutional review board–approved prospective registry of all hip arthroscopy procedures performed during a 3-year period (December 2006 to December 2009) by a single, high-volume arthroscopic hip surgeon was queried for subject recruitment. All patients consented to be included in the registry for research purposes during their initial consultation. Inclusion criteria for subject recruitment from the registry included an arthroscopic psoas tendon lengthening at the time of surgery, a

Demographics

Patient demographics are shown in Table 1. Mean postoperative follow-up was 1 year (range, 0.5 to 2.0 years). There were 60 female and 7 male patients, but there was no statistical difference in gender distribution between the low/normal and high version groups. In addition, no differences were seen between the version groups with respect to age, side of injury, dominance of operative extremity (i.e., the leg that the patient naturally uses to kick a ball), alpha angle, or duration of

Discussion

The purpose of this study was to determine whether there is any association between femoral anteversion and clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon in young patients. We hypothesized that, given the anatomic location of the psoas tendon at the anterior aspect of the capsulolabral junction and femoral head, it may act as a dynamic anterior stabilizer of the hip joint, as well as that excessive femoral anteversion may be associated with decreased

Conclusions

Patients with increased femoral anteversion may be at greater risk for inferior clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon. The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities, particularly terminal extension and external rotation, when the tendon is typically at its highest tension. These results may help surgeons

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Cited by (137)

Femoral Anteversion Is Associated With a Thinner Anterior Capsule in Patients With Femoroacetabular Impingement Syndrome
2024, Arthroscopy - Journal of Arthroscopic and Related Surgery
To measure femoral torsion on computed tomography images in patients with femoroacetabular impingement syndrome and explore whether femoral torsion was significantly correlated with anterior capsular thickness.
Prospectively collected data of surgical patients were retrospectively reviewed. Only patients aged 16 to 55 years who underwent primary hip surgery were included in this study. Patients with a history of revision hip surgery, previous knee surgery, hip dysplasia, hip synovitis, and/or incomplete radiographs and medical records were excluded from the study. Femoral torsion was measured via computed tomography imaging using transcondylar slices of the knee. Anterior capsular thickness was measured using oblique-sagittal sequences on a 3.0-T magnetic resonance imaging system. The association between anterior capsular thickness and related variables, including femoral torsion, was assessed via multiple linear regression. The patients were then divided into 2 groups to further confirm the effect of femoral torsion on capsular thickness: Patients in the study group had hips with moderate (20°-25°) or severe (>25°) antetorsion, whereas patients in the control group had hips with normal torsion (5°-20°) or retrotorsion (<5°). Anterior capsular thickness was also compared between the 2 groups.
A total of 156 patients (89 female patients [57.1%] and 67 male patients [42.9%]) were finally included in the study. The mean age and body mass index of the included patients were 35.8 ± 11.2 years and 22.7 ± 3.5, respectively. The mean femoral torsion for the entire study population was 15.9° ± 8.9°. Multivariable regression analysis showed that femoral torsion (P < .001) and sex (P = .002) were significantly correlated with anterior capsular thickness. Propensity-score matching yielded 50 hips in the study group and 50 hips in the control group on femoral torsion subanalysis. The results showed that anterior capsular thickness was significantly smaller in the study group than in the control group (3.8 ± 0.5 mm vs 4.7 ± 0.7 mm, P < .001).
Femoral torsion is significantly inversely correlated with anterior capsular thickness.
Level III, retrospective comparative study.
Combined femoral and acetabular version is sex-related and differs between patients with hip dysplasia and acetabular retroversion
2023, European Journal of Radiology
Frequency of abnormal femoral and acetabular version (AV) and combinations are unclear in patients with developmental dysplasia of the hip (DDH). This study aimed to investigate femoral version (FV), the proportion of increased FV and femoral retroversion, and combined-version (CV, FV+AV) in DDH patients and acetabular-retroversion (AR).
A retrospective IRB-approved observational study was performed with 78 symptomatic DDH patients (90 hips) and 65 patients with femoroacetabular-impingement (FAI) due to AR (77 hips, diagnosis on AP radiographs). CT/MRI-based measurement of FV (Murphy method) and central AV were compared. Frequency of increased FV(FV > 25°), severely increased FV (FV > 35°) and excessive FV (FV > 45°) and of decreased FV (FV < 10°) and CV (McKibbin-index/COTAV-index) was analysed.
Mean FV and CV was significantly (p < 0.001) increased of DDH patients (mean ± SD of 25 ± 11° and 47 ± 18°) compared to AR (16 ± 11° and 28 ± 13°). Mean FV of female DDH patients (27 ± 16°) and AR (19 ± 12°) was significantly (p < 0.001) increased compared to male DDH patients (18 ± 13°) and AR (13 ± 8°). Frequency of increased FV (>25°) was 47% and of severely increased FV (>35°) was 23% for DDH patients.
Proportion of femoral retroversion (FV < 10°) was significantly (p < 0.001) higher in patients AR (31%) compared to DDH patients (17%). 18% of DDH patients had AV > 25° combined with FV > 25°. Of patients with AR, 12% had FV < 10° combined with AV < 10°.
Patients with DDH and AR have remarkable sex-related differences of FV and CV. Frequency of severely increased FV > 35° (23%) is considerable for patients with DDH, but 17% exhibited decreased FV, that could influence management. The different combinations underline the importance of patient-specific evaluation before open hip preservation surgery (periacetabular osteotomy and femoral derotation osteotomy) and hip-arthroscopy.
Femoral Version May Impact Hip Arthroscopy Outcomes in Select Patient Populations: A Systematic Review
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Fabricant et al.20 and Nwachukwu et al.21 found that patients with FRV had smaller improvement across all PROMs compared with NFV and additionally had lower odds of reaching minimally clinically important differences (Table 5). Lastly, in patients with symptomatic coxa sultans, patients with FAV had worse HOS-SSS score preoperatively and worse HOS-ADL scores postoperatively27 (Table 4). Seven studies investigated the impact of FV on subsequent hip operations including revision hip arthroscopy, periacetabular osteotomy, hip resurfacing arthroplasty, and total hip arthroplasty (THA) (Table 6).
To provide further clarity regarding the management of patients with abnormal femoral version in the setting of hip arthroscopy and will discuss the definition of femoral version, the diagnostic and clinical evaluation of abnormal femoral version, and several described measurement techniques.
A systematic review was conducted in literature published before August 2021 that measured femoral version and reported patient-reported outcomes measures or rates of subsequent procedures following hip arthroscopy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and the electronic databases, PubMed, OvidMedLine, Scopus, and Web of Science were searched. Two blinded reviews screened and evaluated data quality using the Newcastle-Ottawa Scale.
Eighteen studies were included with 11 studies reporting patient outcomes and 7 studies reporting rates of subsequent procedures. The most commonly used definition of femoral version was 5° to 20° of femoral anteversion. Computed tomography scan was the most commonly used imaging modality. The majority of studies (7 of 11) demonstrated that femoral version does not have an impact on patient-reported outcomes measures and is not predictive of clinically meaningful improvement scores. However, in select studies, patients with femoral retroversion were found to experience slightly inferior outcomes following hip arthroscopy for femoroacetabular impingement. While femoral retroversion may be a risk factor for subsequent procedures, 3 of 7 studies refute this claim. Although in patients with borderline hip dysplasia, excessive femoral anteversion led to greater rates of subsequent hip procedures.
While the majority of studies show that femoral version does not have an impact on patient-reported outcomes following hip arthroscopy, those with femoral retroversion and with excessive anteversion with coexisting borderline hip dysplasia need to be educated on their increased risk of subsequent operation. Ultimately, this review suggests that clinical improvement can likely be achieved regardless of femoral version.
IV; systematic review of Level I-IV studies.
Do femoral version abnormalities play a role in hip function of patients with hip pain?
2022, Clinical Biomechanics
A high prevalence of femoral version abnormalities has been observed in hip pain patients, with impact on hip range of motion and muscle strength that should be elucidated.
Cross-sectional study. Thirty-one patients with hip pain (16 men and 15 female) were subjected to Biplanar X-Rays to quantify femoral version using three-dimensional measurements. The 62 hips were divided into normal version (10–20°, n = 18), anteverted (>20°, n = 19), and retroverted (<10°, n = 25). Joint range of motion for flexion, internal rotation, and external rotation was assessed through digital goniometry. Maximal isometric hip strength (flexion, extension, internal rotation, external rotation at 0° and 30°, abduction, adduction) was evaluated through hand-held dynamometry. Hip rotation index was calculated as external rotation minus internal rotation.
Anteverted hips had greater internal rotation, while retroverted hips had greater external rotation (p = 0.001). Anteverted hips were weaker than retroverted hips for external rotation at 30° (p < 0.001), abduction (p = 0.006) and adduction (p < 0.001), and weaker than normal version hips for extension (p = 0.018). All three groups had different rotation index: retroverted>normal>anteverted (p < 0.001). The ordinal logistic regression found higher values of rotation index with higher probability of being retroverted (common odds ratio = 1.20). There was a strong correlation between femoral version group and rotation index (r_S = 0.76, p < 0.001). There was probability >70% of a hip being anteverted if the rotation index was <11°, and being retroverted if the index was >40°.
Range of motion and muscle strength differed in hips with different femoral versions. The hip rotation index was a strong femoral version predictor.
Assessment of Femoral Torsion on Magnetic Resonance Imaging is More Reliable Using Axial-Oblique Sequences Compared With Standard Axial Slices in Patients With Femoroacetabular Impingement Syndrome
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
To determine the agreeability of femoral torsion measurements on axial and oblique axial magnetic resonance imaging (MRI) sequences in patients with femoroacetabular impingement syndrome (FAIS).
Patients who underwent primary hip arthroscopy for FAIS between January 2012 to January 2019 were identified. Inclusion criteria were all patients with an MRI scan containing the pelvis and knee imaging. MRI-based measurements of femoral torsion were performed on axial and oblique-axial slices by 2 raters, and inter-rater and intrarater reliability was assessed. Bland Altman plots were constructed to evaluate the agreeability between femoral torsion measurements performed using axial and oblique-axial slices. Bivariate correlation analyses were performed to assess the relationship between measurement methods on each respective scan. A linear regression was performed between measurements performed using axial and oblique-axial sequences.
A total of 164 patients were included. The mean true-axial and oblique axial femoral torsion were 12.2° ± 9.9° and 11.1° ± 9.2°, respectively. The intrarater reliability for axial and oblique-axial measurements were 0.993 and 0.997, respectively. The inter-rater reliability for axial and oblique-axial measurements were 0.925 and 0.965, respectively. The number of differences within the limits of agreement for axial and oblique-axial femoral torsion measurements was 58.54%. On Pearson correlation analysis, strong positive correlations were found between oblique-axial measurements at multiple time points (r = 0.994, P < .001), as well as axial measurements at multiple time points (r = 0.986, P < .001). A strong positive correlation was found between axial and oblique-axial measurements (r = 0.894, P < .001). A significant regression equation indicated that for each additional increase in axial femoral torsion, the oblique-axial femoral torsion increased 0.837 (95% confidence interval 0.772-0.901).
Femoral torsion values measured on oblique-axial sequences are smaller than on true-axial sequences. Femoral torsion measurements on axial and oblique-axial MRI sequences exhibit poor agreement. Oblique-axial sequences demonstrated greater measurement consistency at multiple timepoints. When evaluating torsional measurements, it is important to delineate which axial sequence was used, especially in patients with suspected severe femoral antetorsion. Standardization of MRI femoral version protocols within one’s practice can ensure more consistent decision-making, especially in patients with suspected femoral antetorsion.
Retrospective cohort, level III.
Snapping in the lower limbs: a narrative review
2024, Minerva Orthopedics

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original ArticleClinical Outcomes After Arthroscopic Psoas Lengthening: The Effect of Femoral Version

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Patient Selection

Demographics

Discussion

Conclusions

Arthroscopy

Arthroscopy

J Orthop Sci

Arthroscopy

Arthroscopy

Arthroscopy

Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections

AJR Am J Roentgenol

Arthroscopic psoas release for iliopsoas impingement after total hip replacement

Acta Orthop Belg

Surgical correction of internal coxa saltans: A 20-year consecutive study

Am J Sports Med

Evaluation and management of the snapping iliopsoas tendon

Instr Course Lect

The iliopsoas muscle complex: Iliacus muscle, psoas tendon release

Clin Orthop Relat Res

Original Article
Clinical Outcomes After Arthroscopic Psoas Lengthening: The Effect of Femoral Version