M fl

FIGURE 12.1. The iliopsoas courses over the iliopectineal line.

Technique

The patient is positioned for the lateral approach (see Chapter 9).6,7 After the hip has undergone a diagnostic arthroscopy, the traction is completely released. The foot is maximally externally rotated, thus bringing the lesser trochanter to an anterior position and is viewed orthogonal with the C-arm fluoroscope (Figure 12.4A,B).

Two additional safe portals are needed: the an-teroinferior (AI) and far anteroinferior (FAI). Originally, we used the anteroinferior medial (AIM) and AI (Figure 12.5A,B).

Arthroscope Placement

An intracath is directed from the AFI portal to a point just proximal to the lesser trochanter into the ilio-psoas bursa. A Nitanol wire is passed through the in-tracath and the skin is anesthetized with marcaine/

epinephrine. The skin is incised with a no. 11 blade, and the cannulated scope sheath is passed over the wire into the bursa under fluoroscopic control. The inflow is started to distend the bursa.

Instrument Placement

A second AI portal is created in the same manner and a switcher stick is placed. The iliopsoas tendon is palpated while viewing with a 30-degree arthroscope (Figure 12.6A,B). It may be necessary to clear bursa or muscle to view the tendon. A long cannula may aid in passing instruments or to maintain outflow to prevent distension.

The Release

The iliopsoas tendon is sectioned with a radiothermal cutter so as to coagulate bleeders as it is cut. We have

Iliacus muscle

Psoas muscle

Conjoined tendon

Iliacus muscle

Psoas muscle

Conjoined tendon

FIGURE 12.2. The iliacus and psoas muscles form a conjoined tendon that inserts onto the lesser trochanter.

used the ArthroCare devices (ArthroCare, Sunnyvale, CA) and the Mitek VAPR (Ethicon, Someville, NJ) with good success. Starting from the medial side of the tendon, it is sectioned working laterally (Figure 12.7A-D). Whether to do a partial or complete release is based on clinical judgment. The goal is to lengthen the musculotendinous unit, and a partial release accomplishes this. If there is pathology in the tendon such as a bifid or trifid appearance (Figure 12.8) or if the lesser trochanter has a spur, a complete release is recommended.

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