GTPS encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and LSH. Conservative treatment is successful in more than 90% of cases [3,4,5,6, 9]. Lateral hip pain associated with disease of the proximal ITB is often misdiagnosed and attributed to other intra- and extra-articular structures.
LSH syndrome is associated with a tight ITB. Surgical options for LSH range from open surgery—including resection of the ITB, either in combination or not with partial reconstruction of the posterior flap (70–90% success rate) [11,12,13,14] and step cut, and z-plasty lengthening (30–100% success rate) [15,16,17,18,19,20,21]—to endoscopic surgery. Endoscopic surgery techniques vary from creating a cross-shaped cut plus a diamond defect [22, 23] a transversal release [24] to gluteus maximus tendon release [25].
No surgical techniques have proven superior to transverse release. In fact, open procedures including z-plasty and resection (elliptical, cross-shaped, diamond-shaped) plus partial reconstruction seem to result in slightly poorer outcomes than resections of the fascia or lengthening in terms of recurrence and scar sensitivity [12, 14]. Therefore, effective ultrasound-guided release of the ITB with a 1-mm incision may be a valid and attractive alternative to open or endoscopic surgery, as in other forms of ultrasound-guided surgery.
We postulated that performing complete release of the ITB via a 1- to 2-mm incision was sufficient to interrupt its tension and therefore the snap over the greater trochanter. Our preliminary study in cadavers showed the surgical procedure to be safe and effective, with complete release of the proximal ITB.
During the past 6 years, we have operated on 14 patients following these principles. Our limited experience is promising. Twelve patients were satisfied after 3 months, including the 2 cases with associated distal release of the ITB, and all were satisfied after 1 year.
The patient with severe gluteal fibrosis, who needed several portals and a modification of the technique in order to resolve the snap, experienced pain and was limited for sports for 1 year. We had to perform a large z-plasty and detach part of the union of the gluteus maximus to the ITB using a vertical cut. This may have led to instability, although we may also have damaged part of the gluteal fibers, as the tissue was fibrotic and the snap persisted. Consequently, the patient experienced weakness while running that took 1 year to resolve. However, we do not know whether this is a limitation for ultrasound-guided surgery or simply a special situation that required prolonged training and recovery [37].
The patient with the hip prosthesis reported improvement in pain, burning, hypersensitization, and tension in the greater trochanter area. The snap disappeared. This patient only walks and needs a crutch for long distances.
Of greater interest, despite the delayed functional recovery, is the fact that the snap had not recurred at her last check-up, after a minimum follow-up of 2 years. In addition, as anesthesia is local, the surgeon can ask the patient to actively move the entire hip and leg and check the result immediately. This approach enables us to resolve the snap with a transverse cut, reaching the anterior and posterior border of the proximal ITB. Z-plasty and larger release were necessary in only 1 patient. Given that the technique is easy to perform, it can be modified with partial release or z-plasty.
With the approach described here, complications and surgical aggressiveness are minimal. Furthermore, we can combine other procedures, such as double, proximal, and distal release of the ITB, all with local anesthesia.
Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless in uncomplicated cases (with a VAS of 0 and an HHS of 91 at 3 months). Weight bearing is immediate, and patients usually need crutches for only 2–3 days.
All but 1 patient was satisfied after 3 months, and all were satisfied at their last follow-up. Minor hematomas were the most common complication. No stitches are required, and the incision measures 1–2 mm. Since the risk of bleeding is minimal and immediate weight bearing is allowed, patients did not take low-molecular-weight heparin.
The learning curve is quick, although the surgeon must perfect the technique with cadavers and become competent in the use of ultrasound. This technique is easier than other ultrasound-guided procedures such as tarsal tunnel release, carpal tunnel release, and gastrocnemius lengthening, in which the authors also have experience. However, the technique may be subject to limits and contraindications. First, it may not be possible in cases with gluteal fibrosis, which could make the procedure more complicated and aggressive. Weakness of the abductor muscles with a positive Trendelenburg sign may also be a contraindication [28].
More prospective studies are necessary to compare our approach with other forms of surgery. However, we think ultrasound-guided release of the proximal ITB is an excellent surgical option for LSH, with encouraging results in patients for whom conservative protocols have failed.