Ian James Palmer

The Function of the Hip Capsular Ligaments: A Quantitative Report

PURPOSE Our purpose was to analyze the anatomy and quantitative contributions of the hip capsular ligaments. METHODS The stabilizing roles of the medial and lateral arms of the iliofemoral ligament, pubofemoral ligament, and ischiofemoral ligament were examined in 12 matched pairs of fresh-frozen cadaveric hips (6 male and 6 female hips). The motion at the hip joint was measured in internal and external rotation through ranges of motion from 30 degrees flexion to 10 degrees extension along a neutral swing path. The motion was standardized by use of frame stabilization and motion tracking. RESULTS There is a clear and consistent ligamentous pattern within the hip corresponding to a distinct function and contribution to internal and external rotation. On releasing the ischiofemoral ligament, the greatest gain in range of motion was that of internal rotation. The largest increase of motion by releasing the pubofemoral ligament was observed in external rotation, especially during extension. The release of the medial and lateral arms of the iliofemoral ligament each gave the greatest increase of motion in external rotation, with the lateral arm release providing more range of motion in flexion and in a neutral position. The lateral arm release also showed a significant motion increase in internal rotation, primarily in extension. CONCLUSIONS The ischiofemoral ligament controls internal rotation in flexion and extension. The lateral arm of the iliofemoral ligament has dual control of external rotation in flexion and both internal and external rotation in extension. The pubofemoral ligament controls external rotation in extension with contributions from the medial and lateral arms of the iliofemoral ligament. Together, these findings can have significant clinical applications. CLINICAL RELEVANCE When abnormal muscular and osseous pathology can be eliminated as a cause of instability or restrictive range of motion, the understanding of the independent functions of the hip ligaments will aid in defining accurate assessment and nonsurgical and arthroscopic treatment techniques.

The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome.

PURPOSE The purpose of this study was to investigate the historical, clinical, and radiographic presentation of deep gluteal syndrome (DGS) patients, describe the endoscopic anatomy associated with DGS, and assess the effectiveness of endoscopic surgical decompression for DGS. METHODS Sciatic nerve entrapment was diagnosed in 35 patients (28 women and 7 men). Portals for inspection of the posterior peritrochanteric space (subgluteal space) of the hip were used as well as an auxiliary posterolateral portal. Patients were treated with sciatic nerve decompression by resection of fibrovascular scar bands, piriformis tendon release, obturator internus, or quadratus femoris or by hamstring tendon scarring. Postoperative outcomes were evaluated with the modified Harris Hip Score (MHHS), verbal analog scale (VAS) pain score, and a questionnaire related specifically to sciatic hip pain. RESULTS The mean patient age was 47 years (range, 20 to 66 years). The mean duration of symptoms was 3.7 years (range, 1 to 23 years). The mean preoperative VAS score was 6.9 ± 2.0, and the mean preoperative MHHS was 54.4 ± 13.1 (range, 25.3 to 79.2). Of the patients, 21 reported preoperative use of narcotics for pain; 2 continued to take narcotics postoperatively (unrelated to initial complaint). The mean time of follow-up was 12 months (range, 6 to 24 months). The mean postoperative MHHS increased to 78.0 and VAS score decreased to 2.4. Eighty-three percent of patients had no postoperative sciatic sit pain (inability to sit for >30 minutes). CONCLUSIONS Endoscopic decompression of the sciatic nerve appears useful in improving function and diminishing hip pain in sciatic nerve entrapment/DGS.

Evaluation of the hip.

The evaluation of the hip has evolved over generations of orthopedic surgeons. A number of diagnostic tests have been described for specific pathologies that include a common base of maneuvers. A consistent hip examination is conducted to screen the hip, back, abdominal, neurovafscular, and neurologic systems and to find any comorbidities that often exist with complex hip pathology. Provided is a comprehensive evaluation of the hip with proposed descriptions of traditional tests along with provocative maneuvers. Through the use of a common set of diagnostic procedures and terminology, there will be improvement in the accuracy of diagnostic exams for determining hip pathology.

History and physical examination of the hip: the basics.

The history and physical examination of the hip is the key component for evaluation of patients presenting with hip pain. As our understanding of the anatomy and biomechanics of the normal hip vs the pathologic hip advances, the physical examination progresses as well. As with the shoulder and knee examinations, there are critical steps that form the basis of the examination of the hip joint. This hip examination contains 21 steps, which compares well with the shoulder 20 step exam and the knee 33 step exam. Consideration should be given for the hip as comprised of 4 layers: the osseous, capsulolabral, musculotendinous, and neurovascular. The hip represents the link between the upper body and lower body, therefore the fifth layer, the kinematic chain, plays an essential role in treatment recommendations. A clinical evaluation of the hip that incorporates this multifactor thought process will lead to an accurate diagnosis in a timely manner. This paper is a description of the 21 core examinations of a standardized clinical evaluation of the hip.

Physiological Changes as a Result of Hip Arthroscopy Performed With Traction

PURPOSE To evaluate the physiological effects of hip arthroscopy using traction on venous blood flow, nerve conduction, soft-tissue injury, fibrinolysis, and patient pain. METHODS Thirty subjects were prospectively analyzed in an institutional review board-approved study. The visual analog scale pain score, creatine phosphokinase (CPK)-MM level, and D-dimer test were obtained preoperatively, postoperatively, and 5 days postoperatively. Doppler ultrasound (group A) (n = 15) of femoral and popliteal venous blood flow and somatosensory evoked potentials (SSEPs) (group B) (n = 15) of the posterior tibial nerve and superficial peroneal nerve were monitored intraoperatively. RESULTS Mean operation and traction times were 131.7 and 27.3 minutes, respectively. During traction (mean, 57.7 lb), decreased blood flow was determined at the popliteal vein (15 of 15 subjects) and femoral vein (4 of 15 subjects). Blood flow returned to baseline after traction in all subjects. Mean CPK-MM levels were 86.0 ± 29.6 mU/mL preoperatively, 232.1 ± 224.6 mU/mL postoperatively, and 138.1 ± 109.3 mU/mL at 5 days postoperatively. The number of subjects positive for D-dimer was 7 preoperatively, 12 postoperatively, and 21 at 5 days postoperatively. SSEPs showed a greater than 50% decrease in amplitude on the operative (8 of 15) and nonoperative (9 of 15) limbs. No significant correlations were determined between visual analog scale pain score, body mass index, CPK-MM level, traction time, or operating room time. CONCLUSIONS Doppler ultrasound showed decreased blood flow of the popliteal vein with traction, which returned to normal after traction. SSEPs showed changes with and without traction on operative and nonoperative legs. Consideration should be given for knee flexion of the contralateral leg after traction to protect nerve function. Hip arthroscopy resulted in an increase in a positive D-dimer test from immediately postoperatively to postoperative day 5. There is variability in the soft-tissue damage with hip arthroscopy, which is independent of time (<2 hours), body mass index, or pain. Traction affects the vascular and neurologic structures of the operative and nonoperative extremity independent of time. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Ischiofemoral Impingement and Hamstring Syndrome as Causes of Posterior Hip Pain: Where Do We Go Next?

Recent advances in understanding hip joint anatomy and biomechanics have contributed to improvement of diagnosis and treatment decisions for distal causes of deep gluteal syndrome (DGS). Ischiofemoral impingement and hamstrings syndrome are sources of posterior hip pain that can simulate symptoms of DGS. The combination of a comprehensive history and physical examination with imaging and ancillary testing are critical for diagnosis. Six key physical examination tests are described to differentiate distal versus proximal sources of extrapelvic posterior hip pain. Outcomes depend on patient compliance and the understanding of the entire anatomy, biomechanics, clinical presentation, and open versus endoscopic treatment options.

Is there a relationship between psoas impingement and increased trochanteric retroversion

The concept of psoas impingement secondary to a tight or inflamed iliopsoas tendon causing impingement of the anterior labrum during hip extension has been suggested. The purpose of this study was to assess the relationship between the lesser trochanteric version (LTV) in symptomatic patients with psoas impingement as compared with asymptomatic hips. The femoral neck version (FNV) and LTV were evaluated on axial magnetic resonance imaging, as well as the angle between LTV and FNV. Data from 12 symptomatic patients and 250 asymptomatic patients were analysed. The mean, range and standard deviations were calculated. Independent t-tests were used to determine differences between groups. The lesser trochanteric retroversion was significantly increased in patients with psoas impingement as compared with asymptomatic hips (−31.1° SD ± 6.5 versus −24.2° ± 11.5, P < 0.05). The FNV (9° ± 8.8 versus 14.1° ± 10.7, P > 0.05) and the angle between FNV and LTV (40.2° ± 9.7 versus 38.3° ± 9.6, P > 0.05) were not significantly different between groups. In conclusion, the lesser trochanteric retroversion is significantly increased in patients with psoas impingement as compared with asymptomatic hips.

Monopolar Radiofrequency Use in Deep Gluteal Space Endoscopy: Sciatic Nerve Safety and Fluid Temperature

PURPOSE The purpose of this study was to evaluate the temperature at the sciatic nerve when using a monopolar radiofrequency (RF) probe to control bleeding in deep gluteal space endoscopy, as well as assess the fluid temperature profile. METHODS Ten hips in 5 fresh-frozen human cadaveric specimens from the abdomen to the toes were used for this experiment. Temperatures were measured at the sciatic nerve after 2, 5, and 10 seconds of continuous RF probe activation over an adjacent vessel, a branch of the inferior gluteal artery. Fluid temperatures were then measured at different distances from the probe (3, 5, and 10 mm) after 2, 5, and 10 seconds of continuous probe activation. All tests were performed with irrigation fluid flow at 60 mm Hg allowing outflow. RESULTS After 2, 5, or 10 seconds of activation over the crossing branch of the inferior gluteal artery, the mean temperature increased by less than 1°C on the surface and in the perineurium of the sciatic nerve. Considering the fluid temperature profile in the deep gluteal space, the distance and duration of activation influenced temperature (P < .05). Continuous delivery of RF energy for 10 seconds caused fluid temperature increases of 1.2°C, 2°C, and 3.1°C on average at 10 mm, 5 mm, and 3 mm of distance, respectively. CONCLUSIONS This study found the tested monopolar RF device to be safe during use in vessels around the sciatic nerve after 2, 5, and 10 seconds of continuous activation. The maximum fluid temperature (28°C) after 10 seconds of activation at 3 mm of distance is lower than the minimal reported temperature necessary to cause nerve changes (40°C to 45°C). CLINICAL RELEVANCE Monopolar RF seems to be safe to the neural structures when used at more than 3 mm of distance and with less than 10 seconds of continuous activation in deep gluteal space endoscopy with fluid inflow and outflow.

Iliopsoas tendon insertion footprint with surgical implications in lesser trochanterplasty for treating ischiofemoral impingement: an anatomic study

The objective of this study was to describe the footprint location of the iliopsoas tendon on the lesser trochanter to clarify the surgical implications of the lesser trochanterplasty for treating ischiofemoral impingement. Ten non-matched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62.4 years; range, 48–84 years; 7 male and 3 female) were included. Registered measures included bony parameters of the lesser trochanter (lesser trochanteric area, distances from the tip to the base in a coordinate system, height and area) and tendinous iliopsoas footprint descriptions (areas and detailed location). The mean height of the lesser trochanter was 13.1 (SD ± 1.8) mm, with female having a smaller lesser trochanter on average (11.3, SD ± 2.0). A double tendinous footprint was found in 7 (70%) specimens. The average area of the single- and double-footprint was 211.2 mm2 and 187.9 mm2, respectively. An anterior cortical area with no tendinous insertion on the anterior aspect of lesser trochanter was present in all specimens and measured 4.9 mm (SD ± 0.6) on average. The mean ratio between the bald anterior wall and the lesser trochanter height was 38% (SD ± 0.05). The iliopsoas tendon footprint is double (psoas and iliacus) in most cases and is located on the anteromedial tip of the lesser trochanter. A bald anterior wall on the bottom of the lesser trochanter indicates that a partial or total lesser trochanterplasty for increasing the ischiofemoral space without detaching partially or entirely the iliopsoas tendon is improbable.

The Endoscopic Treatment of Sciatic Nerve Entrapment/Deep Gluteal Syndrome

Sciatic nerve entrapment can be caused by diversified etiologies in different points along the deep gluteal space. Therefore deep gluteal syndrome has been the term suggested to describe the clinical manifestation of these various points of nervous compressive pathology. Differential diagnoses include causes of posterior hip pain and sciatica. The whole sciatic nerve trajectory in the deep gluteal space can be addressed by an endoscopic surgical technique, allowing the treatment of the diverse causes of sciatic nerve entrapment.