Juan Gómez-Hoyos

Deep gluteal syndrome

Deep gluteal syndrome describes the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve. Several structures can be involved in sciatic nerve entrapment within the gluteal space. A comprehensive history and physical examination can orientate the specific site where the sciatic nerve is entrapped, as well as several radiological signs that support the suspected diagnosis. Failure to identify the cause of pain in a timely manner can increase pain perception, and affect mental control, patient hope and consequently quality of life. This review presents a comprehensive approach to the patient with deep gluteal syndrome in order to improve the understanding of posterior hip anatomy, nerve kinematics, clinical manifestations, imaging findings, differential diagnosis and treatment considerations.

Femoral Neck Anteversion and Lesser Trochanteric Retroversion in Patients With Ischiofemoral Impingement: A Case-Control Magnetic Resonance Imaging Study.

PURPOSEnTo assess the relationship between the femoral neck version (FNV) and lesser trochanteric version (LTV) in symptomatic patients with ischiofemoral impingement (IFI) as compared with asymptomatic hips.nnnMETHODSnThe FNV and LTV of patients with symptomatic IFI who underwent magnetic resonance imaging assessment including a standardized femoral version study protocol were compared with those of patients with asymptomatic hips in this retrospective, observational study. Patients with isolated intra-articular pathology, prior hip fracture, and lesser trochanter deformity were excluded. The FNV, LTV, ischiofemoral space, and quadratus femoris space were evaluated on axial magnetic resonance imaging, as well as the angle between the LTV and the FNV. Independent t-tests were used to determine differences between groups.nnnRESULTSnData from 11 out 15 symptomatic patients and 250 out of 320 asymptomatic patients were analyzed. The mean ischiofemoral space (11.9 v 22.9 mm; P < .001; 95% confidence interval [CI], 6.9 to 15.2) and mean quadratus femoris space (7.2 mm v 14.9 mm; P < .001; 95% CI, 5.4 to 8.6) were significantly smaller in symptomatic patients versus asymptomatic patients. There was no difference in mean LTV between groups (-23.6° vxa0-24.2°; Pxa0= .8; 95% CI,xa0-7.5 to 6.4), however, the mean FNV (21.7° v 14.1°; Pxa0= .02; 95% CI,xa0-14.2 toxa0-1.1) and the angle between the FNV and LTV on average (45.4° v 38.3°; Pxa0= .01; 95% CI,xa0-12.9 toxa0-1.3) were higher in symptomatic than in asymptomatic patients, with statistical significance.nnnCONCLUSIONSnThe femoral mean neck anteversion and the mean angle between the FNV and LTV are significantly higher in patients with symptomatic IFI. The mean LTV is not increased in patients with symptomatic ischiofemoral impingement as compared with those patients with asymptomatic hips.nnnLEVEL OF EVIDENCEnLevel III, diagnostic study.

Accuracy of 2 Clinical Tests for Ischiofemoral Impingement in Patients With Posterior Hip Pain and Endoscopically Confirmed Diagnosis.

PURPOSEnTo establish the accuracy of the long-stride walking (LSW) and ischiofemoral impingement (IFI) tests for diagnosing IFI in patients whose primary symptom is posterior hip pain.nnnMETHODSnConfirmed IFI cases and cases in which IFI had been ruled out were identified considering imaging, injections, and endoscopic assessment, combined with pain relief and negative IFI-specific tests after treatment. Demographic data, duration of symptoms, pain location, ischiofemoral space, quadratus femoris space, quadratus femoris edema, surgical findings, and visual analog scale score for pain before and after treatment were computed for all patients included in this study. Sensitivity, specificity, predictive values, likelihood ratios, and diagnostic odds ratios were computed individually for the LSW test and IFI test.nnnRESULTSnCases from 1,166 consecutive hip operations and charts from 564 consecutive outpatients were retrospectively reviewed to identify patients who underwent injection and/or endoscopic surgery because of posterior hip pain. Thirty individuals (21 women and 9 men) with a mean age of 49.8 years (range, 20 to 76 years; standard deviation, 13.0 years) were included for analysis. Of the 30 patients, 17 (56.6%) were confirmed as positive for IFI and 13 (43.4%) were confirmed as negative for IFI. The IFI test had a sensitivity of 0.82, specificity of 0.85, positive predictive value of 0.88, negative predictive value of 0.79, positive likelihood ratio of 5.35, negative likelihood ratio of 0.21, and diagnostic odds ratio of 25.6. The LSW test had a sensitivity of 0.94, specificity of 0.85, positive predictive value of 0.89, negative predictive value of 0.92, positive likelihood ratio of 6.12, negative likelihood ratio of 0.07, and diagnostic odds ratio of 88.8.nnnCONCLUSIONSnIn patients with complaints of posterior hip pain and negative evaluation findings for lumbosacral spine involvement or static/dynamic mechanical axis malalignment, the IFI and LSW tests are highly accurate to help identify those with or without IFI. LEVELxa0OF EVIDENCE: Level III, diagnostic study.

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° SDu2009±u20096.5 versus −24.2°u2009±u200911.5, Pu2009<u20090.05). The FNV (9°u2009±u20098.8 versus 14.1°u2009±u200910.7, Pu2009>u20090.05) and the angle between FNV and LTV (40.2°u2009±u20099.7 versus 38.3°u2009±u20099.6, Pu2009>u20090.05) 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.

Dry Endoscopic-Assisted Mini-Open Approach With Neuromonitoring for Chronic Hamstring Avulsions and Ischial Tunnel Syndrome

Chronic hamstring origin avulsions and ischial tunnel syndrome are common causes of posterior hip pain. Although physical therapy has shown benefits in some cases, recent evidence has reported better outcomes with surgical treatment in appropriately selected patients. The full-open approach has been the classic procedure to address this problem. However, the complications related to extensive tissue exposure and the proximity of the incision to the perianal zone have led to the description of full-endoscopic techniques. Achieving an accurate hamstring repair could be technically demanding with a full-endoscopic procedure. Accurate reattachment is crucial in hamstring repair because of the functional demand of the muscles crossing of 2 major joints (hip and knee). This surgical note describes a mixed technique including a mini-open approach, neuromonitoring, and dry endoscopic-assisted repair of the hamstring origin as an alternative for treating patients with chronic hamstring avulsions and ischial tunnel syndrome that remain symptomatic despite nonoperative treatment.

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 (SDu2009±u20091.8) 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 4.9u2009mm (SDu2009±u20090.6) on average. The mean ratio between the bald anterior wall and the lesser trochanter height was 38% (SDu2009±u20090.05). 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 effects of hip abduction on sciatic nerve biomechanics during terminal hip flexion

Abstract Terminal hip flexion contributes to increased strain in peripheral nerves at the level of the hip joint. The effects of hip abduction and femoral version on sciatic nerve biomechanics are not well understood. A decrease in sciatic nerve strain will be observed during terminal hip flexion and hip abduction, independent of femoral version. Six un-embalmed human cadavers were utilized. Three Differential Variable Reluctance Transducers (DVRTs) sensors were placed on the sciatic nerve while the leg was flexed to 70° with a combination ofu2009−u200910°, 0°, 20° and 40° adduction/abduction. DVRT placement included: (i) under piriformis, (ii) immediately distal to the gemelli/obturator, (iii) four centimeters distal to sensor two. A de-rotational osteotomy to decrease femoral version 10° was performed, and sciatic nerve strain was measured by the same procedure. Data were analyzed with three-way analysis of variance and Bonferroni post-hoc analysis to identify differences in the mean values of sciatic nerve strain between native and decreased version state, hip abduction angle and DVRT sensor location. Significant main effects were observed for femoral version (P = 0.04) and DVRT sensor location (P = 0.01). Sciatic nerve strain decreased during terminal hip flexion and abduction in the decreased version state. An 84.23% decrease in sciatic nerve strain was observed during hip abduction from neutral to 40° in the presence of decreased version at terminal hip flexion. The results obtained from this study confirm the role of decreased femoral version and hip abduction at terminal hip flexion to decrease the strain in the sciatic nerve.

The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints

PURPOSEnTo assess the relation between ischiofemoral impingement (IFI) and lumbar facet joint load during hip extension in cadavers.nnnMETHODSnTwelve hips in 6 fresh T1-to-toes cadaveric specimens were tested. A complete pretesting imaging evaluation was performed using computed tomography scan. Cadavers were positioned in lateral decubitus and fixed to a dissection table. Both legs were placed on a frame in a simulated walking position. Through a posterior lumbar spine approach L3-4 and L4-5 facet joints were dissected bilaterally. In addition, through a posterolateral approach to the hip, the space between the ischium and the lesser trochanter was dissected and measured. Ultrasensitive, and previously validated, piezoresistive force sensors were placed in lumbar facet joints of L3-4 and L4-5. Lumbar facet loads during hip extension were measured in native hip conditions and after simulating IFI by performing lesser trochanter osteotomy and lengthening. Four paired t-tests were performed comparing normal and simulated IFI on the L3-L4 and L4-L5 facet joint loads.nnnRESULTSnAfter simulating IFI, mean absolute differences of facet joint load were 10.8xa0N (standard error of the mean [SEM] ±4.53, Pxa0= .036) for L3-4 at 10° of hip extension, 13.71xa0N (SEM ±4.53, Pxa0= .012) for L3-4 at 20° of hip extension, 11.49xa0N (SEM ±4.33, Pxa0= .024) for L4-5 at 10° of hip extension, and 6.67xa0N (SEM ±5.43, Pxa0= .245) for L4-5 at 20° of hip extension. A statistically significant increase in L3-4 and L4-5 lumbar facet joint loads of 30.81% was found in the IFI state as compared with the native state during terminal hip extension.nnnCONCLUSIONSnLimited terminal hip extension due to simulated IFI significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-IFI native hips.nnnCLINICAL RELEVANCEnThis biomechanical study directly links IFI to increased lumbar facet loads and supports the clinical findings of IFI causing lumbar pathology. Assessing and treating (open or endoscopic) hip disorders that limit extension could have benefit in patients with concomitant lower back symptoms.

Factores asociados al fracaso terapéutico de la cirugía artroscópica en pacientes con choque femoroacetabular: un estudio de cohorte

OBJECTIVEnThe aim of this study was to evaluate the association of the anatomical and functional characteristics with therapeutic failure in patients with femoroacetabular impingement, who underwent hip arthroscopy.nnnMATERIALS AND METHODSnA cohort study was performed on 179 patients with femoroacetabular impingement who underwent hip arthroscopy between 2004 and 2012. The demographic, anatomical, functional, and clinical information were recorded. A logistic regression model and ANCOVA were used in order to compare the described characteristics with the treatment outcomes of the hip arthroscopy.nnnRESULTSnThe median time of follow-up for symptoms was 13 months (8-30), and the mean time of follow-up after surgery was 23.83 ± 9.8 months. At the end of the follow-up 3.91% of the patients were considered as a therapeutic failure. The WOMAC score in pain and functional branches, as well as the total WOMAC score, showed significant differences (P<.05). The mean WOMAC score was higher (0 to 100 with 0 being a perfect score) in the group of patients who failed after surgery as compared with the group who meet the requirements for a successful treatment, 65.9 vs 48.8, respectively (mean difference 17.0; 95% CI; 1.3-32.6; P=.033).nnnCONCLUSIONnThe poor functional state prior to arthroscopic treatment of femoroacetabular impingement, mainly due to preoperative pain, assessed using the WOMAC scale, is associated with a higher therapeutic failure rate.

Influence of Aging on Microvascular Supply of the Gluteus Medius Tendon: A Cadaveric and Histologic Study

PURPOSEnThe purpose of this cadaveric study was to assess the relation between age and microvascular supply of 3 areasxa0of the gluteus medius tendon using a previously validated CD31 immunohistochemistry staining technique.nnnMETHODSnTwenty-four fresh-frozen gluteus medius specimens were obtained through a posterolateral approach to the hip. Specimens aged 18xa0years or older, of either sex, and of any race were considered for this study. The average age of donors was 47.3xa0years (range, 18-68xa0years). Each sample was divided into 3 portions: musculotendinous, tendinous, and tendon-bone junction. H&E staining was used for qualitative structural analysis, and then all samples underwent staining with CD31 immunohistochemistry for quantitative assessment of vessels per square millimeter. A comparison of the microvessel density between zones according to age was performed by an analysis of variance. To evaluate the relation between microvessel supply and age, a regression model with curvilinear estimation was used. The data were fitted to a quadratic model.nnnRESULTSnVascular supply in transversal and longitudinal cuts regardless of the zone was, on average, 53.9 ± 32.1 vessels/mm2 and 51.1 ± 19.3 vessels/mm2, respectively. All the areas of the tendon showed a strength of relation (R) ranging from 0.41 to 0.76 between age and vascular supply. In addition, the proportion of vascular supply change explained by age (R2) was significant in most cases (ranging from 0.17 to 0.56, with P < .05).nnnCONCLUSIONSnThere is a chronological relation between aging and microvascular supply of the gluteus medius tendon, in which an initial increase occurs from 18xa0years of age to 30 to 40xa0years of age, with a progressive decrease after 50xa0years of age.nnnCLINICAL RELEVANCEnThe findings of our study may have implications for increased vulnerability of the gluteus medius tendon and decreased healing potential.