Open Ischiofemoral Impingement Decompression

Abstract

Ischiofemoral impingement is a relatively rare cause of posterior hip pain associated with narrowing of the space between the lateral aspect of the ischium and the lesser trochanter. Symptoms typically consist of lower buttock, groin, and/or medial thigh pain, which is commonly exacerbated by adduction, extension, and external rotation of the hip. This condition can be treated nonoperatively in many circumstances; however, recalcitrant cases may require surgical intervention. Whereas described operative treatment options for this pathology range from endoscopic to open procedures, this Technical Note describes a safe and reliable technique for open ischiofemoral decompression with sciatic nerve neurolysis through a posterior approach for treatment of ischiofemoral impingement refractory to conservative treatment.

Fig 1

Physical examination findings of ischiofemoral impingement. (A) Pain with passive extension of affected hip. (B) No pain when hip is extended and abducted. (Courtesy of Gomez-Hoyos et al. Arthroscopy 2016.)

Fig 2

The patient is positioned prone with gel rolls oriented transversely at the chest and pelvis. A 5-cm transverse incision is planned and made in the gluteal crease. This location allows for better cosmesis.

Fig 3

The gluteal fascia is split along the transverse fibers, and a plane is bluntly developed to the ischium using finger dissection. Rake retractors are used for assistance with superior soft-tissue retraction.

Fig 4

Once the plane is established, Deaver retractors are placed in the gluteal musculature and retracted superiorly. The sciatic nerve (N) is identified immediately lateral to the origin of the proximal hamstring tendons.

Fig 5

Sciatic nerve (N) neurolysis. After identification of the sciatic nerve, neurolysis of the sciatic nerve is performed using Metzenbaum scissors. A vessel loop is placed around the sciatic nerve to allow identification and gentle traction, if needed.

Fig 6

Lesser trochanter exposure. A pointed Hohmann retractor is placed on the ischial tuberosity, with careful observation of the position of the sciatic nerve, and the hip is extended and internally rotated to expose the lesser trochanter further. Blunt Hohmann retractors are then placed around the lesser trochanter with the help of blunt dissection.

Fig 7

Fluoroscopic confirmation of position. The position of the lesser trochanter is confirmed on fluoroscopy, and the soft tissue is removed from the lesser trochanter using a key elevator.

Fig 8

The hip is extended and internally rotated. Blunt Hohmann retractors are placed around the lesser trochanter to protect the sciatic nerve, and part of the iliopsoas tendon insertion is released. An oscillating saw is used to cut across the heterotopic bone after intraoperative fluoroscopy is used to confirm the angle of the cut. Care should be taken not to angle toward the femoral neck and cause iatrogenic fracture.

Fig 9

Osteotomy completion. The cut across the heterotopic bone is completed using an osteotome and mallet, with care taken to avoid the sciatic nerve. The cut is confirmed on intraoperative fluoroscopy.

Fig 10

Confirmation of lesser trochanter position. Intraoperative radiographs are used to confirm the position on the lesser trochanter (arrow), and the iliopsoas tendon is released.

Fig 11

Confirmation of adequate resection. After resection, the hip is taken through a full range of motion to ensure no further impingement. Additional assessment using radiographs with the hip in full external and internal rotation confirms no residual impingement. Radiographs also confirm that an over-resection into the femoral neck has not occurred.