Surgical Excision for Refractory Ischiogluteal Bursitis: A Consecutive Case Series of 21 Patients

Abstract

Purpose: A response to conservative treatment is usually obtained in cases of ischiogluteal bursitis. However, the time required to achieve relief of symptoms can vary from days to weeks, and there is a high recurrence rate, thus invasive treatment in addition to conservative treatment can occasionally be effective. Therefore, the aim of this study was to examine surgical excision in cases of refractory ischiogluteal bursitis and to evaluate patients' progression and outcome.

Materials and methods: A review of 21 patients who underwent surgical excision for treatment of ischiogluteal bursitis between February 2009 and July 2020 was conducted. Of these patients, seven patients were male, and 14 patients were female. Injection of steroid and local anesthetic into the ischial bursa was administered at outpatient clinics in all patients, who and they were refractory to conservative treatment, including aspiration and prescription drugs. Therefore, surgery was considered necessary. Excisions were performed by two orthopedic specialists using a direct vertical incision on the ischial area. A review of each patient was performed after excision, and quantification of the outcomes recorded using clinical scoring systems was performed.

Results: The results of radiologic evaluation showed that the mean lesion size was 6.2 cm×4.5 cm×3.6 cm. The average disease course after excision was 21.6 days (range, 15-48 days). Measurement of clinical scores, including the visual analog scale and Harris hip scores, was performed during periodic visits, with scores of 0.7 (range, 0-2) and 98.1 (range, 96-100) at one postoperative month, respectively.

Conclusion: Surgical excision, with an expectation of favorable results, could be considered for treatment of ischiogluteal bursitis that is refractory to therapeutic injections, aspirations, and medical prescriptions, particularly in moderate-to-severe cases.

Keywords: Ischiogluteal bursitis; Surgical excision.

Fig. 1. Surgical technique for the excision of the bursal sac. (A) Patient position: The patient lay in the prone position with both hip joints flexed to flatten the gluteal fold. (B) A longitudinal incision was made over the gluteus maximus (palpable bursa), and the ischial bursa was identified. And the entire bursal sac was removed from the ischial bone (C). (D) A well-separated soft-tissue cyst was observed.

Fig. 2. Pathological findings of the excised bursal sac. Histologically, bursitis is observed as an inflamed tissue rather than a characteristic feature. When bursitis has become a chronic, healing state, granulation tissues (new vessel formation–capillary vessels, fibroblasts) presumed to be a result of continuous irritation and inflammation and fibrinoid material due to bleeding are observed. Yellow circle: fibrinoid materials, Red circle, fibrinoid material with hemorrhage and vascular proliferation, Black circle: stromal fibrous change and fibroblasts. H&E stain, ×100.

Fig. 3. Enlarged gluteal lesion in ischiogluteal bursitis. A conspicuously large mass located in the gluteal region (asterisks) was observed in several cases.

Fig. 4. Magnetic resonance imaging (MRI) findings; axial (top), coronal (bottom left), and sagittal image (bottom right). MRI showed that the mass was lobulated and septate, with thin septa. The mass showed low signal intensity on T1-weighted image and high signal intensity on T2-weighted image. After contrast enhancement, the wall of the cystic mass was enhanced.

Fig. 5. Change in visual analog scale (VAS) score from preoperative phase to final follow-up.