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Ischiofemoral Impingement
Allston J Stubbs, MD, MBAProfessor & Medical Director Hip Arthroscopy
Department of Orthopaedic Surgery
September 9, 2018
World Series of Surgery
Sports Medicine SymposiumChicago, Illinois USA
Disclosures
Royalties: Thieme Publishing
Boards & Committees: ISHA, AANA, ISAKOS, AAOS, ABOS, AOSSM, Journal of Hip Preservation Surgery, MASH Group
Atypical Impingement in Native Hip
Ischiofemoral
Trochanteric-Iliac (LCP)
Subspinous (AIIS)
Sutter et al Atypical Hip Impingement AJR 2013
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Ischiofemoral Impingement1977
Johnson KA Impingement of the Lesser Trochanter on the Ischial Tuberosity after Total Hip Arthroplasty JBJS-Am 1977
Ischiofemoral Impingement
Congenital
Acquired Positional
Larger femoral cross sectionPosteromedial position of femur
Hyperlaxity
Adduction/Abduction
Flexion/Extension
Expansile bone lesions
Valgus intertrochanteric osteotomy
Proximal HSenthesiopathy
OA
Fractures
Internal/ExternalRotation
Lower ischiopubic ramusProminence of lesser trochanter
Female pelvis: >AP width
Adapted from Taneja et al Ischiofemoral Impingement. MRI Clin N Am (21) 65-73: 2013.Ganz et al. The lesser trochanter as a cause of hip impingement: pathophysiology and treatment options. Hip Int 2013.Siebenrock et al. Valgus hip with high antetorsion causes pain through posterior extraarticular FAI. CORR 2013.
LCP
Valgus hip with high antetorsion
PostPartum
Why are the apparent #’s increasing?
Improved recognition by MDs
Better educated patient population
MRI
Analysis of failures
Torr iani et al. Ischiofemoral Impingement Syndrome: An entity with hip pain and abnormalities of the quadratus femoris muscle. AJR (193) 186-190: 2009.
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Profile
Female > Male
Wide age range 11-77 y/o
Unilateral > bilateral (25-40%)
Medialized anterior to posterior hip pain
Referred Patterns: Ischiofemoral ImpingementHip – Spine ConnectionAsymmetric Sacroiliac Pain
IFI
Simulated Posterior ImpingementRisk of Valgus Hip
Siebenrock et al. Valgus hip with high antetorsion causes pain through posterior extraarticular FAI. CORR 2013.
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Clinical Presentation
Hip pain: anterior, groin, posterior
Mechanical symptoms
Neurologic symptoms along sciatic nerve
Gait abnormality: hip extension phase
Radiographic narrowing of the space between the lesser trochanter and ilium
Abnormal MRI signal of quadratus femoris muscle
IF Space Anatomy
Tosun et al. Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability. Skeletal Radiology (41) 575-587: 2012.
IF Space Anatomy
Tosun et al. Ischiofemoral impingement: evaluation with new MRI parameters and assessment of their reliability. Skeletal Radiology (41) 575-587: 2012.
Sciatic Nerve
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Clinical Evaluation of Hip History
Physical Examination
Plain X-Ray Films
MRI
IF Space Injection
Other CT: 3D Reconstruction & PLAN Analysis Bone Scan Lumbar spine work-up Rheumatology work-up
Ischiofemoral Impingement Tests
“Johnson Test”: THAExtensionAdductionExternal Rotation
“Dynamic IF Impingement Test”: non-THAKnee ExtensionHip ExtensionAdductionInternal Rotation
Sussman et al. Quantitative assessment of the ischiofemoralspace and evidence of degenerative changes in the quadratusfemoris muscle. Surg Radiol Anat (35) 273-281: 2013.
LATERAL POSITION
PRONE POSITION
Dynamic IFS Test
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Imaging Findings
Plain film Cystic or sclerotic changes at lesser trochanter or ischial
tuberosity IF space calcification IF space narrowing Flamingo View
MRI IF space narrowing Edema signal pattern within IF space Degenerative signal (edema, tearing, fatty change) within
quadratus femoris muscle Tendonopathy (edema and partial tears) changes of hamstring
origin
Torriani et al. Ischiofemoral Impingement Syndrome: An entity with hip pain and abnormalities of the quadratus femoris muscle. AJR (193) 186-190: 2009.
Preop Plain Film Imaging
Severe IFISupine AP Pelvis
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Severe IFILeft Flamingo View
Severe IFIT2 FS Axial MRI
A= IF space (nominal) >17mm
B= QFM space (effective) >8mm
Figure adapted from Taneja et al Ischiofemoral Impingement. MRI Clin N Am (21) 65-73: 2013.
MRI Assessment of the At Risk Hip
Measurements adapted from Torriani et al. Ischiofemoral Impingement Syndrome: An entity with hip pain and abnormalities of the quadratus femoris muscle. AJR (193) 186-190: 2009.
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Dyonics PLAN 4D IFI Evaluation
Treatment
Activity modification
Gait training
Hip bracing
Injection of IF Space
Surgical Decompression
Primum non nocere
Fluoro, U/S, or CT Guided IF Space Injection
Diagnostic and Therapeutic
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Endoscopic Surgical Approach(Prone View Right Hip)
Modified from Sussman et al. Quantitative assessment of the ischiofemoral space and evidence of degenerative changes in the quadratus femoris muscle. Surg Radiol Anat (35) 273-281: 2013.
IT
GT
LT
Two Endoscopic Surgical Approaches
1) Anterior Approach, Safran et al. Knee Surg Sports TraumatolArthrosc. 20142) Posterolateral Approach, Howse et al. Arthros Tech 2015
IF Space Portals: Posterolateral ApproachRight Hip(Psoas Sparing Approach)
30 deg
GT
HEAD FOOTHowse et al. Arthroscopy Techniques 2015
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Endoscopic Posterolateral ApproachRight Hip
QFM
Sciatic Nerve
HEAD FOOT
Endoscopic Posterolateral ApproachRight Hip
Sciatic Nerve
QFM Shaver on LT
Inferior Border QFMHEAD FOOT
LTQFM
Inferior Border QFMHEAD FOOT
Endoscopic Posterolateral ApproachRight Hip
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LT
Subperiosteal ResectionHEAD FOOT
Endoscopic Posterolateral ApproachRight Hip
LT
Subperiosteal ResectionHEAD FOOT
Endoscopic Posterolateral ApproachRight Hip
Plain Film Post Op AssessmentPRE OP POST OP
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Plain Film Post Op Assessment
POST OPPRE OP
Post-op Rehabilitation
Passive then active ROM
Weight bearing protected 2 weeks
Particular emphasis on restoring IR
Hip flexion limited <90 deg for 2 weeks to reduce sciatic nerve stress
May also consider brace graduated knee extension based on sciatic neurolysis
Patients seen at 4 weeks for clinical and radiographic follow-up
Functional rehab is important: 12-16 weeks protected activity for contact sports
Outcomes
Level 4 & 5 clinical experience
Small series and case reports
Matching indications & symptoms with anatomy important
Risks Subtrochanteric fracture Sciatic Nerve injury AVN Femoral Head
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Summary
Emerging understanding of ischial tunnel and ischiofemoral impingement
Clinical diagnosis supported by thorough evaluation
Posterolateral cutting block approach may spare iliopsoas
Thank You!
ISHA October 2019www.isha.net@ishanet