Comprehensive Open Management of Buttock/Ischiofemoral Symptoms: The COMBIS Procedure for Posterior Hip Pain

Abstract

Background:

Posterior hip and buttock pain can arise from several overlapping but distinct etiologies. Ischiofemoral impingement, sciatic neuropathy, and proximal hamstring tendinopathy, occurring alone or in combination, have been implicated as precipitants. However, diagnosis and management of underlying pathology can be challenging, as few diagnostic modalities reliably differentiate between these etiologies and surgeon decision-making may be complicated by uncertainty over which pathology to address.

Indications:

Posterior hip and buttock pain which occurs in a sciatic nerve distribution and is refractory to conservative measures (eg, physical therapy, analgesics, and activity modification) raises suspicion for 1 or several of the above pathologies. A combined procedure to address all 3—ischiofemoral decompression, sciatic neurolysis, and proximal hamstring repair—is described here.

Technique Description:

The patient is placed prone on a radiolucent table. An incision is made, and dissection is taken down through the superficial layers of the buttock, gluteal fascia, and fascia overlying the proximal hamstring tendons. The sciatic nerve is identified, mobilized, and lysed using blunt dissection. The fascia overlying the ischium is incised and the tendinous insertion decorticated with rongeur. Two anchors are placed, and sutures are passed through the proximal hamstring tendon in mattress fashion. An incision is made in line with the external rotators and dissection is taken down to the lesser trochanter. The lesser trochanter is identified, and osteotomy performed, with mobilization and removal of the resected fragment. The interval in the external rotators is closed with interrupted suture.

Results:

This is an uncommon procedure with little data on patient outcomes. Nonetheless, it is effective for relief of symptoms related to the pathologies enumerated above. Keys to success include careful diagnosis and comfort with surgical technique.

Conclusion:

The COMBIS procedure simultaneously addresses 3 common etiologies of posterior hip and buttock pain. Although it is important to conduct a thorough diagnostic evaluation to rule out imitators, patients with symptoms due to ischiofemoral impingement, sciatic neuropathy, proximal hamstring tendinopathy, or combination thereof may experience good relief of symptoms with appropriate application of this technique.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Management of posterior hip and buttock pain can be challenging for orthopedic surgeons as these patients oftentimes have overlapping symptoms between various pathologies and there is a lack of highly specific diagnostic examination maneuvers or imaging tests.

These patients may oftentimes have several structural issues including ischiofemoral impingement, sciatic neuropathy, or proximal hamstring tendinopathy. This creates a treatment dilemma for surgeons in deciding which pathology to address.

Ischiofemoral impingement was first described in 1977 in patients following total hip arthroplasty. This is a rare diagnosis with a poorly defined prevalence. The pathobiomechanics are also poorly understood with abnormal osseous alignment as a suggested contributing factor.

Ischiofemoral impingement has also been proposed as an etiology in sciatic nerve compression and proximal hamstring tendinopathy. Patients may present with an insidious onset of posterior hip or buttock pain. If the sciatic nerve is involved, then neuropathic symptoms may present down the posterior leg. It is important to differentiate between other regional etiologies of posterior hip pain, such as a lumbar radiculopathy.

On examination, patients may present with a shortened stride length for ischiofemoral impingement. Tenderness at the lateral aspect of the ischium is consistent with proximal hamstring tendinopathy. This is different from tenderness at the soft tissue region lateral to the ischium itself, which is more consistent with ischiofemoral impingement.

The ischiofemoral impingement test involves hip extension in the lateral decubitus position. When symptoms are increased while the hip is adducted this is considered a positive test. Additionally, providers can do the reverse plank test to test for proximal hamstring tendinopathy and localized analgesic injections can also provide symptomatic relief.

As seen here the ischiofemoral impingement test first involves hip extension with the leg in abduction, followed by hip extension in the leg with adduction.

Diagnostic imaging often starts with plain radiographs which may be normal; however, chronic cases may show sclerosis at the ischium or lesser trochanter. Dynamic ultrasound or magnetic resonance imaging (MRI) can also be used.

Findings on MRI may include quadratus femoris edema. Additionally, the ischiofemoral space can be measured though no pathologic cutoff value is agreed upon at this point.

Non-operative treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and activity modification. Additionally, a localized corticosteroid injection can provide symptomatic relief in some cases.

Operative treatment options may include ischiofemoral decompression, sciatic neurolysis, or proximal hamstring repair. It is important to address each pathology on a case-by-case basis, only if symptomatic.

This case example involves a 47-year-old woman who underwent bilateral total hip arthroplasties and presented with left posterior hip pain that radiated down her leg in a sciatic distribution. She had failed nonoperative measures, and her pain was temporarily relieved with ischiofemoral injections.

On examination, she had a shortened stride length, was tender over the ischium and ischiofemoral space, and she had increased pain with hip extension, adduction, and external rotation during the ischiofemoral test. Additionally, she had increased pain and weakness with reverse plank testing.

Her radiographs showed her prior hip arthroplasty implants, but otherwise were unremarkable. Her MRI, seen here, showed edema in the quadratus femoris. Additionally, cross-sectional imaging through the proximal hamstring origin demonstrated proximal hamstring tendinopathy and tearing.

In summary, this is a 47-year-old woman who presented following bilateral total hip arthroplasties with a clinical picture concerning for left ischiofemoral impingement, sciatic nerve entrapment, and symptomatic partial proximal hamstring tearing.

The plan for this patient was a COMBIS procedure, which includes an open left ischiofemoral decompression, sciatic neurolysis, and proximal hamstring repair. Of note, the patient had similar symptoms on the contralateral side and underwent the same procedure with good results.

Positioning for this procedure involves placing the patient prone on a radiolucent table, padding all bony prominences. The entire operative leg is prepped and draped in the usual sterile fashion, allowing for rotation of the femur to improve access.

An incision is made, and dissection is taken down through the superficial layers of the buttock region to the gluteal fascia.

After the gluteal fascia is incised, blunt dissection is used to mobilize the soft tissues.

Deep retractors are inserted, and dissection is taken down on the overlying fascia of the proximal hamstring tendons.

The sciatic nerve is identified and mobilized using blunt dissection. A vessel loop is placed around the sciatic nerve. With the sciatic nerve mobilized, blunt dissection is taken proximal to complete the neurolysis.

Attention is then turned to the proximal hamstring repair. An incision is made on the overlying fascia of the ischium. The insertion of the tendon is decorticated using a rongeur. A drill hole is made for anchor insertion. The drill hole is tapped, and the anchor is inserted into the ischium.

The process is repeated, and a second anchor is inserted.

The sutures are passed through the proximal hamstring tendon in a mattress fashion. The sutures are tied down, fixing the proximal hamstring tendon to the ischium with excellent fixation.

Attention is then turned to the ischiofemoral decompression. An incision is made in line with the external rotators. Care is taken to not damage the medial femoral circumflex artery which in a native hip can result in avascular necrosis.

Dissection is taken down to the lesser trochanter. The lesser trochanter is palpated confirming the correct level of dissection. A saw is used for a lesser trochanter osteotomy. An osteotome is inserted into the site of the cut. The fragment is mobilized and removed. The resected aspect of the lesser trochanter is seen here.

Fluoroscopy is used to confirm an adequate decompression is performed. The pre-resection image is seen at the far left and the post-resection image is seen at the far right.

The interval in the external rotators is closed with interrupted suture.

Postoperatively, the patient can begin physical therapy with no range of motion restrictions. They will be partial weight bearing for 2 weeks and then can progress to weight bearing as tolerated.

The patient is given indomethacin for heterotopic ossification prophylaxis followed by naproxen for 3 weeks. Deep vein thrombosis prophylaxis includes aspirin for 3 weeks.

Potential complications include failure of symptomatic improvement, which may be a result of incorrect diagnosis versus surgical technique. Care should be taken to avoid neurovascular injury by protecting the sciatic nerve, posterior femoral cutaneous nerve, and medial femoral circumflex artery. While this case example involves a total hip arthroplasty, damage to the medial femoral circumflex artery in a native hip can result in avascular necrosis. Furthermore, iatrogenic fracture, iliopsoas tendinopathy, and heterotopic ossification are potential complications of this procedure.