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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