Deep gluteal space problems: piriformis syndrome, ischiofemoral impingement and sciatic nerve release.

BACKGROUND: Deep gluteal syndrome (DGS) is an underdiagnosed entity characterized by pain and/or dysesthesias in the buttock area, hip or posterior thigh and/or radicular pain due to a non-discogenic sciatic nerve entrapment in the subgluteal space. Multiple pathologies have been incorporated in this all-included "piriformis syndrome", a term that has nothing to do with the presence of fibrous bands, obturator internus/gemellus syndrome, quadratus femoris/ischiofemoral pathology, hamstring conditions, gluteal disorders and orthopedic causes. METHODS: This article describes the subgluteal space anatomy, reviews known and new etiologies of DGS, and assesses the role of the radiologist and orthopaedic surgeons in the diagnosis, treatment and postoperative evaluation of sciatic nerve entrapments. CONCLUSION: DGS is an under-recognized and multifactorial pathology. The development of periarticular hip endoscopy has led to an understanding of the pathophysiological mechanisms underlying piriformis syndrome, which has supported its further classification. The whole sciatic nerve trajectory in the deep gluteal space can be addressed by an endoscopic surgical technique. Endoscopic decompression of the sciatic nerve appears useful in improving function and diminishing hip pain in sciatic nerve entrapments, but requires significant experience and familiarity with the gross and endoscopic anatomy. LEVEL OF EVIDENCE: IV.

Usefulness of MR arthrography of the hip with leg traction in the evaluation of ligamentum teres injuries.

PURPOSE: To retrospectively evaluate the diagnostic accuracy of magnetic resonance (MR) arthrography of the hip with leg traction in the evaluation of ligamentum teres lesions and to evaluate whether there is increased articular distraction, possibly indicating secondary instability, in hips with ligamentum teres injuries. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this retrospective study. MR arthrograms of the hip with leg traction of 184 consecutive patients, including 108 men (mean age, 32.6 years; range, 19-53 years) and 76 women (mean age, 38.5 years; range, 18-56 years), who underwent hip arthroscopy were assessed for the presence of ligamentum teres lesions. The MR arthrographic findings were independently assessed by two radiologists who were blinded to the arthroscopic results. The inclusion criteria stipulated no previous surgery, arthroscopy within 1 month after MR arthrography, and availability of a detailed surgical report with ligamentum teres findings. The arthroscopy findings served as the reference standard. Sensitivity, specificity, accuracy, and K statistics for interobserver and intraobserver agreement were calculated. RESULTS: At arthroscopy, 32 ligamentum teres injuries were found. The ligamentum teres was normal in 152 (82.6%) patients and had suffered low-grade partial tears in 15 (8.1%) patients, high-grade partial tears in 10 (5.4%) patients, and complete ruptures in 7 (3.8%) patients. MR arthrography with axial traction demonstrated moderate sensitivity and high specificity for both low-grade (62/93%) and high-grade (66/96%) partial tears. Grouping low- and high-grade partial tears increased the diagnostic performance of MR arthrography, yielding a sensitivity of 87% and a specificity of 95%. For complete ligamentum teres tears, MR arthrography with leg traction demonstrated high sensitivity (92%) and specificity (98%). Articular distraction was significantly increased in patients with complete ruptures of the ligamentum teres (p = 0.001). CONCLUSION: MR arthrography with leg traction offers accurate diagnosis of ligamentum teres injuries. Patients with complete tears of the ligamentum teres exhibit increased articular distraction that may indicate secondary hip instability.

Arthroscopic subtalar arthrodesis: the posterior approach in the prone position.

Arthroscopic subtalar arthrodesis, as reported by Tasto, is done in the lateral decubitus position, and the portal sites are lateral. This report describes a new alternative method in which the patient is in the prone position and a posterior 2-portal approach is used, as described by van Dijk et al. The initial debridement and synovectomy are performed with 4- and 5-mm resectors. Debridement and decortication are done posterior to the interosseous ligament because only the posterior facet is fused. Denudation of the articular surfaces is performed with curettes, as well as 4.5- and 5.5-mm burs, to remove 2 mm of subchondral bone. Stabilization in 5 degrees of hindfoot valgus is accomplished with 2 percutaneous cannulated headless screws from the non-weight-bearing portion of the calcaneal tuberosity directed to a point 5 to 10 mm posterior to the anterior margin of the posterior facet. The advantages of this alternative treatment are better intra-articular visualization, more thorough preparation of the fusion site, and minimal bone removal of the lateral side with better control of the arthrodesis position and with less chance of malunion, as well as the possibility to perform a concomitant surgical fusion or debridement of the ankle joint during the same operative procedure with no need for additional portals or orientation.

Innovations in arthroscopic management of Basal joint arthritis of the thumb.

Thumb arthroscopy and arthroscopically assisted treatment of the thumb are safe and effective techniques. This report describes technical innovations particularly useful in the surgical performance of arthroscopically assisted treatment of basal joint arthritis. (1) With adduction and hyperextension of the thumb, the bony landmarks are easier to palpate and a volar radial soft spot is clearly defined between the trapezium and metacarpal (i.e., the adduction-hyperextension maneuver). (2) After the distension of the joint with saline solution, the thumb automatically abducts and flexes if the capsule has been distended successfully (i.e., the flexion-abduction sign). (3) The radial and ulnar borders of the proximal phalanx and the local tendons can serve as external landmarks if fluid extravasation occurred. (4) Finally, the simultaneous use of the 3 portals described in the first carpometacarpal joint is very effective for better visualization and performance of the procedures in this joint (i.e., the 3-portal technique). We propose a new description of the portals for carpometacarpal arthroscopy as follows: (1) volar portal, which is just distal to the oblique ridge of the trapezium following a line referencing the radial edge of the flexor carpi radialis; (2) ulnar portal, which is just ulnar to the extensor pollicis brevis; and (3) radial portal, which is just radial to the abductor pollicis longus.

Arthroscopic Keller technique for Freiberg disease.

Freiberg disease is a disorder that has a predilection for the second metatarsal head. Keller excision of the base of the proximal phalanx is a procedure described for the treatment of late-stage Freiberg disease. We describe a case of a 60-year-old man, with a stage IV lesion according to Smillie's classification, treated by debridement, removal of the free body, and arthroscopic Keller excision. Arthroscopic treatment allows the patient to begin and maintain an aggressive postoperative physical therapy program immediately after surgery, thus decreasing the risk of scarring and contracture. At last evaluation, 2 years postoperatively, he is symptom-free. A suggested pattern of minimally invasive surgery management of this disease is proposed.

The radial portal for scaphotrapeziotrapezoid arthroscopy.

The scaphotrapeziotrapezoidal (STT) joint is a complex joint in which the arthroscope and instruments can be used through the radial midcarpal and STT-ulnar portals. This report describes a new arthroscopic portal at the STT joint to complete and improve the evaluation and treatment of this joint by arthroscopy: The STT-radial (STT-R) portal is situated immediately radial to the abductor pollicis longus at the STT level. Five cadaveric wrist specimens were dissected immediately after the portal was established, and photographed to determine the proximity of neurovascular structures. Magnetic resonance imaging evaluation of 15 hands was performed to measure the proximity of the radial artery. A cadaveric distal scaphoid excision was also created arthroscopically to show the real usefulness of this portal. Results of the anatomic study showed that no lesions of nerves or vessels were seen at this portal. Magnetic resonance imaging showed that the radial artery was located at a safe distance from the portal. The distal scaphoid excision was performed 15 minutes after the STT portals were established. Our results suggest that this new portal is safe and effective.