Ischiofemoral impingement syndrome: A five-case series report.

Gluteal pain is a frequent cause of medical attention in the daily clinical practice. It can be caused by multiple pathologies, being ischiofemoral impingement syndrome among those included in its differential diagnosis. Encompassed within the deep gluteal syndromes, this entity occurs as a consequence of the entrapment of the neuromuscular structures between the lesser femoral trochanter and the ischial tuberosity, causing pain in the root of the lower limb, with irradiation towards the thigh or the gluteal region and poor tolerance to deambulation and sedestation. The magnetic resonance imaging of the hip is fundamental for its diagnosis, and its management consists on medical treatment at onset. Despite not being a frequent diagnosis in the clinical practice in Rheumatology, keeping it in mind helps improving its prognosis by establishing an early and adequate treatment.

van Neck-Odelberg disease: a common but poorly known and often misdiagnosed condition.

van Neck-Odelberg disease, a condition involving the ischiopubic synchondrosis in children, is a commonly encountered but poorly known ailment, which is now considered a normal variant. Symptoms can include pain, discomfort, and fever, leading to van Neck-Odelberg disease often being discovered in the context of patients presenting with non-specific clinical manifestations. In this essay, we describe what is currently known about van Neck-Odelberg disease and illustrate the condition using images acquired from multiple patients, with some using multiple imaging techniques from the same patients. Awareness of van Neck-Odelberg disease is essential for radiologists who are involved in the treatment of children, as well as for paediatricians, to prevent misdiagnosis and unnecessary invasive procedures for what is a benign and self-resolving condition.

Editorial Commentary: Diagnosis of Hip Acetabular Retroversion Requires 3-Dimensional Imaging.

Diagnosis of global hip acetabular retroversion requires 3-dimensional imaging. Using anteroposterior pelvis radiographs, the crossover sign has been associated with retroversion. Recent research reports that the ischial spine sign and posterior wall sign also should be considered, yet even taking into account all 3 signs, the false-positive rate for retroversion is reported as greater than 35%. In truth, an anteroposterior radiograph is not sufficient for determination of acetabular retroversion. Retroversion is a 3-dimensional condition, and magnetic resonance imaging or computed tomography-based measurements are required. Thus, before we can determine the efficacy of hip arthroscopy versus periacetabular osteotomy for patients with hip impingement secondary to acetabular retroversion, we need to precisely measure to confirm our diagnosis.

Colgajo DIEP pediculado para reconstrucción de úlceras isquiáticas y trocantéricas sin opción a colgajo local / DIEP pedicled flap for reconstruction of ischial and trochanteric ulcers without local flap option

Introducción y objetivo: El colgajo DIEP pediculado ofrece una alternativa reproducible en el manejo de úlceras isquiáticas y trocantéricas en las que no hay tejido sano periférico disponible para la realización de un colgajo local. Describimos la técnica quirúrgica y presentamos 2 casos clínicos en los que empleamos este procedimiento. Material y método: Previo rastreo con ultrasonido doppler de las arterias perforantes periumbilicales, trazamos una isla cutánea vertical de 10 x15 cm, disecamos el pedículo hasta la unión con la arteria epigástrica inferior profunda que disecamos lo más proximal posible. Realizamos un túnel subcutáneo hasta el área a tratar para el paso sin tensión del pedículo vascular y colocamos el colgajo en su área receptora, suturándolo en dos planos. Resultados: Describimos 2 casos en los que obtuvimos excelentes resultados funcionales con baja morbilidad del área donadora. Conclusiones: En nuestra experiencia, el colgajo DIEP pediculado fue una adecuada opción reconstructiva en pacientes con úlceras isquiáticas y trocantéricas en quienes los tejidos periféricos no permitían reconstrucción con colgajos locales, ya que presenta una baja morbilidad en la zona donadora y un pedículo relativamente largo que le permite alcanzar la zona del defecto.(AU)

Background and objective: The pedicled DIEP flap offers a reproducible alternative in the management of ischial and trochanteric ulcers where healthy peripheral tissue is not available for the realization of a local flap. We describe the surgical technique and present 2 clinical cases in which this procedure has been used, offering a reproducible alternative in the treatment of these conditions. Methods: A doppler ultrasound scan of the periumbilical perforating arteries is carried out, tracing a 10 x 15 cm vertical skin island. The pedicle is dissected down to the junction with the deep inferior epigastric artery, which is dissected as proximal as possible. A subcutaneous tunnel is made to the area to be treated for the passage without tension of the vascular pedicle and the flap is placed in its receiving area, suturing it in two planes. Results: We present 2 clinical cases in which we obtained excellent functional results and low morbidity in the donor area. Conclusions: In our experience, the pedicled DIEP flap was an adequate reconstructive option in patients with ischial and trochanteric ulcers in whom peripheral tissues do not allow reconstruction with local flaps, since it has low morbidity in the donor area and a relatively long pedicle that allows it to reach the defect area.(AU)

Bilateral pubic and ischial osteotomy in cats offers good exposure for resection of large vaginal masses with minimal postoperative complications.

OBJECTIVE: To describe the clinical presentation, diagnostic imaging findings, surgical technique, histopathological diagnosis, and postoperative outcome in 3 cats with extensive vaginal masses. ANIMALS: Medical records of cats diagnosed with vaginal masses that had a bilateral pubic and ischial osteotomy and vaginectomy between 2004 and 2022 were retrospectively reviewed. Three cats met the inclusion criteria. CLINICAL PRESENTATION: Histopathological diagnosis included T-cell-rich B-cell lymphoma (n = 1), mycetoma (1), and vaginal polyp (1). Diagnostic imaging included CT (n = 2) and MRI (1), and tumor length/width/height percentages in relation to the pelvic dimensions were 53% X 62% X 63% (case 1), 50% X 100% X 60% (case 2), and 150% X 120% X 120% (case 3). A bilateral pubic and ischial osteotomy was performed in all 3 cases. RESULTS: All 3 cases developed mild pelvic-limb splaying postoperatively; all resolved within 8 weeks, and 2 cases fully resolved within 14 days. Two of the 3 cases presented with mild stranguria postoperatively, which resolved fully in both cases. CLINICAL RELEVANCE: Vaginal neoplasia, either malignant or benign, is infrequently reported in cats in the veterinary literature. Bilateral pubic and ischial osteotomy for resection of vaginal masses in cats is a successful surgical approach, offering good exposure for resection of large vaginal masses, with minimal postoperative complications.

Focused Extracorporeal Shock Wave Therapy for Ischial Apophysitis in Young High-Level Gymnasts.

OBJECTIVE: We aimed to investigate the effect and safety of extracorporeal shock wave therapy (ESWT) on ischial apophysitis (IA) in young high-level gymnasts. We hypothesized that ESWT would be safe and effective in alleviating pain. DESIGN: Retrospective case series. SETTING: Funabashi Orthopedic Hospital. PATIENTS: The subjects were 18 high-level gymnasts (mean age of 13 years) with a chief complain of chronic buttock pain diagnosed with IA. INTERVENTIONS: Ten patients received only physiotherapy (PT), whereas 8 received both PT and ESWT to the ischial tuberosity. The basic protocol for ESWT was to use an energy dose of 0.20 mJ/mm 2 or less with 3000 shots per session at 4-week intervals. MAIN OUTCOME MEASURES: We investigated whether PT and ESWT relieved the pain and allowed the patient to return fully to gymnastics. Based on radiographs at the last observation, we examined whether early closure of the apophyseal line of the ischium and around hip joint on the affected side occurred. RESULTS: In the PT group, pain was relieved in 2 of 10 patients. In the ESWT group, pain was relieved and full return to gymnastics was possible in all 8 patients. None of the patients showed early closure of the apophyseal line. CONCLUSIONS: Extracorporeal shock wave therapy can be a safe and effective treatment option for IA in young high-level gymnasts.

Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases.

BACKGROUND: Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents. METHODS: A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms. RESULTS: Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019. CONCLUSIONS: Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries. LEVEL OF EVIDENCE: This is a level III retrospective study.

Bilateral Ischial Tuberosity Stress Fractures in an Adolescent Football Player: A Case Report.

ABSTRACT: Pelvic stress fractures are rare, making up an estimated 1% to 7% of all stress fractures with the primary locations being the pubic rami, pubic symphysis, and sacrum. Two cases of stress fractures of the ischium have been previously described in the literature, with both occurring in the ischial body. In this case, a 17-year-old high school American football player presented with nonspecific pelvic pain and bilateral point tenderness on deep palpation of the ischial tuberosities. Advanced imaging identified bilateral ischial tuberosity stress fractures. This report outlines the diagnosis and management of the first reported case of bilateral ischial tuberosity stress fractures. We report how ischial tuberosity stress fractures present clinically, potential management strategies, and highlight the use of computed tomography imaging for pelvic stress fractures. Knowledge of unusual stress fracture locations may improve early diagnosis, limit complications, reduce healthcare costs, and promote an accelerated recovery time.

Comparison of the anterior pelvis and levator ani muscle on MRI in women with and without anterior pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the differences in pelvic and levator ani muscle diameters in women with and without anterior pelvic organ prolapse. METHODS: Three groups were included, including 50 nulliparous women (nulliparous group), 50 women with stage III-IV anterior vaginal prolapse (prolapse group), and 50 women of the same age as the prolapse group but without prolapse (nonprolapse control group). The ischial interspinous diameter (ISD), anterior pelvic area (APA), levator defect score (LDS), levator ani hiatus width (LH-W), H-line, M-line, levator ani plate length, levator ani plate angle, and cervix length (CL) were measured. RESULTS: There were no significant differences in ISD (10.6±0.8 vs 10.6±0.9 cm), LH-W (3.0±0.4 vs 3.3±0.4 cm), or CL (2.9±0.6 vs 3.0±0.5 cm) between the nulliparous group and the nonprolapse control group (p>0.05). However, there were significant differences between them and the prolapsed group (11.2±0.6 cm, 3.6±0.4 cm, 4.2±1.5 cm; p<0.05). There were no significant differences in LDS (0.70±0.61 vs 0.70±0.65) or APA (58.4±8.4 vs 60.1±7.4 cm2) between the nonprolapse control group and the prolapse group (p>0.05), but they were significantly different from those of the nulliparous group (0.08±0.34, 55.1±6.0 cm2) (p<0.05). The area under the receiver-operating characteristic curve for the ISD of nonprolapse control and prolapse groups was 0.713, and the cutoff value was 10.95 cm. CONCLUSIONS: The levator ani hiatus width and cervix length were larger in patients with anterior vaginal prolapse than in those without prolapse. An ischial ISD greater than 10.95 cm was associated with prolapse.

Screw Apophysiodesis for Chronic Ischial Apophysitis Refractory to Apophyseal Drilling in a Teenage Athlete: A Case Report.

CASE: A 17-year-old elite male soccer player, initially treated for chronic ischial apophysitis with transapophyseal drilling 18 months before, presented with persistent apophysitis symptoms and unfused apophysis on imaging. An open screw apophysiodesis was performed. The patient was able to gradually return to play and, within 8 months, was competing symptom-free at a high-level soccer academy. At 1 year postoperatively, the patient was still playing soccer and continued to be asymptomatic. CONCLUSION: In refractory cases not responding to conservative management or transapophyseal drilling, screw apophysiodesis may be used to obtain apophyseal closure with symptom resolution.

Outcomes following adolescent athlete proximal hamstring apophyseal avulsion bone fragment excision and direct tendon-ischial tuberosity reattachment.

Apophyseal proximal hamstring bone avulsion is uncommon, occurring in adolescents following sudden forceful contraction of the musculotendinous unit. It can be severely disabling, preventing return to sport. This study assessed outcome following avulsed bone excision and direct hamstring tendon-ischial tuberosity reattachment using bone anchors. Validated hamstring-specific Sydney hamstring orthopaedic research evaluation PROMs were prospectively collected from consecutively treated athletes (7 elite and 11 recreational) by a single surgeon over 13 years. Outcomes at 1-year and final follow-up for primary acute surgery at less than 3 months after injury (group 1), primary chronic surgery at more than 3 months after established nonunion (group 2) and revision following failed screw fixation (group 3) were analyzed with sport participation and level at 1 year. Sixteen primary and two revision procedures were analyzed. Mean injury age was 14.6 years (SD, 1.8). Combined primary mean injury scores improved from 11.89 (SD, 7.32) to 33.31 (SD, 2.30) and showed mean 1 year and final follow-up scores within 0.3-6.1% of preinjury values. Pronounced improvement occurred from injured scores for groups 1 versus 2, respectively at 1 year by 247.7% versus 59.0% and at final follow-up by 251.0% versus 64.1%, for groups 1 versus 2, respectively. Final outcome scores of group 3 were high. All cases returned to preinjury sport level by 1 year and indicated satisfaction to repeat treatment. No significant complications occurred. As the largest series to assess outcomes following this surgical technique, success is highlighted by high score improvements close to preinjury values and return to preinjury sport level.

Preference for Fasciocutaneous Flap Over Musculocutaneous Flap as a First-Line Option for Ischial Pressure Wound Reconstruction: A Review of 64 Cases.

The ischial pressure wound usually comprises a large, extensive defect and involves the repair of more than a small opening. Most surgeons have used a musculocutaneous flap to fill the large dead space of an ischial pressure wound. However, sacrificing muscle tissue has a potential risk of postoperative bleeding. The transferred muscle ultimately loses function as a cushion to absorb pressure. Conservation of muscle structures may be beneficial for use in future recurrence, which is common with ischial pressure wound. We compared the difference in outcome between musculocutaneous and fasciocutaneous flaps and analyzed factors affecting complications with the flaps in ischial pressure wound reconstruction. This study reviewed the results of 64 flaps in 44 patients with ischial wounds. The wounds were reconstructed with 34 musculocutaneous flaps (53%) and 30 fasciocutaneous flaps (47%). Twenty-three cases (36%) had complete healing, and 41 (64%) had complications. There was no significant difference in outcomes between fasciocutaneous and musculocutaneous flap groups. Crude logistic regression analysis showed no significant risk factors for occurrence of major complications. When fasciocutaneous flaps were used, the neighboring perforators and muscle tissues could be conserved. With a perforator-based fasciocutaneous flap, a de-epithelized distal portion of the flap could be used to fill the dead space. Therefore, the fasciocutaneous flap may have priority over the musculocutaneous flap as a first-line option for ischial pressure wound reconstruction.

Quadratus femoris muscle edema in children.

OBJECTIVE: To assess the prevalence and clinical relevance of quadratus femoris muscle edema (QFME) in pediatric pelvic MRI. MATERIALS AND METHODS: The axial T2-W with fat saturation sequence of pelvic/hip MRI examinations of pediatric patients (≤ 18 years) and a control group of young adults aged 19-45 years was retrospectively and independently evaluated by two musculoskeletal radiologists for the presence of QFME in each hip. Demographics, indication for imaging studies, and pain location were documented. The prevalence of QFME was compared between the groups on a patient level and on a hip level. RESULTS: The study group included 119 children (164 MRI examinations; F:M 1:1.08, mean age 11.4 ± 3.6 years), and 120 young adults, > 18, < 45 years old, served as controls (F:M 1:0.9, mean age 33.7 ± 6.4 years). QFME was significantly more prevalent among the study compared to the control group, both on a patient level (15% and 4.2%, respectively, p < 0.05) and on a hip level (12.1% and 2.5%, respectively, p < 0.05). This significant difference was also seen in the subgroup of MRI studies performed for orthopedic indications but not for non-orthopedic indications. There was no correlation between the side of localized pain and the side with QFME. CONCLUSION: QFME is significantly more prevalent in pediatric patients compared to adults under 45 years old, especially in subjects scanned for orthopedic indications. The clinical relevance of QFME in children and adolescents is unclear.

Topographical anatomy of the albino rat's ischiotrochanteric muscle group.

The obturator internus, gemelli, and quadratus femoris muscles are thought to be postural muscles. Thus, they are in the focus of research. Although these muscles are described in other species, detailed descriptions are still lacking for the albino rat. We hypothesized that the rat's ischiotrochanteric muscle group is comparable to that of humans. We aimed to provide a detailed description, and to compare the rat's condition with other species including humans. Both hind limbs of 30 adult male formalin-fixed albino rats were carefully dissected and photo documented. Our results were then compared with data for other species and descriptions of human anatomy. The gemellus muscle was one single muscle mass, originating from the lesser sciatic notch and an unnamed groove on the dorsal aspect of the ischium. The obturator internus muscle arose from the inner aspect of the tabula of ischium. Both muscles formed a continuum and inserted as one complex on the medial aspect of the greater trochanter. The quadratus femoris muscle originated from the outer aspect of the tabula of ischium and inserted on the distal portion of the intertrochanteric crest, and the dorsal aspect of the lesser trochanter. Despite minor differences, the topographical conditions of these muscles are comparable between rats and other mammals including humans.

Endoscopic Ischial Tuberosity Osteophyte Resection for Treatment of Ischiofemoral Impingement: A Case Report.

ABSTRACT: Ischiofemoral impingement is a distinct pathologic finding with abnormal osseous contact between the ischium and the lesser trochanter of the femur. Lesser trochanter excision has been recommended for recalcitrant ischiofemoral impingement through an open or endoscopic approach; however, no study has included ischial tuberosity osteophyte resection and refixation of the hamstring tendon. We report an endoscopic procedure involving ischial tuberosity osteophyte resection with refixation of the partially detached hamstring insertion through a posterior approach in the prone position. Using this technique, it is easier to reach the lesion and less likely to injure the sciatic nerve. The postoperative pain score (visual analogy score) was significantly decreased, the modified Harris hip score increased from 39 preoperatively to 86 postoperatively, and there was no adverse effect on the hamstring tendon.

Ischiofemoral impingement syndrome: a case report and review of literature.

INTRODUCTION: The etiology of ischiofemoral impingement (IFI) syndrome, an unusual and uncommon form of hip pain, remains uncertain. Some patients demonstrate narrowing of the space between the ischial tuberosity and lesser trochanter from trauma or abnormal morphology of the quadratus femoris muscle. Combined clinical and imaging aid in the diagnosis. CASE REPORT: A 32-year-old female presented with a 3 years history of pain over the lower aspect of the right buttock, aggravated by movements of the right hip, and partially relieved with rest and medications. The right hip showed extreme restriction of abduction and external rotation. MRI of the right hip showed reduced ischiofemoral space and quadratus femoris space when compared to the left hip. The patient underwent endoscopic resection of the right lesser trochanter, with no recurrence of pain at 2 years. CONCLUSION: An unusual cause of hip pain, IFI syndrome, should be suspected when hip pain at extremes of movement is associated with signal abnormality of quadratus femoris muscle. Management is tailored to address the inciting factors that precipitated the IFI syndrome.

Defining the canal for ischial and pubic screws in cup revision surgery.

PURPOSE: When revising acetabular cups, it is often necessary to provide additional stabilisation with screws. In extensive defect situations, the placement of screws caudally in the ischium and/or pubis is biomechanically advantageous. Especially after multiple revision operations, the surgeon is confronted with a reduced bone stock and unclear or altered anatomy. In addition, screw placement caudally is associated with greater risk. Therefore, the present study aims to identify and define safe zones for the placement of caudal acetabular screws. METHODS: Forty-three complete CT datasets were used for the evaluation. Sixty-three distinctive 3D points representing bone landmark of interests were defined. The coordinates of these points were then used to calculate all the parameters. For simplified visualisation and intra-operative reproducibility, an analogue clock was used, with 12 o'clock indicating cranial and 6 o'clock caudal. RESULTS: A consistent accumulation was found at around 4.5 ± 0.3 hours for the ischium and 7.9 ± 0.3 hours for the pubic bone. CONCLUSIONS: The anatomy of the ischium and pubis is sufficiently constant to allow the positioning of screws in a standardised way. The interindividual variation is low - regardless of gender - so that the values determined can be used to position screws safely in the ischium and pubis. The values determined can provide the surgeon with additional orientation intra-operatively when placing caudal acetabular screws.