Ischiofemoral Impingement Tratamento endoscopico por abordagem posterior do

pequeno trocanter

Jorge Cruz de Melo

The Porto Hip Unit

PHM2015

The Porto Hip Unit

PHM2015

Ischiofemoral ImpingementThe hip has main bony sources for impingement ! Abnormal contact sites:- acetabulum vs femur - ischium vs femur

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Ischiofemoral Impingement

Diminuição da distância entre a tuberosidade isquiática e o pequeno trocanter

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Ischiofemoral ImpingementQ: Quadratus femoris muscle (QFM) is a flat muscle which has a orgin on the Lateral margin of the obturator ring above ischial tuberosity and insertion on the Quadrate tubercle and adjacent bone of intertrochanteric crest of proximal posterior femur.

IG: Inferior gemellus

OI: Obturator internius

SG: Superiorgemellus

P: PiriformisSN: Sciaticnerve.

Q: Quadratus femoris

Lesser trochanter

I: Ischium tuberosity

H: Hamstrings tendon

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Ischiofemoral Impingement

Síndrome)do)conflito)isquiofemoral):""Anca"dolorosa""Espaço"isquio2"femoral"–"13mm"±"5mm"""Edema/Indefinição"do"M."QF"

Torriani defined: The ischiofemoral space (IFS) as a gap between the ischium tuberosity and the iliopsoas tendon or the lesser trochanter. The ischiofemoral space – 13mm ± 5mm

(23mm ± 8mm)

The quadratus femoris space (QFS) as the smallest gap between the superolateral surface of the hamstring tendons and the posteromedial surface of the iliopsoas tendon or the lesser trochanter.The quadratus femoris space - 7 mm ± 3mm (12mm ± 4mm)

Lesser trochanter

IschiumHamstrings Tendeon

Quadratus femoris muscle

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Ischiofemoral Impingement

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MRI findings that shows reduced IFS with edema and wasting of quadratus femoris

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Ischiofemoral Impingement

1977!

Johnson!KA.!

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Ischiofemoral Impingement

2008!

Kassarijan!A!

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Ischiofemoral Impingement

2008!

Patti J W

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Ischiofemoral Impingement

2009!

Torriani!M.!

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Ischiofemoral Impingement

2011!

Mohsan!A.!

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Ischiofemoral Impingement

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Ischiofemoral Impingement

!  Idiopatic

!  Previous surgery, fracture or arthrosis iopatic

!  Hamstrings tendinopathy

!  Positional

!  Coxa valga

Etiology

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Ischiofemoral Impingement

! Non focal groin or buttock pain! Ischialgia with radiation to the medial thigh ! Painful popping, difficult to localize! Often diagnosed as “snapping iliopsoas”

Clinical presentation

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Ischiofemoral Impingement

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Diagnosis

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Ischiofemoral Impingement

Diagnosis

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Ischiofemoral Impingement

• Rx e RM com alterações evidentes • Clinica Evidente

• Rx e RM com alterações evidentes • Clinica Duvidosa

• Rx e RM com alterações evidentes • Sem Clinica

?X

V

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PHM2015

Ischiofemoral Impingement

Infiltracoes Diagnósticas/Terapeuticas

Ropivacaina 7.5 % 3 ml + Triancinolona 40 mg

Avaliar as primeiras 12 horas (1º dia) Avaliar os 2º-3º dias Avaliar 2 semanas depois

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Ischiofemoral Impingement

Treatment! To modify activity + NSAID

Active rest & to avoid provoking activities

! Fisioterapy

! Injections: diagnostic & therapeutic

! To widen ischiofemoral space

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Ischiofemoral Impingement

Tratamento endoscopico por abordagem do pequeno trocanter

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PHM2015

Ischiofemoral Impingement

! To widen ischiofemoral space

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Tratamento endoscopico por abordagem do pequeno trocanter

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The Porto Hip Unit

PHM2015

Ischiofemoral Impingement

! To widen ischiofemoral space

Tratamento endoscopico por abordagem do pequeno trocanter

Lesser Trochanter

Lesser Trochanter

Iliopsoas

Iliopsoas

Posterior Aproach

Iliopsoas

Lesser TrochanterLesser Trochanter

Anterior Aproach

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Ischiofemoral Impingement

! Posteriot Aproach

Tratamento endoscopico por abordagem do pequeno trocanter

VIDEO

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Ischiofemoral Impingement

Conclusion

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Pre-op Pos-op

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Ischiofemoral Impingement

!  Ischiofemoral impingement could be the source of hip pain or ischialgia in women

!  Idiopatic or acquired narrowing of the IFS could lead to edema and atrophy of the QFM ! Not all patients with IF Impingement have narrowing of the IFS ! Not all IF space narrowing or QFM edema are symptomatic ! In doubt, the diagnosis could be confirmed by local infiltration

! The conservative measures with rest, activity restriction, NSAID’s, physical therapy and steroid injection (image guided) may produce pain relief.

! Surgical treatment is reserved to patients in whom conservative treatment fails.! The endoscopic posterior approach is a very good solution (parcial reception of the

leser trochanter and preservation of iliopsoas tendon)

Conclusion

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