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Editorial Commentary: Subgluteal Hip Arthroscopy for Sciatic Nerve Entrapment, Ischiofemoral Impingement, or Proximal Hamstring Tears: Beyond the Comfort Zone

      Abstract

      Advancements in hip arthroscopy are astounding. Circumferential labral reconstruction, labral augmentation, and capsular reconstruction are valuable tools. Beyond the “comfort zone” of the hip intra-articular realm, new frontiers include the peritrochanteric space, and a similarity to the subacromial space of the shoulder makes the transition attainable. In contrast, the subgluteal space is seen as outside the box. Sciatic nerve entrapment (SNE), ischiofemoral impingement (IFI), and tears of the proximal origin of the hamstring are among the subgluteal space pathologies. Clinical assessment of deep gluteal syndrome, defined as nondiscogenic sciatic nerve entrapment, can be particularly difficult but is critical and one of the skills that we as hip sports surgeons need to master. The respective treatments for SNE, IFI, and hamstring tears are nerve decompression, lesser trochanteric resection, and hamstring repair. Complications can occur, most commonly temporary injury of the sciatic nerve and permanent injury of the posterior femoral cutaneous nerve. While all located in the deep gluteal space, SNE, IFI, and proximal hamstring tears are unique entities. When thinking outside the box, it's important to consider the complicated contents of Pandora’s box.
      With all the lights pointing to femoroacetabular impingement syndrome (FAIS), femoroacetabular impingement has become the epicenter of the hip arthroscopy field. The incidence of FAIS diagnosis was reported to be 54.4 per 100,000 person-years and has consistently increased between 2000 and 2016.
      • Hale R.F.
      • Melugin H.P.
      • Zhou J.
      • et al.
      Incidence of femoroacetabular impingement and surgical management trends over time.
      Yet, this is only one of the many indications that can be addressed with hip arthroscopy/endoscopy. Sciatic nerve entrapment (SNE), ischiofemoral impingement (IFI), and tears of the proximal origin of the hamstring are amid the subgluteal space pathologies.
      In their study, “Complications of Hip Endoscopy in the Treatment of Subgluteal Space Pathologies,” Aguilera-Bohórquez, Pacheco, Castillo, Calvache, and Cantor
      • Aguilera-Bohórquez B.
      • Pacheco J.
      • Castillo L.
      • Calvache D.
      • Cantor E.
      Complications of hip endoscopy in the treatment of subgluteal space pathologies.
      address one of the brainteasers that, until this investigation, I have found difficult to elucidate. In this retrospective case series, the authors included 97 hips with subgluteal space pathologies that underwent hip endoscopy with a median follow-up of 43 months. Concretely, 77 hips were intervened for SNE, 5 for IFI, 12 for SNE plus IFI, and 3 hips for proximal hamstring tears. A sciatic nerve decompression was performed in 77 (79.38%) hips, lesser trochanter resection in 5 (5.15%) hips, and hamstring repair in 3 (3.09%) hips. Concomitant sciatic nerve decompression and lesser trochanter resection were performed simultaneously in 12 (12.37%) hips. The rates of minor complications, major complications, and revision were reported to be 7.22%, 12.37%, and 6.18%, respectively. Temporary injury of the sciatic nerve and permanent injury of the posterior femoral cutaneous nerve were the most common complications.
      Although these pathologies are all located in the deep gluteal space,
      • Leite M.J.
      • Pinho A.R.
      • Silva M.R.
      • Lixa J.C.
      • Madeira M.D.
      • Pereira P.G.
      Deep gluteal space anatomy and its relationship with deep gluteal pain syndromes [published online October 11, 2020]. Hip Int.
      SNE, IFI, and proximal hamstring tears are unique entities.
      • Carro L.P.
      • Hernando M.F.
      • Cerezal L.
      • Navarro I.S.
      • Fernandez A.A.
      • Castillo A.O.
      Deep gluteal space problems: Piriformis syndrome, ischiofemoral impingement and sciatic nerve release.
      • Aguilera-Bohorquez B.
      • Cardozo O.
      • Brugiatti M.
      • Cantor E.
      • Valdivia N.
      Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results.
      • Kay J.
      • de Sa D.
      • Morrison L.
      • et al.
      Surgical management of deep gluteal syndrome causing sciatic nerve entrapment: A systematic review.
      • Fletcher A.N.
      • Cheah J.W.
      • Nho S.J.
      • Mather R.C.
      Proximal hamstring injuries.
      • Nakano N.
      • Shoman H.
      • Khanduja V.
      Treatment strategies for ischiofemoral impingement: A systematic review.
      Kay et al.
      • Kay J.
      • de Sa D.
      • Morrison L.
      • et al.
      Surgical management of deep gluteal syndrome causing sciatic nerve entrapment: A systematic review.
      performed a systematic review that assessed complications following SNE surgical management. These authors reported that the endoscopic alternative resulted in an astonishingly low incidence of complications with a rate less than 1%. Regarding IFI, Nakano et al.
      • Nakano N.
      • Shoman H.
      • Khanduja V.
      Treatment strategies for ischiofemoral impingement: A systematic review.
      reported no neurologic or vascular complications after partial or complete endoscopic lesser trochanter resection, in a systematic review that included 5 studies involving this surgical management. Excellent patient-reported outcomes have been reported following endoscopic proximal hamstring repair.
      • Kurowicki J.
      • Novack T.A.
      • Simone E.S.
      • et al.
      Short-term outcomes following endoscopic proximal hamstring repair.
      In a multicenter study, we reported only one complication following 19 endoscopic proximal hamstring repairs.
      • Maldonado D.R.
      • Annin S.
      • Lall A.C.
      • et al.
      Outcomes of open and endoscopic repairs of chronic partial- and full-thickness proximal hamstring tendon tears: A multicenter study with minimum 2-year follow-up.
      When addressing proximal hamstring tears endoscopically, particularly in the initial phase of the learning curve, my attention was centered on the sciatic nerve leaving the PFCN in an underserved second plane. Aguilera-Bohórquez et al. demonstrated that the incidence of permanent nerve lesion was more frequent for the PFCN; therefore, attention to this structure must be prioritized.
      One point that kept my attention in the study by Aguilera-Bohórquez et al. was that only 3.09% of the cases within the subgluteal space were proximal hamstring tears. As a sports surgeon, I have encountered more surgical treatments involving proximal hamstring tear repair than SNE and IFI. Hamstring injuries are common in sports, representing 12% to 29% of all injuries in athletes. Proximal hamstring tears represent 12% of all hamstring injuries, data that by any means are negligible.
      • Fletcher A.N.
      • Cheah J.W.
      • Nho S.J.
      • Mather R.C.
      Proximal hamstring injuries.
      The patient population may play a role regarding this finding.
      Except for hamstring tears, I have found the IFI and particularly the SNE diagnosis to be challenging, and I agree with Park et al. that many physicians remain unfamiliar with the concept of deep gluteal syndrome.
      • Park J.W.
      • Lee Y.-K.
      • Lee Y.J.
      • Shin S.
      • Kang Y.
      • Koo K.-H.
      Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain.
      Clinical assessment of deep gluteal syndrome, defined as nondiscogenic sciatic nerve entrapment,
      • Kizaki K.
      • Uchida S.
      • Shanmugaraj A.
      • et al.
      Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: A systematic review.
      can be difficult but is critical and one of the skills that we as hip sports surgeons, need to master.
      • Carro L.P.
      • Hernando M.F.
      • Cerezal L.
      • Navarro I.S.
      • Fernandez A.A.
      • Castillo A.O.
      Deep gluteal space problems: Piriformis syndrome, ischiofemoral impingement and sciatic nerve release.
      As Aguilera-Bohórquez et al. mentioned, their study was not without limitations; nonetheless, this is a valuable study, and I applaud the work presented. Outcome data and complications following endoscopic treatment of subgluteal pathologies, and deep gluteal syndrome, are scarce in the current literature. Further, this study gives us a more realistic expectation of complications faced when surgically managing these hip conditions.

      Supplementary Data

      References

        • Hale R.F.
        • Melugin H.P.
        • Zhou J.
        • et al.
        Incidence of femoroacetabular impingement and surgical management trends over time.
        Am J Sports Med. 2021; 49: 35-41
        • Aguilera-Bohórquez B.
        • Pacheco J.
        • Castillo L.
        • Calvache D.
        • Cantor E.
        Complications of hip endoscopy in the treatment of subgluteal space pathologies.
        Arthroscopy. 2021; 37: 2152-2161
        • Leite M.J.
        • Pinho A.R.
        • Silva M.R.
        • Lixa J.C.
        • Madeira M.D.
        • Pereira P.G.
        Deep gluteal space anatomy and its relationship with deep gluteal pain syndromes [published online October 11, 2020]. Hip Int.
        https://doi.org/10.1177/1120700020966255
        • Carro L.P.
        • Hernando M.F.
        • Cerezal L.
        • Navarro I.S.
        • Fernandez A.A.
        • Castillo A.O.
        Deep gluteal space problems: Piriformis syndrome, ischiofemoral impingement and sciatic nerve release.
        Muscles Ligaments Tendons J. 2016; 6: 384-396
        • Aguilera-Bohorquez B.
        • Cardozo O.
        • Brugiatti M.
        • Cantor E.
        • Valdivia N.
        Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results.
        Rev Esp Cir Ortop Traumatol. 2018; 62: 322-327
        • Kay J.
        • de Sa D.
        • Morrison L.
        • et al.
        Surgical management of deep gluteal syndrome causing sciatic nerve entrapment: A systematic review.
        Arthroscopy. 2017; 33: 2263-2278.e1
        • Fletcher A.N.
        • Cheah J.W.
        • Nho S.J.
        • Mather R.C.
        Proximal hamstring injuries.
        Clin Sports Med. 2021; 40: 339-361
        • Nakano N.
        • Shoman H.
        • Khanduja V.
        Treatment strategies for ischiofemoral impingement: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 2772-2787
        • Kurowicki J.
        • Novack T.A.
        • Simone E.S.
        • et al.
        Short-term outcomes following endoscopic proximal hamstring repair.
        Arthroscopy. 2020; 36: 1301-1307
        • Maldonado D.R.
        • Annin S.
        • Lall A.C.
        • et al.
        Outcomes of open and endoscopic repairs of chronic partial- and full-thickness proximal hamstring tendon tears: A multicenter study with minimum 2-year follow-up.
        Am J Sports Med. 2021; 49: 721-728
        • Park J.W.
        • Lee Y.-K.
        • Lee Y.J.
        • Shin S.
        • Kang Y.
        • Koo K.-H.
        Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain.
        Bone Joint J. 2020; 102-B: 556-567
        • Kizaki K.
        • Uchida S.
        • Shanmugaraj A.
        • et al.
        Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 3354-3364