Deep Gluteal Pain Syndrome: Technical Description of the Endoscopic Approach and Anatomical Considerations.

Abstract

Background: Fibrovascular bands are currently considered the most relevant cause of deep gluteal pain syndrome, according to various reports^1-6. This condition often exists concurrently with hypertrophic bursae in the peritrochanteric space due to the same inflammatory process because of the anatomical continuity between both spaces^7-10. In such cases, we perform bursectomy of the lateral space and resection of fibrovascular bands in the posterior space. Our technique has shown good results, without requiring a piriformis tenotomy¹¹. In the present video article, we demonstrate our endoscopic technique with modified portals, which addresses both spaces providing complete management of the pathology.

Description: The patient is placed in the supine position with the operative limb placed freely on the operative field for easy manipulation. The distance between the anterior and posterior borders of the greater trochanter at the level of the vastus tuberosity is demarcated. This distance is projected lengthwise onto the posterior third of the femur, delineating the proximal posterolateral accessory (PPLA) and distal posterolateral accessory (DPLA) portals. Under direct visualization, the DPLA portal is made, followed by the PPLA portal. A wide bursectomy in the peritrochanteric space is performed, followed by a partial tenotomy of the distal insertion of the gluteus maximus. Once in the subgluteal space, fibrovascular adhesions in the piriformis branch of the inferior gluteal artery are carefully released. Once the nerve has been identified, resection of the fibrovascular bands is performed in the subgluteal space, and the recovery of epineural circulation and free excursion of the nerve are evaluated.

Alternatives: Nonoperative treatment is a valid alternative as the initial management of deep gluteal pain syndrome. If there is a poor response to nonoperative treatment or a chronic pathology of both compartments, surgical treatment should be considered. Open procedures have been described, which are more invasive and could generate a greater inflammatory response³. Several reports have described the difficulty of endoscopic treatment in both the peritrochanteric and subgluteal spaces, which necessitates the use of accessory portals for management of hypertrophic bursae and release of the sciatic nerve^12,14,17,18. Routine piriformis tenotomy has also been described for use alongside resection of fibrovascular bands^4,12-16.

Rationale: This endoscopic technique allows access to the peritrochanteric and subgluteal spaces through 2 portals. The locations of, and method for, using these portals have been previously established in cadaveric studies. We observed the presence of fibrovascular bands in all of the specimens under study. In our medium-term clinical study, resection of the fibrosis from the lateral to the posterior compartment without performing a piriformis tenotomy resulted in recovery of the epineural circulation of the sciatic nerve and its free excursion in all patients, with good to excellent results and no recurrences¹¹.

Expected outcomes: Previous studies have focused on similar procedures performed via different endoscopic portals, exclusively accessing the subgluteal space with or without a piriformis tenotomy^6,13-16. We performed a study of 57 patients who underwent endoscopic treatment of an inflammatory pathology in both compartments and resection of fibrovascular bands without piriformis tenotomy. Patients showed improved modified Harris Hip (mHHS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) scores, and 70% of patients had good to excellent results at a mean follow-up of almost 2 years¹¹.

Important tips: The procedure must be performed by an experienced surgeon.The distal portal must be located proximal to the distal insertion of the gluteus maximus to aid in performing the posterior partial tenotomy.Extensive bursectomy should be performed in the peritrochanteric space.The sciatic nerve should be identified, and extensive resection of the fibrovascular bands and inflammatory bursae should be performed in the subgluteal space.Take care not to damage the piriformis branch of the inferior gluteal artery.An assisting surgeon should maintain control of the extremity throughout the procedure.Do not perform epineurolysis, which has been associated with poor clinical results.Observe the recovery of perineural circulation and free excursion of the sciatic nerve.

Acronyms and abbreviations: PPLA = proximal posterolateral accessoryDPLA = distal posterolateral accessoryMRI = magnetic resonance imagingASIS = anterior superior iliac spineVT = vastus tuberosityIQR = interquartile rangemHHS = modified Harris Hip ScoreiHOT-12 = International Hip Outcome ToolVAS = visual analog scale.