Curley Andrew J, Setliff Joshua C, Greiner Justin J, Keeling Laura E, Mauro Craig S
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Video J Sports Med. 2022 Dec 1;2(6):26350254221129627. doi: 10.1177/26350254221129627. eCollection 2022 Nov-Dec.
Posterior hip and buttock pain can arise from several overlapping but distinct etiologies. Ischiofemoral impingement, sciatic neuropathy, and proximal hamstring tendinopathy, occurring alone or in combination, have been implicated as precipitants. However, diagnosis and management of underlying pathology can be challenging, as few diagnostic modalities reliably differentiate between these etiologies and surgeon decision-making may be complicated by uncertainty over which pathology to address.
Posterior hip and buttock pain which occurs in a sciatic nerve distribution and is refractory to conservative measures (eg, physical therapy, analgesics, and activity modification) raises suspicion for 1 or several of the above pathologies. A combined procedure to address all 3-ischiofemoral decompression, sciatic neurolysis, and proximal hamstring repair-is described here.
The patient is placed prone on a radiolucent table. An incision is made, and dissection is taken down through the superficial layers of the buttock, gluteal fascia, and fascia overlying the proximal hamstring tendons. The sciatic nerve is identified, mobilized, and lysed using blunt dissection. The fascia overlying the ischium is incised and the tendinous insertion decorticated with rongeur. Two anchors are placed, and sutures are passed through the proximal hamstring tendon in mattress fashion. An incision is made in line with the external rotators and dissection is taken down to the lesser trochanter. The lesser trochanter is identified, and osteotomy performed, with mobilization and removal of the resected fragment. The interval in the external rotators is closed with interrupted suture.
This is an uncommon procedure with little data on patient outcomes. Nonetheless, it is effective for relief of symptoms related to the pathologies enumerated above. Keys to success include careful diagnosis and comfort with surgical technique.
The COMBIS procedure simultaneously addresses 3 common etiologies of posterior hip and buttock pain. Although it is important to conduct a thorough diagnostic evaluation to rule out imitators, patients with symptoms due to ischiofemoral impingement, sciatic neuropathy, proximal hamstring tendinopathy, or combination thereof may experience good relief of symptoms with appropriate application of this technique.The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
髋关节后部和臀部疼痛可能由多种相互重叠但又不同的病因引起。坐骨股骨撞击症、坐骨神经病变和股后肌腱近端病变，单独或合并出现，都被认为是引发因素。然而，潜在病理状况的诊断和处理可能具有挑战性，因为很少有诊断方法能可靠地区分这些病因，而且外科医生的决策可能会因不确定该处理哪种病理状况而变得复杂。
发生在坐骨神经分布区域且对保守治疗措施（如物理治疗、止痛药物和活动调整）无效的髋关节后部和臀部疼痛，会引发对上述一种或多种病理状况的怀疑。本文描述了一种针对所有三种状况——坐骨股骨减压、坐骨神经松解和股后肌腱近端修复——的联合手术。
患者俯卧于可透射线的手术台上。做一个切口，通过臀部浅层、臀筋膜以及股后肌腱近端上方的筋膜进行解剖分离。识别坐骨神经，钝性分离使其游离并松解。切开坐骨上方的筋膜，用咬骨钳去除肌腱附着处的皮质骨。置入两个锚钉，缝线以褥式缝合法穿过股后肌腱近端。沿外旋肌做一切口，向下解剖至小转子。识别小转子，进行截骨，将切除的骨块游离并取出。外旋肌间隙用间断缝线缝合。
这是一种不常见的手术，关于患者预后的数据很少。尽管如此，它对缓解上述病理状况相关的症状是有效的。成功的关键包括仔细诊断和熟悉手术技术。
COMBIS手术同时处理髋关节后部和臀部疼痛的三种常见病因。尽管进行全面的诊断评估以排除类似病症很重要，但因坐骨股骨撞击症、坐骨神经病变、股后肌腱近端病变或其组合而出现症状的患者，通过适当应用该技术可能会获得良好的症状缓解。作者证明已获得本出版物中出现的任何患者的同意。如果个体可被识别，作者已随本投稿附上患者的豁免声明或其他书面批准形式以供发表。
