Obturator Internus Tendon Research Articles

Return to Pre-Injury Level of Sport in an Elite Age-Group Triathlete after Non-Operative Treatment of Combined Complete Obturator Internus and Partial Hamstring Tendon Tears

Introduction Proximal hamstring tendon tears are uncommon injuries. Currently there is no consensus on what constitutes optimum management but the literature demonstrates a recent trend towards surgical management. Several authors have demonstrated less long-term disability and better return to sporting activity with surgical treatment when compared to non-operative treatment. However, these reports have focused on complete tears and there is a dearth of evidence to guide management of partial tears particularly in the high performance athlete. Complete tear of the obturator internus tendon has rarely been described in the literature and has not been reported in combination with proximal hamstring tendon pathology. Case description A 58-year-old female elite age-group triathlete presented with an acute on chronic exacerbation of increasing right buttock pain that had reduced her mobility such that she was unable to continue sports participation or walk unaided. Examination revealed ischial tuberosity tenderness, reduced hamstring strength and pain on hip extension. Magnetic resonance imaging revealed a 25% partial thickness tear of the conjoined hamstring tendon and complete tear of the obturator internus. In the absence of a history of trauma and no underlying osseous abnormality, the aetiology of the injury was presumed to be related to overuse and her high training load. Results and conclusions Surgical management was considered due to the considerable disability and duration of symptoms. However, repair of the partial tear would require conversion to a full tear to repair the deep fibres and surgical management of obturator internus rupture has not previously been described. Ultrasound guided steroid injection to the ischial tuberosity and physiotherapy was performed as lower risk initial options. The patient experienced immediate relief of symptoms, and this improvement is maintained at latest follow-up (12 months). There was no significant difference between the pre-injury and latest SF36 and proximal hamstring questionnaire scores and she has returned to the pre-injury level of long distance cycling but has been unable to return to running Take-home message This case report describes an injury pattern not previously described (complete rupture of obturator internus and partial tear of hamstring tendons). This case report is therefore important in demonstrating that this injury pattern can allow return to non-impact pre-injury level of sport when treated non-operatively. The case report also has broader applicability to isolated partial hamstring tendon ruptures, which occur more frequently, but have a limited evidence base to guide management. This report highlights that despite an increasing trend towards surgical management of hamstring tendon tears, patients with partial tears treated with injection and physiotherapy have the potential to return to athletic performance.

Sacrotuberous Ligament Healing following Surgical Division during Transgluteal Pudendal Nerve Decompression: A 3-Tesla MR Neurography Study.

Pelvic pain due to chronic pudendal nerve (PN) compression, when treated surgically, is approached with a transgluteal division of the sacrotuberous ligament (STL). Controversy exists as to whether the STL heals spontaneously or requires grafting. Therefore, the aim of this study was to determine how surgically divided and unrepaired STL heal. A retrospective evaluation of 10 patients who had high spatial resolution 3-Tesla magnetic resonance imaging (3T MRI) exams of the pelvis was done using an IRB-approved protocol. Each patient was referred for residual pelvic pain after a transgluteal STL division for chronic pudendal nerve pain. Of the 10 patients, 8 had the STL divided and not repaired, while 2 had the STL divided and reconstructed with an allograft tendon. Of the 8 that were left unrepaired, 6 had bilateral surgery. Outcome variables included STL integrity and thickness. Normative data for the STL were obtained through a control group of 20 subjects. STL integrity and thickness were measured directly on 3 T MR Neurography images, by two independent Radiologists. The integrity and thickness of the post-surgical STL was evaluated 39 months (range, 9–55) after surgery. Comparison was made with the native contra-lateral STL in those who had unilateral STL division, and with normal, non-divided STL of subjects of the control group. The normal STL measured 3 mm (minimum and maximum of absolute STL thickness, 2–3 mm). All post-operative STL were found to be continuous regardless of the surgical technique used. Measured at level of Alcock’s canal in the same plane as the obturator internus tendon posterior to the ischium, the mean anteroposterior STL diameter was 5 mm (range, 4–5 mm) in the group of prior STL division without repair and 8 mm (range, 8–9 mm) in the group with the STL reconstructed with grafts (p<0.05). The group of healed STLs were significantly thicker than the normal STL (p<0.05). We conclude that a surgically divided STL will heal spontaneously and will be significantly thicker after healing.

Greater inadvertent muscle damage in direct anterior approach when compared with the direct superior approach for total hip arthroplasty

We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches. In eight cadavers, the DA approach was performed on one side, and the DS approach on the other, a single brand of uncemented hip prosthesis was implanted by two surgeons, considered expert in their surgical approaches. Subsequent reflection of the gluteus maximus allowed the extent of muscle and tendon damage to be measured and the percentage damage to each anatomical structure to be calculated. The DA approach caused substantially greater damage to the gluteus minimus muscle and tendon when compared with the DS approach (t-test, p = 0.049 and 0.003, respectively). The tensor fascia lata and rectus femoris muscles were damaged only in the DA approach. There was no difference in the amount of damage to the gluteus medius muscle and tendon, piriformis tendon, obturator internus tendon, obturator externus tendon or quadratus femoris muscle between approaches. The posterior soft-tissue releases of the DA approach damaged the gluteus minimus muscle and tendon, piriformis tendon and obturator internus tendon. The DS approach caused less soft-tissue damage than the DA approach. However the clinical relevance is unknown. Further clinical outcome studies, radiographic evaluation of component position, gait analyses and serum biomarker levels are necessary to evaluate and corroborate the safety and efficacy of the DS approach. Cite this article: Bone Joint J 2016;98-B1036-42.

Dynamic Ultrasonography of the Deep External Rotator Musculature of the Hip: A Descriptive Study

BackgroundNo detailed reports exist describing the methodology of ultrasound image acquisition of the deep external rotator muscles of the hip. Because gluteal pain and sciatica are common, ultrasound may be a useful dynamic imaging adjunct in the evaluation of these patients. ObjectiveTo describe dynamic ultrasonography of the deep external rotator muscles of the hip for diagnostic purposes. DesignDescriptive. SettingUniversity radiology department. ParticipantsParticipants (n = 25; 14 male) without gluteal pain or sciatica were enrolled (mean age 27.6 ± 4.7 years; mean body mass index 26.0 ± 4.1 kg/m2). MethodsUltrasonographic cine clips oriented to the long axis of each deep external rotator muscle were captured. In addition, cine clips of the piriformis tendon and obturator internus tendon were obtained. Cine clips were analyzed approximately 1 week after completion of image acquisition independently by 2 blinded raters. Main Outcome MeasuresA 5-point Likert scale to evaluate the diagnostic utility of the ultrasound image. ResultsThe modal Likert scores for rater 1 were as follows: piriformis muscle = 4; piriformis tendon = 4; superior gemellus muscle = 3; obturator internus muscle = 4; obturator internus tendon = 4; inferior gemellus muscle = 4; quadratus femoris muscle = 4. The modal scores for rater 2 were: piriformis muscle = 4; piriformis tendon = 3; superior gemellus muscle = 4; obturator internus muscle = 3; obturator internus tendon = 4; inferior gemellus muscle = 3; quadratus femoris muscle = 4. ConclusionDynamic ultrasonography may be useful to image the hip deep external rotator musculature for diagnostic purposes and therefore aid in the evaluation of gluteal pain and sciatica. Future work should investigate the reliability and validity of ultrasonography in the evaluation of pathology of these muscles.

Piriformis and obturator internus morphology: A cadaveric study

Preservation of piriformis during exposure of the hip joint via a posterior approach may result in a lower rate of dislocation following total hip arthroplasty. The aim of this study was to identify anatomical variations in the tendons of piriformis and obturator internus which could inform piriformis sparing approaches to the hip. Twenty-nine proximal femora from 15 cadavers, 5 male and 10 female aged 65-79 years, were examined. Tendon crossing angles, location and mode of insertion to the greater trochanter and the extent of fusion between tendons prior to insertion were noted. The mean (and associated standard deviation) of the vertical and horizontal widths of the piriformis tendon were 4.78 ± 1.31 mm and 7.35 ± 1.74 mm, respectively. The mean (and associated standard deviation) of the vertical and horizontal widths of the obturator internus tendon were 6.87 ± 1.61 mm and 5.72 ± 1.38 mm, respectively. The mean distances of the anterior and posterior margins of the piriformis tendon insertion from the posterior limit of the greater trochanter, defined as a percentage of the anteroposterior length of the greater trochanter, were 63.3% ± 9.4% and 43.0% ± 9.4%, respectively. Equivalent mean distances for the obturator internus insertion were 73.0% ± 6.6% and 55.9% ± 7.0%, respectively. On the basis of the relationship between the piriformis and obturator internus tendons in terms of the angle and point at which they cross, in addition to any degree of tendon fusion, four classifications were identified. This study shows that the most posterior margins of the piriformis and obturator internus attachments are located more than one-third of the way along the greater trochanter, suggesting that current osteotomies would not include these external rotators in the majority of cases.

MR Imaging Features of Obturator Internus Bursa of the Hip

The authors report two cases with distension of the obturator internus bursa identified on MR images, and describe the location and characteristic features of obturator internus bursitis; the "boomerang"-shaped fluid distension between the obturator internus tendon and the posterior grooved surface of the ischium.

Piriformis muscle: clinical anatomy and consideration of the piriformis Syndrome

Patients with lumbosacral and buttock pain provide tacit support for recognizing the piriformis muscle as a contributing factor to the pain (piriformis syndrome). One hundred and twelve cadaveric specimens were observed to elucidate the anatomical variations of the piriformis muscle referred to the diagnostic and treatment of the piriformis syndrome. The distance between the musculotendinous junction and the insertion was measured and the piriformis categorized into three types: Type A (71, 63.39%): long upper and short lower muscle belly; Type B (40, 35.71%): short upper and long lower muscle belly; Type C (1, 0.9%): fusion of both muscle bellies at the same level. The diameter of the piriformis tendon at the level of the musculotendinous junction ranged from 3 to 9 mm (mean: 6.3 mm). The piriformis showed the following possible fusions with adjacent tendons. In type one (60, 53.57%) a rounded tendon of the piriformis reached the upper border of the greater trochanter. In type two (33, 29.46%) it first joined into the gemellus superior tendon and at last both fused with the obturator internus tendon and inserted into the medial surface of the greater trochanter. A fusion of the piriformis, obturator internus and gluteus medius tendon with the same insertion area as above was observed in type three (15, 13.39%) and finally in type four (4, 3.57%) the tendon fused with the gluteus medius to reach the upper surface of the greater trochanter. Based on this survey anatomical causes for the piriformis syndrome are rare and a more precise workup is necessary to rule out more common diagnosis.

THE CLASSIC: Complete Replacement Arthroplasty of the Hip by the Ring Prosthesis

THE CLASSIC: Complete Replacement Arthroplasty of the Hip by the Ring Prosthesis

Entry point soft tissue damage in antegrade femoral nailing: a cadaver study.

Little attention is paid to insertion site morbidity associated with antegrade femoral nailing. However, residual peritrochanteric pain after nailing is not uncommon. Additionally, the end branches of the medial femoral circumflex artery (m.f.c.a.) supplying the femoral head are in close proximity to the insertion site of the nail, and the occurrence of avascular necrosis of the femoral epiphysis after nailing in adolescents is rather frequent. The aim of this study was to assess iatrogenic soft tissue injuries at the site of nail insertion. Nailing with a reamed AO universal femoral nail was performed on sixteen adult cadavers followed by dissection of the proximal part of the femur to assess possible damage to the soft tissues. Three entry portals were defined. (A) entry portal lateral to the junction of the neck and the greater trochanter; (B) entry portal at the base of the greater trochanter anterior to a line along the longitudinal axis of the femoral neck; and (C) entry portal at the base of the greater trochanter posterior to a line along the axis of the femoral neck (at the piriformis fossa). In Group A, partial avulsion of the piriformis and the obturator internus tendon were present in four and in one of five specimens, respectively. Group B showed injuries to the piriformis tendon in two and to the gluteus minimus tendon in one of four cases. In Group C, partial avulsion of the piriformis, obturator internus, and obturator externus tendon were encountered in five, six, and two of seven specimens, respectively. Anterior branches of the ramus profundus of the m.f.c.a. within the synovial fold were damaged in all of these cases. To select the best nail entry portal, the ease of nail insertion must be weighed against the resulting soft tissue damage at the site of insertion. The nail entry portal at the piriformis fossa, although geometrically ideal and most recommended, causes the most significant damage to muscle and tendons as well as to the blood supply to the femoral head. Therefore, even if reported only once, the occurrence of avascular necrosis of the femoral head after nailing in adults is a possible complication of this nail entry portal. The authors therefore prefer to avoid this entry portal in every case. The nail entry portal anterior to the longitudinal axis of the femoral neck, as in group B, although better with respect to the soft tissue damage, has the worst geometric and biomechanical disadvantages. The results of the current study favor the nail entry portal lateral at the greater trochanter as in Group A, which is equal to the entry portal B with respect to the soft tissue damage but allows introduction of the nail into the medullar cavity without difficulties.

Obturator Interims Muscle Autotransplantation: A New Concept for the Treatment of Obstructive Constipation

The feasibility of using obturator internus muscle autotransplantation in order to construct an anal dilator mechanism for the treatment of obstructive constipation was studied anatomically, physiologically and pathologically. Electromyographic studies of 15 obturator internus muscles in 10 healthy adult male volunteers and 3 other muscles in patients with documented spastic anal sphincters demonstrated the ability of the obturator internus muscles to contract during straining at stools. The proposed surgical approach was studied in 9 cadavers (5 stillbirths and 4 adults), followed by formal anatomical dissection of the obturator internus muscle and tendon, pudendal nerve and vessels, inferior rectal nerve and nerve to the obturator internus. Anatomical studies proved the feasibility, ease, rapidity and safety of the technique with or without division of the obturator internus tendon with no incidence of injury to the surrounding nerves, vessels or muscles using a purely perineal approach.