Thank you and wonderful speakers and I'm always learning and this is part of my midlife crisis I think. You reach a stage you say you know what else can I do that's interesting and I want to make a disclaimer. These are my disclosures. I don't do these that often but I do think there's a wonderful skill set, a wonderful technique set that can help a lot of patients that before we would do subject to the big big surgery. So the next frontier I think in hypothyrosophy is the deep gluteal space. That's anything behind that's deep to the gluteus medius maximus and the three principle diagnosis you may encounter and again you haven't seen them but they've seen you are ischial femoral impingement, deep gluteal space syndrome otherwise known as piriformis syndrome and hamstring injury and I am indebted to Hal Martin I think I tried to get him to come here I think he was tied up but he's really the pioneer behind most if not all the deep gluteal space work and he has really blazed the trail for certainly for me. Let's start with ischial femoral impingement it's compression of the quadratus femoris between the ischium and lesser trochanter and these patients will present with buttock pain that's worse with extension and adduction and external rotation and it's been described to have that they have a long stride test they'll have pain particularly at extension of stride and then really in the buttock area and this is the ischial femoral impingement test described by Hal really tries to abut the lesser tuberosity with the ischium and you do that by extension and actually a little bit of internal rotation. The x-ray is often self-evident as you see here and failure to conserve treatment is an indication I'm not so sure what conserve treatment is tell them to walk with a shorter stride stretching may help occasional injections there's not a lot written about conserve treatment for ischial femoral impingement but I can tell you this if they fail conserve treatment this is one procedure that does work and Hal and Al Stubbs have both taught me to approach these posteriorly because you have to minimize the size of the lesser trochanter and before we do those psoas releases anteriorly if you do it posteriorly you get less calcification and less vascular disruption so I approach these posteriorly and it's been much easier so this is Hal's pictures basically it's almost like an acromioplasty and this is one of my cases you're looking proximally and working posteriorly and I bring the burn after I shelled at the lesser tuberosity and it's really pretty much doing like a Mumford in the shoulder and you can bring x-ray in to quantify resection no one really knows how much is enough but I think if you take maybe four or five millimeters it's probably enough this is an evolving field I'm not going to be up here and tell you all these numbers I have no idea about but I try to get that lesser tuberosity flatter and this is what the resection looks like pre and post op and this is one of my learning curves I'm on the journey but I can tell you this a few patients have done this one have demonstrated significant improvement Hal Martin has the only series in literature besides case reports five patients VES scores went from 6.6 to 1 how about deep gluteal syndrome extrapelvic nerve compression now it's important this is piriformis syndrome and fibrous bands gluteal muscle hamstring muscle gamele space occupying lesions vascular and bone there's been a couple articles about anomalous obturator internus even hamstring fibrous bands can cause compression and they all have buttock pain they'll have radicular pain very very much like sciatica they'll have pain with sitting and in my experience particularly piriformis syndrome there's often trauma I don't think piriformis syndrome happens in a vacuum and it is rare it is really rare if you see an article and someone's doing a hundred piriformis syndrome releases time to find a new surgeon this is the piriformis test you basically put the muscle and stretch and you have them actively externally rotate and it compresses the sciatic nerve and they'll have reproducible pain posteriorly now how also in this genius to strive to test a seated piriformis stretch test where you have the patient in extension internally rotate and then resist and that can light up a patient he also does a dynamic EMG which I don't do but I probably should again failure of conservative treatment which includes injections I think pre-op planning is key and you can see here I always try to know where the sciatic nerve is because that's the key to the case obviously and I do these prone and I do these with the table flexed get the buttock out of the way I use three portals usually and this is your ischium right there and I use a 70 you scope and the key is just to find the nerve and you follow approximately and sometimes I'll maybe make additional more proximal portals I follow the nerve up and this is where the Hail Mary start right here you find the nerve and then you find the constriction and once you develop confidence you have the nerve you can use thermal until it gets tighter and then I'll bring in an instrument a upbiter like this and it's it's amazing how patients will tell you I call my post office the next day and they'll tell me like the next day doc I feel different I thank you so this is not snake oil this works it's just that it's rare so these are case series not a lot out there how has 35 patients the largest series and his modified Harris hip scores went from 54 to 78 not homeless run as Maximus but certainly an improvement and happy paid patients the thing you really want to talk about today was the hamstring pathology and this is where I probably do the most surgery for particularly the proximal tendinosis you'll get a in the aging of America I see a lot of patients in their 50s and 60s but are doing triathlons and they come in with this buttock pain and they're tender over the ischium and you get an MRI and they have tendinosis I'm not done many displaced tears and I've read about people don't I've maybe done one or two of my career but I think the focus of the lecture really was about the tendinosis you'll get the axial MRI and you'll see this abortive healing response from repetitive micro trauma again this is the active middle-aged female male that's run almost super triathlons and they can't get better I put them on eccentric strengthening program I put them on PRP and we did it write a paper that this is association of this with FAI because it's part of the kinetic chain Jim Bradley has a series of patients using ACP and he says 50% of his patients get better with three injections that's not been my experience so God bless them but I have a hard time getting these folks better because they want to run their 10 12 miles and so forth through their triathlons and it's an abortive healing response this is not a tear this is really just schmutz as we say in Yiddish just off the tuberosity here just doesn't heal it needs help Susie Miller did the most seminal work on anatomy and remember the static nerve is about a sonometer lateral to the ischium and the semi membranosis which is usually the tenant involved is lateral it's a key point to this and it almost looks like a yin and yang sign with is the conjoint conjoined tendon of the semi tendinosis and the biceps is medial and the semi membranosis which for some mysterious reason because probably the twisting of the whole muscle tendon junction is the is the tendon that's most involved it's lateral and the whole composite is lateral it's not that we sit on that area it's really lateral to our sitting pressure area so I do a scope because less infection I can see better no need to retract the gluteus and there's less inflammation clearly and again I can see the nerve better with the scope this is the my portals again the same ones I use for my piriformis release so step one I find the nerve I know where it is lots of Hail Marys and once I know where the nerve is then I can find out where the ischium is this is the ischial tuberosity this is Carlos Conchet lent me this because my videos were yucky and there's the conjoined tendon but it's mostly the semi membranosis which is more lateral that's the agent and then we split it this is Carlos's video and this is mine and once you split it and peel off this memory knows you found this deep cavity it's like a huge hole that you'd never suspected by looking at it closely then I'll take a bird I'll just burn it down you gotta be careful and I do percutaneous anchor insertion I usually do two anchors and I use either a shuttle or direct pass I shut on my sutures and this is I'm not a big double row guy in the shoulder but this is one time I will do a double row take one of these interference fixation devices and I put a second anchor immediately on these interference push in devices and you get actually a pretty good repair and this one looks like before and after and evulsions this is the indications if you want to fix them I don't do that many at all because most the time I they're older and just rehab of three tendons two tendons two centimeters or displaced bony evulsion so this is Carlos's video the same principles apply you just basically have to pass sutures to get it back I I've done one or two of these with the most of the ones I'm doing I'm late have been the tendinosis variety the technique papers not much on these Ben and Dierckman and Jackson have all written technique papers not a lot of follow-up so the bottom line is the hope schools great promise for these deep gluteal space syndromes and the learning curve is steep the data is sparse but it's encouraging thank you

hypothyrosophy

deep gluteal space

ischial femoral impingement

piriformis syndrome

hamstring injury