Three-In-One Scarring
In rare instances, orthopedic hip related procedures can give rise to significant pelvic pain. Screws placed through the ilium may go into the pelvis through the iliacus muscle and can be the cause of severe pain on movement as the iliopsoas muscle moves to balance the patient.
One of these cases needed confirmation of the cause of the pain by blocking the iliopsoas tendon inserting into the lesser trochanter. The complete pain relief was followed by abdominal surgery peeling off the iliacus muscle from the ilium and filing up the very long screw; almost reaching the iliac arteries. A couple of years later, the patient noted severe weakness of the quadriceps muscle. On palpation above the knee, saphenous nerve pain was noted and it became obvious that this was the consequence of scarring of the femoral sheath and the compression of femoral nerves. Therefore, we did a hydrodissection of the femoral sheath using a 20g 2” Stealth needle inserting one centimeter lateral to the femoral artery and one centimeter below the ilioinguinal ligament. Contrast injection under fluoroscopy verified femoral sheath entry by the blunted stealth needle and the total volume of 35cc was injected. Injection consisted of contrast 10 mL, hyaluronidase 10mL, 5cc of 0.25% Bupivacaine, 5cc of 1% Lidocaine and 40 mg of Triamcinolone, spreading in the direction of the three-in-one nerves; femoral, obturator, lateral femoral cutaneous plus the bonus fourth nerve, the genitofemoral. Additionally, we injected the painful saphenous nerve in the Hunter’s Canal, 4 inches above the knee with 10 mL mixture of local anesthetic and steroid.
This was 15 years ago and patient had rapid recovery with full use of the quadriceps muscle and did not need any additional procedure because of the femoral sheath scarring. Quadriceps femois weakness is evident by the patient having to lift the thigh moving while in the sitting position. And only careful history taking will reveal this or an evaluation for the quadriceps muscle.
