I just want to document this really interesting anatomy here. You can see down here, this is piriformis muscle here, it’s just the nerve anatomy is very unusual. So there’s two main piriformis muscles with the lateral division transiting between them and then the medial or anterior muscle belly is also split and there’s another nerve coming through it. And then this patient has had a total hip arthroplasty and the tendon has scarred down very tightly over the medial division as well.
That’s anatomy I’ve never seen before. Really interesting, specific configuration. And also, it’s not something that’s described in any literature anywhere. Anytime you look up piriformis muscle anatomy, you’ll get this little drawing that has six basic, six different sort of variations in terms of the anatomy, but this is not one of them. This surgery’s a little bit like that game you played as a kid, that pickup sticks. It’s all about trying to remove these muscles that are all intertwined with the nerves.
I mean, if you have a single muscle, which is the most common configuration, it’s much more straightforward. But when you start to get muscles that are splitting and nerves passing between muscle bellies and stuff, then it could be quite a challenge sometimes to get the muscle out. I’m the only one I’d want to be doing this case on me. This is a very tough one because of the anatomy here. You always got to be careful when you’re doing this because, again, I’ve done close to 450 of these surgeries, I’ve never seen that. So if I just assumed that it was just the regular and just start blasting through here, you could damage that nerve. So every case has to be like, you assume you’re going to find something you never saw before sort of thing.
We are all done with the case. As you can see, all those pieces of muscle have been removed from where they were. The last video left off, we were having to take the muscle out and leave this nerve intact, which we were able to do safely. You can see that the piriformis muscle is totally gone. This is a very complicated case just because of the way that the piriformis muscle is really honeycombed with the nerve passing through in several different spots so I think this will give you a lot of relief.