Arthroscopic management of greater trochanter pain syndrome and abductor tears has demonstrated promising results in terms of improvement in pain scores and functional outcomes: a scoping review

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BACKGROUND

Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes.

METHODS

Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA.

RESULTS

The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex.

CONCLUSIONS

Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction.

LEVEL OF EVIDENCE

Level 2 (High quality prospective cohort study).

Ultrasound-Guided Subfascial Platelet-Rich Plasma Injections Versus Enthesis Needling for Greater Trochanteric Pain Syndrome: A Randomized Controlled Trial

Background

Greater trochanteric pain syndrome (GTPS) is characterized by gluteal enthesopathy involving the peritrochanteric space and associated with chronic pain and functional impairment. A corticosteroid injection in the trochanteric bursa is the usual palliative treatment for pain. However, it is important to investigate treatment options that will relieve pain in the peritrochanteric space.

Purpose

To compare the clinical efficacy of subfascial platelet-rich plasma (PRP) injection and enthesis needling for GTPS.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 92 patients (90% women; mean age, 55 years old; mean body mass index, 25.3 kg/m2) were randomly divided into a subfascial PRP injection group and an enthesis needling group. Descriptive data and radiographic measurements of the pelvis-including leg-length difference, pelvic width difference, and pelvic trochanteric index-were recorded. The primary outcome measures were the Hip Outcome Score (HOS) activities of daily living (HOS-ADL) and sports-specific (HOS-SS) subscales and the visual analog scale for pain at 3, 6, and 12 months posttreatment. In addition, we evaluated the presence or absence of ultrasound characteristics (fascia nodules, trochanteric bursa distension, and calcium deposits) over time in response to treatment.

Results

Baseline demographic and radiological characteristics were similar between the groups. The PRP group saw significantly greater improvement from baseline to 12 months posttreatment on the HOS-SS subscore compared with the needling group (32.09 [95% CI, 28.99-40.20] vs 20.52 [95% CI, 11.99-29.05]; P = .048). At 3 months, 60% of patients in the PRP group versus 33.3% in the needling group had a reduction in pain compared with a baseline of >20% (P = .040). After subfascial PRP injection, fewer patients had a fascia nodule over the trochanter and/or bursa distension (P = .006 and P = .004, respectively). The pelvic trochanteric index was predictive of HOS-ADL and HOS-SS outcomes (P = .011 and P = .022, respectively). The interaction between treatment modality and fascia nodule influenced HOS-ADL and HOS-SS outcomes (P = .021 and P = .023) as well as the interactions of treatment modality, fascia nodules, and calcifications (P = .027).

Conclusion

Both subfascial PRP injection and enthesis needling resulted in clinical improvements, but the improvement in the HOS-SS was greater in the PRP group.

Registration

NCT04231357 (ClinicalTrials.gov identifier).

Current and future advances in practice: tendinopathies of the hip

Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

Comparison of open surgery versus endoscopic-assisted release for gluteal muscle contracture: a systematic review and meta-analysis

PURPOSE

This study aimed to perform a systematic review and meta-analysis to compare the clinical outcomes of open surgery and arthroscopic release in gluteal muscle contracture (GMC).

METHODS

Two independent reviewers YM and WL conducted a systematic search of PubMed, Embase, Cochrane Library, and Web of Science to identify clinical trials that adhered to the PRISMA guidelines (Appendix A), spanning from inception to July 2023. Search items included (("gluteal" OR "gluteus") AND ("contracture" OR "fibrosis")). Research comparing open surgery or arthroscopic release was included. Clinical outcomes were compared using the risk ratio for dichotomous variables and the standardized mean difference for continuous variables. A P value < 0.05 was deemed statistically significant.

RESULTS

Four studies with 453 patients met the selection criteria and were included in this review. Compared with open surgery, in the case of similar postoperative functional satisfaction (1.21, 95% CI = 0.46-3.17, P = 0.70), the arthroscopic release achieved advantages in postoperative complications (3.5, 95% CI = 1.75-7.03, P = 0.0004), cosmetic satisfaction (0.07, 95% CI = 0.01-0.65, P = 0.02), length size (5.65, 95% CI = 4.11-7.19, P < 0.001), and hospitalization duration (1.57, 95% CI = 0.89 to 2.26, P < 0.001).

CONCLUSION

This research shows that both open surgery and arthroscopic release improve functional satisfaction. The arthroscopic release could result in fewer complications, better cosmetic satisfaction, shorter length size, and shorter hospitalization duration. Registration and protocol There is no registration and protocol for this meta-analysis.

The Gluteus Medius Experiences Significant Excursion With Hip Flexion

Purpose

To evaluate the effect of hip flexion and rotation on excursion of the gluteus medius (Gmed) and minimus (Gmin) myotendinous unit.

Methods

Seven hips from 4 cadaveric specimens (males, 68.5 ± 18.3 years old) were dissected to isolate the Gmed posterior and lateral insertions and the Gmin proximal and distal insertions. Sutures were placed from tendon insertions through origins created in the iliac fossa to simulate the myotendinous unit. A load of 10N was applied. Myotendinous excursion was measured at 10° hip extension and 0°, 45°, and 90° of hip flexion in neutral rotation, and from maximum internal and external rotation in 90° flexion. The amount of abduction and rotation was also measured at each flexion position with 20N applied to each tendon. Repeated-measures analysis of variance with Tukey post hoc was used for statistics.

Results

Gmed-lateral excursion ranged from 2.4 ± 0.4 mm in 10° of hip extension to 23.0 ± 1.5 mm in 90° of flexion (P < .001), and Gmed-posterior excursion ranged from 0.92 ± 0.5 mm in 10° of extension to 38.1 ± 1.1 mm in 90° of flexion (P < .001). Gmin excursion shortened with hip flexion from 4.2 ± 0.3 mm in 10° of extension to -0.2 ± 1.5 mm in 90° of flexion (Gmin-prox: P = .525, Gmin-distal: P < .001). At 90° flexion from maximum internal to maximum external rotation, Gmin-distal and proximal demonstrated a 92.6% and 51.3% increase in excursion, respectively (P < .001). Gmed-lateral and Gmed-posterior demonstrated 49.4% and 23.1% increase in excursion with external rotation, respectively (P < .001).

Conclusions

The Gmed myotendinous unit undergoes significant excursion with hip flexion, whereas both Gmed and Gmin had significant excursion with femoral external rotation in 90° flexion.

Clinical Relevance

It is important to understand whether active or passive hip flexion or rotation in the early postoperative period causes excessive strain to an abductor tendon repair. We found that consideration should be given to limit flexion after Gmed repair and external rotation after Gmed or Gmin repairs.

Good clinical outcomes, a high level of patient satisfaction and an acceptable re-operation rate are observed 7-10 years after augmented hip abductor tendon repair

PURPOSE

To investigate the clinical outcome, level of patient satisfaction, re-injury and re-operation rates of patients 7-10 years after augmented hip abductor tendon repair.

METHODS

Between October 2012 and May 2015, 146 patients were referred to the senior author with symptomatic hip abductor tendon tears, of which 110 (101 female, 92%) were included in the current study and underwent hip abductor tendon repair augmented with LARS. Patients had a mean age of 63.2 years (range 43-82), body mass index of 27.8 (range 20.0-40.2) and duration of symptoms of 3.6 years (range 6 months-18 years). Patient-reported outcome measures (PROMs) were evaluated pre-operatively and at 3, 6, 12 and 24 months, as well as 7-10 years post-operatively, including the Oxford Hip Score (OHS), 12-item Short Form Health Survey (SF-12), a Visual Analogue Pain Scale (VAS) evaluating the frequency (VAS-F) and severity (VAS-S) of hip pain, and patient satisfaction. Adverse events, surgical failures, revisions and subsequent treatments on the ipsilateral hip were reported.

RESULTS

A significant improvement (p < 0.05) was observed for all PROMs and, while a mean deterioration was observed for all PROMs from 24 months to final review (7-10 years), these were not significant (n.s.). In the 90 patients retained and assessed at final review, 93% were satisfied with their hip pain relief and 89% with their ability to participate in recreational activities. Overall, 9 (of 110, 8.2%) surgical failures were observed over the 7-10-year follow-up period.

CONCLUSIONS

Good clinical scores, a high level of patient satisfaction and an acceptable re-injury rate were observed at 7-10 years after augmented hip abductor tendon repair, demonstrating satisfactory repair longevity.

LEVEL OF EVIDENCE

IV.

Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review

PURPOSE

The primary purpose of this study was to systematically review the literature on intraoperative findings during endoscopic treatment for greater trochanteric pain syndrome (GTPS). Secondary outcomes were preoperative imaging findings and postoperative functional outcome measures.

METHODS

Medline, PubMED, and Embase databases were searched from inception (1946, 1966, and 1974, respectively), to July 15, 2021, for records reporting intraoperative findings during endoscopic surgery for GTPS. Studies of Level I-IV evidence were eligible. All studies were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) score.

RESULTS

Sixteen studies met the inclusion criteria. Most patients underwent endoscopic greater trochanteric bursectomy with repair of the gluteal tendons. Intraoperative conditions reported were gluteal tendon tears usually involving the gluteus medius tendon, labral tears, and chondral lesions. Three studies reported an average of 9% of patients who subsequently underwent conversion to total hip arthroplasty. Pain was assessed using the visual analog scale, and functional outcome measures were measured using the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score Sport-Specific subscale, Hip Outcome Score Activities of Daily Living subscale, and iHOT-12. Pain and functional outcomes demonstrated significant improvement in nearly all the studies where they were reported.

CONCLUSIONS

Patients who underwent endoscopic management of GTPS commonly underwent repair of gluteal tendon tears, and in many cases had concomitant labral tears and chondral lesions identified intraoperatively. There were low rates of adverse events, repair failure, and revision surgery. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively.

LEVEL OF EVIDENCE

IV, systematic review of level IV or better investigations.

Satisfactory results after endoscopic gluteus medius repair combined with selective gluteus maximus reflected tendon release for the treatment of a full-thickness tear of gluteus medius

PURPOSE

The current study aimed to report the mid-term follow-up results of endoscopic gluteus medius repair combined with a systematic release of the gluteus maximus reflected tendon.

METHODS

Twenty-two patients with a symptomatic full-thickness tear of the gluteus medius tendon, as diagnosed by clinical examination and imaging (MRI), and who had a failure of conservative treatment for at least 6 months, were retrospectively enrolled for this study. An endoscopic repair of gluteus medius was performed for all patients in combination with gluteus maximus reflected tendon release according to the Polesello technique. The Visual Analogue Scale (VAS) for pain, Modified Harris Hip Score (mHHS), Lower Extremity Functional Scale (LEFS), Hip Outcome Score-Activity Daily Life (HOS-ADL), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS) were administered to each patient before surgery for 6 months, 1 year, and every following year after surgery.

RESULTS

All analysed hip scores (mHHS, LEFS, HOS-ADL, and HOS-SSS) showed statistically significant improvements between the pre-operative and post-operative values at 6 months, 1 year, and the latest follow-up appointments after surgery (p < 0.001). The mean pre-operative pain was 8.6 ± 1.0 on the VAS. After surgical treatment, the pain was significantly reduced (p < 0.001) on the VAS at 6 months (5.4 ± 1.5), 1 year (4.4 ± 1.8) and the latest follow-up control visit (3.6 ± 2.2). No patient-reported major complications (re-rupture, deep infection or neurovascular injury). Eleven (50%) patients indicated the results as excellent, 7 (32%) as good, 2 (9%) as fair, and 2 (9%) as poor.

CONCLUSION

The use of abductor tendon repair in combination with a systematic release of the reflected tendon of the gluteus maximus according to the Polesello technique seems to be a safe and effective endoscopic way of treating a full-thickness tear of the gluteus medius.

LEVEL OF EVIDENCE

Level IV.

Clinical results after open gluteus medius repair in single-row technique

Purpose

The aim of this retrospective study is to present the clinical results of open repair of gluteus medius and gluteus minimus tendon tears using the single-row suture anchor technique.

Methods

This retrospective study included 43 participants after open repair of the abductor tendon of the hip joint using a single-row suture anchor technique. Clinical outcome parameters were assessed by VAS (0–10), gait safety (1 = absolutely safe gait without assistive devices - 10 = gait not possible), SHV (0–100%), mHHS, WOMAC, and gluteal muscle strength status from single-leg stance and against gravity.

Results

Thirty-two female and 11 male subjects with an average age of 65.2 years were included in this study. Overall, a significant decrease in pain (VAS 3.2) and improvement in joint function is observed after a period of 22.3 months. The mHHS reached 61.9 points, WOMAC 28.2, SHV 69.8% and gait stability measured by the VAS reached 3.4. 58.1% of the participants reported not having Trendelenburg, while 4% could not control the single leg stance.

Conclusions

The present study shows that single row repair for open glutueus medius refixation indicates limited clinical results. Although there was an improvement in clinical outcome. The majority of subjects continued to report limiting symptoms.

Asymptomatic gluteal tendinosis does not influence outcome in arthroscopic treatment of femoroacetabular impingement syndrome

PURPOSE

To compare outcomes after arthroscopy in FAIS patients with preoperative asymptomatic gluteal tendinosis (GT) to a control group with no gluteal tendinosis.

METHODS

A retrospective analysis was performed using data from FAIS patients who had arthroscopy between 2016 and 2018. Asymptomatic GT was diagnosed using hip MRI without clinical symptoms. Patients with asymptomatic GT were 1:1 propensity-score matched to patients without GT. Patient-reported outcomes (HOS-ADL, iHOT-12, mHHS), VAS scores, radiographic measures, performed procedures, complications, and revision surgery were compared and analyzed for both groups.

RESULTS

A total of 105 asymptomatic GT hips and 105 hips without GT were found using propensity-score matching. When compared to preoperative levels, both groups demonstrated significant improvements in PROs and VAS scores at the final follow-up. Besides, there were no significant differences in preoperative scores, final outcome scores, or score improvements between the groups. Patients in the GT group were significantly less likely to achieve the MCID for the VAS score (72.4% vs 83.8%, p = 0.045). However, there were no other differences in the rate of meeting the PASS and MCID between the study and the control groups.

CONCLUSION

It was demonstrated in this study that FAIS patients with asymptomatic gluteal tendinosis can expect to experience similar good short-term patients-reported outcomes as compared with patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Arthroscopic treatment of type I and II greater trochanteric pain syndrome

The goal of this study was to describe and evaluate endoscopic bursectomy combined with fascia lata lengthening in the treatment of type I and II greater trochanteric pain syndrome recalcitrant to conservative management. This was a retrospective study of 20 patients (7 type I, 13 type II) reviewed with a minimum follow-up of 2 years. The mean follow-up was 44±11 [26-65] months. While significant improvements in pain, mHHS and NAHS were found, 80% of patients still had hip pain graded at≥3 on VAS. The satisfaction rate was 7/10±2 [3-10]. Snapping in the hip had been eliminated in 100% of cases. No complications were observed. This is a minimally invasive surgery that is feasible in patients who have failed an optimal course of conservative treatment. But patients must be informed that pain might not be completely eliminated by this procedure. LEVEL OF EVIDENCE: IV; retrospective, case series.

Rehabilitation After Gluteus Medius and Minimus Treatment

We reviewed the current literature regarding rehabilitation after gluteus medius and minimus tears as part of a conservative management or postoperative protocol. The greater trochanteric pain syndrome includes a constellation of pathologies that generate pain in the greater trochanteric region and may be accompanied by varying degrees of hip abductor disfunction. It may be related to tendinitis of the gluteus medius and minimus, greater trochanteric bursitis, or even formal tears of the hip abductor tendons. The initial management strategy of the hip abductor tears is conservative, including different anti-inflammatory therapies such as physical therapy and cortisone and platelet-rich plasma injections. The clearest indication for surgical management is failure of conservative management and loss of abductor muscle power. Surgical management has been performed both open and endoscopic with good reported clinical results. More severe tears typically require a more rigid and complex type of fixation. Exorcise intervention seem to improve symptoms after 4 months to a year of therapy therefore a very close supervision of the rehabilitation protocol is mandatory. Gluteus medius and minimus tears are frequent and may be not diagnosed timely. Treatment of these of lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. Conservative management is based on protecting the hip abductor tendons from excessive tensile and compression stresses while applying progressive load in conjunction with physical and medical anti-inflammatory measures. Surgical treatment is indicated when conservative management fails or an abductor power deficit is associated with pain. Similar physical therapy protocols to those used in conservative management are used postoperatively.

Level of Evidence

Level V, expert opinion.

[Avulsion injuries of the gluteus medius and gluteus minimus muscles]

Avulsion injuries of the gluteus medius and gluteus minimus muscles represent a diagnostic and therapeutic challenge. Such injuries are rarely to be expected in high-energy trauma. Degenerative damage or iatrogenic injuries in the context of hip surgery are more frequently identified as the cause. Clinically, in addition to lateral hip pain, limping is an important finding and depends on the extent of the tendon damage. In addition to the medical history and clinical examination, imaging by means of sonography and, above all, magnetic resonance imaging (MRI, possibly with artifact-reduced sequences in the presence of an endoprosthesis) are diagnostically groundbreaking. Therapeutically, a stepwise approach is indicated according to the extent of rupture and quality of the gluteal tendon and muscle tissues. Specific conservative training regimens, mini-open/endoscopic anatomic reconstruction techniques in cases of gluteal muscle integrity and muscle transfer techniques as salvage option with chronic mass ruptures are available. The common goal is the restoration of everyday occupational and private activities to regain the quality of life.