Clinical outcomes and frontal plane two-dimensional biomechanics during the 30-second single leg stance test in patients before and after hip abductor tendon reconstructive surgery

Recommendations in the rehabilitation of patients undergoing hip abductor tendon repair: a systematic literature search and evidence based rehabilitation protocol

INTRODUCTION

Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is hip abductor tendon (HAT) tears. Traditionally, these patients have been managed non-operatively, often with temporary pain relief. More recently, there has been an increase in published work presenting the results of surgical intervention. A variety of open and endoscopic transtendinous, transosseous and/or bone anchored suture surgical techniques have been reported, with and without the use of tendon augmentation for repair reinforcement. While patient outcomes have demonstrated improvements in pain, symptoms and function, post-operative rehabilitation guidelines are often vague and underreported, providing no guidance to therapists.

MATERIALS AND METHODS

A systematic search of the literature was initially undertaken to identify published clinical studies on patients undergoing HAT repair, over a 3-year period up until May 2020. Following the application of strict inclusion and exclusion criteria, studies were identified and the detail relevant to rehabilitation was synthesized and presented. Published detail was combined with the authors clinical experience, with a detailed overview of rehabilitation proposed for this patient cohort.

RESULTS

A total of 17 studies were included, reporting varied detail on components of rehabilitation including post-operative weight bearing (WB) restrictions, the initiation of passive/active hip range of motion (ROM) and resistance exercises. A detailed rehabilitation guide is proposed.

CONCLUSION

In combining the current published literature on rehabilitation after HAT repair and our own clinical experience in the surgical management and post-operative rehabilitation of these patients, we present an evidence-based, structured rehabilitation protocol to better assist surgeons and therapists in treating these patients. This rehabilitation protocol has been implemented for several years through our institutions with encouraging published clinical outcomes.

Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background:

Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain.

Purpose:

To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed.

Results:

A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation).

Conclusion:

There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

A roadmap to develop clinical guidelines for open surgery of acute and chronic tears of hip abductor tendons

PURPOSE

Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm.

METHODS

Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips.

RESULTS

A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%.

CONCLUSION

The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments.

LEVEL OF EVIDENCE

IV.

Both open and endoscopic gluteal tendon repairs lead to functional improvement with similar failure rates: a systematic review

IMPORTANCE

Operative treatment of gluteal tendon tears is becomingly increasingly more common with varying surgical techniques and rehabilitation protocols.

OBJECTIVE

To perform a systematic review of gluteal tendon repair as it relates to tear characteristics, rehabilitation protocols, patient-reported outcomes, satisfaction, resolution of gait deviation and complication rates.

EVIDENCE REVIEW

A comprehensive literature search of PubMed and Embase/MEDLINE was used to identify all literature pertaining to gluteal tendon repair. A total of 389 articles were identified.

FINDINGS

A total of 22 studies (611 hips) were included in this review. The majority of tears were noted to be partial thickness (77.9% vs 22.1%). Both arthroscopic and open repair demonstrated improvements in functional outcomes. Within studies documenting gait deviation, 54% were noted to have gait deviation preoperatively, of which approximately 70% had resolution following repair. On average, abduction strength increased almost one whole grade (0.84) following repair. Overall complication rate was found to be 5.2% (20 of 388 hips). Endoscopic repair demonstrated a decreased complication rate compared with open (0.7% vs 7.8%). Retear rate was found to be 3.8%, with open repair having a slightly increased rate compared with endoscopic repair (3.4% vs 4.1%).

CONCLUSIONS AND RELEVANCE

The majority of tears tend to be partial thickness with involvement of gluteus medius in almost all cases and concomitant involvement of gluteus minimus in close to half of cases. Both endoscopic and open gluteal tendon repairs resulted in improvements in outcomes and functional improvement. Retear rates were similar between the two repair techniques, while endoscopic repair demonstrated a lower complication rate.

LEVEL OF EVIDENCE

Level IV, systematic review.