Trochanteric micropuncture: treatment for gluteus medius tendinopathy

Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome

PURPOSE

To use a prospectively collected database to internally validate a previously published intraoperative classification system by determining its utility in improving patient-reported outcome scores (PROS).

METHODS

Open or endoscopic procedures performed at a single center between February 2008 and March 2018 with minimum 2-year follow-up were reviewed. Patients were prospectively classified intraoperatively as one of five greater trochanteric pain syndrome (GTPS) types according to the Lall GTPS classification system and underwent one of the six following surgical procedures: trochanteric bursectomy (TB, type I); TB with trochanteric micropuncture (type II); endoscopic suture staple repair (type IIIA); endoscopic single row transtendinous repair (type IIIB); open or endoscopic double row repair (type IV); and gluteus maximus/tensor fasciae latae transfers (type V). The following PROS were analyzed to assess the efficacy of treatment and validity of the classification scheme: modified Harris Hip Score (mHHS), Nonarthritic Hip Score, The International Hip Outcome Tool, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale for pain.

RESULTS

In total, 324 patients (287 female, 37 male) underwent surgical management per GTPS classification type: 109 type I; 26 type II; 20 type IIIA; 118 type IIIB; 44 type IV; and 7 type V. The mean age and follow-up time were 51.9 ± 12.5 years and 44.5 ± 20.5 months, respectively. All patients PROS improved from baseline to minimum 2-year follow-up (P < .05). High rates of the minimal clinically important difference for mHHS (70.0-100.0) and Nonarthritic Hip Score (73.1-92.7) and patient acceptable symptomatic state for mHHS (70.0-94.5) and International Hip Outcome Tool (58.1-86.7) were achieved per GTPS type. Patient satisfaction was 7.9/10.

CONCLUSIONS

This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. These findings provide surgeons with a validated classification system and treatment algorithm to manage peritrochantric pathology diagnosed intraoperatively.

LEVEL OF EVIDENCE

III, prognostic study.

Repair of Symptomatic Partial Gluteus Medius Tear During Total Hip Arthroplasty Through the Direct Anterior Approach

Gluteus medius (GM) tears are a well-established source of pain and disability. Considering previous studies, which have reported rates of incidental GM tears in 20% of patients undergoing primary total hip arthroplasty (THA) and a 3-fold greater rate in elderly female patients, additional focus should be placed on identifying treatment options. The direct anterior approach (DAA) for primary THA has gained popularity within the past few years. However, there has been a paucity in the literature on how to address symptomatic and partial GM tears through this approach. The purpose of this Technical Note is to describe a method to repair partial GM tears during primary THA using the DAA.

Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review

PURPOSE

To perform a systematic review of the outcomes of platelet-rich plasma (PRP) injections as an in-office procedure versus surgical treatment for recalcitrant greater trochanteric pain syndrome (GTPS).

METHODS

The MEDLINE and Embase databases were searched in June 2019 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Clinical studies on patients with recalcitrant GTPS treated with PRP or surgery were included. Demographic characteristics, patient-reported outcomes (PROs), and complications were compared. A qualitative analysis using the Methodological Index for Non-randomized Studies and Cochrane Risk of Bias Tool scores was performed.

RESULTS

A total of 5 PRP and 5 surgery studies met the inclusion criteria, contributing 94 and 185 patients, respectively. The mean follow-up time was shorter for the PRP studies (range, 2-26 months) than with surgery (range, 12-70 months). The mean Methodological Index for Non-randomized Studies scores for the PRP and surgery groups were 11.25 and 11.4, respectively, and the only randomized trial had a low risk of bias. Two studies in the PRP group (n = 56) reported improvements in the modified Harris Hip Score at final follow-up (from 53.8 to 82.6 and from 56.7 to 74.2). The other PRP studies reported improvements using other measures. In the surgery group, 2 studies reported improvements in the Harris Hip Score (from 53.0 to 80 and from 53.3 to 88) whereas 3 used unique PROs (Oxford score, from 20.4 to 37.3; modified Harris Hip Score, from 54.9 to 76.2; and Merle d'Aubigné and Postel score, from 10.9 to 16.7). Although significant improvement was reported in all studies included, PRP showed a large effect size whereas surgery showed a moderate to large effect size. No major complications were associated with PRP treatment; however, the surgery group reported a higher rate of complications including recurrent external snapping hip, retears resulting from falls, trochanteric fracture, venous thrombosis, and wound-related problems.

CONCLUSIONS

Both PRP and surgical intervention for the treatment of recalcitrant GTPS showed statistically and clinically significant improvements based on PROs. Although not covered by most medical insurance companies, PRP injections for recalcitrant GTPS provides an effective and safe alternative after failed physical therapy. If surgery is indicated, endoscopy is safer than the open technique.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).

Gluteus medius tears of the hip: a comprehensive approach

Greater trochanteric pain syndrome (GTPS) is a common clinical condition that can affect a wide range of patients. Historically, the condition has been associated with trochanteric bursitis. More recently, however, a growing body of literature has demonstrated gluteus medius tendinopathy and tearing is present in many cases of GTPS. Pathology of the gluteus medius can result in significant hip pain, loss of motion, and decreased function. Affected patients characteristically have symptoms including lateral hip pain and a Trendelenburg gait, which may be refractory to conservative management such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and injections. In these cases, both open and arthroscopic repair techniques have been described, with recent literature demonstrating excellent patient-reported outcomes. We present a comprehensive review of gluteus medius tears including relevant anatomy, clinical evaluation, diagnosis, and treatment options.

All-Endoscopic Single-Row Repair of Full-Thickness Gluteus Medius Tears

Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.