Endoscopic Management of Gluteus Medius Tendon Tears

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Endoscopic treatment of gluteus medius tendon tear

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

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.

Endoscopic transfer of gluteus maximus and tensor fasciae latae for massive gluteus medius tear: Preliminary results

We report preliminary results for a novel technique of endoscopic Whiteside transfer for massive gluteus medius tear: i.e., tendon reinsertion not or only partly feasible and/or severe fatty atrophy of the muscle. Endoscopic transfer of gluteus maximus and/or tensor fasciae latae is associated to gluteus medius tendon reinsertion if at least partial tendon repair is feasible. In a continuous series of 6 patients at a minimum 2 years' follow-up, there was 1 early failure; 2 patients showed no improvement in pain and limping; 3 had satisfactory results, including 2 with complete resolution of limping and pain. Endoscopic Whiteside transfer associated to gluteus medius tendon repair provided only moderate results in terms of recovery of abduction power and resolution of Trendelenburg gait.

Endoscopic Gluteus Medius Repair With an ITB-Sparing Versus ITB-Splitting Approach: A Systematic Review and Meta-analysis

Background:

During hip endoscopy, the iliotibial band (ITB) can be split or preserved to access the peritrochanteric workspace. To our knowledge, no comparative studies have been performed to analyze patient-reported outcomes (PROs) and surgical failure rates (gluteus medius retear and/or revision surgery rates) for ITB-sparing versus ITB-splitting approaches in endoscopic gluteus medius repairs.

Purpose:

To perform a systematic review and meta-analysis of the literature to evaluate PROs and failure rates of patients undergoing ITB-sparing versus ITB-splitting repairs of the gluteus medius.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed by following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines and using the PubMed, Cochrane CENTRAL, and Embase databases. The quality of evidence was evaluated using the modified Coleman Methodology Score. Level 1-4 studies were evaluated for endoscopic abductor repair techniques on all types of gluteus medius tears. Given the small number of studies and varying population sizes, all quantitative data were adjusted for study population size.

Results:

A total of 13 studies met our inclusion criteria, while more granular data, including ITB approach, were available for 8 studies. Because of the paucity of literature on the subject, all included studies were of lower quality per the modified Coleman Methodology Score. The visual analog scale for pain, the modified Harris Hip Score (mHHS), and the surgical failure rates were compared between approaches. Patients who underwent ITB splitting had a significantly greater change in mHHS (45.5 ± 4.6 vs 27.3 ± 6.5; P < .001) and lower surgical failure rates (3.67 ± 2.33 vs 4.75 ± 2.54; P = .04). There was no significant difference in change in visual analog scale for splitting versus sparing (4.26 ± 0.41 vs 4.39 ± 0.14; P = .96). The results may have been biased by between-group differences, such as patients who undergo ITB sparing being significantly younger.

Conclusion:

Endoscopic gluteus medius repair is a reliable procedure to improve pain and function in appropriately selected patients. This study highlighted the lack of high-quality literature available regarding ITB approach. However, the evidence to date has suggested that ITB approach may influence hip-specific PROs. Splitting the ITB during abductor repair may be associated with a greater improvement in mHHS and lower surgical failure rates. Further prospective comparative studies are warranted to evaluate the effect of ITB approach.

Spinopelvic parameters in greater trochanteric pain syndrome: a retrospective case-control study

PURPOSE

Greater trochanteric pain syndrome (GTPS) is a condition resulting in lateral hip pain, most commonly caused by tendinosis or tear of the gluteus medius and minimus tendons, and greater trochanteric bursitis. Our aim was to assess pelvic parameters and proximal femoral anatomy in patients suffering from surgical-stage GTPS compared with a control group.

METHODS

This retrospective, case-control study assessed 43 patients suffering from GTPS, matched according to age, gender, body mass index and level of sport and physical activity to 43 control patients, between 2013 and 2018. Pelvic parameters, including pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS), and proximal femoral anatomy, including femoral offset (FO) and neck-shaft angle (NSA), were measured using the EOS Imaging™ system.

RESULTS

GTPS patients had a significantly lower mean (± SD) SS than control patients (33.1 ± 10.4 vs. 39.6 ± 9.7°, respectively; p < 0.05). There was no significant difference in PT (21.3 ± 7.1 vs. 19.0 ± 7.2°), PI (53.5 ± 11.6 vs. 57.7 ± 10.5°), FO (40.4 ± 8 vs. 42.2 ± 6.8°) or NSA (125.1 ± 5.8 vs. 124.4 ± 4.7°). There was no difference in lower back pain symptoms in a subgroup analysis of GTPS patients.

CONCLUSIONS

Sacral slope was lower in patients with surgical-stage GTPS than in asymptomatic hip patients, using the EOS Imaging™ system.

Influence of Muscle Fatty Degeneration on Functional Outcomes After Endoscopic Gluteus Medius Repair

PURPOSE

To report the early outcomes of endoscopic repair of tears of the gluteus medius tendon and to determine whether the fatty degeneration had an influence on clinical results.

METHODS

Between October 2012 and June 2014, data were prospectively collected and retrospectively reviewed for all patients who underwent endoscopic gluteus medius repair. Patients were assessed pre- and postoperatively using the modified Harris hip score, the nonarthritic hip score, and visual analog scale for pain. The gluteus minimus and the 3 distinct parts of the gluteus medius (anterior, middle, and posterior) were assigned a grade of fatty degeneration on preoperative magnetic resonance imaging scans.

RESULTS

Twenty-two hips (in 20 patients) were assessed with the mean follow-up of 31.7 months (range: 24 to 47 months). There were 15 partial-thickness and 7 full-thickness tears. No patient was lost to follow-up. The mean age at the time of surgery was 66 years (range: 45 to 82 years). Of the 20 magnetic resonance imaging-assessed hips included in the study, 14 had fatty degeneration of the gluteus medius (partial-thickness tears: n = 8, full-thickness tears: n = 6). The mean gluteus medius fatty degeneration index was 1.57 (range: 0.33 to 3.33). Postoperative improvement was seen in modified Harris hip score (33.7 points vs 80.2 points, P = .0001), nonarthritic hip score (47.7 points vs 76.8 points, P = .0001), and in the visual analog scale for pain (7.2 vs 3.2, P < .05). Increasing preoperative fatty degeneration index of the gluteus medius correlated with decreased postoperative functional hip score values (regression coefficient, 0.5839; P < .0001). Tear characteristics (partial or full-thickness) did not correlate with fatty degeneration or muscular atrophy and did not affect postoperative outcomes.

CONCLUSIONS

Endoscopic surgical repair can be an effective treatment of gluteus medius tears in the short term. Fatty degeneration of the gluteus medius and minimus has a negative impact on clinical outcomes of endoscopic gluteus medius repair.

LEVEL OF EVIDENCE

Level IV, therapeutic case series (no control group).

Predictors of Clinical Outcomes After Hip Arthroscopy: A Prospective Analysis of 1038 Patients With 2-Year Follow-up

BACKGROUND

As hip arthroscopy has expanded in popularity and volume, more information is needed about indications for the procedure and the predictive factors of clinical outcomes.

PURPOSE

To evaluate clinical outcomes of hip arthroscopy in a prospective study and to analyze the cohort to identify factors that are predictive of improvement.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were collected prospectively on all patients undergoing hip arthroscopy between February 2008 and June 2012. We included all patients undergoing hip arthroscopy who agreed to participate and who completed 4 patient-reported outcome (PRO) instruments at a minimum 2-year follow-up: the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale. The NAHS was selected as our primary outcome instrument. All patients with any previous hip conditions were excluded. We analyzed 34 preoperative and intraoperative variables using bivariate and multivariate analyses compared with NAHS.

RESULTS

The cohort consisted of 1038 patients with a mean follow-up of 30.1 months (range, 24.0-61.2 months). Mean age was 36.4 years (range, 13.2-76.4 years). All postoperative PRO scores showed significant improvement ( P < .001) at 2 years compared with preoperative scores. Bivariate analysis identified 15 variables (7 categorical and 8 continuous) and multivariate analysis identified 10 variables that were predictive of 2-year postoperative NAHS. Preoperative NAHS, preoperative HOS-ADL, preoperative mHHS, age, duration of symptoms, body mass index (BMI), and revision hip arthroscopy were identified as predictive factors in both bivariate and multivariate analyses. The predictive value of preoperative NAHS was accentuated for patients with higher BMI.

CONCLUSION

This study reports favorable clinical outcomes in the largest cohort of hip arthroscopies with a minimum 2-year follow-up in the literature to date. Factors identified as predictive in both bivariate and multivariate analyses included preoperative NAHS, HOS-ADL, and mHHS; age; duration of symptoms; BMI; and revision hip arthroscopy. These predictive factors may be useful to the clinician in determining prognosis and operative indications for hip arthroscopy.