Arthroscopic Repair of the Hip Abductor Musculotendinous Unit: The Effect of Microfracture on Clinical Outcomes

Forty-One to 75% of Patients Achieve a Patient Acceptable Symptomatic State After Endoscopic Repair of Hip Abductor Tendon Tears: A Systematic Review

PURPOSE

To systematically review clinical and functional outcomes of endoscopic repairs of hip abductor tendon tears.

METHODS

A search following guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was performed in the PubMed, Embase, and Cochrane databases using variations of the terms "endoscopy," "gluteus medius," "hip abductor," "outcome," "success," and "failure." Data for patient demographics, tear severity and location, patient-reported outcomes (PROs), clinical benefit, and rates of retears and revision surgery were collected and tabulated. Forest plots depicting preoperative versus postoperative PROs were generated. Quality assessment was performed using the modified Coleman Methodology Score.

RESULTS

In total, 13 studies, 3 Level III and 10 Level IV, were included in this review, with a total of 272 patients whose ages ranged from 46.0 to 66.9 years and follow-up times from 16.4 to 46.7 months. Most tears were isolated to the gluteus medius, with the number of partial- versus full-thickness tears being similar. Trendelenburg gait, reported by 4 studies, persisted in 0% to 13.6% of patients after repair. Of 9 studies reporting both preoperative and postoperative PROs at latest follow-up, 8 reported significant improvements in all PROs (P < .05). In 5 studies, rates of achieving minimal clinically important difference and patient-acceptable symptomatic state ranged from 50.0% to 93.3% and 40.7% to 75.0%, respectively. Surgical complication rates were 0% in 11 studies and 4.3% and 18.2% in 2 studies. Retear rates were 0% in 10 studies and ranged from 6.7% to 33.3% in 3 studies. Rates of revision due to retear, reported by 12 studies, were 0% in 8 studies and ranged from 2.2% to 13.0% in 4studies.

CONCLUSIONS

Endoscopic repairs of both partial- and full-thickness hip abductor tendon tears have good-to-excellent PROs and low complication, retear, and revision rates. However, rates of minimal clinically important difference and patient-acceptable symptomatic state achievement rates are highly variable and less than favorable.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Surgical Treatment and Outcomes for Gluteal Tendon Tears

PURPOSE OF REVIEW

Gluteus medius and minimus tears, or hip abductor tendon tears, are increasingly identified as a source of lateral hip pain. Once underappreciated and undertreated, they are now recognized as a cause of greater trochanteric pain syndrome and a pathology amenable to both nonoperative and operative modalities. This review summarizes relevant anatomy, clinical presentation, and treatment options for gluteus medius tears, focusing on surgical options.

RECENT FINDINGS

When surgical intervention is indicated, repair, reconstruction, or tendon transfer may be considered. Open and endoscopic repair techniques demonstrate similar outcomes with improvements in patient-reported outcomes and low complication and retear rates for both partial and full thickness tears. Variations in fixation construct and graft augmentations have been described, though clinical evidence remains limited to support specific techniques. Gluteus maximus transfer via open approach is a salvage option for the severely atrophied, retracted, or revision gluteus tendon; however, persistent limitations in abduction strength and gait abnormalities are common. Emerging evidence continues to evolve our understanding of surgical decision-making for gluteus tendon tears. The current literature supports either open or endoscopic repair techniques and open tendon transfer as a salvAage option. Further study is needed to determine the optimal fixation construct, the role of graft augmentation, and patient-related factors that influence postoperative outcomes.

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.

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.

A Review of Abductor Tendon Tears: The Hidden Lesion of the Hip

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Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years.

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Abductor tendon tears are becoming a more recognized cause of lateral hip pain in patients without hip osteoarthritis.

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Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies.

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Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

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.

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.