Surgical repair of chronic tears of the hip abductor mechanism

Endoscopic Repair of Partial Gluteus Medius Tear: Staple Configuration With Suture Anchors

Tears of the gluteus medius and minimus have emerged as significant contributors to lateral hip pain and functional impairment. Surgical intervention reliably delivers pain alleviation and ability to return to activities. Nevertheless, conventional open procedures entail substantial incisions, extensive tissue damage, and protracted recovery. Endoscopic approaches have provided minimally invasive alternative strategies. This Technical Note details a method for addressing partial gluteus medius tears by recreating the hip abductor tendon insertion footprint and employing a bioinductive patch to promote wound healing.

The Gluteus-Score-7 Predicts the Likelihood of Both Clinical Success and Failure Following Surgical Repair of the Hip Gluteus Medius and/or Minimus

PURPOSE

To identify patient preoperative history, examination, and imaging characteristics that increase the risk of postoperative failure of gluteus medius/minimus repair, and to develop a decision-making aid predictive of clinical outcomes for patients undergoing gluteus medius/minimus repair.

METHODS

Patients from 2012 to 2020 at a single institution undergoing gluteus medius/minimus repair with minimum 2-year follow-up were identified. MRIs were graded according to the "three-grade" classification system: grade 1: partial-thickness tear, grade 2: full-thickness tears with <2 cm of retraction, grade 3: full-thickness tears with ≥2 cm retraction. Failure was defined as undergoing revision within 2 years postoperatively or not achieving both a cohort-calculated minimal clinically important difference (MCID) and responding "no" to patient acceptable symptom state (PASS). Inversely, success was defined as reaching both an MCID and responding "yes" to PASS. Predictors of failure were verified on logistic regression and a predictive scoring model, the Gluteus-Score-7, was generated to guide treatment-decision making.

RESULTS

In total, 30 of 142 patients (21.1%) were clinical failures at mean ± SD follow-up of 27.0 ± 5.2 months. Preoperative smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.0-8.4; P = .041), lower back pain (OR, 2.8; 95% CI, 1.1-7.3; P = .038), presence of a limp or Trendelenburg gait (OR, 3.8; 95% CI, 1.5-10.2; P = .006), history of psychiatric diagnosis (OR, 3.7; 95% CI, 1.3-10.8; P = .014), and increased MRI classification grades (P ≤ .042) were independent predictors of failure. The Gluteus-Score-7 was generated with each history/examination predictor assigned 1 point and MRI classes assigned corresponding 1-3 points (min 1, max 7 score). A score of ≥4/7 points was associated with risk of failure and a score ≤2/7 points was associated with clinical success.

CONCLUSIONS

Independent risk factors for revision or not achieving either MCID or PASS after gluteus medius and/or minimus tendon repair include smoking, preoperative lower back pain, psychiatric history, Trendelenburg gait, and full-thickness tears, especially tears with ≥2 cm retraction. The Gluteus-Score-7 tool incorporating these factors can identify patients at risk of both surgical treatment failure and success, which may be useful for clinical decision-making.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Management of Hip Abductor Tears and Recalcitrant Trochanteric Bursitis in Native Hips

Hip abductor tears have recently gained recognition as a more prevalent injury than previously thought. This article will detail the pathophysiology of injury, physical symptoms commonly found at presentation, diagnostic imaging to best diagnose tears and when they should be ordered, and how to properly classify the injury and finally summarize the treatment options available with expert opinions about which are most successful.

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.

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

»

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.

»

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

»

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.

»

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.

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears

BACKGROUND

Gluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair.

METHODS

All sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance.

RESULTS

38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes.

CONCLUSION

While fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Gluteus Medius Repair using a Gluteus Maximus Flap Augmented with Synthetic Polyethylene Mesh: Surgical Technique and Case Series

Introduction

Gluteus medius tendon tears may not be feasible for direct repair when significant retraction or fatty degeneration is present. Several augmentation techniques have been reported for challenging cases. We describe a novel technique using a transfer of the anterior portion of the gluteus maximus combined with synthetic mesh to reinforce the direct suture of the gluteus medius. The goal of this study was to assess the functional and pain outcomes in three patients treated with this reconstruction technique.

Case presentation

A retrospective study was performed including 3 patients with complete and retracted ruptures of the abductor mechanism. When conservative management failed, surgical treatment was attempted. After a minimum follow-up of 12 months (mean follow-up of 18 months), all of the patients showed clinical improvement.The mean Harris Hip Score improved from 31.8 to 75.6, with an average postoperative abduction strength of 3 in the Medical Research Council muscle strength grading system, and no residual limp was noticed. The mean Visual Analogue Scale pain score decreased from 8.3 preoperatively to 1.6 postoperatively. No complications were reported.

Conclusion

In conclusion, this technique demonstrates efficacy in terms of improving clinical symptoms and functional status and is a reproducible way to augment irreparable gluteus medius tears.

Repair of gluteus medius tears with bioinductive collagen patch augmentation: initial evaluation of safety and imaging

The purpose of this study was to perform an initial, prospective evaluation of imaging findings and outcomes after open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation. A prospective study was performed of patients with clinical and magnetic resonance imaging (MRI) evidence of symptomatic gluteus medius tears who underwent open, double-row suture anchor repair with bioinductive bovine collagen patch augmentation. Preoperative and 6-month postoperative MRIs were reviewed by a fellowship-trained musculoskeletal radiologist, and outcome scores were recorded preoperatively and 6 months postoperatively [Hip Outcome Score (HOS) Sport; HOS Activities of Daily Living (HOS ADL); Modified Harris Hip Score (mHHS) and International Hip Outcomes Tool (iHOT-33)]. Nine patients, four high-grade tears (≥50% tendon thickness) and five low-grade tears (<50% thickness) underwent surgical repair. At 6 months, 7/9 (77.8%) of tendons were qualitatively classified as completely healed on MRI, with no complications. Mean tendon thickness increased significantly: mediolateral dimension by 5.8 mm (P < 0.001), anteroposterior dimension by 4.1 mm (P = 0.02) and cross-sectional area (CSA) by 48.4 mm² (P = 0.001). Gluteus medius and minimus CSA did not change significantly (P > 0.05). Patients demonstrated improvements in mean scores for HOS ADL, mHHS and iHOT that met defined minimum clinically important differences (P < 0.05). Open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation is safe and associated with increased tendon thickness on postoperative MRI. Early outcome scores are encouraging and should be evaluated after patients have completed postoperative rehabilitation to measure the whole effect of treatment.

Clinical outcomes of open hip abductor tendon repair with minimum two-year follow-up

BACKGROUND

The results of open hip abductor tendon repair remains poorly defined. We sought to present the results and complications of this procedure using modern suture anchor fixation.

MATERIALS AND METHODS

Our prospective institutional hip preservation registry was queried for all patients who underwent open hip abductor tendon repair with minimum 2-year follow-up were identified. Demographic, clinical, intraoperative, and functional outcome details were recorded. Patient-reported outcome scores (PROs) including the modified Harris Hip Score (mHHS), HOS-ADL, HOS-S, and iHOT-33 were collected for the preoperative and final postoperative state. Risk factors for lower final mHHS and change in mHHS were analysed using a multiple regression model.

RESULTS

A total of 21 patients with mean 48 months clinical follow-up (range 24-84 months). Median mHHS improved from 49.50 preoperatively to 82.50 postoperatively (p < 0.001), median HOS-ADL improved from 60.29 to 82.35 (p = 0.001), median HOS-S improved from 37.50 to 60.00 (p = 0.04), and median iHOT-33 improved from 29.81 to 70.15 (p = 0.001). All patients had +4 or +5 hip abductor strength at final in-person examination at mean 17 months postoperatively. All patients with a preoperative Trendelenburg gait had complete resolution at final examination. There 2 complications, and no patient had re-tear or revision surgery. LCEA < 25° and a history of prior ipsilateral hip surgery were independently predictive of smaller improvement in mHHS at final follow-up.

CONCLUSIONS

Open abductor tendon repair is a safe and effective procedure that provides sustained symptomatic and functional improvements at mid-term follow-up.

Clinical Outcomes for Open Hip Abductor Repair Using Tenodesis and Bone Trough Repair Techniques

BACKGROUND

Hip abductor complex tears remain an injury without a clear consensus on management. Surgical treatment has been recommended after unsuccessful nonoperative management. This study evaluates both tenodesis and bone trough techniques, with treatment choices guided by previously described tear classification.

METHODS

This is a retrospective cohort study of 45 hips in 44 patients who underwent surgical treatment for symptomatic, chronic hip abductor tear unresponsive to nonoperative treatment. Demographics and preoperative and postoperative values (including visual analog scale pain scores, gait assessment, and muscle strength) were evaluated. Type I tears were treated using tendon tenodesis. Type II tears were treated through a bone trough repair.

RESULTS

Forty-five hips (44 patients) were operated on with a minimum of 6-month follow-up. There were 27 type I and 18 type II tears. Eighty-seven percent of patients were female. Twenty-eight percent of type II patients (5/18) had a preexisting arthroplasty in place. Significant improvements in pain (P < .001), gait (P < .001), and muscle strength (P < .001) were achieved in both the tear types. Type I repairs showed superior results to type II repairs. However, both showed significant improvements. Postoperative magnetic resonance imaging at 6 months showed healed tenodesis in 81% (17/21) of type I tears and 50% (5/10) of type II tears.

CONCLUSION

Our study shows improvement in pain and function after surgical repair of hip abductor tendon injuries in both simple and complex tears. This improvement is seen even during ongoing surgical site healing. Magnetic resonance imaging findings may remain abnormal for more than 1 year after surgery and do not clearly denote repair failure.

The Intergluteal Fat Stripe in Patients With Hip Abductor Tears

Background:

With a hip abductor tendon tear, widening of the intergluteal space, or “fat stripe,” is a characteristic change seen in and around the gluteus medius and minimus.

Purpose:

To determine the relationship of the intergluteal fat stripe in hips with pathologic abductor tears compared with the contralateral side and to evaluate the association of fat stripe size with hip-specific patient-reported outcome measures.

Study Design:

Case series; Level of evidence, 4.

Methods:

Of the 43 patients (42 female, 1 male; mean age, 56.6 years; range, 38-85 years) who underwent endoscopic gluteus medius repair, 19 met inclusion criteria of preoperative bilateral hip magnetic resonance imaging (MRI) scans and 2-year follow up. A single board-certified fellowship-trained orthopaedic surgeon (J.F.), who was blinded to outcomes, evaluated the MRI scans to measure the intergluteal fat stripe on the operative and nonoperative sides. The 2-year postoperative International Hip Outcome Tool (iHOT-12) and modified Harris Hip Score (mHHS) values were analyzed to determine their relationship to the size of the fat stripe. Statistical analysis was performed using a paired t test, and associations were determined using Pearson product correlation as well as nonparametric measurements.

Results:

The size of the intergluteal fat stripe differed significantly between the operative and nonoperative sides. The area of the fat stripe on the operative side was 645.73 ± 513.09 mm2, and on the nonoperative side it was 313.47 ± 360.71 mm2, an average of 332.36 mm2 greater than the nonoperative side ( P = .02). The width of the fat stripe was 9.10 ± 4.60 mm on the operative side and 5.15 ± 3.87 mm on the nonoperative side, 3.95 mm greater than the nonoperative side ( P < .01). There was no correlation between the width or area of the fat stripe on the operative side and iHOT-12 or mHHS values at 2-year follow-up.

Conclusion:

The study findings indicated that the intergluteal fat stripe is significantly wider and has a significantly larger area in hips with abductor tears compared with unaffected hips. This did not correlate with 2-year patient-reported outcomes.

Modelling gluteus medius tendon degeneration and repair in a large animal model

INTRODUCTION

Gluteus medius tendon tears often occur in the context of chronic tendinopathy and remain a difficult clinical problem. Surgical repair is challenging as it is often delayed and performed in degenerative tendons. No animal model currently exists to mimic the delayed repair of tendinopathic gluteus medius tears. The aims of this study were to develop a chronic model of gluteus medius tendinopathy and tear and then compare this model to an acute gluteus medius tear and repair.

MATERIALS AND METHODS

Six gluteus medius muscles were dissected and examined in mature sheep to confirm anatomical similarity to the human counterpart. Ten separate adult sheep underwent tendon detachment, followed by relook and histological sampling at 6 and 16 weeks to assess the extent of tendon degeneration. Six adult sheep underwent tendon repair at 6 weeks and were later assessed for healing of the tendon and compared to a further four adult sheep who underwent an acute tendon detachment and repair procedure.

RESULTS

The sheep gluteus medius muscle consisted of three compartments, the anterior, middle and posterior. All compartments inserted via the common tendon on the superolateral aspect of the greater trochanter. At both 6 and 16 weeks, there was significant tendinopathic changes on histology compared to controls as assessed by modified Movin's score (p = 0.018, p = 0.047) but no difference between the 6- and 16-week groups (p = 0.25). There were significant differences between delayed and acute repair in both histological appearance (p = 0.025) and biomechanical properties (p = 0.019), with acute repair superior in both.

CONCLUSIONS

Tendon detachment for 6 weeks is sufficient to produce histological changes similar to chronic tendinopathy and repair of this degenerative tendon results in significantly poorer healing when compared to an acute repair model. Animal models for gluteus medius tears should use a delayed repair model to improve clinical validity.

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.

Gluteus maximus tendon transfer for chronic abductor insufficiency: the Geneva technique

INTRODUCTION

The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon.

METHODS

We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months.

RESULTS

The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported.

CONCLUSIONS

This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.

A Comparison of Outcomes After Endoscopic Repair of Partial- Versus Full-Thickness Tears of the Gluteus Medius Tendon

PURPOSE

The purpose of this study was to evaluate and compare the functional outcomes after endoscopic repair of partial or full-thickness gluteus medius tears at a minimum 2 years' follow-up.

METHODS

Patients with isolated tears of the gluteus medius tendon repaired endoscopically between 2012 and 2017 were evaluated at a minimum 2 years of follow-up. Patients with large, retracted and/or irreducible tears, advanced atrophy, or fatty degeneration or with concomitant other hip pathology were excluded. Functional outcomes were assessed using the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain preoperatively and at the last follow-up RESULTS: Forty-six patients, 3 men and 43 women with a mean (SD) age of 63 (9; range, 43-82) years, were included. Thirty-three patients (72%) had partial-thickness tears and 13 (28%) had full-thickness tears. Pain was reduced significantly from a median of 8 (IQR: 6-8) at the preoperative visit to a median of 2 (IQR: 15) at the most recent follow-up (P < .0001). The mHHS and NAHS improved significantly from a median of 44 (IQR: 35-52) to 80 (IQR: 64-87) (P < .0001) and 52 (IQR: 43-56) to 75 (IQR: 66-94) (P < .0001), respectively. These improvements were clinically relevant and surpass the reported minimal clinically important difference. Patients with partial tears had significant functional gains in the mHHS in comparison with patients with full-thickness tears (P = .02). No other statistically significant difference between groups of tear grade was observed.

CONCLUSIONS

Endoscopic repair of gluteus medius tendon tears yields excellent functional outcomes at a minimum follow-up of 2 years. A lower functional improvement for full-thickness tears was observed; this difference was statistically significant for 1 of the 2 scores evaluated.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort.

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.

Hip Abductor and Peritrochanteric Space Conditions

The hip trochanteric bursa, tendinous insertions of the gluteal muscles, and the origin vastus lateralis make up the main structures of the peritrochanteric space. Greater trochanteric pain syndrome (GTPS) refers to pain generated by one or multiple disorders of the peritrochanteric space, such as trochanteric bursitis, gluteus medius and minimus tendinopathy or tear, and disorders of the proximal iliotibial band. Patients with GTPS might present with associated intra-articular hip pathology, which requires further investigation and appropriate management. Successful midterm outcomes have been reported in patients undergoing surgical treatment of GTPS using an open or endoscopic approach.

People after gluteal tendon repair have gait characteristics which are similar to those of a healthy cohort

BACKGROUND

Gluteal-tendon repair is reported to be effective for relieving pain and improving function in patients with gluteal-tendon tears. However, post-operative three-dimensional gait analysis has never been conducted in gluteal-tendon repair patients. Thus, our primary aim was to investigate how biomechanical gait parameters differ between age- and sex-matched participants with and without gluteal-tendon repair.

METHODS

Vicon motion analysis technology was used to measure gait characteristics of 25 gluteal-tendon repair participants and 29 matched healthy comparison group participants. A generalised linear multivariate model was used to compare external hip-adduction moment, range of movement in hip adduction and internal rotation, pelvic obliquity, trunk lean, stride length and velocity of both cohorts throughout stance.

FINDINGS

There were no differences between the groups in external hip adduction moment, pelvic obliquity and range of movement in hip adduction and internal rotation. Gluteal-tendon repair participants had a shorter stride length (P = 0.031) and reduced walking velocity (P = 0.015). Ipsilateral trunk lean was reduced in gluteal-tendon repair participants at the first-peak external hip-adduction moment (P = 0.016), mid-stance minimum external hip-adduction moment (P = 0.029) and second-peak external hip-adduction moment (P = 0.006).

INTERPRETATION

There were no differences between the gluteal-tendon repair and comparison groups for external hip-adduction moment and pelvic obliquity. This suggests that gluteal-tendon repair may restore hip control in stance. Slower walking speed, reduced stride length and decreased ipsilateral trunk lean may reflect persistence of pre-operatively developed gait adaptations. Future studies of gait biomechanics before and after gluteal-tendon repair would be needed to substantiate this theory.

Clinical Outcomes After Endoscopic Repair of Gluteus Medius Tendon Tear Using a Knotless Technique With a 2-Year Minimum Follow-Up

PURPOSE

To evaluate clinical outcomes in patients who underwent endoscopic gluteus medius repair with at least 2-year follow-up.

METHODS

This was a single-center, single-surgeon retrospective study of 19 patients (20 hips) who underwent endoscopic knotless gluteus medius repair between August 2010 and August 2016 with ≥2 years of follow-up. Preoperative magnetic resonance imaging (MRI) was reviewed and graded according to the Goutallier/Fuchs classification; preoperative X-rays were reviewed and graded according to the Tonnis classification. Baseline and 2-year postoperative modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were prospectively collected. The numbers of patients reaching the minimal clinically important difference (MCID) and patient acceptable symptomatic rate (PASS) were determined.

RESULTS

Twenty hips from 19 patients met the inclusion criteria and were separated based on tear type. The study population comprised 15 (79%) females and 4 (21%) males presenting with a mean age of 51.3 ± 11.9 years and an average body mass index of 25.3 ± 3.9 kg/m². Patients with partial tears reported average preoperative mHHS and NAHS of 33.6 ± 11.3 and 40.4 ± 14.9, respectively; at 2-year follow-up, average mHHS and NAHS of 72.9 ± 22.9 and 77.2 ± 19.7 were reported. Patients with full-thickness tears reported average preoperative mHHS and NAHS of 43.8 ± 14.7 and 46.4 ± 8.3, respectively; at 2-year follow-up, average mHHS and NAHS of 80.1 ± 8.5 and 79.5 ± 10.1 were reported. There was significant clinical improvement at 2-year follow-up, relating to both outcome measures in each subject group (P < .001). At 2 years, 90% of hips surpassed MCID, and 63% of hips achieved PASS.

CONCLUSION

Endoscopic repair for gluteus medius tears results in improved mHHS and NAHS at 2 years of follow-up compared with baseline. Most patients reach critical thresholds of minimal and satisfactory clinical improvement.

LEVEL OF EVIDENCE

Level IV, case series with subgroup analysis.

Combined Transfer of the Gluteus Maximus and Tensor Fasciae Latae for Irreparable Gluteus Medius Tear Using Contemporary Techniques: Short-Term Outcomes

Combined transfer of the gluteus maximus and tensor fasciae latae (TFL) has been acknowledged as a treatment for irreparable full-thickness gluteus medius tears; yet, there is a paucity of reports on outcomes for this topic in the current literature. The purpose of the present study was to report short-term patient-reported outcome scores in patients who underwent combined transfer of the gluteus maximus and TFL in the setting of an irreparable gluteus medius tear.

METHODS

Data for patients who underwent hip preservation and hip arthroplasty between July 2011 and November 2017 were prospectively collected and retrospectively reviewed. Patients were considered for this study if they had undergone combined transfer of the gluteus maximus and TFL for irreparable gluteus medius tears. Inclusion criteria consisted of patients who had a minimum 1-year follow-up for the modified Harris hip score, Non-Arthritic Hip Score, Hip Outcome Score Sports Specific Subscale, visual analog scale score for pain, and patient satisfaction. The exclusion criterion was Workers' Compensation status.

RESULTS

The study included 18 hips in 18 patients who underwent combined transfer of the gluteus maximus and TFL, with a mean follow-up of 39.75 months (range, 12.04 to 93.88 months). The average age was 68.48 ± 11.05 years, the average body mass index was 29.54 ± 6.23 kg/m2, and 13 patients were female. Abductor strength improved in 7 of 17 patients, with abduction data unavailable for 1 patient. Significant improvements were observed in modified Harris hip score from 49.73 ± 16.85 to 74.94 ± 17.91 (p < 0.001), Non-Arthritic Hip Score from 55.02 ± 22.53 to 72.78 ± 19.17 (p = 0.032), and visual analog scale for pain from 5.42 ± 3.42 to 1.57 ± 1.68 (p = 0.0004). No secondary surgeries were reported.

CONCLUSIONS

Significant improvements in patient-reported outcomes were observed in patients who underwent combined transfer of the gluteus maximus and TFL for the treatment of irreparable full-thickness gluteus medius tears at short-term follow-up.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Endoscopic Transfer of Gluteus Maximus and Tensor Fascia Lata for Primary Hip Abductor Deficiency

Complete avulsion of hip abductor muscles may cause severe gait dysfunction and pain. An open surgical procedure to transfer tendons of the gluteus maximus and the tensor fasciae latae to the greater trochanter to make up for the deficient hip abductor has been proposed. The purpose of this study was to describe an endoscopic procedure to transfer gluteus maximus and the tensor fasciae latae to the greater trochanter for hip abductor deficiency.

Gluteus Maximus Transfer as an Augmentation Technique for Patients With Severe Abductor Deficiency of the Hip

Impaired abductor function of the hip following severe abductor deficiencies can be devastating for functionality and quality of life. Recently, gluteus maximus transfer has been proposed as a solution to these difficult problems. However, outcome results are sparse. The aim of this study was to evaluate the effects of gluteus maximus transfer on improvement of pain, disability, and quality of life in patients with severe hip abductor deficiencies. Gluteus maximus transfer was performed in 16 patients with severe disruption of the abductor muscles of the hip. Data were collected preoperatively and at 6 weeks, 3 and 6 months, and 1 to 2 years after surgery. The measurements pertained to complications, healing of the flap based on magnetic resonance imaging (MRI) findings (in 10 patients), evaluation of Trendelenburg gait and sign, and patient-reported outcome measures of pain, disability, and quality of life. Preoperatively, all patients had a positive Trendelenburg sign and reported severe pain at the level of the greater trochanter. At a mean follow-up of 20 months, the Trendelenburg sign was negative in 7 patients and the Trendelenburg gait had disappeared in 7 patients. There was an improvement in patient-reported outcome measures but not to a significant level except for the pain subscores. Two patients had a postoperative seroma that resulted in a visible bump on the lateral side. Seven of 10 repairs with MRI follow-up showed perfect ingrowth on MRI without signs of rerupture. Gluteus maximus transfer for abductor deficiency of the hip may be effective for pain relief and functional improvements. Most patients showed an improved quality of life but were not completely pain free. [Orthopedics. 2020;43(4):e299-e305.].

Equivalent Mid-Term Results of Open vs Endoscopic Gluteal Tendon Tear Repair Using Suture Anchors in Forty-Five Patients

BACKGROUND

Little is known about the relative efficacy of open (OGR) vs endoscopic (EGR) gluteal tendon repair of gluteal tendon tears in minimizing pain and restoring function. Our aim is to compare these 2 surgical techniques and quantify their impact on clinical outcomes.

METHODS

All patients undergoing gluteal tendon tear repair at our institution between 2015 and 2018 were retrospectively reviewed. Pain scores, limp, hip abduction strength, and the use of analgesics were recorded preoperatively and at last follow-up. The Hip disability and Osteoarthritis Outcome Score Junior and Harris Hip Score Section1 were obtained at last follow-up. Fatty degeneration was quantified using the Goutallier-Fuchs Classification (GFC). Statistical analysis was conducted using one-way analysis of variance and t-tests.

RESULTS

Forty-five patients (mean age 66, 87% females) met inclusion criteria. Average follow-up was 20.3 months. None of the 10 patients (22%) undergoing EGR had prior surgery. Of 35 patients (78%) undergoing OGR, 12 (27%) had prior hip replacement (75% via lateral approach). The OGRs had more patients with GFC ≥2 (50% vs 11%, P = .02) and used more anchors (P = .03). Both groups showed statistical improvement (P ≤ .01) for all outcomes measured. GFC >2 was independently associated with a worst limp and Harris Hip Score Section 1 score (P = .05). EGR had a statistically higher opioid use reduction (P < .05) than OGR. Other comparisons between EGR and OGR did not reach statistical significance.

CONCLUSION

In this series, open vs endoscopic operative approach did not impact clinical outcomes. More complex tears were treated open and with more anchors. Fatty degeneration adversely impacted outcomes. Although further evaluation of the efficacy of EGR in complex tears is indicated, both approaches can be used successfully.

Open Hip Abductor Tendon Repair into a Bone Trough: Improved Outcomes for Hip Abductor Tendon Avulsion

Hip abductor tendon tears are a well-recognized entity that results in progressive lateral hip pain, weakness, and limping. These can occur in patients with native hips or in patients following total hip arthroplasty. However, treatment of these 2 distinct groups does not differ. We describe a new repair technique utilizing a longitudinal bone trough in the greater trochanter. We compare our results (focusing on gluteus medius tendon avulsions) and traditional repair with suture anchors or transosseous bone tunnels. Additionally, we propose a classification system that attempts to describe the different types of tears to guide treatment, as the current classification system is not helpful in defining pathology or guiding treatment. Our proposed classification will help to better describe tear types anatomically and thereby guide appropriate surgical interventions based on these types.

Primary Open Abductor Reconstruction: A 5 to 10-Year Study

BACKGROUND

Gluteal tears are recognized as the source of pain over the greater trochanter. We investigated the outcome of primary open abductor tendon reconstruction with a 5-10 year follow-up.

METHODS

One hundred sixty-five consecutive hips underwent an open abductor tendon reconstruction, with all tears confirmed preoperatively by magnetic resonance imaging. Oxford Hip Scores (OHS) were assessed at the initial visit, and at 5-10 years.

RESULTS

The average preoperative OHS was 22 (range 7-34) and average postoperative OHS was 40 a difference of 18 (P < .0001).

CONCLUSION

Surgical reconstruction of degenerate abductor tendons should be considered in the presence of a magnetic resonance imaging confirmed separation where clinical findings are consistent with the known tendon disruption. Open transosseous reconstruction reliably results in good pain relief at 5-10 years.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

A Prospective 2-Year Clinical Evaluation of Augmented Hip Abductor Tendon Repair

Background:

Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome. Studies reporting surgical outcomes are often on small cohorts and with limited information on functional improvement.

Purpose:

To report the 2-year clinical and functional outcomes in a series of patients undergoing HAT repair augmented with a ligament augmentation and reconstruction system (LARS) ligament.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between October 2012 and December 2016, a total of 142 patients with symptomatic HAT tears underwent open bursectomy, V-Y lengthening, and reattachment of the tendon with suture anchors augmented with a LARS ligament. This included 132 women (93%) with a mean age of 64.3 years (range, 43-84 years), a mean body mass index of 28.2 kg/m² (range, 20.0-41.3 kg/m²), and an average duration of symptoms of 4.0 years (range, 6 months-20 years). Following surgery, patients underwent a graduated rehabilitation program consisting of hydrotherapy and land-based exercises. Patient-reported outcome measures (PROMs) were evaluated preoperatively and at 3, 6, 12, and 24 months postoperatively with the Harris Hip Score, Oxford Hip Score, 12-item Short Form Health Survey, and visual analog scale (VAS) for pain. Hip range of motion, hip abduction strength, 30-s single-leg stance (SLS), and 6-minute walk test (6MWT) capacity were evaluated. Patient satisfaction and perceived global rating of change were evaluated postsurgery. Analysis of variance was employed to evaluate clinical improvement over time.

Results:

A significant improvement (P < .05) was demonstrated up to 24 months in all PROMs and clinical scores, including hip range of motion in all planes, hip abductor strength limb symmetry indices (mean ± SD; presurgery, 90.1% ± 42.5%; 24 months, 102.6% ± 15.0%), and the 6MWT (presurgery, 421.8 ± 91.9 m; 24 months, 509.7 ± 105.1 m). Furthermore, several variables, including pain (VAS and pain scores during the 6MWT and 30-s SLS) and patient-perceived improvement (global rating of change), continued to improve from 12 to 24 months. At 24 months, 95.7% of patients were satisfied with their surgical outcome (excluding 3 patients who underwent reoperation within the 24-month period). There was a 5.6% (n = 8) failure rate over the study period.

Conclusion:

HAT repair augmented with a synthetic ligament demonstrated significantly improved clinical and functional outcomes, high levels of patient satisfaction, and a relatively low failure rate up to 24 months postsurgery.

Registration:

ACTRN12616001655437 (Australian New Zealand Clinical Trials Registry).

Acute Traumatic Tear of the Gluteus Medius and Gluteus Minimus in a Marathon Runner

Background: Tears of the gluteus medius and gluteus minimus are common causes of chronic lateral hip pain in the middle-aged population. These tears are postulated to occur after chronic degeneration of the muscle-tendon unit. The majority of these patients have a long history of peritrochanteric pain. Acute traumatic tear of the gluteus medius and gluteus minimus in otherwise asymptomatic patients is rare but can occur.

Case Report: We report the case of a 78-year-old male marathon runner with acute traumatic tear of the gluteus medius and gluteus minimus. After conservative management (physical therapy, a nonsteroidal antiinflammatory drug for pain, and cortico-steroid and local anesthetic injection) failed, the patient underwent operative repair. The surgery was successful, and the patient returned to his preinjury lifestyle 6 months postoperatively with no limitations.

Conclusion: In most cases, chronic injuries are far more common than acute tears. Because of the nonspecific and slowly progressive symptoms, patients are often misdiagnosed with radiculopathy, osteoarthritis, or trochanteric bursitis. Patients typically present to the clinic with an insidious onset of dull pain over the lateral hip. This pain is often worse when lying on the affected side. Certain gluteal-focused movements, such as climbing stairs, may exacerbate the pain. To our knowledge, our report is only the third case of acute traumatic tear of the gluteus medius and gluteus minimus reported in the literature.

Superior Gluteal Reconstruction for Severe Hip Abductor Deficiency

Abductor tendon tears are one of the common causes of recalcitrant laterally based hip pain and dysfunction. In most cases, abductor tendon tears are associated with chronic nontraumatic tearing of the gluteus medius tendon. Restoring abductor function of the hip by primary repair of the gluteus medius tendon has been reported to have good and excellent outcomes. However, primary repair might not be as effective for chronic detachment of the gluteus medius tendon with a wide separation from the femoral footprint or severe tendon loss. The lack of tendinous foot for repair and the intrinsically degenerative condition of the tendon may create high tension at the repair site thereby predisposing to surgical failure. We believe that the use of soft-tissue allograft from the Achilles tendon or human dermal allograft may help strengthen the surgical site. We describe a superior gluteal reconstruction technique that is suitable for cases with abductor tendon tear with severe tendon loss.

Hip abductor repair improves patient outcome, function, and satisfaction in patients without and with total hip arthroplasty

Purpose

Determine whether patient pain and function are similar following hip abductor repair in patients without and with total hip arthroplasty (THA).

Methods

Patients who underwent hip abductor repair were categorized as to whether they had a THA or not. Pre- and postoperative pain and Harris Hip Score (HHS) were recorded and compared between groups.

Results

There were no differences in improvement in pain level, improvement in HHS, satisfaction with surgery.

Conclusions

Hip abductor repair leads to similar pain, function, and satisfaction in patients without and with THA.

[Surgical repair of gluteus medius muscle in hip replacement surgery]

Injury of gluteus medius muscle is a serious often complication after hip replacement surgery followed by pain, claudication and significant deterioration of the quality of life. Prevention of intraoperative injury of this muscle is especially relevant in young patients. Normal function of this muscle provides rapid rehabilitation and early postoperative recovery. However, hip replacement surgery through Hardinge's direct lateral approach is accompanied by fatty degeneration of gluteus medius muscle in 12-20% of cases. Moreover, two or more redo procedures lead to fatty degeneration of almost 70% of anterior and 40% of central muscular segment. Currently, there are many methods of surgical treatment of this complication including transosseous muscle fixation, endoscopic procedures, repair using Achilles tendon, gluteus maximus muscle, lateral head of quadriceps muscle and allografts. However, various publications devoted to this problem have certain disadvantages including short follow-up period, small sample size and often unsatisfactory outcomes. Therefore, the question of surgical repair of hip abductor function remains open.

Gluteus medius avulsion in posterior hip fracture dislocation–A rare injury

A 44-year-old male presented to us with right hip pain and limb shortening following road traffic accident. He was diagnosed to have blunt abdominal injury, right hip posterior fracture dislocation, right knee dislocation with vascular injury. Though vascular repair was attempted, he ended up with an above knee amputation. Hip joint was unstable even after closed reduction and intraoperatively, gluteus medius avulsion was noted. This is the second reported case of abductor tendon avulsion in posterior hip dislocations.

Knotless "Suture Staple" Technique for Endoscopic Partial Thickness Abductor Tendon Repair

Transtendinous abductor tendon repair is a technique the authors described previously to diagnose and treat undersurface tears of the abductor tendons. In this surgical technique article, the authors describe a technique for knotless repair of undersurface tears of the abductor tendons that does not require a transtendinous split or suture passage through the abductor tendon. Because there is no suture passage through the abductor tendon or knot tying, the potential advantages include expeditious technique, compression of tendon against bony footprint, anatomic repair, and avoidance of knots facing the undersurface of the iliotibial band, which may lead to bursal irritation.

Does Greater Trochanter Decortication Affect Suture Anchor Pullout Strength in Abductor Tendon Repairs? A Biomechanical Study

BACKGROUND

Greater trochanter decortication is frequently performed at the time of abductor tendon repair to theoretically increase healing potential. No previous studies have determined the effect that greater trochanter decortication has on the pullout strength of suture anchors. Hypothesis/Purpose: The purpose of this study is to determine whether greater trochanter decortication and bone mineral density affect suture anchor pullout strength in abductor tendon repair. The authors hypothesize that both will have a significant detrimental effect on suture anchor pullout strength.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nineteen cadaveric proximal femurs with accompanying demographic data and computed tomography scans were skeletonized to expose the greater trochanter. Bone density measurements were acquired by converting Hounsfield units to T-score, based on a standardized volumetric sample in the intertrochanteric region of the femur. The gluteus medius insertion site on the lateral facet of the greater trochanter was evenly divided into 2 regions, anterior-distal and posterior-proximal, and each region was randomly assigned to receive either no decortication or 2 mm of bone decortication. A single biocomposite anchor was implanted in each region and initially tested with cyclic loading for 10 cycles at 0-50 N, 0-100 N, 0-150 N, and 0-200 N, followed by load to failure (LTF) tested at 1 mm/s. For each trial, the number of cycles endured, LTF, mechanism of failure, and stiffness were recorded.

RESULTS

Greater trochanters with no decortication and 2 mm of decortication survived a mean ± SD 35.1 ± 6.4 and 28.5 ± 10.6 cycles, respectively ( P < .01). Load to failure for nondecorticated specimens was 206.7 ± 75.0 N versus 152.3 ± 60.2 N for decorticated specimens ( P < .001). In a multivariate analysis, decortication and bone density were determinants in LTF ( P < .05).

CONCLUSION

Decortication and decreased bone mineral density significantly decreased the pullout strength of suture anchors in the lateral facet of the greater trochanter.

CLINICAL RELEVANCE

Bone density should be considered when determining whether to perform greater trochanter decortication in abductor tendon repairs.

The Effect of Platelet-Rich Fibrin Matrix at the Time of Gluteus Medius Repair: A Retrospective Comparative Study

PURPOSE

To evaluate the effect of platelet-rich fibrin matrix (PRFM) on outcomes after surgical repair of gluteus medius tendons.

METHODS

This is a retrospective review of prospectively collected data comparing patients who underwent gluteus medius repair with PRFM and patients without PRFM. Preoperative characteristics, intraoperative characteristics, and postoperative outcomes at a minimum of 1 year were recorded. Statistical analysis was performed using a multivariate analysis of variance to test for differences in continuous demographic variables and postoperative-only scores between patient groups, χ² tests were performed for categorical variables, and a repeated-measures analysis of variance was performed to test for the effects of PRFM. We also assessed for interobserver variation in grading adductor tendon tears.

RESULTS

In total, the series of gluteus medius repairs without PRFM included 29 patients (25 women and 4 men, 15 right and 4 left) with a mean age of 63.09 ± 12.0 years. The series of gluteus medius repairs with PRFM included 18 patients (16 women and 2 men, 6 right and 12 left) with a mean age of 60.26 ± 8.8 years. There were no differences in patient preoperative variables or intraoperative characteristics. Although there was a significant effect of surgical intervention on the visual analog scale for pain, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific, and modified Harris Hip Score, the use of PRFM had no significant effect on outcome. Linear models showed a significant positive effect of PRFM on only postoperative Short Form 12 Physical and International Hip Outcome Tool 12 scores.

CONCLUSIONS

PRFM augmentation does not appear to have an effect on gluteus medius tendon repair in terms of pain or clinical evidence of retears but may have a role in improving subjective outcomes of overall and hip-specific physical functioning.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical and functional outcomes after augmented hip abductor tendon repair

INTRODUCTION

Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome. Surgical studies are often reported in small cohorts and with limited information on functional improvement. This study reports the clinical and functional outcomes after HAT repair.

METHODS

112 patients with symptomatic HAT tears, diagnosed via magnetic resonance imaging, underwent open bursectomy, V-Y lengthening of the iliotibial band, debridement of the diseased tendon, decortication of the trochanteric foot-plate and reattachment of the tendon with suture anchors, augmented with a LARS ligament through a trans-osseous tunnel. Patients were evaluated pre-surgery and at 3, 6 and 12 months post-surgery using the Harris (HHS) and Oxford (OHS) Hip Scores, SF-12, hip range of motion, 6-minute walk and 30-second single leg stance tests. Maximal isometric hip abduction strength (HAS) was assessed and limb symmetry indices (LSIs) were calculated between the operated and non-operated limbs. Patient satisfaction and perceived global rating of change (GRC) was evaluated. Analysis of variance evaluated improvement over time.

RESULTS

There was a significant improvement (p<0.05) in all clinical and functional measures. HAS significantly improved over time (p<0.002) and all LSIs were >85% at 12 months. At 12 months, a mean GRC score of 3.5 (range -1 to 5) was reported, while 96% of patients were satisfied with their surgical outcome. There was a 2.7% (n = 3) failure rate at 12 months.

CONCLUSIONS

HAT reconstruction, augmented with a synthetic ligament, demonstrated significantly improved clinical and functional outcomes, high levels of patient satisfaction and a low failure rate to 12 months post-surgery.

Greater trochanteric pain syndrome and gluteus medius and minimus tendinosis: nonsurgical treatment

Greater trochanteric pain syndrome (GTPS) affects 10–25% of people in developed countries. The underlying etiology for GTPS is most commonly the tendinosis or a tendon tear of the gluteus medius, minimus or both at the greater trochanter; the inflammation of the tendon is not a major feature. We critically evaluated conservative treatment, for which we reviewed 76 publications, grading them according to four levels of evidence. We identified a wide variety of conservative treatment options: home therapy (insoles, walking sticks/crutches, orthotic devices, stretching exercises and preventive measures); physiotherapy (massage and stretching exercises); infiltrations (corticosteroids and local anesthetics); image-guided infiltrations (fluoroscopy and ultrasound); shockwave therapy; platelet-rich plasma injection; and drug therapy. Severe complications associated with infiltrations are extremely rare, as are those associated with shockwave therapy. The most effective treatments were infiltrations with corticosteroids and shockwave therapy. We propose a graded treatment schedule for patients with GTPS.

Outcomes of gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip

PURPOSE

This study aims to present 3 patients' results after undergoing gluteus maximus and tensor fascia lata (TFL) transfer for chronic abductor tears unable to be repaired primarily.

METHODS

3 patients were identified intraoperatively as having an abductor tear unable to be repaired primarily. The anterior 1/3 of the gluteus maximus and the posterior 1/3 of the TFL were mobilised and transferred to the greater trochanter in order to reproduce the normal force vector of the gluteus medius and minimus. Data was prospectively collected for changes in gait, abductor strength, and the following patient reported outcomes (PROs): modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), visual analogue scale (VAS), and satisfaction.

RESULTS

The patients were female, 63-75 years old, with BMIs of 23-28. All patients had follow-up at mean 2.1 years (1.25-2.5) with positive Trendelenburg signs preoperatively; 2 patients normalised postoperatively. For 2 patients, abductor strength improved by 2 grades postoperatively; the other patient maintained grade four. 2 patients' PROs all improved; the other patient's PROs all improved except mHHS. Postoperative VAS scores were 0, 0, 1. 2 patients reported maximum satisfaction.

CONCLUSIONS

This case series suggests that gluteus maximus and TFL transfer for irreparable abductor deficiency may be effective for pain relief, improving abductor strength, and reconstructing abductor function. Although this is a small series, it is to our knowledge the first report of clinical outcomes of this procedure.

How to address ischiofemoral impingement? Treatment algorithm and review of the literature

Ischiofemoral impingement (IFI) is a rare cause of hip pain defined by a narrowing of the space between the lateral aspect of the os ischium and the lesser trochanter of the femur. Several underlying anatomic, functional and iatrogenic pathologies have been identified for symptomatic IFI in native hip joints and after total hip arthroplasty. Clinical symptoms vary but most commonly consist of pain of the lower buttock and groin including the inner thigh, and a snapping or clunking phenomenon is often reported. Symptoms may be provoked by a combined extension, adduction and external rotation during physical examination and during long-stride walking. Radiographs of the pelvis and an axial or false-profile-view of the hip as well as magnetic resonance imaging (MRI)-scans should be obtained to strengthen the diagnosis. On MRI, the quadratus femoris muscle signal and the space confined by the anatomic structures surrounding the muscle, the quadratus femoris space, are to be assessed. Targeted infiltration of the muscle can be helpful both diagnostically and therapeutically. The literature on differential diagnoses and treatment options for IFI is limited; therapeutic suggestions are offered only in case reports and series. With this work, we aim to give a systematic approach to the non-surgical and surgical treatment options for IFI based upon the current literature and the authors' personal experience.

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

BACKGROUND

Hip abductor tendon tears are a common cause of Greater Trochanteric Pain Syndrome. Conservative treatments are often ineffective and surgical reconstruction may be recommended. This study investigated the improvement in clinical outcomes and frontal plane two-dimensional biomechanics during a 30-second single leg stance test, in patients undergoing reconstruction. We hypothesized that clinical scores and pertinent biomechanical variables would significantly improve post-surgery, and these outcomes would be significantly correlated.

METHODS

Twenty-one patients with symptomatic tendon tears underwent reconstruction. Patients were evaluated pre-surgery, and at 6 and 12months post-surgery, using patient-reported outcome measures, assessment of hip abductor strength and six-minute walk capacity. Frontal plane, two-dimensional, biomechanical variables including pelvis-on-femur angle, pelvic drop, trunk lean and lateral pelvic shift, were evaluated throughout a 30-second single leg stance test. ANOVA evaluated outcomes over time, while Pearson's correlations investigated associations between clinical scores, pain, functional and biomechanical outcome variables.

FINDINGS

While clinical and functional measures significantly improved (P<0.05) over time, no significant group differences (P>0.05) were observed in biomechanical variables from pre- to post-surgery. While five patients displayed a positive Trendelenburg sign pre-surgery, only one was positive post-surgery. Clinical outcomes and biomechanical variables during the single leg stance test were not correlated.

INTERPRETATION

Despite improvements in clinical and functional measures over time, biomechanical changes during a weight bearing single leg stance test were not significantly different following tendon repair. Follow up beyond 12months may be required, whereby symptomatic relief may precede functional and biomechanical improvement.

Abductor Reconstruction with Gluteus Maximus Transfer in Primary Abductor Deficiency during Total Hip Arthroplasty

Abductor deficiency in native hip joint may cause severe limping and pain. It is more serious situation in case of arthroplasty due to instability and recurrent dislocation. Well-known causes of abductor deficiency are repeated surgery, chronic trochanteric bursitis, superior gluteal nerve injury, failure of repair of abductor tendon insertion to the greater trochanter. Author had experienced primary abductor deficiency during total hip replacement and treated successfully with the transfer of gluteus maximus. We'd like to introduce the operation technique with the review of literature.

Results following repair of gluteus medius defects following total hip arthroplasty

13 patients with tears in the gluteus medius tendon following total hip arthroplasty were studied. The diagnosis of a gluteal tear was made on the basis of clinical signs and a positive arthrogram of the hip in all cases. 11 patients underwent gluteus medius repair and two patients declined surgery. 10 patients attended a review clinic (eight gluteal repair patients and two conservatively managed patients) and three were reviewed by telephone and medical notes. The mean follow up was 61 months (range 12-116 months). The mean age at follow up was 71.42 years (69-79 years) and the male to female ratio was 5:8. The mean duration of symptoms prior to repair was 16 months. An anterolateral transgluteal approach had been used for primary surgery in nine cases and in four cases the original surgical approach was unknown. The mean Harris Hip score prior to repair was 77.4 (range 55-87), which improved to a mean post operative Harris hip score of 86.97 (range 79-96) following repair. The Oxford hip score prior to repair was 20 (range 16-25) which improved to a mean of 14.2 after repair (range 4-29). 9 out of 11 patients who had the repair were satisfied and would recommend the procedure. We believe an accurate and timely diagnosis together with repair can reduce the morbidity associated with this post-operative complication following THA.

The management of greater trochanteric pain syndrome: A systematic literature review

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain. Most cases respond to conservative treatments with a few refractory cases requiring surgical intervention. For many years, this condition was believed to be caused by trochanteric bursitis, with treatments targeting the bursitis. More recently gluteal tendinopathy/tears have been proposed as potential causes. Treatments are consequently developing to target these proposed pathologies. At present there is no defined treatment protocol for GTPS. The purpose of this systematic literature review is to evaluate the current evidence for the effectiveness of GTPS interventions, both conservative and surgical.