Platelet-Rich Plasma Injections With Needle Tenotomy for Gluteus Medius Tendinopathy: A Registry Study With Prospective Follow-up

Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis

OBJECTIVES

To systematically assess the efficacy of percutaneous ultrasound-guided needle tenotomy (PUNT) in the treatment of chronic tendinopathy and fasciopathy.

METHODS

A comprehensive literature search was performed with the following search terms: tendinopathy, tenotomy, needling, Tenex, fasciotomy, ultrasound-guided, and percutaneous. Inclusion criteria consisted of original studies evaluating pain or function improvement after PUNT. Meta-analyses investigating standard mean differences were performed to assess the pain and function improvement.

RESULTS

Thirty-five studies with 1674 participants (1876 tendons) were enrolled in this article. Of which 29 articles were included in meta-analysis and the remaining 9 articles without enough numeric data were included in descriptive analysis. PUNT significantly alleviated pain with the standard mean difference of 2.5 (95% CI: 2.0-3.0; p < 0.05), 2.2 (95% confidence interval (CI): 1.8-2.7; p < 0.05), and 3.6 (95% CI: 2.8-4.5; p < 0.05) points in short-term, intermediate-term, and long-term follow-up intervals, respectively. It was also associated with marked improvement in function with 1.4 (95% CI: 1.1-1.8; p < 0.05), 1.8 (95% CI: 1.3-2.2; p < 0.05), and 2.1 (95% CI: 1.6-2.6; p < 0.05) points, respectively in short-term, intermediate-term, and long-term follow-ups.

CONCLUSION

PUNT improved pain and function at short-term intervals with persistent results on intermediate- and long-term follow-ups. PUNT can be considered an appropriate minimally invasive treatment for chronic tendinopathy with a low rate of complications and failures.

CLINICAL RELEVANCE

Tendinopathy and fasciopathy are two common musculoskeletal complaints that can cause prolonged pain and disability. PUNT as a treatment option could improve pain intensity and function.

KEY POINTS

• The best improvement in pain and function was achieved after the first 3 months following PUNT and was continued to the intermediate- and long-term follow-ups. • No significant difference was found between different tenotomy methods in terms of pain and function improvement. • PUNT is a minimally invasive procedure with promising results and low complication rates for treatments of chronic tendinopathy.

Tips and tricks in ultrasound-guided musculoskeletal interventional procedures

Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.

Lower extremity ultrasound-guided interventions: tendon, ligament, and plantar fascia

Lower extremity tendinopathy and soft tissue injury are common clinical problems that can cause significant disability. Ultrasound-guided minimally invasive treatments using orthobiologics and image-guided percutaneous treatments continue to gain relevance with an ever-growing body of literature. We review the indications, technique, risks, and benefits according to the literature of common ultrasound-guided interventions utilized in the lower extremities.

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

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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.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

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.

Pertrochanteric Calcifications in Patients With Greater Trochanteric Pain Syndrome: Description, Prevalence, and Correlation With Intraoperatively Diagnosed Hip Abductor Tendon Injuries

BACKGROUND

Pertrochanteric calcifications can be found in patients with greater trochanteric pain syndrome (GTPS). A systematic description of the types and prevalence of these calcifications has not been undertaken. Furthermore, there is conflicting evidence regarding their association with abductor tendon injuries.

PURPOSE

(1) To describe the various types and prevalence of pertrochanteric calcifications in patients presenting for the surgical management of recalcitrant GTPS. (2) To evaluate the association of the various calcifications with intraoperatively diagnosed hip abductor tendon injuries, including tendinosis, partial-thickness tears, and full-thickness tears.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients undergoing surgical management for GTPS, in isolation or as an ancillary procedure during hip arthroscopy for femoroacetabular impingement, between April 2008 and February 2020 were included. Of these, 85 procedures were isolated treatment of GTPS and the remaining 628 were ancillary to hip arthroscopy. Radiographs were scrutinized for the presence of pertrochanteric calcifications. The hip abductor tendon status was intraoperatively classified as intact, partial-thickness tear, or full-thickness tear. The prevalence and correlation of the various radiographic findings in relation to the intraoperatively classified tendon condition were analyzed via the odds ratio (OR).

RESULTS

Surgery was performed on 713 hips with recalcitrant GTPS. No tear was found in 340 hips (47.7%), 289 hips (40.5%) had a partial-thickness tear, and 84 hips (11.8%) had a full-thickness tear. Radiographically, 102 hips (14.3%) demonstrated proximally directed enthesophytes, and 34 (4.8%) had distally directed enthesophytes. In addition, 75 hips (10.5%) had amorphous calcifications, 47 (6.6%) had isolated ossicles, and 110 (15.4%) had surface irregularities. The presence of any calcification was associated with partial-thickness tears (OR, 1.67 [95% CI, 1.21-2.21]; P = .002) and full-thickness tears (OR, 6.40 [95% CI, 3.91-10.47]; P < .001). Distally directed enthesophytes (OR, 10.18 [95% CI, 3.08-33.63]; P < .001) and proximally directed enthesophytes (OR, 8.69 [95% CI, 4.66-16.21]; P < .001) were the findings with the highest OR for the presence of any type of tear. Distally directed enthesophytes were the findings with the highest OR for a full-thickness tear (OR, 15.79 [95% CI, 7.55-33.06]; P < .001). Isolated ossicles were the findings with the highest OR for a partial-thickness tear (OR, 1.73 [95% CI, 0.96-3.13]; P = .070).

CONCLUSION

Pertrochanteric calcifications were common radiographic findings in patients with GTPS and can help guide management in these patients. Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear, and increasing size of the findings was associated with more severe tendon injuries.

Extra-spinal sciatica and sciatica mimics: a scoping review

Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are: piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome, cluneal nerve disorder, and osteitis condensans ilii. In some cases, extra-spinal sciatica may have a catastrophic course when the sciatic nerve is involved in cyclical sciatica, or the piriformis muscle in piriformis pyomyositis. In addition to cases of sciatica with clear spinal or extra-spinal origin, some cases can be a product of both origins; the same could be true for pseudo-sciatica or sciatica mimics, we simply don’t know how prevalent extra-spinal sciatica is among total sciatica cases. As treatment regimens differ for spinal, extra-spinal sciatica, and sciatica-mimics, their precise diagnosis will help physicians to make a targeted treatment plan. As published works regarding extra-spinal sciatica and sciatica mimics include only a few case reports and case series, and systematic reviews addressing them are hardly feasible at this stage, a scoping review in the field can be an eye-opener for the scientific community to do larger-scale prospective research.

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

Hip abductor tendon tears: where are we now?

Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilising the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic injury during arthroplasty and chronic degenerative tendinopathy. Ultrasound and magnetic resonance imaging have provided limited clues regarding the pattern of disease and further work is required to clarify both the macro and microscopic pattern of disease. While surgery has been attempted over the last 2 decades, the outcomes are variable and the lack of high-quality studies have limited the uptake of surgical repair. Hip abductor tendon tears share many features with rotator cuff tears, hence, innovations in surgical techniques, materials and biologics may apply to both pathologies.

Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review

OBJECTIVE

Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols.

LITERATURE SURVEY

A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018.

METHODOLOGY

After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed.

SYNTHESIS

Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection.

CONCLUSION

Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Orthobiologics for the Hip Region: A Narrative Review

Management of hip region disorders is challenging. Orthobiologic treatments including platelet rich plasma (PRP), mesenchymal stem cells, and amniotic injectables have gained popularity as promising treatments despite a lack of robust evidence for their effectiveness. We review rationale and current evidence for orthobiologics for three common hip region conditions: hip osteoarthritis, gluteal tendinopathy, and proximal hamstring tendinopathy. Overall, the current state of evidence is extremely limited for orthobiologic treatments and is predominantly relevant to PRP injections. There is currently a lack of data to support the use of mesenchymal stem cells or amniotic injectables in these conditions of the hip.

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.

Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study

Purpose

The purpose of this clinical study was to evaluate and compare the effectiveness of ultrasound (US)-guided platelet-rich plasma (PRP) injections versus US-guided corticosteroid injections (CSI) in the treatment of greater trochanteric pain syndrome (GTPS).

Methods

Between January 2015 and December 2016, 24 patients with GTPS were enrolled and randomized in two groups (A and B). Group A (study group) patients received US-guided PRP injection treatment, while group B (control group) patients received US-guided CSI treatment. Clinical outcomes in both groups were evaluated and compared using the Visual Analogue Scale (VAS) of pain, the Harris Hip Score (HHS) and the presence or absence of complications at 4, 12, and 24 weeks post-injection. The level of significance was set at p<0.05.

Results

Both groups showed improved scores (VAS and HHS) compared to the pre-injection period, but patients in group A had a statistically significant (p <0.05) decrease in VAS score and a significantly increased HHS at the last follow-up (24 weeks post-injection). No complications were reported.

Conclusions

In conclusion, patients with GTPS present better and longer-lasting clinical results when treated with US-guided PRP injections compared to those with CSI. Further studies are needed to optimize the technical preparation of PRP, the sample concentration, the number of injections and the time intervals between them, in order to achieve the maximum desired results.

Myths and Facts of In-Office Regenerative Procedures for Tendinopathy

Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common. Physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections have been the mainstay of treatment but are not optimal given that most tendon disorders seem to involve degenerative changes in addition to inflammation. The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma, stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed. This will make it possible to provide recommendations on appropriate treatment options for tendinopathy.

A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a painful condition characterised by pain around the greater trochanter usually affecting middle-aged women. The majority of patients will improve with conservative management such as physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs); however, if this fails then more invasive treatments including corticosteroid injections and surgery may be required. Platelet-rich plasma (PRP) is an autologous blood product, which has a higher concentration of growth factors postulated to provide enhanced healing and anti-inflammatory properties. There have been numerous studies on PRP's efficacy in musculoskeletal soft tissue conditions with similar pathology to GTPS, with varying results, most promising being in plantar fasciopathy and patellar tendinopathy. Corticosteroids are the established second-line treatment, but do not always work long term. PRP may be a suitable alternative to corticosteroid in GTPS with longer-term effects; however, there are very limited reports. The Hip Injections PRP Vs Placebo (HIPPO) trial aims to assess the ability of PRP to improve symptoms and function in patients with GTPS.

METHODS/DESIGN

HIPPO is a single-centre, double-blind randomized placebo-controlled study in patients with a radiologically confirmed diagnosis of gluteus medius or minimus tendinopathy with swelling within the tendon insertion with or without bursitis. We aim to randomise 102 patients with GTPS to either the PRP or placebo (normal saline injection) treatment arm. Participants will receive one ultrasound (US) guided PRP/placebo injection into the trochanteric bursa and surrounding gluteus medius/minimus tendons. The primary outcome measure is the International Hip Outcome Tool-12. Secondary outcome measures will include a visual analogue score for pain, the three-level version of the EuroQol five-dimensional questionnaire and the modified Harris Hip Score. Outcomes will be measured at baseline, 3, 6 and 12 months. Participants will have the option at 6 months to have a repeat blinded injection or cross over to PRP. Analyses of primary and secondary outcomes will be made according to the intention-to-treat principle. The trial reporting will comply with Consolidated Standards of Reporting Trials (CONSORT) guidelines.

DISCUSSION

The HIPPO study has been designed to test the hypothesis that PRP is effective in treating GTPS in patients who have failed conservative management and to assess the duration of effect of PRP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03479190 . Registered on 27 March 2018.

The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review

This review aims to determine whether platelet-rich plasma (PRP) has any role in improving clinical outcomes in patients with symptomatic greater trochanteric pain syndrome (GTPS). A search of NICE healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE and AMED databases) was conducted from their year of inception to April 2018 with the keywords: ‘greater trochanteric pain syndrome’ or ‘GTPS’ or ‘gluteus medius’ or ‘trochanteric bursitis’ and ‘platelet rich plasma’ (PRP). A quality assessment was performed using the JADAD score for RCTs and MINORS for non-RCT studies. Five full-text articles were included for analysis consisting of three RCTs and two case series. We also identified four additional studies from published conference abstracts (one RCT and three case series). The mean age in 209 patients was 58.4 years (range 48–76.2 years). The majority of patients were females and the minimum duration of symptoms was three months. Diagnosis was made using ultrasound or MRI. Included studies used a variety of outcome measures. Improvement was observed during the first 3 months after injection. Significant improvement was also noted when patients were followed up till 12 months post treatment. PRP seems a viable alternative injectable option for GTPS refractory to conservative measures. The current literature has revealed that PRP is relatively safe and can be effective. Considering the limitations in these studies, more large-sample and high-quality randomized clinical trials are required in the future to provide further evidence of the efficacy for PRP as a treatment in GTPS.

Pure bone marrow aspirate injection for chronic greater trochanteric pain syndrome: a case report

There are limited treatment options for patients with a chronic refractory greater trochanteric pain syndrome. Orthobiologic interventions may stimulate tendon healing and improve pain and function in patients who fail the standard conservative treatment. Since the US FDA's new position statement regarding the centrifugation of bone marrow aspirate products as a potentially 'more than minimally manipulated' product, there is a growing concern about the most common bone marrow aspirate concentrate technique. In this case, a 57 year old female with a debilitating chronic greater trochanteric pain syndrome was treated with a pure autologous bone marrow aspirate injection using a novel aspiration technique. The patient showed significant improvements in pain and function without recurrence at 1-year follow-up. This is the first case report to illustrate this novel technique for aspirating pure bone marrow that should comply with the new FDA regulations.

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.

Editorial Commentary: Pioneering the Gluteal Interval: Understanding and Treating Undersurface and Full-Thickness Gluteus Medius Tears of the Hip

Lateral-based hip disease is severely impairing for many patients. Treatment decision making requires a thorough understanding of the biomechanical and clinical interpretation of the physical examination. The outcomes of these under-recognized pathologies are explained with success. A recent study has described the diagnostic and surgical treatment outcomes of this impairing condition of partial and full-thickness gluteus medius tears.