Lesions of the abductors in the hip

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BACKGROUND

Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes.

METHODS

Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA.

RESULTS

The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex.

CONCLUSIONS

Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction.

LEVEL OF EVIDENCE

Level 2 (High quality prospective cohort study).

Use of Electrocautery to Facilitate Suture Passage Through the Greater Trochanter of the Femur: A Biomechanical Study

Introduction

The specific aims of this study were to evaluate (1) the axial force reduction of suture passage utilizing electrocautery when applied to the greater trochanter of the femur, (2) the temperature change caused while using electrocautery for suture passage, and (3) the failure loads and failure modes utilizing this technique.

Methods

Five matched pairs of fresh-frozen femurs were used and classified into two groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Two bicortical, osseous tunnels were made around the insertion of the gluteus medius tendon. Each specimen was sequentially tested in a needle penetration test and a single load-to-failure test. A #5 Ethibond suture with a straight needle was used.

Results

Electrocautery reduced the peak axial force for bone penetration in 40% (near cortex) and 70% (far cortex) of the trials, and no significant difference was detected between groups or between two osseous tunnels. The average peak force was significantly higher for the far cortex for both groups and for both osseous tunnels compared to the near cortex. There was no significant change in temperature of the tunnel site with electrocautery. Ninety percent of the samples experienced bone tunnel failure for the study group compared to 70% in the control group. The average ultimate failure load for the study group was lower compared with the control group, but this finding was not statistically significant (range: 6%-15%).

Conclusions

Suture passage using electrocautery may not significantly decrease the peak force needed to pass a needle directly through the greater trochanter.

Asymptomatic Gluteal Tendinosis Does Not Adversely Affect Outcomes of Primary Total Hip Arthroplasty

BACKGROUND

The aim of this study was to compare outcomes after total hip arthroplasty (THA) in patients who have preoperative asymptomatic gluteal tendinosis (aGT) to a control group with no gluteal tendinosis (GT).

METHODS

A retrospective analysis was performed using data from patients who underwent THA between March 2016 and October 2020. An aGT was diagnosed using hip magnetic resonance imaging (MRI) without clinical symptoms. Patients who had aGT were matched (1:1) to patients without GT on MRI. A total of 56 aGT hips and 56 hips without GT were found using propensity-score matching. Patient-reported outcomes, intraoperative macroscopic evaluation, outcome measurements, postoperative physical examinations, complications, and revisions were compared for both groups.

RESULTS

When compared to preoperative outcomes, both groups demonstrated significant improvements in patients-reported outcomes at the final follow-up. There were no significant differences between both groups for preoperative scores, 2-year postoperative outcome scores, or the magnitude of improvement. Patients in the aGT group were significantly less likely to obtain the MCID for the SF-36 MCS score (50.2 versus 69.3%, P = .034). However, there were no other differences in the rates of meeting the MCID between both groups. The aGT group demonstrated significantly higher rates of partial tendon degeneration of the gluteus medius muscle.

CONCLUSION

Asymptomatic gluteal tendinosis patients who have osteoarthritis and undergo THA may expect favorable patients-reported outcomes at minimum 2-year follow-up. These results were comparable with those of a control group of patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Outcomes analysis of anterior and lateral approach for open repair of hip abductor tendons

BACKGROUND

Gluteal tendons tears are increasingly being recognised as a cause of recalcitrant trochanteric pain, but there is a paucity of robust studies analysing the type of tears, results and predictors of outcome.

METHODS

Patients with gluteal tendon tears resistant to conservative treatment who underwent isolated open repair (IR) or total hip arthroplasty and concomitant repair (THA+repair) with a minimum 1-year follow-up were retrospectively assessed separately. Type of tear, surgical approach, and fixation methods were registered. Complications and postoperative outcomes were analysed: visual analogue scale (VAS) of pain, VAS satisfaction, and activity level. Univariate regressions and multivariable models were developed.

RESULTS

90 cases were included: 62 cases underwent IR and 28 cases THA+repair, with an average follow-up of 3.9 years and 2.6 years, respectively. 13 complications were found (n = 5 IR, n = 8 THA+repair), including 9 re-operations (n = 4 IR, n = 5 THA+repair). Mean VAS pain score was 3.02 (SD 2.74) for the IR and 2.32 (SD 2.43) for THA+repair group. Mean VAS satisfaction was 7.09 (SD 3.07) and 7.68 (SD 2.71) for the IR and THA+repair group, respectively. In the IR group 61.4% returned to all pre-injury activities, whereas in the THA+repair group 79% did. Full-thickness tears had higher VAS pain scores (p = 0.0175), and there was trend (p > 0.05) towards higher complications, re-tears and lower VAS satisfaction in this type of tears in both groups. No statistically significant differences were found in outcomes when comparing THA+repair through direct anterior (DAA) with lateral approach (LA).

CONCLUSIONS

Isolated gluteal tendon repair or THA+repairs seem to be safe procedures with high levels of satisfaction at short- to mid-term follow-up. The presence of a full-thickness tear is a predictor of inferior outcomes.

Good clinical outcomes, a high level of patient satisfaction and an acceptable re-operation rate are observed 7-10 years after augmented hip abductor tendon repair

PURPOSE

To investigate the clinical outcome, level of patient satisfaction, re-injury and re-operation rates of patients 7-10 years after augmented hip abductor tendon repair.

METHODS

Between October 2012 and May 2015, 146 patients were referred to the senior author with symptomatic hip abductor tendon tears, of which 110 (101 female, 92%) were included in the current study and underwent hip abductor tendon repair augmented with LARS. Patients had a mean age of 63.2 years (range 43-82), body mass index of 27.8 (range 20.0-40.2) and duration of symptoms of 3.6 years (range 6 months-18 years). Patient-reported outcome measures (PROMs) were evaluated pre-operatively and at 3, 6, 12 and 24 months, as well as 7-10 years post-operatively, including the Oxford Hip Score (OHS), 12-item Short Form Health Survey (SF-12), a Visual Analogue Pain Scale (VAS) evaluating the frequency (VAS-F) and severity (VAS-S) of hip pain, and patient satisfaction. Adverse events, surgical failures, revisions and subsequent treatments on the ipsilateral hip were reported.

RESULTS

A significant improvement (p < 0.05) was observed for all PROMs and, while a mean deterioration was observed for all PROMs from 24 months to final review (7-10 years), these were not significant (n.s.). In the 90 patients retained and assessed at final review, 93% were satisfied with their hip pain relief and 89% with their ability to participate in recreational activities. Overall, 9 (of 110, 8.2%) surgical failures were observed over the 7-10-year follow-up period.

CONCLUSIONS

Good clinical scores, a high level of patient satisfaction and an acceptable re-injury rate were observed at 7-10 years after augmented hip abductor tendon repair, demonstrating satisfactory repair longevity.

LEVEL OF EVIDENCE

IV.

Gluteal muscle fatty infiltration, fall risk, and mobility limitation in older women with urinary incontinence: a pilot study

OBJECTIVE

Gluteal muscle quality influences risk of falling and mobility limitation. We sought (1) to compare gluteal muscle fatty infiltration (FI) between groups of older women with urinary incontinence (UI) at risk for falling (at-risk group) and not at risk for falling (not-at-risk group), and (2) to determine correlation of gluteal FI with Timed Up and Go (TUG) and Short Physical Performance Battery (SPPB) performance.

MATERIALS AND METHODS

Prospective pilot study of gluteal FI on pelvis MRI for 19 women with UI, aged ≥ 70 years. A musculoskeletal radiologist selected axial T1-weighted MR images; then, two blinded medical student research assistants analyzed gluteal FI by quantitative fuzzy C-means segmentation. TUG and SPPB tests were performed. TUG ≥ 12 s defined participants as at risk for falling. Descriptive, correlation, and reliability analyses were performed.

RESULTS

Mean age, 76.3 ± 4.8 years; no difference for age or body mass index (BMI) between the at-risk (n = 5) versus not-at-risk (n = 14) groups. SPPB score (p = 0.013) was lower for the at-risk group (6.4 ± 3.1) than for the not-at-risk group (10.2 ± 1.9). Fuzzy C-means FI-%-estimate differed between the at-risk group and the not-at-risk group for bilateral gluteus medius/minimus (33.2% ± 15.6% versus 19.5% ± 4.1%, p = 0.037) and bilateral gluteus maximus (33.6% ± 15.6% versus 19.7% ± 6.9%, p = 0.047). Fuzzy C-means FI-%-estimate for bilateral gluteus maximus had significant (p < 0.050) moderate correlation with age (rho =  - 0.64), BMI (rho = 0.65), and TUG performance (rho = 0.52). Fuzzy C-means FI-%-estimates showed excellent inter-observer and intra-observer reliability (intraclass correlation coefficient, ≥ 0.892).

CONCLUSION

Older women with UI at risk for falling have greater levels of gluteal FI and mobility limitation as compared to those not at risk for falling.

Clinical and Radiological Results after Endoscopic Treatment for Gluteal Tendon Injuries with a Minimum Follow-Up of 12 Months

Objectives

The study aimed to evaluate the clinical and radiological results after endoscopic repair of gluteus medius muscle injuries and proposed an anatomical classification for the different injury classes.

Methods

A retrospective case series, including patients who had undergone endoscopic repair of the hip abductor tendon. The surgical procedure was standardized. Magnetic resonance imaging (MRI) studies were analyzed, and the injuries were classified into three types: nontransfixing partial-extension (nTPE) tear, transfixing partial-extension (TPE) tear, and transfixing full-extension (TFE) tear. TPE and TFE were considered high-grade tears. The postoperative outcomes were as follows: duration of walking aid requirement, duration of physical therapy, time to return to daily activities, modified Harris Hip score (mHHS) and Nonarthritic Hip Score (NAHS) functional scores, pain visual analog scale (VAS), satisfaction, claudication, Trendelenburg test, and reoperation.

Results

Sixteen patients were included (94% women; mean age 65 years), with a mean follow-up of 42 months (12-131, range). Out of the cases with preoperative exams available for analysis, four cases (31%) were nTPE, three (23%) TPE, and six (46%) TFE tears. Thus, 69% of the patients had high-grade injuries. These patients had a higher degree of fat infiltration (P = 0.034), but this was not correlated with inferior postoperative clinical or radiological results. One patient required reoperation due to a recurrent injury.

Conclusion

Isolated extra-articular injuries to the tendons of the gluteus medius and minimus evolved satisfactorily after endoscopic repair. Due to the small number of cases, it was not possible to observe differences in outcomes between high-and low-grade injuries.

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.

Avulsión traumática aguda del músculo glúteo medio en una paciente sin antecedente de dolor de cadera: presentación de un caso

Introducción: Se presenta el caso clínico de una mujer con avulsión aguda completa del glúteo medio en su inserción distal en el trocánter mayor, con cuadro de evolución menor de 24 horas desde la aparición del dolor peritrocantérico, en ausencia de un claro desencadenante o desgaste crónico degenerativo documentado. En la evaluación por urgencias ante la sospecha diagnóstica, se hace radiografía anteroposterior (AP) de pelvis y lateral de la cadera afectada, con posterior confirmación de hallazgospor resonancia magnética nuclear (RMN). El tratamiento se realiza mediante una técnica quirúrgica reconstructiva dentro de la primera semana de la lesión, con excelentes resultados clínicos y funcionales. Conclusión: La avulsión traumática aguda del músculo glúteo medio es una patología con una baja incidencia, lo que hace que la evidencia disponible para guiar su manejo sea escasa. Se presenta este caso clínico con la intención de exponer el abordaje clínico y diagnóstico de esta entidad y mostraruna opción de manejo con resultados satisfactorios.

Diagnosis and Treatment Options of Abductor Insufficiency After Total Hip Replacement

Abductor insufficiency can cause abnormal gait, lateral hip pain, and abduction weakness in both native and prosthetic hips. In the setting of total hip arthroplasty (THA), abductor insufficiency may occur secondary to iatrogenic injury to the superior gluteal nerve or gluteus medius muscle, adverse local tissue reactions owing to metal-associated prosthetics, and osteolysis owing to bearing wear or infection. Surgical reconstruction of the abductor complex is indicated for patients with chronic tears who have pain, weakness, limp, and/or instability. This article reviews the pearls and pitfalls of surgical reconstruction options for abductor insufficiency following THA.

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.

Asymptomatic gluteal tendinosis does not influence outcome in arthroscopic treatment of femoroacetabular impingement syndrome

PURPOSE

To compare outcomes after arthroscopy in FAIS patients with preoperative asymptomatic gluteal tendinosis (GT) to a control group with no gluteal tendinosis.

METHODS

A retrospective analysis was performed using data from FAIS patients who had arthroscopy between 2016 and 2018. Asymptomatic GT was diagnosed using hip MRI without clinical symptoms. Patients with asymptomatic GT were 1:1 propensity-score matched to patients without GT. Patient-reported outcomes (HOS-ADL, iHOT-12, mHHS), VAS scores, radiographic measures, performed procedures, complications, and revision surgery were compared and analyzed for both groups.

RESULTS

A total of 105 asymptomatic GT hips and 105 hips without GT were found using propensity-score matching. When compared to preoperative levels, both groups demonstrated significant improvements in PROs and VAS scores at the final follow-up. Besides, there were no significant differences in preoperative scores, final outcome scores, or score improvements between the groups. Patients in the GT group were significantly less likely to achieve the MCID for the VAS score (72.4% vs 83.8%, p = 0.045). However, there were no other differences in the rate of meeting the PASS and MCID between the study and the control groups.

CONCLUSION

It was demonstrated in this study that FAIS patients with asymptomatic gluteal tendinosis can expect to experience similar good short-term patients-reported outcomes as compared with patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Rehabilitation After Gluteus Medius and Minimus Treatment

We reviewed the current literature regarding rehabilitation after gluteus medius and minimus tears as part of a conservative management or postoperative protocol. The greater trochanteric pain syndrome includes a constellation of pathologies that generate pain in the greater trochanteric region and may be accompanied by varying degrees of hip abductor disfunction. It may be related to tendinitis of the gluteus medius and minimus, greater trochanteric bursitis, or even formal tears of the hip abductor tendons. The initial management strategy of the hip abductor tears is conservative, including different anti-inflammatory therapies such as physical therapy and cortisone and platelet-rich plasma injections. The clearest indication for surgical management is failure of conservative management and loss of abductor muscle power. Surgical management has been performed both open and endoscopic with good reported clinical results. More severe tears typically require a more rigid and complex type of fixation. Exorcise intervention seem to improve symptoms after 4 months to a year of therapy therefore a very close supervision of the rehabilitation protocol is mandatory. Gluteus medius and minimus tears are frequent and may be not diagnosed timely. Treatment of these of lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. Conservative management is based on protecting the hip abductor tendons from excessive tensile and compression stresses while applying progressive load in conjunction with physical and medical anti-inflammatory measures. Surgical treatment is indicated when conservative management fails or an abductor power deficit is associated with pain. Similar physical therapy protocols to those used in conservative management are used postoperatively.

Level of Evidence

Level V, expert opinion.

Short-term outcomes following mini-open repair of chronic gluteus medius tendon tears using a double-row technique

Gluteal tendon tears represent a common but underreported cause of lateral hip pain and dysfunction. In case of conservative management failure, a surgical procedure must be performed to relieve patient symptoms. Current operative treatments, either open or endoscopic, have been however associated with different drawbacks which led to the introduction of the mini-open technique. The aim of this study was to evaluate and report the short-term outcomes of patients operated through the aforementioned surgical technique for gluteus medius (GM) chronic tears. We retrospectively analysed the records of 14 consecutive patients operated at the La Tour hospital by mini-open repair using a double-row technique for full-thickness GM chronic tears. Intra- and post-operative complications were recorded. The pre- and post-operative pain on visual analogue scale (pVAS), modified Harris Hip score (mHHS), abduction strength and gait dysfunction were assessed for all patients. Pre- and post-operative values were compared to evaluate whether improvements were statistically significant and clinically relevant. The study cohort comprised 13 women (93%) and 1 man (3%) aged 62.4 ± 18.0 at index surgery. No intra- or post-operative complications were noted. Compared to pre-operative values, patients reported a significant improvement in mHHS (59.1 ± 7.1 vs 92.7 ± 4.6) and pVAS (7.4 ± 1.0 vs 1.3 ± 1.3) at last follow-up. Patients exhibited a perfect improvement in muscle strength (3.6 ± 0.5 vs 5.0 ± 0.0), and the proportion of patients with a positive Trendelenburg sign decreased from 71% to 0%. Mini-open repair of chronic GM tendon tears using a double-row technique demonstrated excellent clinical and functional outcomes at short follow-up. Level of Evidence: IV.