Operative repair of bilateral spontaneous gluteus medius and minimus tendon ruptures. A case report

Recommendations in the rehabilitation of patients undergoing hip abductor tendon repair: a systematic literature search and evidence based rehabilitation protocol

INTRODUCTION

Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is hip abductor tendon (HAT) tears. Traditionally, these patients have been managed non-operatively, often with temporary pain relief. More recently, there has been an increase in published work presenting the results of surgical intervention. A variety of open and endoscopic transtendinous, transosseous and/or bone anchored suture surgical techniques have been reported, with and without the use of tendon augmentation for repair reinforcement. While patient outcomes have demonstrated improvements in pain, symptoms and function, post-operative rehabilitation guidelines are often vague and underreported, providing no guidance to therapists.

MATERIALS AND METHODS

A systematic search of the literature was initially undertaken to identify published clinical studies on patients undergoing HAT repair, over a 3-year period up until May 2020. Following the application of strict inclusion and exclusion criteria, studies were identified and the detail relevant to rehabilitation was synthesized and presented. Published detail was combined with the authors clinical experience, with a detailed overview of rehabilitation proposed for this patient cohort.

RESULTS

A total of 17 studies were included, reporting varied detail on components of rehabilitation including post-operative weight bearing (WB) restrictions, the initiation of passive/active hip range of motion (ROM) and resistance exercises. A detailed rehabilitation guide is proposed.

CONCLUSION

In combining the current published literature on rehabilitation after HAT repair and our own clinical experience in the surgical management and post-operative rehabilitation of these patients, we present an evidence-based, structured rehabilitation protocol to better assist surgeons and therapists in treating these patients. This rehabilitation protocol has been implemented for several years through our institutions with encouraging published clinical 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.

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.

Posttraumatic Isolated Right Gluteus Minimus Tear: A Case Report

Greater trochanteric pain syndrome (GTPS) is often diagnosed in patients who present with pain over the lateral aspect of the hip. Trauma with injury to the gluteus minimus and medius muscles results in hip pain, which should be considered when diagnosing chronic pain of the lateral hip. The gluteus minimus tendon insertion is located anterior to the anterior facet of the greater trochanter of the femur anatomically. Hence, gluteus minimus tendon pathology may also manifest as chronic lateral hip pain and is considered as the etiology of GTPS. These conditions do not respond to physiotherapy and analgesia. Both open and keyhole endoscopic methods have produced good results in addressing hip pain and abduction weakness. There is a lack of literature regarding isolated gluteus minimus tendon tear as the cause of chronic lateral hip pain or GTPS. Here, we present a rare case of a middle-aged lady with GTPS due to isolated gluteus minimus injury.

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.

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.

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.

Acute Isolated Tear of Gluteus Medius in Young Male

The hip rotator cuff tear usually develops in the middle-aged through gradual degenerative changes, similar to rotator cuff tears in the shoulder. An acute tear in the hip abductor by a traumatic event in young ages is very uncommon. The authors experienced an unusual case of an acute traumatic tear isolated to the gluteus medius in a young male; thus, we report the treatment results in this rare case with a review of the literature.

All-Endoscopic Single-Row Repair of Full-Thickness Gluteus Medius Tears

Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.

Prevalence and pattern of gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI

PURPOSE

To evaluate gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI.

METHODS

A retrospective MRI study of 185 individuals was performed. The inclusion criterion was age ≥50. Exclusion criteria were hip surgery, fracture, infection, tumor, or inadequate image quality. Greater trochanteric bursitis was graded none, mild, moderate, or severe. Gluteus medius, gluteus minimus, and iliopsoas tendinopathy was graded normal, tendinosis, low-grade partial tear, high-grade partial tear, or full thickness tear. Gluteus medius, gluteus minimus, tensor fascia lata, and iliopsoas muscle atrophy was scored using a standard scale. Insertion site of tendinopathy and location of muscle atrophy were assessed. Descriptive and statistical analysis was performed.

RESULTS

There was increasing greater trochanteric bursitis and gluteus medius and minimus tendinopathy and atrophy with advancing age with moderate to strong positive associations (p < 0.0001) for age and tendinopathy, age and atrophy, bursitis and tendinopathy, and tendinopathy and atrophy for the gluteus medius and minimus. There is a weak positive association (p < 0.0001) for age and tensor fascia lata atrophy, and no statistically significant association between age and tendinopathy or between age and atrophy for the iliopsoas. Fisher's exact tests were statistically significant (p < 0.0001) for insertion site of tendon pathology and location of muscle atrophy for the gluteus medius.

CONCLUSIONS

Gluteus medius and minimus tendon pathology and muscle atrophy increase with advancing age with progression of tendinosis to low-grade tendon tears to high-grade tendon tears. There is an associated progression in atrophy of these muscles, which may be important in fall-related hip fractures.

A review of surgical repair methods and patient outcomes for gluteal tendon tears

Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is gluteal tendon tears. Conservative measures are initially employed to treat GTPS and manage gluteal tears, though patients frequently undergo multiple courses of non-operative treatment with only temporary pain relief. Therefore, a number of surgical treatment options for recalcitrant GTPS associated with gluteal tears have been reported. These have included open trans-osseous or bone anchored suture techniques, endoscopic methods and the use of tendon augmentation for repair reinforcement. This review describes the anatomy, pathophysiology and clinical presentation of gluteal tendon tears. Surgical techniques and patient reported outcomes are presented. This review demonstrates that surgical repair can result in improved patient outcomes, irrespective of tear aetiology, and suggests that the patient with "trochanteric bursitis" should be carefully assessed as newer surgical techniques show promise for a condition that historically has been managed conservatively.

Outcomes after primary open or endoscopic abductor tendon repair in the hip: a systematic review of the literature

PURPOSE

The purpose of this study was to systematically appraise the evidence on primary open and endoscopic abductor tendon repair.

METHODS

A systematic review of the literature was performed to (1) identify the demographic undergoing abductor tendon repair, (2) summarize the overall outcomes after primary surgical abductor tendon repair, (3) identify the type of tear most commonly encountered intraoperatively, (4) summarize the repair methods used, and (5) identify the published complication and tendon retear rates.

RESULTS

A total of 8 articles were identified as eligible for inclusion. All studies were Level IV Evidence. Of the patients undergoing surgical repair, 90% were women. As assessed by a variety of outcome measures, most patients reported good to excellent functional outcomes and pain reduction after open or endoscopic repair. Intraoperatively, tears of the gluteus medius and partial-thickness tears were encountered most often. Tears involving both the gluteus medius and minimus occurred 29% of the time. Complication rates were low for both the open and endoscopic approaches. No tendon retears were documented after endoscopic repair, whereas the retear rate after open repair was 9%.

CONCLUSIONS

Patients undergoing surgical repair for partial- and full-thickness tears are mostly women. Intraoperatively, tears almost always include the gluteus medius, with concomitant tearing of the gluteus minimus in approximately one-third of cases. Both open and endoscopic techniques are viable surgical approaches to repairing abductor tendon tears in the hip that produce good to excellent functional results and reduce pain; however, endoscopic repair appears to result in fewer postoperative complications including tendon retear.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Surgical Technique for the Repair of Tears to the Gluteus Medius and Minimus Tendons of the Hip

Introduction

We describe the surgical treatment of tears to the abductor tendons of the hip, which are typically progressive and can lead to recalcitrant pain and progressive weakness, leading to considerable difficulties with walking.

Step 1 Perform the Exposure and Identify the Tear

Place the patient in the lateral decubitus position, expose the lateral peritrochanteric space, and then identify the extent of the tear.

Step 2 Mobilize the Tendons

Mobilize the typically scarred-in tendons from the surrounding tissue to allow the tendon to be brought back down to the trochanter.

Step 3 Prepare the Tendon and Greater Trochanter

Debride the tendon, and lightly burr the greater trochanter to maximize the healing of the tendon to the bone.

Step 4 Locate the Insertional Site of the Tendons and Place the Suture Anchors or Drill Holes Into This Site

Identify the area of the footprint for each of the tendons; all suture anchors should be placed in the footprint, and the transosseous drill holes should straddle the near and far edges of the footprint.

Step 5 Reattach the Tendons

After all of the sutures are placed, tie them down, starting with the pull sutures first, to bring the tendon back to bone; then secure the tendon down with the simple sutures.

Step 6 Reinforce Larger Tears

Reinforce larger tears to protect them and aid in their healing.

Step 7 Postoperative Protocol

The postoperative protocol period consists of partial weight-bearing for specific periods of time, followed by vigorous physical therapy for strengthening and gait retraining.

Results

Surgical repair can improve function and reliably decreases pain in patients with a hip abductor tear.IndicationsContraindicationsPitfalls & Challenges.

Endoscopic repair of a gluteus medius tear at the musculotendinous junction

Abductor tendon tears are an increasingly recognized clinical entity in patients with lateral thigh pain and weakness. These "rotator cuff tears of the hip" typically result from chronic, nontraumatic rupture of the anterior fibers of the gluteus medius. Although the abductor tendon typically tears from the osseous insertion, the case discussed here ruptured at the musculotendinous junction. This is the first report of this abductor tear subtype and its endoscopic repair.

[Repair of chronic ruptures of the gluteus medius muscle using a nonresorbable patch]

OBJECTIVE

Repair of a chronic rupture with a defect of the gluteus medius muscle with or without a total hip replacement. Improvement of gait and limping by functional stabilization of the pelvis. Reduction of pain in the region of the greater trochanter.

INDICATIONS

Chronic rupture with a defect of the gluteus medius.

CONTRAINDICATIONS

Complete bony defect and absence of the greater trochanter and hip infection.

OPERATIVE TECHNIQUE

Lateral positioning of the patient. Longitudinal incision of 12-15 cm over the greater trochanter. Preparation to the fascia and longitudinal incision slightly dorsal to the greater trochanter. Preparation and mobilization of the ruptured parts of the gluteal muscles. Smoothening of the insertion of the gluteal muscle. Transosseus fixation of the ventral part of the ruptured gluteal muscles using fiber wires (Arthrex, Munich, Germany) with a Mason-Allen technique. Suturing of the mobilized posterior part of the ruptured gluteal muscle on the resutured ventral gluteal part. Securing of the readaptation by suturing a nonresorbable collagen patch (Zimmer, Winterthur, Switzerland) in a rhomboid direction with nonresorbable sutures (Ethibond, Ethicon, Norderstedt, Germany). Wound closure. POSTOPERATIVE TREATMENT: Prophylaxis of deep venous thrombosis. Early functional mobilization. Continuous increase of weight bearing over a period of 6 weeks and 6 weeks no adduction or active abduction.

RESULTS

Ten patients (9 women, 1 man; age 73.4 ± 12.3 years) showed significant improvement of their symptoms after 1 year. All were pain free and did not need crutches anymore. Four could walk without any limping and in 6 slight limping was observed. The Harris Hip Score increased from 47.5 ± 9.5 points preoperative to 85.2 ± 7.6 points 1 year postoperative. Complications were not observed.

The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tears--a systematic review

Gluteal tendon tears are one of the many pathologies causing pain around the greater trochanter that are often labelled as trochanteric bursitis. We systematically reviewed the peer-reviewed literature to establish the accuracy of magnetic resonance imaging and ultrasonography in the diagnosis of gluteal tendon tears in patients with persistent lateral hip pain or Greater Trochanteric Pain Syndrome (GTPS). 7 studies met the inclusion criteria, comparing either imaging modality with a reference standard of surgical findings. Included studies were assessed for methodological quality using the QUADAS checklist. MRI had sensitivity of 33-100%, specificity of 92-100%, positive predictive value of 71-100% and negative predictive value of 50%. False-positives were common. High signal located superior to the trochanter had a stronger association with tears. Ultrasonography had a sensitivity of 79-100% and positive predictive value of 95-100%. The amount and quality of literature on the subject is limited and further well-designed studies are required to establish the optimum diagnostic strategy in this condition. Ultrasonography may prove to be the investigation of choice, despite requiring a skilled practitioner. The orthopaedic surgeon should liaise with an experienced musculoskeletal radiologist to best investigate and diagnose gluteal tendon tears in the clinical picture of GTPS.

Soft tissue pathology around the hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Abductor tendon tears of the hip: evaluation and management

The gluteus medius and minimus muscle-tendon complex is crucial for gait and stability in the hip joint. There are three clinical presentations of abductor tendon tears. Degenerative or traumatic tears of the hip abductor tendons, so-called rotator cuff tears of the hip, are seen in older patients with intractable lateral hip pain and weakness but without arthritis of the hip joint. The second type of tear may be relatively asymptomatic. It is often seen in patients undergoing arthroplasty for femoral neck fracture or elective total hip arthroplasty (THA) for osteoarthritis. The third type of abductor tendon dysfunction occurs with avulsion or failure of repair following THA performed through the anterolateral approach. Abductor tendon tear should be confirmed on MRI. When nonsurgical management is unsuccessful, open repair of the tendons with transosseous sutures is recommended. Good pain relief has been reported following endoscopic repair. Abductor tendon repair has had inconsistent results in persons with avulsion following THA. Reconstruction with a gluteus maximus muscle flap or Achilles tendon allograft has provided promising short-term results in small series.

Repair of a deficient abductor mechanism with Achilles tendon allograft after total hip replacement

BACKGROUND

Abductor mechanism insufficiency after total hip arthroplasty is a rare but debilitating problem. The diagnosis is difficult, and when the condition is recognized there are few successful treatment options. The purpose of this study was to review our experience with a surgical technique involving use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to reconstruct a deficient abductor mechanism after total hip arthroplasty.

METHODS

From 2003 to 2006, we performed seven abductor reconstructions with an Achilles tendon allograft in patients with abductor deficiency after total hip arthroplasty. At a mean of twenty-nine months after the total hip arthroplasty, all seven patients had symptoms of lateral hip pain and abductor muscle weakness as demonstrated by a Trendelenburg test. The abductor tendon rupture was diagnosed on the basis of an arthrogram and was confirmed at surgery.

RESULTS

Before the reconstruction, the average Harris hip score was 34.7 points and the average pain score was 11.4 points. After a minimum duration of follow-up of twenty-four months, the average Harris hip score was 85.9 points and the average pain score was 38.9 points.

CONCLUSIONS

Abductor reconstruction with an Achilles tendon allograft with a calcaneal bone block attached to the greater trochanter can produce substantial relief of pain, increased abductor muscle strength, decreased limp, and improvements in the Trendelenburg sign and in function at the time of early follow-up.

Surgical repair of chronic tears of the hip abductor mechanism

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn't settle and warrants further investigation and treatment. We present a series of 28 patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors. There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D'Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5 (p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

Anatomy and dimensions of the gluteus medius tendon insertion

PURPOSE

The purpose of this study was to determine the area, dimensions, and orientation of the gluteus medius footprint to provide an improved understanding of its insertional anatomy.

METHODS

Eight fresh-frozen cadaveric hips were dissected, leaving only the most distal gluteus medius tendon attached to the greater trochanter. The tendon insertion footprint and proximal femur were digitized and mapped by use of 3-dimensional computer navigation software. The area, location, and dimensions of the tendon insertion were determined.

RESULTS

The gluteus medius tendon has 2 distinct insertion sites on the greater trochanter, the lateral facet and the superoposterior facet. The mean areas of insertion onto the lateral and superoposterior facets were 438.0 mm2 (SD, 57.7 mm2) and 196.5 mm2 (SD, 48.4 mm2), respectively. The lateral facet footprint had a mean longitudinal dimension of 34.8 mm (SD, 4.3 mm), was angled at a mean of 36.8 degrees (SD, 6.7 degrees ) relative to the long axis of the femur, and had a mean minimum width of 11.2 mm (SD, 1.8 mm). The superoposterior facet's shape approximated that of a circle, with a mean diameter of 17 mm (SD, 2.0 mm).

CONCLUSIONS

The gluteus medius tendon has 2 distinct and consistent insertion sites onto the greater trochanter. This information will provide surgeons with a better understanding of the footprint anatomy when evaluating gluteus medius tendon tears.

CLINICAL RELEVANCE

Gluteus medius tendon tears can be a source of significant pain and morbidity. This study describes the anatomic morphology of this tendon insertion, which should aid in its repair when necessary.