Endoscopic Treatment of Greater Trochanteric Pain Syndrome of the Hip

Endoscopic fascia lata release for treatment of gluteal tendinopathy: a prospective study with a follow-up of 6 months to 1 year

Greater trochanteric pain syndrome (GTPS) is clinically defined as greater trochanter pain with mechanical characteristics. The most common diagnosis is gluteal tendinopathy. Most cases of gluteal tendinopathy resolve with conservative management. In case of refractory pain endoscopic surgical treatment can resolved symptoms. This article presents a prospective study of endoscopic proximal fascia lata release associated to trochanteric bursectomy for recalcitrant trochanteric pain syndrome. 33 patients (35 hips) with refractory pain during more than six months were included. All patients were treated by endoscopic iliotibial band release and bursectomy according to Ilizaliturri. Outcomes were assessed by using Harris hip score and Womac hip score. Patients were follow-up until one year after surgery. The mean age was 53.7 years old, there was 9 men and 24 women. There were two bilateral cases in the female group. The average duration of conservative treatment was 20 months (CI95 9 to 31 months). 68% of patients were satisfied of the surgery with disappearance of pain after surgery. WOMAC and Harris hip score significantly improved after surgery until 6 months (respectively from 67 to 29 and from 40 to 76 - p<0.05). No complication was reported. Age, body mass index and duration of conservative treatment did not influence surgical results. This study showed that the endoscopic ilio tibial band (ITB) release and trochanteric bursectomy is simple, safe and easily reproductible but future prospective studies with a larger number of patients are required.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

The Gluteus Medius Tendon and Its Insertion Sites: An Anatomical Study with Possible Implications for Gluteus Medius Tears

BACKGROUND

Gluteus medius tears are a common hip disorder. Despite this, the etiology of these tears and the anatomical background of the gluteus medius tendon remain unclear. This study aimed to clarify the characteristics of the gluteus medius tendon. We hypothesized that the tendinous portions of the gluteus medius have a nonuniform structure contributing to the tear etiology.

METHODS

Twenty-five hips from 15 Japanese cadavers were analyzed. Twenty-one of the hips were analyzed macroscopically, and the other 4 were analyzed histologically. In all of the specimens, the 3-dimensional (3D) morphology of the greater trochanter was examined using microcomputed tomography (micro-CT). In 10 of the 21 hips analyzed macroscopically, the local thickness of the gluteus medius tendon, detached from the greater trochanter, was measured.

RESULTS

The posterior and anterolateral parts of the gluteus medius tendons were roughly distinguished on the basis of the aspects of the iliac origins. The posterior part of the gluteus medius tendon ran in a fan-like shape and converged onto the superoposterior facet of the greater trochanter. The anterolateral part ran posteroinferiorly toward the lateral facet of the greater trochanter. The thickness was greater in the posterior part than in the anterolateral part, and the border between these 2 parts was relatively thin compared with the other parts. The histological study showed that both the posterior and anterolateral parts inserted onto the greater trochanter via fibrocartilage.

CONCLUSIONS

The gluteus medius tendon consists of thick posterior and thin anterolateral parts, which were identified by the facet or aspect of the bone structures and thinness of their border region.

CLINICAL RELEVANCE

Our findings indicate that, given the nonuniform structure of the gluteus medius tendon, the thin anterolateral part may be more prone to tears than the thick posterior part is and tears may generally be limited to the anterolateral part.

Diagnosis, Evaluation, and Endoscopic Repair of Partial Articular Gluteus Tendon Avulsion

In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.

Application of the Goutallier/Fuchs Rotator Cuff Classification to the Evaluation of Hip Abductor Tendon Tears and the Clinical Correlation With Outcome After Repair

PURPOSE

To assess the reliability and reproducibility of the Goutallier/Fuchs classification for the evaluation of abductor tendon tears of the hip, as well as to identify the relation between preoperative tear size, abductor muscle quality, and the success of endoscopic tendon repair.

METHODS

This is a retrospective review of 30 consecutive endoscopic abductor tendon repairs performed by a single surgeon over a 2-year period. Preoperative magnetic resonance imaging scans were reviewed, and the muscle was assigned a grade according to the Goutallier/Fuchs classification. Patient-rated outcome scores--visual analog scale score, Hip Outcome Score (HOS), and modified Harris Hip Score (mHHS)--were collected preoperatively and at a minimum of 2 years postoperatively. Intraobserver and interobserver reliability for muscle grading was calculated. Postoperative outcome measures were compared with preoperative tear size, muscle grade, and repair type to assess for correlations.

RESULTS

Of the 30 hips included in the study, over 75% were classified as grade 1 (n = 15) or grade 2 (n = 8). The intraobserver reliability and interobserver reliability of the classification system averaged 0.872 and 0.916, respectively. Two patients (grades 3 and 4) had repair failure and underwent muscle transfer. In the remaining 28 hips, improvement was seen in the visual analog scale score (6.0 v 1.7, P < .0001), HOS-Activities of Daily Living subscale score (58.8 v 83.4, P < .0001), HOS-Sport-Specific subscale score (40.0 v 75.0, P < .0001), and mHHS (55.6 points v 81.1 points, P < .0001) postoperatively. Increasing preoperative fatty infiltration and atrophy correlated with increased postoperative pain levels (regression coefficient, 0.93; P < .001) and decreased postoperative HOS-Activities of Daily Living subscale scores (regression coefficient, -3.36; P = .011), HOS-Sport-Specific subscale scores (regression coefficient, -5.63; P = .016), mHHS values (regression coefficient, -3.50; P = .0008), and patient satisfaction (regression coefficient, -1.04; P < .0001). Patient age, tear size, or repair type (double v single row) did not affect postoperative outcomes.

CONCLUSIONS

The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair. Increasing preoperative muscle fatty atrophy correlates with increased patient pain and decreased patient satisfaction and functional outcomes after repair.

LEVEL OF EVIDENCE

Level IV, prognostic case series.