Greater Trochanteric Pain Syndrome

Sonographic pathoanatomy of greater trochanteric pain syndrome

AIMS

To identify and highlight pertinent US features that could serve as imaging biomarkers to describe different patient phenotypes, within Great Trochanteric Pain Syndrome (GTPS) clinical diagnosis.

MATERIALS AND METHODS

Using ultrasound we evaluated eighty-eight clinically diagnosed patients with GTPS, for tendon matrix changes and calcium deposits in the gluteus medius (superoposterior and lateral aspects) and in the gluteus minimus. Peritrochanteric examination included fascia lata, trochanteric bursa, cortical irregularities and the presence of enthesophytes. The association of pathological changes with pain and functionality was evaluated using multivariate regression models.

RESULTS

Out of the 88 patients, 86 examinations (97.7%) detected gluteus medius tendinopathy, and 54 patients (61.4%) had gluteus minimus tendinopathy in addition. Calcium deposits were present in 97.7% of patients, associated with tenderness (p = 0.009), and most often located in the gluteus medius rather than in the gluteus minimus (p = 0.014); calcifications were associated with tendon thickness (p = 0.042), hypoechogenicity (p = 0.005) and the presence of partial tears (p = 0.030). Bursa swelling occurred in 36 patients (40.9%); multivariate regression models predicted less pain in patients with bursa distension (p = 0.008) and dysfunction in patients with gluteal muscle atrophy (p = 0.001) and loss of fibrillar pattern in the gluteus medius (p = 0.002).

CONCLUSION

GTPS involves both degenerative calcifying gluteal tendinopathy and alterations in the peritrochanteric space associated with physical function and pain. The severity of GTPS can be assessed using ultrasound imaging biomarkers.

Ultrasound-Guided Blockade of the Lateral Cutaneous Branch of the Iliohypogastric Nerve to Differentiate Neuropathy From Greater Trochanteric Pain Syndrome: Cadaver Study and Initial Case Series

OBJECTIVE

Neuropathy of the lateral cutaneous branch of the iliohypogastric nerve (LCBIN) may represent a differential diagnosis for greater trochanteric pain syndrome (GTPS). Ultrasound-guided neural blockade of the LCBIN may lead to diagnosis of this neuropathy. The aim of this study was to evaluate the accuracy of ultrasound-guided nerve block in cadavers and to present a first clinical case series of patients with neuropathy of the LCBIN where the workup for GTPS remained unremarkable. Ultrasound-guided nerve block led to pain relief in these patients, indicating LCBIN neuropathy.

METHODS

First, ultrasound-guided injections at the LCBIN were performed bilaterally in 24 fresh, non-frozen, non-embalmed body donors. Accuracy and nerve localization were validated by anatomic dissection. Second, a clinical case series of nine patients with suspected GTPS who underwent ultrasound-guided diagnostic LCBIN blockade was retrospectively analyzed.

RESULTS

Ultrasound-guided injections at the LCBIN yielded 91.7% accuracy (95% confidence interval: 0.80-0.98). On the right side the nerve was found within a range of 3-14 cm from the anterior superior iliac spine, and within a range of 7-15 cm on the left side. This clinical case series indicates that ultrasound-guided blockade at the LCBIN provides temporary pain relief and indicates the presence of LCBIN neuropathy.

CONCLUSION

Ultrasound has demonstrated high accuracy for localization and injection guidance in the examination of LCBIN. Ultrasound-guided injection of local anesthetics may help to identify LCBIN neuropathy as a differential diagnosis in patients with suspected GTPS.

Favorable and Durable Outcomes at 10-Year Follow-Up After Endoscopic Gluteus Medius Repair With Concomitant Hip Arthroscopy

PURPOSE

To evaluate 10-year patient-reported outcome (PRO) scores following endoscopic surgery for gluteus medius partial and full-thickness tears with concomitant hip arthroscopy for labral tears and/or femoroacetabular impingement syndrome (FAIS).

METHODS

Prospectively collected data on patients followed for a minimum of 10 years after endoscopic gluteus medius repair with concomitant hip arthroscopy performed by a single surgeon were retrospectively analyzed. Patients with preoperative and 10-year follow-up for the following PROs were included: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and Visual Analog Scale (VAS) score for pain.

RESULTS

There were 13 patients eligible for inclusion, 11 (84.6%) of whom had 10-year follow up, with a mean of 127.6 months (range: 120.0-140.2 months). The group consisted of 10 females (90.9%) and one male (9.1%) with a mean age at surgery of 60.1 years (range: 46.2-74.8 years). PRO scores improved from preoperative to 10-year follow-up as follows: mHHS from 60.4 to 88.0 (P = .011); NAHS from 50.1 to 90.6 (P < .001); HOS-SS from 37.5 to 85.1 (P = .001); and VAS from 4.8 to 1.2 (P = .006). Mean patient satisfaction rating was 8.3. Patients achieved PASS and MCID for mHHS and HOS-SSS at a rate of 81.8%. There was no significant decline in PROs or satisfaction between 2, 5, and 10 years postoperatively. All patients underwent concomitant hip arthroscopy and labral treatment (debridement or repair). One patient, who had arthroscopic findings of acetabular and femoral outerbridge grade 4 lesions, subsequently underwent total hip arthroplasty; however, the GM was assessed during the THA, and it was verified that the repair was intact. There were no clinical failures, secondary operations, or complications.

CONCLUSIONS

Endoscopic repair of gluteus medius tears is a safe procedure with favorable and durable long-term outcomes at minimum 10-year follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Endoscopic management of greater trochanteric pain syndrome (GTPS): a comprehensive systematic review

BACKGROUND

Greater trochanteric pain syndrome (GTPS) presents challenges in clinical management due to its chronic nature and uncertain etiology. Historically attributed to greater trochanteric bursitis, current understanding implicates abductor tendinopathy as the primary cause. Diagnosis usually involves a clinical examination and additional tests such as imaging and provocative testing. Surgical intervention may be considered for cases refractory to conservative therapy, with endoscopic techniques gaining ground over open procedures.

MATERIALS AND METHODS

A systematic review was conducted adhering to the PRISMA guidelines. Relevant studies were searched in four databases: Pubmed, Scopus, Embase, and Medline. The selected articles were evaluated according to the criteria of levels of evidence (LoE). The Coleman methodology score (mCMS) was used to analyze the retrospective studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews.

RESULTS

Surgical success rates ranged from 70.6-100%, significantly improving pain and function. Complications were generally mild, mainly hematomas and seromas, while recurrence rates were low. However, limitations such as the retrospective design and the absence of control groups warrant cautious interpretation of the results.

CONCLUSIONS

Endoscopic surgery emerges as a promising option for refractory GTPS, offering effective symptom relief and functional improvement. Despite limitations, these results suggest a favorable risk-benefit profile for endoscopic procedures. Further research is needed, particularly prospective randomized trials, to confirm these findings and optimize surgical techniques to improve patient outcomes.

The Morbidity of Greater Trochanteric Pain Syndrome Versus That of Patients Awaiting Total Hip Replacement

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a commonly diagnosed medical issue, yet there are little data assessing the relative morbidity of GTPS. We sought to characterize the morbidity on presentation of GTPS and compare it to that of patients with end-stage hip osteoarthritis awaiting total hip arthroplasty. We hypothesized that patients with GTPS would have morbidity similar to or worse than that of patients with osteoarthritis.

MATERIALS AND METHODS

This retrospective case-control study examined patient-reported outcome measures of 156 patients with GTPS (193 hips) and 300 patients with hip osteoarthritis before total hip arthroplasty (326 hips). Patients with secondary hip conditions or previous hip surgeries were excluded from the study. Patient-reported outcome measures were analyzed using an equivalence test and two one-sided t tests.

RESULTS

Equivalence in mean visual analog scale pain scores between GTPS and osteoarthritis was established with a tolerance margin of ±10. The difference in mean visual analog scale pain scores was 0.35 (95% CI, -0.86 to 0.16; P=.02). The Hip disability and Osteoarthritis Outcome Score Quality of Life was much worse for patients with GTPS, placed well outside of the ±10 tolerance margin, and the difference in mean scores was 1.72 (95% Cl, -2.17 to -1.26; P=.99). Equivalence in mean UCLA Activity scores between GTPS and osteoarthritis was established with a tolerance margin of ±5. The difference in mean UCLA Activity scores was 0.002 (95% CI, -0.45 to 0.43; P<.01).

CONCLUSION

The morbidity and functional limitations of patients with GTPS were similar to those of patients undergoing total hip arthroplasty. GTPS remains a functional problem for patients, and clinicians and researchers should consider GTPS as seriously as hip osteoarthritis. [Orthopedics. 2024;47(4):205-210.].

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).

Open and Endoscopic Gluteus Medius and/or Minimus Repair Achieves Clinical Success Regardless of Tear Grade: High-Grade Fatty Infiltration Portends Worse Outcomes

PURPOSE

To evaluate minimum 2-year gluteus medius and/or minimus repair clinical success rates stratified by the 3-grade magnetic resonance imaging (MRI)-based classification (MRI grade) and to evaluate clinical success rates by the surgical approach used at each MRI grade and by the Goutallier-Fuchs (GF) classification.

METHODS

A retrospective review identified patients who underwent primary endoscopic or open gluteus medius and/or minimus repair from 2012 to 2021 performed by a single surgeon. Preoperative MRI scans were classified using the MRI grade and GF classification. Patient-reported outcomes were collected preoperatively and at minimum 2-year follow-up. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was recorded. Rates of clinical success, defined as achievement of the 2-year minimal clinically important difference or patient acceptable symptom state with avoidance of revision surgery, were compared by MRI grade, by surgical approach at each MRI grade, and by GF classification.

RESULTS

A total of 112 patients (71 with MRI grade 1, 19 with grade 2, and 22 with grade 3) were included. MRI grade 1 patients underwent endoscopic repair (P < .001) more often than the other groups. The overall clinical success rate was 90%. Clinical success rates by MRI grade were 93% for grade 1, 95% for grade 2, and 77% for grade 3 (P = .087). Clinical success rates by the endoscopic and open surgical approaches used at each MRI grade were 93% versus 90% for grade 1 (P = .543), 91% versus 100% for grade 2 (P > .999), and 60% versus 92% for grade 3 (P = .135). GF grade 1 tears achieved a higher rate of clinical success than GF grade 4 tears (100% vs 71%, P = .030).

CONCLUSIONS

Primary repair of gluteus medius and/or minimus tears resulted in clinical success in most patients irrespective of MRI grade and irrespective of the surgical approach used at each MRI grade, yet GF grade 1 tears showed a significantly higher clinical success rate than GF grade 4 tears.

LEVEL OF EVIDENCE

Level IV, prognostic retrospective case series.

Parachute Technique for Dermal Allograft Augmentation in Open Gluteal Abductor Repair

Retracted full-thickness tears of the gluteus medius tendon are a well-recognized cause of disabling weakness and pain that significantly impact patients' quality of life. We present an efficient knotless parachute technique for dermal allograft augmentation in open gluteal abductor tendon repairs. Our technique reinforces the suture-tendon interface by incorporating a robust biological scaffold into a knotless double-row fixation. This approach capitalizes on the increased pressure and contact area achieved between the greater trochanter and the dermal allograft/gluteus medius tendon construct without the prominence of knotted sutures.

Three-dimensional Volumetric Visceral and Subcutaneous Fat Analysis on Opportunistic Computed Tomography Imaging of Patients With Greater Trochanteric Pain Syndrome Compared With Those With Predominant Osteoarthritis: A Case-Control Study

OBJECTIVE

This study aimed to address the gap in knowledge assessing the impact of visceral and subcutaneous body fat on 3-dimensional computed tomography imaging in patients with greater trochanteric pain syndrome (GTPS) in comparison with those primarily diagnosed with osteoarthritis (OA).

MATERIALS AND METHODS

We evaluated adult patients with a confirmed diagnosis of GTPS from our institutional hip-preservation clinic spanning 2011 to 2022. Selection criteria included their initial clinic visit for hip pain and a concurrent pelvis computed tomography scan. These patients were age- and sex-matched to mild-moderate OA patients selected randomly from the database. Visceral and subcutaneous fat areas were measured volumetrically from the sacroiliac joint to the lesser trochanter using an independent software. Interreader reliability was also calculated.

RESULTS

A total of 93 patients met the study criteria, of which 37 belonged to the GTPS group and 56 belonged to the OA group. Both groups were sex and race matched. Average age in GTPS and OA groups was 59.3 years and 56 years, respectively. For GTPS group, average body mass index was 28.9 kg/m 2 , and for the OA group, average body mass index was 29.9 kg/m 2 , with no significant difference ( P > 0.05). Two-sample t test showed no significant differences in the visceral fat, subcutaneous fat, or the visceral fat to total fat volume ratio between the GTPS and OA groups. There was excellent interreader reliability.

CONCLUSIONS

Our results indicate that there is no significant difference in fat distribution and volumes among GTPS and OA patients. This suggests that being overweight or obese may not be directly linked or contribute to the onset of GTPS. Other factors, such as gluteal tendinopathy, bursitis, or iliotibial band syndrome, might be responsible and need further investigation.

Gluteus Maximus Transfer for Irreparable Hip Abductor Deficiency: A Systematic Review and Meta-Analysis

BACKGROUND

Gluteus maximus tendon transfer has recently been described as a treatment option for irreparable abductor tendon tears. The purpose of this study was to systematically review outcomes following gluteus maximus tendon transfer for hip abductor deficiency.

METHODS

The published literature was queried for outcomes following gluteus maximus transfer in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes of interest included preoperative and postoperative functional scores, resolution of pain and gait abnormalities, postoperative rehabilitation protocols, surgical complications, reoperation rates, and postoperative magnetic resonance imaging. In total, 10 studies with a total of 125 patients (76% women) with a mean age of 67 years (range, 30 to 87) were identified for inclusion.

RESULTS

Modified Harris Hip Score (+30.1 ± 6.6 [95% confidence interval: +15.5 to +46.5]) and Visual Analog Scale for pain (-4.1 ± 1.1 [95% confidence interval: -7.1 to -1.0]) were improved following gluteus maximus transfer, compared to preoperative levels. No significant improvement was noted in abduction strength and 33% of patients demonstrated a residual Trendelenburg gait postoperatively. The overall complication rate was 5.6% (7 of 125), with a reoperation rate of 1.6% (2 of 125).

CONCLUSIONS

Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. However, patients demonstrate modest improvements in abduction strength, and a significant subset will continue to demonstrate a Trendelenburg gait postoperatively.

Unrepaired Trochanteric Bursae as a Risk Factor for Deep Gluteal Syndrome After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial

BACKGROUND

The trochanteric bursae are often left unrepaired after total hip arthroplasty (THA) and they retract posteriorly over the muscle belly of the piriformis. Deep gluteal syndrome (DGS) is a multifactorial condition presenting as buttock pain and is attributed to nondiscogenic sciatic nerve irritation or impingement causes. The purpose of this study was to investigate the relationship between bursal repair and incidence of DGS in patients undergoing THA.

METHODS

This prospective randomized trial included patients treated with a THA between January and December 2022 for a diagnosis of primary osteoarthritis. Patients were randomized into 2 groups: group 1 underwent a routine bursal repair, while group 2 did not, leaving the bursae unrepaired. Follow-up was performed on the 15th, 30th, and 90th day postoperatively with clinical scores, physical examinations, and laboratory tests. In this cohort of 104 patients, mean age was 55 years (range, 26 to 88). Demographic variables as well as range of motion and overall clinical results showed no significant difference between the groups.

RESULTS

DGS rates were significantly more common in the patients who had an unrepaired bursa (group 2) both on the 30th and 90th postoperative days, while comparison of lateral trochanteric pain on palpation showed similar results between the groups.

CONCLUSIONS

DGS is common in individuals who have unrepaired trochanteric bursal tissue following a THA. Despite its higher frequency, these symptoms did not have a substantial impact on the overall clinical scores, which remained consistent across the study groups.

Gluteus maximus tendon transfer as a salvage option for painful chronic hip abductor insufficiency: clinical and MRI results with a minimum follow-up of 24 months

INTRODUCTION

Chronic hip abductor insufficiency is a rare debilitating condition. In cases refractory to conservative treatment and not amenable to direct repair an augmentation becomes necessary. The preferred salvage method at our institution is augmentation with the anterior third of the gluteus maximus tendon. The aim of this study is to describe the results of 8 patients, treated for painful chronic hip abductor insufficiency with gluteus maximus muscle transfer, after a minimal follow-up of 24 months including a full clinical and MRI evaluation of the hip abductors pre- and postoperatively.

METHODS

We retrospectively reviewed a consecutive series of 8 patients who were surgically managed for painful chronic hip abductor insufficiency. All patients had a Trendelenburg sign, impaired muscle strength (M ⩽ 3) as well as a complete avulsion of the hip abductors with marked fatty degeneration (⩾3). Pain levels, muscle strength, functional scores as well as a postoperative MRI was obtained after a minimal follow-up of 24 months.

RESULTS

The mean age of the patients was 69 years, mean follow-up was 35 (26-54) months. Pain was significantly reduced postoperatively to VAS 2.5 from VAS 5 (p = 0.046). Trendelenburg sign remained positive in all patients and hip abductor strength did not improve significantly from 2.4 to 3.1 (p = 0.19). Complete healing of the transferred tendon was confirmed by MRI in all patients at last follow-up.

CONCLUSIONS

In the setting of painful chronic hip abductor insufficiency refractory to conservative treatment with advanced muscle degeneration without the possibility of a direct reconstruction the gluteus maximus tendon transfer significantly decreased pain. The effect on hip abductor strength and patient-reported functional outcome scores is limited. Despite the modest results it remains our preferred salvage treatment option for lack of better alternatives. Larger studies are necessary to confirm these findings.

Treatment of Greater Trochanteric Pain Syndrome With Ultrasound-Guided Bipolar Pulsed Radiofrequency of the Trochanteric Branches of the Femoral Nerve: A Case Series of Nine Patients

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a prevalent cause of lateral hip pain that often leads to significant functional limitations. Conservative treatment options include physical therapy, pharmacological treatment, and more invasive techniques such as corticosteroid injections. However, despite the high success rates reported with corticosteroid injections, a significant number of patients have their symptoms persist or recur.

OBJECTIVES

In this case series, we present the outcomes of nine patients with GTPS who underwent ultrasound-guided bipolar pulsed radiofrequency targeting the trochanteric branches of the femoral nerve. We aim to discuss the effectiveness and safety of this approach.

MATERIAL AND METHODS

Eligible patients referred to our centre underwent ultrasound-guided bipolar pulsed radiofrequency aimed at the trochanteric branches of the femoral nerve. The procedure consisted of one cycle at 42°C for six minutes, followed by the injection of ropivacaine (0.2%, 3 mL) and dexamethasone (12 mg). The Brief Pain Inventory - Short Form (BPI-sf) and Lequesne Algofunctional Index (LAI) were used before the procedure and at the third and sixth months post-procedure. We monitored immediate and late complications, as well as adverse effects.

RESULTS AND DISCUSSION

Our results indicate a favourable outcome for most patients, with an average pain reduction of 76.51% according to their report of the BPI-sf. Additionally, eight out of nine patients experienced at least 50% relief. These findings align with a previous case series, which reported a similar average pain reduction. Before the procedure, most patients were classified as "extremely severe" in the LAI, with an average score of 18.17. Although there was only a slight reduction of 16.84% at the six-month follow-up, this suggests a potential improvement in their functional status. We did not observe any immediate complications or adverse effects after the procedure, nor were any reported at the subsequent follow-ups, which is consistent with existing literature.

CONCLUSIONS

Our study suggests that ultrasound-guided bipolar pulsed radiofrequency treatment is a promising minimally invasive technique for GPTS, especially for patients who do not respond to conservative treatments. Although our case series provides some evidence of effectiveness and safety, further controlled studies on a larger scale are necessary, particularly to compare this intervention with the use of corticosteroid injections alone.

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.

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

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

Snapping Hip Syndrome: Pathoanatomy, Diagnosis, Nonoperative Therapy, and Current Concepts in Operative Management

» Asymptomatic snapping hip affects 5% to 10% of the population; when pain becomes the primary symptom, it is classified as snapping hip syndrome (SHS).» The snap can be felt on the lateral side of the hip (external snapping hip), often attributed to an iliotibial band interaction with the greater trochanter, or on the medial side (internal snapping hip), often attributed to the iliopsoas tendon snapping on the lesser trochanter.» History and physical examination maneuvers can help distinguish the etiology, and imaging may help confirm diagnosis and rule out other pathologies.» A nonoperative strategy is used initially; in the event of failure, several surgical procedures are discussed in this review along with their pertinent analyses and key points.» Both open and arthroscopic procedures are based on the lengthening of the snapping structures. While open and endoscopic procedures both treat external SHS, endoscopic procedures typically have lower complication rates and better outcomes when treating internal SHS. This distinction does not appear to be as noticeable in the external SHS.

Editorial Commentary: Treatment of Concomitant Intra-Articular Pathology in Patients With Greater Trochanteric Pain Syndrome Is Indicated by Provocative Impingement or Instability Physical Examination and Ultrasound-Guided Analgesic Injection Testing

Endoscopic surgery can be used to address peritrochanteric pathology in patients with greater trochanteric pain syndrome. During management of these patients, surgeons must decide whether adjunctive hip arthroscopy to treat concomitant intra-articular pathology (such as labral tears or chondral lesions) is required, because the prevalence of intra-articular findings may be greater than the clinical significance. A thorough history and physical examination can help distinguish whether the symptoms are arising from a peritrochanteric issue (e.g., gluteal tendinopathy, trochanteric bursitis, external coxa saltans) versus an intra-articular pain generator. Increased symptoms with provocative impingement or instability testing indicate adjunctive hip arthroscopy to address intra-articular abnormalities. In addition, an ultrasound-guided analgesic injection into the hip joint or peritrochanteric region may aid in diagnosis. A patient with partial symptomatic relief from separate injections into both areas is a classic presentation and consistent with a mixed-picture of peritrochanteric and intra-articular pathology, which may be addressed with a combined endoscopic and arthroscopic approach.

Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review

PURPOSE

The primary purpose of this study was to systematically review the literature on intraoperative findings during endoscopic treatment for greater trochanteric pain syndrome (GTPS). Secondary outcomes were preoperative imaging findings and postoperative functional outcome measures.

METHODS

Medline, PubMED, and Embase databases were searched from inception (1946, 1966, and 1974, respectively), to July 15, 2021, for records reporting intraoperative findings during endoscopic surgery for GTPS. Studies of Level I-IV evidence were eligible. All studies were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) score.

RESULTS

Sixteen studies met the inclusion criteria. Most patients underwent endoscopic greater trochanteric bursectomy with repair of the gluteal tendons. Intraoperative conditions reported were gluteal tendon tears usually involving the gluteus medius tendon, labral tears, and chondral lesions. Three studies reported an average of 9% of patients who subsequently underwent conversion to total hip arthroplasty. Pain was assessed using the visual analog scale, and functional outcome measures were measured using the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score Sport-Specific subscale, Hip Outcome Score Activities of Daily Living subscale, and iHOT-12. Pain and functional outcomes demonstrated significant improvement in nearly all the studies where they were reported.

CONCLUSIONS

Patients who underwent endoscopic management of GTPS commonly underwent repair of gluteal tendon tears, and in many cases had concomitant labral tears and chondral lesions identified intraoperatively. There were low rates of adverse events, repair failure, and revision surgery. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively.

LEVEL OF EVIDENCE

IV, systematic review of level IV or better investigations.

The effect of iliotibial band surgery at the hip: a systematic review

BACKGROUND

Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases.

PURPOSE

The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery.

METHODS

The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed.

RESULTS

A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery.

CONCLUSION

ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

Sacroiliitis: A Review on Anatomy, Diagnosis, and Treatment

Introduction

Sacroiliitis is an inflammation of one or both of the sacroiliac (SI) joints, most often resulting pain in the lower back that can extend down the legs. Pain arising from the SI joint can be difficult to diagnose and treat due to the intricate surrounding ligamentous structure, nerve innervation, and its role in transferring weight from the upper body to the lower limbs. SI joint dysfunction accounts for up to 25% of cases of lower back pain and has a debilitating effect on patient functionality. This review aims to provide comprehensive coverage of all aspects of SI joint pain, with a specific focus on differential diagnosis and treatment.

Methods

Current literature on SI joint pain and inflammation, other etiologies of lower back pain, and new treatment options were compiled using the databases PubMed and Cochrane and used to write this comprehensive review. There were no restrictions when conducting the literature search with regard to publication date, study language, or study type.

Results

The diagnosis protocol of SI joint pain arising from sacroiliitis usually begins with the presentation of lower back pain and confirmatory diagnostic testing through fluoroscopy joint block. Reduction in pain following the anesthetic is considered the golden standard for diagnosis. The treatment begins with the conservative approach of physical therapy and analgesics for symptom relief. However, refractory cases often require interventional methods such as corticosteroid injections, prolotherapy, radiofrequency ablation, and even SI joint fusion surgery.

Conclusion

SI joint pain is a complex problem that can present with varying patterns of pain due to uncertainty regarding its innervation and its prominent surrounding structure. It is therefore especially important to obtain a thorough history and physical on top of diagnostic tests such as a diagnostic block to properly identify the source of pain. Conservative treatment options with physical therapy and analgesics should be attempted first before interventional strategies such as ablation, injections, and prolotherapy can be considered. SI joint fusion surgery is a solution to cases in which previous methods do not provide significant relief.

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

»

Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years.

»

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

»

Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies.

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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.

"I feel I have been taken seriously" Women's experience of greater trochanteric pain syndrome treatment-A nested qualitative study

BACKGROUND

Women experiencing greater trochanteric pain syndrome (GTPS) report high levels of pain and reduced quality of life. Exploring how they manage GTPS in a daily life context can provide important knowledge about individual coping strategies. Education, extracorporeal shockwave therapy (ESWT) and exercise have good group level evidence for efficacy in clinical trials and are increasingly used in routine care for patients with GTPS. Exploring women's experiences of such treatment may help understand the mechanisms underpinning these positive results and inform treatment strategies. We therefore aimed to explore how women with GTPS experience and manage their daily life, and their experience of the combined treatment of education, ESWT and exercises.

METHODS

This qualitative study was nested within a cohort study based in a hospital outpatient clinic and a physiotherapy clinic in Denmark assessing the combined treatment of education, ESWT and exercises. Data was collected from eleven women using in-person, individual, semi-structured interviews which were audio recorded. Transcripts were coded and analysed using an inductive thematic analysis approach.

FINDINGS

Five themes were identified: (1) Daily life was controlled and structured by pain; (2) The condition was acknowledged and taken seriously by treating professionals; (3) The participants´ experiences of the intervention-information is key; (4) Improved capability and autonomy in pain management and (5) The women´s perspectives on improving and expanding the intervention. Learning how to manage pain was experienced as the most important element of the program to the women to be able to minimize pain and manage daily life.

CONCLUSION

Exploration of how women with greater trochanteric pain syndrome experienced and managed daily hip pain, and how they experienced and adapted to treatment are important novel findings that will inform clinical practice. This new knowledge may be used to inform an individualized patient education, treatment and evaluation strategy for women with the painful and debilitating condition of GTPS.

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.

Peripheral enthesitis assessed by whole-body MRI in axial spondyloarthritis: Distribution and diagnostic value

Objective

To determine the distribution and diagnostic value of peripheral enthesitis detected by whole-body MRI (WBMRI) in axial spondyloarthritis (axSpA) diagnosis, and to determine the value of the peripheral enthesitis score in axSpA assessment.

Methods

Sixty axSpA patients [mean age of 33.2 (24.8–40.6) years] and 50 controls with chronic low back pain (LBP) [mean age of 34.7 (28.3–41.1) years] were enrolled. The gold standard was physician’s comprehensive diagnosis based on current classification criteria and physical examination. All subjects underwent WBMRI, and 47 peripheral entheses were assessed for each patient with scores of 0–188.

Results

WBMRI identified 155 enthesitis sites in 78.3% (n = 47) patients with axSpA. Meanwhile, 23 enthesitis sites were identified in 32% (n = 16) controls. The pelvis had the maximum number of enthesitis sites (52, 33.5%) in axSpA patients. Pelvic and anterior chest wall enthesitis had the highest sensitivity (51.67%) and specificity (100%) in axSpA diagnosis, respectively. There were different manifestations of enthesitis subtypes between axSpA patients and the control group. Osteitis was more present than soft-tissue inflammation in axSpA patients. The AUC for the number of enthesitis sites was 0.819 (95% CI 0.739–0.899), and that for the enthesitis score was 0.833 (95% CI 0.755–0.910), indicating statistically significant differences (P = 0.025). Based on the Youden index and clinical need, three enthesitis sites (sensitivity of 53.33, specificity of 98, and Youden index of 0.51) and enthesitis score (sensitivity of 58.33, specificity of 98, and Youden index of 0.56) may have the greatest value for axSpA diagnosis.

Conclusion

The distribution of peripheral enthesitis can be adequately assessed by whole-body MRI, which could help diagnose axial spondyloarthritis. The enthesitis score may provide a more accurate assessment and diagnostic tool in axSpA compared with enthesitis site counting.

Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State After Endoscopic Gluteus Medius or Minimus Repair With or Without Labral Treatment and Routine Capsular Closure at Minimum 5-Year Follow-up

BACKGROUND

There is a paucity of information in the literature on midterm outcomes of endoscopic gluteus medius and/or minimus repair with concomitant labral treatment using only modern surgical techniques.

PURPOSE

To define the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) at a minimum of 5 years postoperatively for patients undergoing endoscopic hip abductor repair with routine capsular closure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients who underwent primary endoscopic repair of gluteus medius and/or minimus tears between January 2012 and December 2015 by the senior author were eligible for inclusion. Patient-reported outcome scores were assessed preoperatively and at 5 years postoperatively: Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The MCID was uniquely calculated using the distribution method, and the PASS was determined via the anchor-based method utilizing receiver operating characteristic curves and Youden index.

RESULTS

A total of 46 patients were included in the study. The majority were female (87.0%), with a mean ± standard deviation age of 59.1 ± 8.9 years and body mass index of 27.3 ± 6.9. Significant postoperative improvements (P < .001) in each of the 5 patient-reported outcomes were observed at 5 years postoperatively. The MCID threshold values were calculated as follows: HOS-ADL, 11.5; HOS-SS, 15.1; mHHS, 13.3; iHOT-12, 11.8; and VAS, 15.8. The PASS thresholds were calculated as follows: HOS-ADL, 75.7; HOS-SS, 79.7; mHHS, 81.2; and iHOT-12, 60.8. A majority of patients achieved a clinically significant outcome, with 96.2% of patients reaching a threshold score for the MCID or PASS for at least 1 patient-reported outcome.

CONCLUSION

Endoscopic hip abductor repair with concomitant arthroscopic labral treatment has a high rate of achievement of clinically significant outcomes and survivorship at a minimum 5-year follow-up. We defined the MCID for the HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcome scores to be 11.5, 15.1, 13.3, 11.8, and 15.8, respectively. The PASS threshold scores for the HOS-ADL, HOS-SS, mHHS and iHOT-12 scores of 75.7, 79.7, 81.2, and 60.8, respectively. Future researchers and clinicians can use the MCID and PASS values established in this study to better evaluate mid-term outcomes of patients undergoing hip abductor repair.

¿Conoce la semiología de la Cadera?

La necesidad de mejorar las competencias de los futuros profesionales en salud ha conducido a repensar la manera como se imparten los conocimientos a los estudiantes y de cómo ellos podrían aprender de manera significativa. Actualmente, el aula invertida (AI) o flipped classroom (FC) se convierte en una estrategia de enseñanza alternativa en el campo de la educación en salud. Incentiva el aprendizaje del estudiante al promover la autonomía en el abordaje de los conocimientos antes de cada clase, favorece la motivación, el aprendizaje activo, colaborativo y significativo durante las sesiones presenciales, de tal manera que permite desarrollar el pensamiento crítico para una formación profesional idónea. Al realizar una revisión de la literatura se evidenció un amplio uso del AI en educación en salud con resultados positivos frente a la educación tradicional. Además, las tecnologías juegan un papel importante para presentar contenidos y ejecutar actividades fuera y dentro del aula. Se presentan algunas evidencias de la efectividad del AI en educación médica, cómo podría implementarse en nuestras aulas y la diversidad de recursos disponibles para usar en los diferentes escenarios que plantea esta estrategia.

Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.

PURPOSE

To clarify the relationship between FI and surgical outcomes for hip abductor tears.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.

RESULTS

A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score (P > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair (P > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005).

CONCLUSION

Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.

Prevalence of Contralateral Hip Abductor Tears and Factors Associated With Symptomatic Progression

BACKGROUND

Patients with gluteus medius tendinopathy present with laterally based hip pain that can be diagnosed under the greater trochanteric pain syndrome diagnosis. Magnetic resonance imaging (MRI) can assist in diagnosing pathology of the symptomatic hip, and when a pelvic MRI that includes both hips, the clinician may identify asymptomatic tears in the nonsurgical hip. In patients who undergo unilateral gluteus medius repairs, little is known about the prevalence or subsequent onset of clinical symptoms in the nonsurgical hip.

PURPOSE

To describe (1) the prevalence of asymptomatic contralateral gluteus medius tears in patients with unilateral symptoms, (2) the presentation and time before symptom onset, and (3) the morphological characteristics on MRI of future symptomatic tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 51 consecutive patients who underwent gluteus medius tear surgery were reviewed for contralateral hip pathology; of these, 43 patients were 2 years out from index surgery with reviewable preoperative MRI scans. A musculoskeletal radiologist reviewed the MRI scans for tear size, tendon retraction, and fatty infiltration using the Goutallier-Fuchs grading system. Medical record review identified contralateral hips requiring subsequent treatment.

RESULTS

Of the original 43 patients, 10 (23%) had no contralateral tear, 19 (44%) had low-grade partial tears, 9 (20%) had high-grade partial tears, and 5 (11%) had full-thickness tears. Thirty-seven patients had unilateral symptoms; the other 6 had mild contralateral hip pain at enrollment. Of the 37 patients with unilateral symptoms, 27 (73%) had a contralateral tear; of those, 10 became symptomatic at an average of 24 months after index presentation (range, 6-50 months). In patients with symptomatic progression, 7 had low-grade partial tears, 1 had a high-grade partial tear, and 2 had full-thickness tears, with an average retraction of 17 mm. Tendon tear grade on MRI did not always correlate with symptoms or future presentation. All symptomatic progression remained mild to moderate. Seven patients required a corticosteroid injection, and none needed contralateral hip surgery within 2 years.

CONCLUSION

Of patients who underwent surgery for a gluteus medius tear, 73% (27/37) had an incidental MRI-confirmed contralateral hip abductor tear. Of these, 37% (10/27) developed symptoms consistent with greater trochanteric pain syndrome during the 2-year study period.

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.

Tendinopatias do quadril: Uma atualização de conceitos e abordagens

The present update was based on new scientific evidence of major hip-related tendinopathies. Themes were addressed that involve the principles of the onset of tendinopathies through, mainly, the principle of capacity versus demand and the biomechanical aspects involved in its onset, its main characteristics, and clinical presentations. Associated with this, treatment-related updates were presented, with exercise therapy being the focus of conservative treatment and surgical approaches necessary for the control or resolution of these cases.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Superior Gluteal Reconstruction Results in Promising Outcomes for Massive Abductor Tendon Tears

Purpose

To evaluate the 1-year outcomes of a small patient series following open gluteus medius/minimus repair with human dermal allograft incorporated into the repair construct using a double-row repair.

Methods

Data from consecutive patients undergoing a superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy by a single fellowship trained surgeon from January 2018 to May 2019 were collected and analyzed. Baseline demographic data and magnetic resonance imaging were collected preoperatively. Clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Score-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were recorded at 1-year postoperatively.

Results

A total of 8 patients underwent open superior gluteal reconstruction for severe hip abductor deficiency. The mean age and body mass index were 62.6 ± 7.3 years and 29.6 ± 5.3 kg/m², respectively. The majority of patients were female (N = 7, 87.5%). Three (37.5%) patients had undergone previous endoscopic gluteus medius repair and presented for revision surgery. All patients had full-thickness tears with gluteus medius and gluteus minimus involvement. Patients were evaluated at an average of 11.5 ± 1.7 months from the initial surgical intervention and reported a mean HOS-ADL of 82.9 ± 24.3, HOS-SS of 73.2 ± 37.3, mHHS of 83.6 ± 17.1, iHOT-12 of 63.9 ± 27.4, VAS Pain of 30.0 ± 23.1, and VAS Satisfaction of 87.1 ± 17.0. There was no evidence of retears in this patient cohort as defined by physical examination findings and/or corroborating magnetic resonance imaging.

Conclusions

Superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy is a technique that demonstrates promising 1-year postoperative outcomes in both primary and revision patients.

Level of Evidence

Level IV, therapeutic case series.

Platelet-rich plasma versus steroids injections for greater trochanter pain syndrome: a systematic review and meta-analysis

INTRODUCTION

Greater trochanter pain syndrome (GTPS) is characterized by a persistent and debilitating pain around the greater trochanter. GTPS can be caused by a combination of gluteus medius or minimus tendinopathy, snapping hip or trochanteric bursitis.

SOURCE OF DATA

Recent published literatures identified from PubMed, EMBASE, Google Scholar, Scopus.

AREAS OF AGREEMENT

Platelet rich plasma (PRP) and corticosteroids (CCS) injections are useful options to manage symptoms of GTPS.

AREAS OF CONTROVERSY

Whether PRP leads to superior outcomes compared to CCS injections is unclear.

GROWING POINTS

A systematic review and meta-analysis comparing PRP versus CCS in the management of GTPS was conducted.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP injections are more effective than CCS at approximately 2 years follow-up.

Greater trochanteric pain syndrome in women: Analysis of magnetic resonance, sagittal alignment, muscular strength and endurance of the hip and trunk

INTRODUCTION

There are many studies on the Greater Trochanteric Pain Syndrome (GTPS), however its relationship with radiographic and biomechanics parameters is not established.

OBJECTIVE

To compare the magnetic resonance images (MRI) of the hip, radiographic parameters of sagittal alignment (pelvic incidence, sacral slope and lumbar lordosis), muscular strength and endurance in women with and without GTPS.

METHODS

Forty women, age over 45, IMC <30 Kg/m2 and sedentary, were recruited and distributed in two groups: GTPS group (GTPSG, n = 20) and Control group (CG, n = 20). All participants underwent MRI scans and X-ray for sagittal alignment analysis in the hip and performed tests for muscular strength and endurance of the hip and trunk.

RESULTS

No differences were found between the GTPSG and CG for the frequency of tendinopathy (P = .30), peritendinitis (P = .10), bursitis (P = .68) and enthesitis (P = .15), however the gluteus medius tendon tear was more prevalent in GTPSG (P = .05). There were no differences in radiographic parameters for pelvic incidence (P > .05), sacral slope (P > .05) and lumbar lordosis (P > .05). The GTPSG showed lower strength of all hip muscle groups (abductors, adductors, flexors, extensors and rotators; P < .01 for all), as well as lower endurance in the Supine Bridge test and Prone bridge test (P < .01).

CONCLUSION

The results of the MRI and radiographic parameters did not differentiate women with and without GTPS. However, the evaluation of muscle strength and endurance can establish the difference between groups.

Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome

PURPOSE

To use a prospectively collected database to internally validate a previously published intraoperative classification system by determining its utility in improving patient-reported outcome scores (PROS).

METHODS

Open or endoscopic procedures performed at a single center between February 2008 and March 2018 with minimum 2-year follow-up were reviewed. Patients were prospectively classified intraoperatively as one of five greater trochanteric pain syndrome (GTPS) types according to the Lall GTPS classification system and underwent one of the six following surgical procedures: trochanteric bursectomy (TB, type I); TB with trochanteric micropuncture (type II); endoscopic suture staple repair (type IIIA); endoscopic single row transtendinous repair (type IIIB); open or endoscopic double row repair (type IV); and gluteus maximus/tensor fasciae latae transfers (type V). The following PROS were analyzed to assess the efficacy of treatment and validity of the classification scheme: modified Harris Hip Score (mHHS), Nonarthritic Hip Score, The International Hip Outcome Tool, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale for pain.

RESULTS

In total, 324 patients (287 female, 37 male) underwent surgical management per GTPS classification type: 109 type I; 26 type II; 20 type IIIA; 118 type IIIB; 44 type IV; and 7 type V. The mean age and follow-up time were 51.9 ± 12.5 years and 44.5 ± 20.5 months, respectively. All patients PROS improved from baseline to minimum 2-year follow-up (P < .05). High rates of the minimal clinically important difference for mHHS (70.0-100.0) and Nonarthritic Hip Score (73.1-92.7) and patient acceptable symptomatic state for mHHS (70.0-94.5) and International Hip Outcome Tool (58.1-86.7) were achieved per GTPS type. Patient satisfaction was 7.9/10.

CONCLUSIONS

This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. These findings provide surgeons with a validated classification system and treatment algorithm to manage peritrochantric pathology diagnosed intraoperatively.

LEVEL OF EVIDENCE

III, prognostic study.

Cooled Radiofrequency Ablation of the Trochanteric Branch of the Nervus Femoralis to Treat Greater Trochanteric Pain Syndrome

OBJECTIVE

Greater trochanteric pain syndrome is a common cause of lateral hip pain. Corticosteroid injections are commonly utilized as non-surgical interventions, however they are not effective for all patients. This technical case report describes a method for treating greater trochanteric pain syndrome by utilizing cooled radiofrequency ablation.

METHODS

The trochanteric branch of the nervus femoralis is identified as providing sensory innervation to the greater trochanter and its surrounding structures. We have identified fluoroscopic targets to block the nerve and perform cooled radiofrequency ablation. We present two patient cases which demonstrated significant pain relief of greater trochanteric pain syndrome with this treatment.

CONCLUSIONS

Cooled radiofrequency ablation of the trochanteric branch of the nervus femoralis is a potential treatment for greater trochanteric pain syndrome. This procedure provides a potential steroid-sparing interventional treatment based on reproducible fluoroscopic landmarks.

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.

Endoscopic Treatment of Calcific Tendinitis of the Gluteus Maximus: A Case Report

CASE

Calcific tendinitis of the gluteus maximus is a rare condition with poorly described operative treatment options. We present a 51-year-old man with chronic left posterolateral hip pain because of gluteus maximus calcific tendinitis that was refractory to conservative treatment. Endoscopy was pursued given the severity and chronicity of his symptoms. The patient remains asymptomatic without recurrence.

CONCLUSION

This is the first description of endoscopic management of calcific tendinitis of the gluteus maximus. This is a minimally invasive, efficacious option for management of this pathology.

Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique

BACKGROUND

Greater trochanteric pain syndrome encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and lateral snapping hip (LSH). Surgical options for LSH range from open surgery to endoscopic surgery, including a diamond-shaped cut or a simple transversal release to gluteus maximus tendon release. Resection of an area of proximal iliotibial band (ITB) and step-cut or z-plasty lengthening have not proven superior to transverse release of the ITB. Therefore, making a complete and effective transverse cut guided by ultrasound may represent a potential advance over endoscopic surgery.

PURPOSE

In this case series study, we describe how to perform proximal release of the ITB guided by ultrasound.

METHODS

The surgical technique-either z-plasty or transverse section of the ITB-was first validated on 10 cadaver specimens and then used in clinical practice. Fourteen patients (5 males and 9 females) were operated from 2014 to 2018. Mean age was 43 years (29-62).

RESULTS

The snap resolved in all patients, as verified actively during the surgical procedure as the patient has only local anesthesia. The VAS score for sports activity improved from 7 (5-9) before surgery to 0 (0-2) after 1 year. The HSS score improved from 58 points (47-72) to 96 at 1-2 years. There were no complications other than minor hematomas nor recurrences.

CONCLUSION

Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. It can be performed under local anesthesia in an outpatient setting with minimal aggressiveness. It is relatively easy, quick, and painless; no stitches are required. Weight bearing is immediate, and patients usually need crutches for only 2-3 days. Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless.

A roadmap to develop clinical guidelines for open surgery of acute and chronic tears of hip abductor tendons

PURPOSE

Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm.

METHODS

Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips.

RESULTS

A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%.

CONCLUSION

The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments.

LEVEL OF EVIDENCE

IV.

Hip Abductor and Peritrochanteric Space Conditions

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

Development of a Predictive Algorithm for Symptomatic Hip Abductor Tears in Patients Undergoing Primary Hip Arthroscopy

BACKGROUND

Patients presenting with lateral hip pain may pose a difficult diagnostic challenge, as pain can be due to various causes.

PURPOSE/HYPOTHESIS

The purpose was to identify risk factors and predictors for symptomatic hip abductor tears in a cohort of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome. We hypothesized that body mass index (BMI), female sex, age, and presence of chondral damage would be significant predictors of hip abductor pathologies.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary hip arthroscopy between March 2009 and December 2019. Patients with Tönnis grade >1, previous hip conditions, incomplete radiographic data, or open procedures were excluded. All demographic variables, intraoperative measurements, and radiographic measurements were assessed using a bivariate analysis. A stepwise logistic regression was used to determine predictive variables.

RESULTS

In total, 255 hips with a hip abductor tear that underwent hip arthroscopy and 2106 hips without a tear that underwent hip arthroscopy were included. The stepwise logistic regression successfully created a predictive model using age, sex, BMI, lateral joint space, and alpha angle as variables. The efficiency of the predictive model was 90.7%, with an area under the curve of 0.894. The odds of having a hip abductor tear were 7.41 times higher in females (odds ratio [OR], 7.41; 95% CI, 4.61-11.9). Each additional year of age was associated with a 13.7% (OR, 1.137; 95% CI, 1.12-1.16) increase in the odds of having a tear. Similarly, with each 1-unit increase in BMI, the odds of having a tear increased by 3.4% (OR, 1.034; 95% CI, 1.01-1.06).

CONCLUSION

This study successfully created a predictive model that identified female sex (OR, 7.41), increasing age (OR, 1.137 for each year), and increased BMI (OR, 1.034 for each unit of BMI) as significant independent predictors of the presence of hip abductor tears in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. This model can be used in support of physical examination and imaging suggestive of hip abductor pathology to preoperatively identify the probability of a symptomatic hip abductor tear in these patients.

Return to Activity After Gluteus Medius Repair in Active Patients Older Than 50 Years

Background:

Gluteus medius (GM) tears are a known cause of dysfunction and disability predominantly in older women.

Purpose

To report on return to activity, patient-reported outcomes (PROs), and a uniquely calculated minimal clinically important difference (MCID) at a minimum 2-year follow-up for active patients who had undergone either an endoscopic or an open GM repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients were considered eligible if they (1) underwent a GM repair with or without concomitant central and peripheral compartment procedures; (2) had baseline preoperative and minimum 2-year scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain; and (3) participated in a physical activity or sport within 1 year before their surgery. Return to activity was defined as the patient being able to participate in his or her activity at a minimum of 2 years postoperatively.

Results:

Of 87 eligible patients, 84 (96.6%) met all inclusion criteria. The mean follow-up was at 44.5 months. Six patients (7.1%) underwent an open GM repair, while the remaining 78 (92.9%) underwent an endoscopic GM repair. Concomitant central and peripheral compartment arthroscopic procedures were performed in 69 patients (82.1%). All PROs significantly (P < .001) improved as follows: mHHS, from 59.0 to 85.8; NAHS, from 57.9 to 84.0; HOS-SSS, from 32.6 to 63.7; and VAS pain, from 5.4 to 1.9. A total of 57 patients (67.9%) returned to their preoperative activity at the 2-year follow-up. The MCID was calculated for the mHHS, NAHS, and HOS-SSS to be 7.5, 7.4, and 10.9, respectively, with 79.3%, 86.4%, and 70.2% of patients achieving the MCID for each respective PROs.

Conclusion:

Active patients over the age of 50 years may benefit from endoscopic or open repair of GM tears, as the majority of patients in our cohort were able to return to their activity of choice. All measured PROs had significantly improved at a minimum 2-year follow-up, with high survivorship, satisfaction, and clinical effectiveness. Patients with partial-thickness tears compared with full-thickness tears and those who underwent isolated GM repair compared with GM repair with concomitant procedures had similar return to activity rates and PROs at the latest follow-up.

Asymptomatic Gluteal Tendinopathies Negatively Impact Outcomes of Total Hip Arthroplasty: A Propensity Score-Matched Study

BACKGROUND

The purpose of this study is to compare outcomes after total hip arthroplasty (THA) in patients with preoperative asymptomatic gluteus medius and minimus (GMM) pathology to a control group with no GMM pathology.

METHODS

Patients undergoing THA for osteoarthritis between August 2012 and March 2018 were retrospectively reviewed. Asymptomatic GMM pathology was considered as the presence of gluteal tendinopathy diagnosed by magnetic resonance imaging (MRI) without the following clinical symptoms: Trendelenburg gait or test, abductor weakness, and lateral thigh tenderness. Patients with asymptomatic GMM pathology were matched (1:1) to patients without GMM pathology on MRI. Two-year data were collected on patient-reported outcomes including Harris Hip Score, Forgotten Joint Score, pain, and satisfaction. Postoperative clinical examination, radiographic measures, complications, and revisions for both groups were reviewed.

RESULTS

Fifty cases of asymptomatic GMM pathology were successfully matched to 50 hips without GMM pathology on MRI. Patients with asymptomatic GMM pathology demonstrated significantly worse outcomes regarding 2-year Harris Hip Score (86.24 vs 92.39, P = .04), VAS for pain (1.82 vs 0.98, P = .05), and patient satisfaction (7.69 vs 9.16, P = .002). The study group exhibited significantly higher rates of lateral hip pain postoperatively. Two cases (4%) in the control group underwent a revision THA and 4 cases (8%) in the study group underwent revision THA.

CONCLUSION

In patients undergoing THA for osteoarthritis, those with asymptomatic GMM pathology experience inferior 2-year postoperative patient-reported outcomes compared to a matched group. This finding should raise awareness surrounding this important pathology's negative impact on surgical outcomes, thus warranting increased vigilance, and possibly justifying concomitant treatment, even in cases of asymptomatic GMM tears.

LEVEL OF EVIDENCE

Level III - Retrospective comparative prognostic study.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Superior gluteal nerve injury following landmark-guided corticosteroid injection for greater trochanteric pain: A case report

This report describes an isolated superior gluteal nerve injection injury following a corticosteroid injection for greater trochanteric pain syndrome. Ultrasound-guided injections may be beneficial to target multiple pain-producing regions of the hip while avoiding nerves and tendons.

Differences in Clinical Presentations and Surgical Outcomes of Gluteus Medius Tears Between Men and Women

BACKGROUND

Gluteus medius (GM) tears often occur in women aged >50 years. There is a paucity of literature comparing sex-based differences in those undergoing GM repair.

PURPOSE

To report differences between women and men in clinical presentations and patient-reported outcome (PRO) scores at a minimum 2-year follow-up after undergoing GM repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed. All included patients had postoperative scores for the following PROs: modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12. Men were propensity score matched 1:3 to women according to concomitant arthroscopic procedures and follow-up time. Clinical effectiveness was determined through a uniquely calculated minimal clinically important difference (MCID) for the mHHS and NAHS specific to this study population.

RESULTS

Thirteen men were successfully propensity score matched to 39 women. Women and men were 55.87 ± 11.0 and 62.38 ± 11.63 years old (mean ± SD), respectively (P = .02). Men were at increased risk for associated lumbar pathology as compared with women (relative risk, 3.32; P = .02). Women showed significant improvement from preoperative to minimum 2-year follow-up for the mHHS (59.32 ± 15.36 to 83.81 ± 16.82; P < .01), NAHS (56.23 ± 15.61 to 83.78 ± 17.66; P < .01), HOS-SSS (33.35 ± 20.28 to 67.88 ± 32.35; P < .01), and visual analog scale (5.48 ± 2.00 to 1.93 ± 2.29; P < .01). Similarly, men showed significant improvement for the mHHS (63.50 ± 16.41 to 84.77 ± 13.91; P < .01), NAHS (61.52 ± 9.87 to 84.42 ± 14.87; P < .01), HOS-SSS (33.97 ± 21.20 to 63.62 ± 26.20; P < .01), and visual analog scale (4.93 ± 2.69 to 1.86 ± 2.10; P < .01). The MCIDs for the mHHS and NAHS were calculated to be 7.89 and 7.24. Of the women, 28 (72%) and 34 (87%) met the MCID for the mHHS and NAHS. Eleven (85%) men met the MCID for the mHHS and NAHS.

CONCLUSION

These results suggest that women and men can both benefit after GM repair. Men were older and had increased risk for associated lumbar pathology than women at the time of surgery. Men and women both experienced significant improvements in PROs and compared favorably in terms of clinical effectiveness at a minimum 2-year follow-up.