Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review

Efficacy of Ultrasound-Guided Injections of Type I Collagen-Based Medical Device for Greater Trochanteric Pain Syndrome: A Pilot Study

Background: Greater Trochanteric Pain Syndrome (GTPS) is a frequent clinical condition characterized by acute or chronic pain in the lateral region of the hip. This condition is primarily due to gluteus minimus and medius tendinopathy. Swine-derived type I collagen has shown a positive effect on tenocytes through in vitro studies and on tendinopathies in clinical studies. This pilot study aims to evaluate the clinical effects of swine-derived type I collagen injections on pain, hip function, and strength in GTPS patients. Methods: The study group was treated with three ultrasound-guided swine-derived type I collagen injections once a week for three consecutive weeks. The primary endpoint was pain reduction of at least 3 points on the Numeric Rating Scale (NRS) at ten weeks. Secondary endpoints were NRS average reduction at rest and palpation, modified Harris Hip Score (mHHS), abductor strength, and magnetic resonance imaging (MRI) improvement at six months. Results: 52 patients were screened, 47 enrolled, and 43 completed the study. The primary endpoint was reached by 60.5% of the patients. All secondary endpoints were also reached with statistical significance. Neither early nor late adverse effects were found. Conclusions: In this pilot study, ultrasound-guided peritrochanteric swine-derived type I collagen injections are safe and effective for most patients with GTPS included in the study. Further and more extensive confirmatory investigation studies with a longer follow-up are needed to confirm this pilot study's results and the clinical benefit's persistence.

Preoperative instillation of epinephrine and lidocaine can reduce surgical time in the endoscopic treatment of GTPS

INTRODUCTION

Greater Trochanteric Pain Syndrome (GTPS) is a multifactorial clinical condition affecting the lateral area of the hip. Although conservative treatment shows good results, some patients may still require surgical bursectomy, which can be performed either openly or endoscopically. One of the main technical difficulties of the endoscopic procedure is intraoperative bleeding, which can hinder the medical team's vision and increase the operation time for endoscopic treatment of GTPS.

HYPOTHESIS

An instillation of vasoconstrictors and local anesthetics before endoscopy will cause less intraoperative bleeding, which will translate into shorter surgical time.

MATERIALS AND METHODS

A prospective cohort was retrospectively divided based on the use or absence of a preoperative instillation of physiological saline solution with epinephrine and lidocaine. Surgical time was measured in each procedure and compared between the two groups.

RESULTS

One hundred thirty-nine hips from 139 patients were included in the analysis. One hundred two patients were included in the instillation group versus 37 in the control group. The surgical time was significantly shorter in the instillation group than in the control group, with an average (standard deviation) of 52.01 (14.71) and 72.30 (11.70) minutes, respectively (P<.001).

CONCLUSION

The instillation of a physiological saline solution with epinephrine and lidocaine prior to the surgical treatment of GTPS is effective in reducing surgical times, likely due to a reduction in intraoperative bleeding. Future research should focus on more direct outcomes such as intraoperative blood loss and between different instillation protocols.

Clinical Outcomes of Hip Abductor Repair Using Transosseous Sutures Versus Suture Anchors: A Systematic Review and Meta-analysis

Background

Hip abductor tendon tears have been identified as a common cause of greater trochanteric pain syndrome. While abductor tendon tears are often managed surgically, the optimal tendon attachment technique remains controversial.

Purpose

To compare the outcomes of hip abductor tendon repair between the suture anchor (SA) and transosseous suture (TS) techniques.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed in June 2023 in Embase, PubMed, and Web of Science databases. Studies reporting pre- and postoperative clinical outcomes of hip abductor repairs using SA or TS fixation with a minimum follow-up of 12 months were included in our analysis. From 608 studies initially identified, 21 studies (14 SA and 7 TS) with a total of 680 patients met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist guided the reporting and data abstraction, and the quality of the studies was assessed using the methodological index for non-randomized studies checklist. The results were presented as a narrative summary using descriptive statistics such as ranges and agreement statistics.

Results

Significant pre- to postoperative improvement in pain scores and functional outcomes were reported on all included studies. The mean improvement on the Harris Hip Score/modified Harris Hip Score was 32.5 (95% CI, 28.4-36.7) for the SA technique versus 21.9 (95% CI, 6.7-37.0) for the TS technique, while mean improvement in pain according to the visual analog scale was 5.1 ± 2.3 for SA and 4.8 ± 2.2 for TS (P = .9). There was a trend toward statistical significance regarding retear rates, with higher rates for SA (6.7% ± 7.6%) versus TS (1.3% ± 4.7%) (t[13.9] = 2.0; P = .06).

Conclusion

We observed no significant difference between SA and TS regarding improvements in patient-reported hip outcome and pain scores. However, SA trended toward a higher retear rate. Future research should propose a classification scheme that considers tear size and morphology, the extent of associated muscle degeneration, and the distance of tendon retraction to provide more context for the understanding of expected functional outcomes.

[Translated article] Preoperative instillation of epinephrine and lidocaine can reduce surgical time in the endoscopic treatment of GTPS

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) is a multifactorial clinical condition affecting the lateral area of the hip. Although conservative treatment shows good results, some patients may still require surgical bursectomy, which can be performed either openly or endoscopically. One of the main technical difficulties of the endoscopic procedure is intraoperative bleeding, which can hinder the medical team's vision and increase the operation time for endoscopic treatment of GTPS.

HYPOTHESIS

An instillation of vasoconstrictors and local anaesthetics before endoscopy will cause less intraoperative bleeding, which will translate into shorter surgical time.

MATERIALS AND METHODS

A prospective cohort was retrospectively divided based on the use or absence of a preoperative instillation of physiological saline solution with epinephrine and lidocaine. Surgical time was measured in each procedure and compared between the two groups.

RESULTS

One hundred thirty-nine hips from 139 patients were included in the analysis. One hundred two patients were included in the instillation group versus 37 in the control group. The surgical time was significantly shorter in the instillation group than in the control group, with an average (standard deviation) of 52.01 (14.71) and 72.30 (11.70)min, respectively (p<.001).

CONCLUSION

The instillation of a physiological saline solution with epinephrine and lidocaine prior to the surgical treatment of GTPS is effective in reducing surgical times, likely due to a reduction in intraoperative bleeding. Future research should focus on more direct outcomes such as intraoperative blood loss and between different instillation protocols.

Impact of model geometry and joint center locations on inverse kinematic/dynamic predictions: A comparative study of sexually dimorphic models

This work illustrates the sensitivity of demographically characteristic body segment inertial properties and subject-specific customization on model performance. One characteristic demographic, gender, and one subject-specific characteristic, hip joint center location, were represented with musculoskeletal modeling to evaluate how design decisions may alter model outputs. Generic sexually dimorphic musculoskeletal models were developed from the commonly used Rajagopal model using male and female data adapted by Dumas et al. Hip joint centers of these models were adjusted based on functional joint center testing. The kinematics and dynamics of 40 gait cycles from four subjects are predicted using these models. Two-way analysis of variance (ANOVA) was performed on the continuous time series data using statistical parametric mapping (SPM) to assess changes in kinematics/dynamics due to either choice in model (Rajagopal vs Dumas) or whether joint center adjustment was performed. The SPM based two-way ANOVA of the inverse dynamics found that differences in the Rajagopal and Dumas models resulted in significant differences in sagittal plane moments during swing (0.115 ± 0.032 Nm/kg difference in mean hip flexion moment during initial swing and a 0.077 ± 0.041 Nm/kg difference in mean hip extension moment during terminal swing), and differences between the models with and without hip joint center adjustment resulted in significant differences in hip flexion and abduction moments during stance (0.217 ± 0.055 Nm/kg increased mean hip abductive moment). By comparing the outputs of these differently constructed models with each other, the study finds that dynamic predictions of stance are sensitive to positioning of joint centers, and dynamic predictions of swing are more sensitive to segment mass/inertial properties.

PREHAB FAI- Prehabilitation for patients undergoing arthroscopic hip surgery for Femoroacetabular Impingement Syndrome -Protocol for an assessor blinded randomised controlled feasibility study

BACKGROUND

The past decade has seen an exponential growth of minimally invasive surgical procedures. Procedures such as hip arthroscopy have rapidly grown and become the standard of care for patients with Femoroacetabular Impingement Syndrome (FAIS). Although, the results of such procedures are encouraging, a large proportion of patients do not achieve optimal outcomes due to chronicity and deconditioning as a result of delay in diagnosis and increased waiting times amongst other factors. In a recent systematic review and meta-analysis of randomised control trials, moderate certainty evidence supported prehabilitation over standard care in optimising several domains including muscle strength, pain and health related quality of life in patients undergoing orthopaedic surgical interventions. However, the role of prehabilitation in patients with FAI syndrome undergoing hip arthroscopy has received little attention.

AIM

To evaluate the feasibility, suitability, acceptability and safety of a prehabilitation programme for FAI to inform a future definitive randomised control trial to assess effectiveness.

METHODS

A systematically developed prehabilitation intervention based on a literature review and international consensus will be utilised in this study. A mixed methodology encompassing a two-arm randomised parallel study alongside an embedded qualitative component will be used to answer the study objectives. Patients will be recruited from a tertiary referral NHS centre for young adult hip pathology in the UK. Patient reported outcomes such as iHOT-12, Brief Pain Inventory Scale (Short form), Hospital Anxiety and Depression Scale and Patient Global Impression of Change score will be obtained alongside objective measurements such as Muscle Strength and Star Excursion Balance Test at various time points. Outcome measures will be obtained at baseline (prior to prehabilitation intervention), after prehabilitation before surgery, and at 6 weeks+/- 4 weeks and 6 months +/- 4 weeks (planned primary endpoint for definitive RCT) postoperatively when participants attend the research site for clinical care and remotely at 12 months +/- 4 weeks postoperatively. Mean change and 95% CI, and effect size of outcome measures will be used to determine the sample size for a future RCT. For the qualitative component, in depth face-to-face semi-structured interviews with physiotherapists and focus groups with participants will be conducted to assess the feasibility, suitability, and acceptability of the prehabilitation intervention using a predetermined success criteria. All qualitative data will be recorded, transcribed verbatim and thematically analysed.

DISCUSSION

This study will be first of its kind to evaluate a systematically developed prehabilitation intervention for patients with FAIS undergoing hip arthroscopy. This study will provide important preliminary data to inform feasibility of a definitive RCT in the future to evaluate effectiveness of a prehabilitation intervention.

TRIAL REGISTRATION

ISRCTN 15371248, 09/03/2023.

TRIAL PROTOCOL

Version 2.3, 26th June 2023.

Exploring the Interplay between Bone Marrow Stem Cells and Obesity

Obesity, a complex disorder with rising global prevalence, is a chronic, inflammatory, and multifactorial disease and it is characterized by excessive adipose tissue accumulation and associated comorbidities. Adipose tissue (AT) is an extremely diverse organ. The composition, structure, and functionality of AT are significantly influenced by characteristics specific to everyone, in addition to the variability connected to various tissue types and its location-related heterogeneity. Recent investigation has shed light on the intricate relationship between bone marrow stem cells and obesity, revealing potential mechanisms that contribute to the development and consequences of this condition. Mesenchymal stem cells within the bone marrow, known for their multipotent differentiation capabilities, play a pivotal role in adipogenesis, the process of fat cell formation. In the context of obesity, alterations in the bone marrow microenvironment may influence the differentiation of mesenchymal stem cells towards adipocytes, impacting overall fat storage and metabolic balance. Moreover, bone marrow's role as a crucial component of the immune system adds another layer of complexity to the obesity-bone marrow interplay. This narrative review summarizes the current research findings on the connection between bone marrow stem cells and obesity, highlighting the multifaceted roles of bone marrow in adipogenesis and inflammation.

Satisfactory results after endoscopic gluteus medius repair combined with selective gluteus maximus reflected tendon release for the treatment of a full-thickness tear of gluteus medius

PURPOSE

The current study aimed to report the mid-term follow-up results of endoscopic gluteus medius repair combined with a systematic release of the gluteus maximus reflected tendon.

METHODS

Twenty-two patients with a symptomatic full-thickness tear of the gluteus medius tendon, as diagnosed by clinical examination and imaging (MRI), and who had a failure of conservative treatment for at least 6 months, were retrospectively enrolled for this study. An endoscopic repair of gluteus medius was performed for all patients in combination with gluteus maximus reflected tendon release according to the Polesello technique. The Visual Analogue Scale (VAS) for pain, Modified Harris Hip Score (mHHS), Lower Extremity Functional Scale (LEFS), Hip Outcome Score-Activity Daily Life (HOS-ADL), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS) were administered to each patient before surgery for 6 months, 1 year, and every following year after surgery.

RESULTS

All analysed hip scores (mHHS, LEFS, HOS-ADL, and HOS-SSS) showed statistically significant improvements between the pre-operative and post-operative values at 6 months, 1 year, and the latest follow-up appointments after surgery (p < 0.001). The mean pre-operative pain was 8.6 ± 1.0 on the VAS. After surgical treatment, the pain was significantly reduced (p < 0.001) on the VAS at 6 months (5.4 ± 1.5), 1 year (4.4 ± 1.8) and the latest follow-up control visit (3.6 ± 2.2). No patient-reported major complications (re-rupture, deep infection or neurovascular injury). Eleven (50%) patients indicated the results as excellent, 7 (32%) as good, 2 (9%) as fair, and 2 (9%) as poor.

CONCLUSION

The use of abductor tendon repair in combination with a systematic release of the reflected tendon of the gluteus maximus according to the Polesello technique seems to be a safe and effective endoscopic way of treating a full-thickness tear of the gluteus medius.

LEVEL OF EVIDENCE

Level IV.

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique

PURPOSE

External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique.

METHODS

An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated.

RESULTS

The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€).

CONCLUSION

This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.

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

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

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

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

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Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Isolated pathologies of Tensor Fasciae Latae: Retrospective cohort analysis from a tertiary referral centre

INTRODUCTION

Tensor Fasciae Latae (TFL) and the iliotibial band (ITB) act as a single functional unit in maintaining pelvic stability whilst standing, walking, or running in human beings. The Tensor Fasciae Latae (TFL) muscle acts across the hip and the knee joint. Consequently, though its pathologies traditionally present with lateral hip pain, identifying the precise clinical diagnosis can be a challenge.

PATIENTS AND METHODS

A retrospective search for the keyword 'Tensor Fasciae Latae'/iliotibial band (ITB) was performed of our Radiology Information System (RIS) and Picture Archiving and Communication System (PACS), Computerised Radiology Information System (CRIS) at our tertiary orthopaedic referral centre of a for orthopaedic oncology over a period of 13 years (2007-2020). Data was collected from RIS, oncology database and local histopathology laboratory records. Patient demographics, clinical characteristics, complementary imaging and clinical management outcome were documented.

RESULTS

We identified 35 patients with a mean age of 66 years (range 19-94 years). There were 18 female and 17 male patients. Lateral hip lump and pain were the most frequent clinical finding/presentation features. A variety of pathologies such as benign and malignant tumours, including vascular and tumour mimic lesions involving the TFL muscle were identified. Atrophy and pseudohypertrophy of TFL was the commonest pathology found; accounting for two thirds of the cases.

CONCLUSION

Tensor Fasciae Latae (TFL) can be afflicted with a broad spectrum of pathologies. Radiological imaging especially cross-sectional imaging modality is crucial in guiding appropriate patient management of TFL conditions. Our analysis suggests isolated TFL lesion are more likely to be benign conditions, presenting commonly as hip pain and swelling.