Endoscopic repair of partial-thickness undersurface tears of the gluteus medius tendon

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.

Ilizaliturri Jr. V, Kohlrieser D, Laskovski J, Lifshitz L, P. McGovern R, Monnington K, O’Donnell J, Takla A, Tyler T, Voight M, Wuerz T, Martin RL. The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Endoscopic treatment of gluteus medius tendon tear

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears

BACKGROUND

Gluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair.

METHODS

All sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance.

RESULTS

38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes.

CONCLUSION

While fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Repair of gluteus medius tears with bioinductive collagen patch augmentation: initial evaluation of safety and imaging

The purpose of this study was to perform an initial, prospective evaluation of imaging findings and outcomes after open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation. A prospective study was performed of patients with clinical and magnetic resonance imaging (MRI) evidence of symptomatic gluteus medius tears who underwent open, double-row suture anchor repair with bioinductive bovine collagen patch augmentation. Preoperative and 6-month postoperative MRIs were reviewed by a fellowship-trained musculoskeletal radiologist, and outcome scores were recorded preoperatively and 6 months postoperatively [Hip Outcome Score (HOS) Sport; HOS Activities of Daily Living (HOS ADL); Modified Harris Hip Score (mHHS) and International Hip Outcomes Tool (iHOT-33)]. Nine patients, four high-grade tears (≥50% tendon thickness) and five low-grade tears (<50% thickness) underwent surgical repair. At 6 months, 7/9 (77.8%) of tendons were qualitatively classified as completely healed on MRI, with no complications. Mean tendon thickness increased significantly: mediolateral dimension by 5.8 mm (P < 0.001), anteroposterior dimension by 4.1 mm (P = 0.02) and cross-sectional area (CSA) by 48.4 mm² (P = 0.001). Gluteus medius and minimus CSA did not change significantly (P > 0.05). Patients demonstrated improvements in mean scores for HOS ADL, mHHS and iHOT that met defined minimum clinically important differences (P < 0.05). Open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation is safe and associated with increased tendon thickness on postoperative MRI. Early outcome scores are encouraging and should be evaluated after patients have completed postoperative rehabilitation to measure the whole effect of treatment.

Clinical outcomes of open hip abductor tendon repair with minimum two-year follow-up

BACKGROUND

The results of open hip abductor tendon repair remains poorly defined. We sought to present the results and complications of this procedure using modern suture anchor fixation.

MATERIALS AND METHODS

Our prospective institutional hip preservation registry was queried for all patients who underwent open hip abductor tendon repair with minimum 2-year follow-up were identified. Demographic, clinical, intraoperative, and functional outcome details were recorded. Patient-reported outcome scores (PROs) including the modified Harris Hip Score (mHHS), HOS-ADL, HOS-S, and iHOT-33 were collected for the preoperative and final postoperative state. Risk factors for lower final mHHS and change in mHHS were analysed using a multiple regression model.

RESULTS

A total of 21 patients with mean 48 months clinical follow-up (range 24-84 months). Median mHHS improved from 49.50 preoperatively to 82.50 postoperatively (p < 0.001), median HOS-ADL improved from 60.29 to 82.35 (p = 0.001), median HOS-S improved from 37.50 to 60.00 (p = 0.04), and median iHOT-33 improved from 29.81 to 70.15 (p = 0.001). All patients had +4 or +5 hip abductor strength at final in-person examination at mean 17 months postoperatively. All patients with a preoperative Trendelenburg gait had complete resolution at final examination. There 2 complications, and no patient had re-tear or revision surgery. LCEA < 25° and a history of prior ipsilateral hip surgery were independently predictive of smaller improvement in mHHS at final follow-up.

CONCLUSIONS

Open abductor tendon repair is a safe and effective procedure that provides sustained symptomatic and functional improvements at mid-term follow-up.

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

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

Endoscopic transfer of gluteus maximus and tensor fasciae latae for massive gluteus medius tear: Preliminary results

We report preliminary results for a novel technique of endoscopic Whiteside transfer for massive gluteus medius tear: i.e., tendon reinsertion not or only partly feasible and/or severe fatty atrophy of the muscle. Endoscopic transfer of gluteus maximus and/or tensor fasciae latae is associated to gluteus medius tendon reinsertion if at least partial tendon repair is feasible. In a continuous series of 6 patients at a minimum 2 years' follow-up, there was 1 early failure; 2 patients showed no improvement in pain and limping; 3 had satisfactory results, including 2 with complete resolution of limping and pain. Endoscopic Whiteside transfer associated to gluteus medius tendon repair provided only moderate results in terms of recovery of abduction power and resolution of Trendelenburg gait.

Treatment of Gluteal Tendinopathy: A Systematic Review and Stage-Adjusted Treatment Recommendation

Background:

Gluteal tendinopathy is the most common lower limb tendinopathy. It presents with varying severity but may cause debilitating lateral hip pain.

Purpose:

To review the therapeutic options for different stages of gluteal tendinopathy, to highlight gaps within the existing evidence, and to provide guidelines for a stage-adjusted therapy for gluteal tendinopathy.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We screened Scopus, Embase, Web of Science, PubMed, PubMed Central, Ovid MEDLINE, CINAHL, UpToDate, and Google Scholar databases and databases for grey literature. Patient selection, diagnostic criteria, type and effect of a therapeutic intervention, details regarding aftercare, outcome assessments, complications of the treatment, follow-up, and conclusion of the authors were recorded. An assessment of study methodological quality (type of study, level of evidence) was also performed. Statistical analysis was descriptive. Data from multiple studies were combined if they were obtained from a single patient population. Weighted mean and range calculations were performed.

Results:

A total of 27 studies (6 randomized controlled trials) with 1103 patients (1106 hips) were included. The mean age was 53.7 years (range, 17-88 years), and the mean body mass index was 28.3. The ratio of female to male patients was 7:1. Radiological confirmation of the diagnosis was most commonly obtained using magnetic resonance imaging. Reported treatment methods were physical therapy/exercise; injections (corticosteroids, platelet-rich plasma, autologous tenocytes) with or without needle tenotomy/tendon fenestration; shockwave therapy; therapeutic ultrasound; and surgical procedures such as bursectomy, iliotibial band release, and endoscopic or open tendon repair (with or without tendon augmentation).

Conclusion:

There was good evidence for using platelet-rich plasma in grades 1 and 2 tendinopathy. Shockwave therapy, exercise, and corticosteroids showed good outcomes, but the effect of corticosteroids was short term. Bursectomy with or without iliotibial band release was a valuable treatment option in grades 1 and 2 tendinopathy. Insufficient evidence was available to provide guidelines for the treatment of partial-thickness tears. There was low-level evidence to support surgical repair for grades 3 (partial-thickness tears) and 4 (full-thickness tears) tendinopathy. Fatty degeneration, atrophy, and retraction can impair surgical repair, while their effect on patient outcomes remains controversial.

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.

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.

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.

A Technique for Endoscopic in Situ Repair of Undersurface Hip Abductor Tears

Endoscopic repair of hip abductor tendons has been shown to have equivalent outcomes and lower complication rates compared with open repair. First reported in 2007, endoscopic repair has become more frequent, with multiple techniques previously described. Frequently, hip abductor tears involve a partial-thickness undersurface component that has been previously addressed endoscopically by making a longitudinal split in the tendon to access the diseased tissue. However, we present a technique for addressing these undersurface tears in situ, accessing the undersurface of the tear by coming under the distal anterior edge of the gluteus medius tendon.

Both open and endoscopic gluteal tendon repairs lead to functional improvement with similar failure rates: a systematic review

IMPORTANCE

Operative treatment of gluteal tendon tears is becomingly increasingly more common with varying surgical techniques and rehabilitation protocols.

OBJECTIVE

To perform a systematic review of gluteal tendon repair as it relates to tear characteristics, rehabilitation protocols, patient-reported outcomes, satisfaction, resolution of gait deviation and complication rates.

EVIDENCE REVIEW

A comprehensive literature search of PubMed and Embase/MEDLINE was used to identify all literature pertaining to gluteal tendon repair. A total of 389 articles were identified.

FINDINGS

A total of 22 studies (611 hips) were included in this review. The majority of tears were noted to be partial thickness (77.9% vs 22.1%). Both arthroscopic and open repair demonstrated improvements in functional outcomes. Within studies documenting gait deviation, 54% were noted to have gait deviation preoperatively, of which approximately 70% had resolution following repair. On average, abduction strength increased almost one whole grade (0.84) following repair. Overall complication rate was found to be 5.2% (20 of 388 hips). Endoscopic repair demonstrated a decreased complication rate compared with open (0.7% vs 7.8%). Retear rate was found to be 3.8%, with open repair having a slightly increased rate compared with endoscopic repair (3.4% vs 4.1%).

CONCLUSIONS AND RELEVANCE

The majority of tears tend to be partial thickness with involvement of gluteus medius in almost all cases and concomitant involvement of gluteus minimus in close to half of cases. Both endoscopic and open gluteal tendon repairs resulted in improvements in outcomes and functional improvement. Retear rates were similar between the two repair techniques, while endoscopic repair demonstrated a lower complication rate.

LEVEL OF EVIDENCE

Level IV, systematic review.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Endoscopic Repair of Full-Thickness Gluteus Medius and Minimus Tears-Prospective Study With a Minimum 2-Year Follow-Up

PURPOSE

To evaluate the short-term outcomes of endoscopic repair of full-thickness gluteus medius and minimus tendon tears with a minimum of 2-year follow-up and add to the paucity of literature on abductor tendon tears.

METHODS

All patients who underwent endoscopic abductor tendon repair between December 2013 and August 2017 were prospectively evaluated. The inclusion criteria for this study were primary full-thickness gluteal tendon tears and at least 2-years of follow-up. Clinical outcome data consisted of visual analog scale (VAS) pain score, hip abduction strength, Trendelenburg sign, complications, and patient-reported outcome measures (PROMs): modified Harris Hip Score, Hip Outcome Score, Non-arthritic Hip Scale, International Hip Outcome Tool-33, and Lower Extremity Functional Scale.

RESULTS

A total of 15 hips, all full-thickness tears, met inclusion criteria with an average follow-up of 31.2 months, with no patients being excluded. On physical examination, there was a significant improvement in VAS pain score from 5.36 to 2.43 (P = .0243), hip abduction strength with 8 (53.3%) hips improving by at least 1 point (P = .02056), and resolution of Trendelenburg sign in all 15 hips at 2-years (P = .0019). The mean difference for all 6 PROMs was statistically significant, even after Bonferroni adjustment, with the majority of patient improvement exceeding the minimal clinically important difference (MCID) thresholds: modified Harris Hip Score: 86.67%, Hip Outcome Score-ADL: 86.67%, Hip Outcome Score-SSS: 66.67%, Non-arthritic Hip Scale: 93.33%, and International Hip Outcome Tool-33: 80%. Greater Goutallier grade was associated with a greater VAS pain score. There were no complications, including no retears.

CONCLUSIONS

In this study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average of 31.2 months follow-up, while offering the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair.

LEVEL OF EVIDENCE

Level 4, Case Series.

Equivalent Mid-Term Results of Open vs Endoscopic Gluteal Tendon Tear Repair Using Suture Anchors in Forty-Five Patients

BACKGROUND

Little is known about the relative efficacy of open (OGR) vs endoscopic (EGR) gluteal tendon repair of gluteal tendon tears in minimizing pain and restoring function. Our aim is to compare these 2 surgical techniques and quantify their impact on clinical outcomes.

METHODS

All patients undergoing gluteal tendon tear repair at our institution between 2015 and 2018 were retrospectively reviewed. Pain scores, limp, hip abduction strength, and the use of analgesics were recorded preoperatively and at last follow-up. The Hip disability and Osteoarthritis Outcome Score Junior and Harris Hip Score Section1 were obtained at last follow-up. Fatty degeneration was quantified using the Goutallier-Fuchs Classification (GFC). Statistical analysis was conducted using one-way analysis of variance and t-tests.

RESULTS

Forty-five patients (mean age 66, 87% females) met inclusion criteria. Average follow-up was 20.3 months. None of the 10 patients (22%) undergoing EGR had prior surgery. Of 35 patients (78%) undergoing OGR, 12 (27%) had prior hip replacement (75% via lateral approach). The OGRs had more patients with GFC ≥2 (50% vs 11%, P = .02) and used more anchors (P = .03). Both groups showed statistical improvement (P ≤ .01) for all outcomes measured. GFC >2 was independently associated with a worst limp and Harris Hip Score Section 1 score (P = .05). EGR had a statistically higher opioid use reduction (P < .05) than OGR. Other comparisons between EGR and OGR did not reach statistical significance.

CONCLUSION

In this series, open vs endoscopic operative approach did not impact clinical outcomes. More complex tears were treated open and with more anchors. Fatty degeneration adversely impacted outcomes. Although further evaluation of the efficacy of EGR in complex tears is indicated, both approaches can be used successfully.

Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review

PURPOSE

To perform a systematic review of the outcomes of platelet-rich plasma (PRP) injections as an in-office procedure versus surgical treatment for recalcitrant greater trochanteric pain syndrome (GTPS).

METHODS

The MEDLINE and Embase databases were searched in June 2019 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Clinical studies on patients with recalcitrant GTPS treated with PRP or surgery were included. Demographic characteristics, patient-reported outcomes (PROs), and complications were compared. A qualitative analysis using the Methodological Index for Non-randomized Studies and Cochrane Risk of Bias Tool scores was performed.

RESULTS

A total of 5 PRP and 5 surgery studies met the inclusion criteria, contributing 94 and 185 patients, respectively. The mean follow-up time was shorter for the PRP studies (range, 2-26 months) than with surgery (range, 12-70 months). The mean Methodological Index for Non-randomized Studies scores for the PRP and surgery groups were 11.25 and 11.4, respectively, and the only randomized trial had a low risk of bias. Two studies in the PRP group (n = 56) reported improvements in the modified Harris Hip Score at final follow-up (from 53.8 to 82.6 and from 56.7 to 74.2). The other PRP studies reported improvements using other measures. In the surgery group, 2 studies reported improvements in the Harris Hip Score (from 53.0 to 80 and from 53.3 to 88) whereas 3 used unique PROs (Oxford score, from 20.4 to 37.3; modified Harris Hip Score, from 54.9 to 76.2; and Merle d'Aubigné and Postel score, from 10.9 to 16.7). Although significant improvement was reported in all studies included, PRP showed a large effect size whereas surgery showed a moderate to large effect size. No major complications were associated with PRP treatment; however, the surgery group reported a higher rate of complications including recurrent external snapping hip, retears resulting from falls, trochanteric fracture, venous thrombosis, and wound-related problems.

CONCLUSIONS

Both PRP and surgical intervention for the treatment of recalcitrant GTPS showed statistically and clinically significant improvements based on PROs. Although not covered by most medical insurance companies, PRP injections for recalcitrant GTPS provides an effective and safe alternative after failed physical therapy. If surgery is indicated, endoscopy is safer than the open technique.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

A Prospective 2-Year Clinical Evaluation of Augmented Hip Abductor Tendon Repair

Background:

Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome. Studies reporting surgical outcomes are often on small cohorts and with limited information on functional improvement.

Purpose:

To report the 2-year clinical and functional outcomes in a series of patients undergoing HAT repair augmented with a ligament augmentation and reconstruction system (LARS) ligament.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between October 2012 and December 2016, a total of 142 patients with symptomatic HAT tears underwent open bursectomy, V-Y lengthening, and reattachment of the tendon with suture anchors augmented with a LARS ligament. This included 132 women (93%) with a mean age of 64.3 years (range, 43-84 years), a mean body mass index of 28.2 kg/m² (range, 20.0-41.3 kg/m²), and an average duration of symptoms of 4.0 years (range, 6 months-20 years). Following surgery, patients underwent a graduated rehabilitation program consisting of hydrotherapy and land-based exercises. Patient-reported outcome measures (PROMs) were evaluated preoperatively and at 3, 6, 12, and 24 months postoperatively with the Harris Hip Score, Oxford Hip Score, 12-item Short Form Health Survey, and visual analog scale (VAS) for pain. Hip range of motion, hip abduction strength, 30-s single-leg stance (SLS), and 6-minute walk test (6MWT) capacity were evaluated. Patient satisfaction and perceived global rating of change were evaluated postsurgery. Analysis of variance was employed to evaluate clinical improvement over time.

Results:

A significant improvement (P < .05) was demonstrated up to 24 months in all PROMs and clinical scores, including hip range of motion in all planes, hip abductor strength limb symmetry indices (mean ± SD; presurgery, 90.1% ± 42.5%; 24 months, 102.6% ± 15.0%), and the 6MWT (presurgery, 421.8 ± 91.9 m; 24 months, 509.7 ± 105.1 m). Furthermore, several variables, including pain (VAS and pain scores during the 6MWT and 30-s SLS) and patient-perceived improvement (global rating of change), continued to improve from 12 to 24 months. At 24 months, 95.7% of patients were satisfied with their surgical outcome (excluding 3 patients who underwent reoperation within the 24-month period). There was a 5.6% (n = 8) failure rate over the study period.

Conclusion:

HAT repair augmented with a synthetic ligament demonstrated significantly improved clinical and functional outcomes, high levels of patient satisfaction, and a relatively low failure rate up to 24 months postsurgery.

Registration:

ACTRN12616001655437 (Australian New Zealand Clinical Trials Registry).

Superior Gluteal Reconstruction for Severe Hip Abductor Deficiency

Abductor tendon tears are one of the common causes of recalcitrant laterally based hip pain and dysfunction. In most cases, abductor tendon tears are associated with chronic nontraumatic tearing of the gluteus medius tendon. Restoring abductor function of the hip by primary repair of the gluteus medius tendon has been reported to have good and excellent outcomes. However, primary repair might not be as effective for chronic detachment of the gluteus medius tendon with a wide separation from the femoral footprint or severe tendon loss. The lack of tendinous foot for repair and the intrinsically degenerative condition of the tendon may create high tension at the repair site thereby predisposing to surgical failure. We believe that the use of soft-tissue allograft from the Achilles tendon or human dermal allograft may help strengthen the surgical site. We describe a superior gluteal reconstruction technique that is suitable for cases with abductor tendon tear with severe tendon loss.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Influence of Muscle Fatty Degeneration on Functional Outcomes After Endoscopic Gluteus Medius Repair

PURPOSE

To report the early outcomes of endoscopic repair of tears of the gluteus medius tendon and to determine whether the fatty degeneration had an influence on clinical results.

METHODS

Between October 2012 and June 2014, data were prospectively collected and retrospectively reviewed for all patients who underwent endoscopic gluteus medius repair. Patients were assessed pre- and postoperatively using the modified Harris hip score, the nonarthritic hip score, and visual analog scale for pain. The gluteus minimus and the 3 distinct parts of the gluteus medius (anterior, middle, and posterior) were assigned a grade of fatty degeneration on preoperative magnetic resonance imaging scans.

RESULTS

Twenty-two hips (in 20 patients) were assessed with the mean follow-up of 31.7 months (range: 24 to 47 months). There were 15 partial-thickness and 7 full-thickness tears. No patient was lost to follow-up. The mean age at the time of surgery was 66 years (range: 45 to 82 years). Of the 20 magnetic resonance imaging-assessed hips included in the study, 14 had fatty degeneration of the gluteus medius (partial-thickness tears: n = 8, full-thickness tears: n = 6). The mean gluteus medius fatty degeneration index was 1.57 (range: 0.33 to 3.33). Postoperative improvement was seen in modified Harris hip score (33.7 points vs 80.2 points, P = .0001), nonarthritic hip score (47.7 points vs 76.8 points, P = .0001), and in the visual analog scale for pain (7.2 vs 3.2, P < .05). Increasing preoperative fatty degeneration index of the gluteus medius correlated with decreased postoperative functional hip score values (regression coefficient, 0.5839; P < .0001). Tear characteristics (partial or full-thickness) did not correlate with fatty degeneration or muscular atrophy and did not affect postoperative outcomes.

CONCLUSIONS

Endoscopic surgical repair can be an effective treatment of gluteus medius tears in the short term. Fatty degeneration of the gluteus medius and minimus has a negative impact on clinical outcomes of endoscopic gluteus medius repair.

LEVEL OF EVIDENCE

Level IV, therapeutic case series (no control group).

The Effect of Platelet-Rich Fibrin Matrix at the Time of Gluteus Medius Repair: A Retrospective Comparative Study

PURPOSE

To evaluate the effect of platelet-rich fibrin matrix (PRFM) on outcomes after surgical repair of gluteus medius tendons.

METHODS

This is a retrospective review of prospectively collected data comparing patients who underwent gluteus medius repair with PRFM and patients without PRFM. Preoperative characteristics, intraoperative characteristics, and postoperative outcomes at a minimum of 1 year were recorded. Statistical analysis was performed using a multivariate analysis of variance to test for differences in continuous demographic variables and postoperative-only scores between patient groups, χ² tests were performed for categorical variables, and a repeated-measures analysis of variance was performed to test for the effects of PRFM. We also assessed for interobserver variation in grading adductor tendon tears.

RESULTS

In total, the series of gluteus medius repairs without PRFM included 29 patients (25 women and 4 men, 15 right and 4 left) with a mean age of 63.09 ± 12.0 years. The series of gluteus medius repairs with PRFM included 18 patients (16 women and 2 men, 6 right and 12 left) with a mean age of 60.26 ± 8.8 years. There were no differences in patient preoperative variables or intraoperative characteristics. Although there was a significant effect of surgical intervention on the visual analog scale for pain, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific, and modified Harris Hip Score, the use of PRFM had no significant effect on outcome. Linear models showed a significant positive effect of PRFM on only postoperative Short Form 12 Physical and International Hip Outcome Tool 12 scores.

CONCLUSIONS

PRFM augmentation does not appear to have an effect on gluteus medius tendon repair in terms of pain or clinical evidence of retears but may have a role in improving subjective outcomes of overall and hip-specific physical functioning.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of Extensive Gluteus Muscle Tears With Transosseous Fixation and a Nonresorbable Collagen Patch

BACKGROUND

Extensive tearing of the gluteus muscles (spontaneous or subsequent to hip arthroplasty) is difficult to treat. We are carrying out osseous fixation with securement of the suture anchor by a nonresorbable collagen patch. The objective of this study is to examine the follow-up data of 30 patients and to assess whether the clinical outcomes depended on the extent of the fatty degeneration of the gluteus medius.

METHODS

Thirty patients (28 female and 2 male) with a mean age of 76.8 ± 4.3 years (68-83 years) were followed for a mean of 46.8 ± 23.1 months (24-101 months).

RESULTS

Pain improved significantly from a preoperative visual analog scale score of 7.0 ± 1.52 (6-10) to 0.83 ± 0.77 (0-3) 24-month postoperative. The gluteus medius muscle force increased from 2.09 ± 0.81 to 3.3 ± 0.78 using the British Medical Research Council Scale. All patients exhibited a severe limp before the operation. Postoperatively, only 5 patients had a severe limp, while 14 exhibited a mild limp and 11 no limp at all. The modified Harris Hip Score increased from a preoperative value of 44.5 ± 4.2 (26-66) to a value of 81.1 ± 7.79 (60-100) 24-month postoperative. The functional results were dependent on the level of fatty degeneration of the muscle.

CONCLUSION

The first results for this surgical technique appear to be very promising for the treatment of extensive tearing of the gluteus musculature that has a degree of fatty degeneration less than 75%.

Clinical and functional outcomes after augmented hip abductor tendon repair

INTRODUCTION

Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome. Surgical studies are often reported in small cohorts and with limited information on functional improvement. This study reports the clinical and functional outcomes after HAT repair.

METHODS

112 patients with symptomatic HAT tears, diagnosed via magnetic resonance imaging, underwent open bursectomy, V-Y lengthening of the iliotibial band, debridement of the diseased tendon, decortication of the trochanteric foot-plate and reattachment of the tendon with suture anchors, augmented with a LARS ligament through a trans-osseous tunnel. Patients were evaluated pre-surgery and at 3, 6 and 12 months post-surgery using the Harris (HHS) and Oxford (OHS) Hip Scores, SF-12, hip range of motion, 6-minute walk and 30-second single leg stance tests. Maximal isometric hip abduction strength (HAS) was assessed and limb symmetry indices (LSIs) were calculated between the operated and non-operated limbs. Patient satisfaction and perceived global rating of change (GRC) was evaluated. Analysis of variance evaluated improvement over time.

RESULTS

There was a significant improvement (p<0.05) in all clinical and functional measures. HAS significantly improved over time (p<0.002) and all LSIs were >85% at 12 months. At 12 months, a mean GRC score of 3.5 (range -1 to 5) was reported, while 96% of patients were satisfied with their surgical outcome. There was a 2.7% (n = 3) failure rate at 12 months.

CONCLUSIONS

HAT reconstruction, augmented with a synthetic ligament, demonstrated significantly improved clinical and functional outcomes, high levels of patient satisfaction and a low failure rate to 12 months post-surgery.

Editorial Commentary: Pioneering the Gluteal Interval: Understanding and Treating Undersurface and Full-Thickness Gluteus Medius Tears of the Hip

Lateral-based hip disease is severely impairing for many patients. Treatment decision making requires a thorough understanding of the biomechanical and clinical interpretation of the physical examination. The outcomes of these under-recognized pathologies are explained with success. A recent study has described the diagnostic and surgical treatment outcomes of this impairing condition of partial and full-thickness gluteus medius tears.

Endoscopic Gluteus Medius Repair With Concomitant Arthroscopy for Labral Tears: A Case Series With Minimum 5-Year Outcomes

PURPOSE

To report the minimum 5-year outcomes of endoscopic gluteus medius repair for partial- and full-thickness tears with concomitant hip arthroscopy.

METHODS

Data for all patients who underwent hip arthroscopy between February 2009 and September 2011 were prospectively collected. We included patients who underwent endoscopic gluteus medius repair with concomitant arthroscopic labral treatment and for whom the following measures were obtained preoperatively and at a minimum of 5 years' follow-up: modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score for pain. For included patients, the International Hip Outcome Tool-12 (iHOT-12) score and satisfaction rating were also available at latest follow-up. Patients with at least 1 of the following criteria were excluded: preoperative Tönnis osteoarthritis grade of 2 or greater, previous hip conditions, severe dysplasia, and Workers' Compensation claims.

RESULTS

There were 16 patients eligible for inclusion, 14 (87.5%) of whom had minimum 5-year follow-up, with a mean of 68.8 months (range, 60.1-79.6 months). The study group consisted of 13 women (92.9%) and 1 man (7.1%) with a mean age at surgery of 57.4 years (range, 46.3-74.8 years). Outcome scores improved as follows: modified Harris Hip Score, from 52.4 to 81.2 (P = .004); Non-Arthritic Hip Score, from 48.0 to 82.5 (P = .002); Hip Outcome Score-Sports Specific Subscale, from 30.1 to 66.4 (P < .001); and visual analog scale score, from 6.2 to 2.6 (P = .001). At minimum 5-year follow-up, the mean iHOT-12 score was 73.8 and the mean patient satisfaction rating was 8.4. Survivorship was 92.9%, with 1 patient who underwent conversion to total hip arthroplasty. There was no deterioration in patient outcomes and satisfaction between 2 and 5 years postoperatively. There were no clinical failures of gluteus medius repair and no complications.

CONCLUSIONS

Endoscopic gluteus medius repair with concomitant hip arthroscopy for labral tears is safe and shows favorable outcomes at minimum 5-year follow-up. Patient outcomes were as favorable at 5 years as they were at 2 years postoperatively.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Clinical outcomes and frontal plane two-dimensional biomechanics during the 30-second single leg stance test in patients before and after hip abductor tendon reconstructive surgery

BACKGROUND

Hip abductor tendon tears are a common cause of Greater Trochanteric Pain Syndrome. Conservative treatments are often ineffective and surgical reconstruction may be recommended. This study investigated the improvement in clinical outcomes and frontal plane two-dimensional biomechanics during a 30-second single leg stance test, in patients undergoing reconstruction. We hypothesized that clinical scores and pertinent biomechanical variables would significantly improve post-surgery, and these outcomes would be significantly correlated.

METHODS

Twenty-one patients with symptomatic tendon tears underwent reconstruction. Patients were evaluated pre-surgery, and at 6 and 12months post-surgery, using patient-reported outcome measures, assessment of hip abductor strength and six-minute walk capacity. Frontal plane, two-dimensional, biomechanical variables including pelvis-on-femur angle, pelvic drop, trunk lean and lateral pelvic shift, were evaluated throughout a 30-second single leg stance test. ANOVA evaluated outcomes over time, while Pearson's correlations investigated associations between clinical scores, pain, functional and biomechanical outcome variables.

FINDINGS

While clinical and functional measures significantly improved (P<0.05) over time, no significant group differences (P>0.05) were observed in biomechanical variables from pre- to post-surgery. While five patients displayed a positive Trendelenburg sign pre-surgery, only one was positive post-surgery. Clinical outcomes and biomechanical variables during the single leg stance test were not correlated.

INTERPRETATION

Despite improvements in clinical and functional measures over time, biomechanical changes during a weight bearing single leg stance test were not significantly different following tendon repair. Follow up beyond 12months may be required, whereby symptomatic relief may precede functional and biomechanical improvement.

Clinical results of endoscopic treatment without repair for partial thickness gluteal tears

INTRODUCTION

Various surgical treatments have been proposed for greater trochanteric pain syndrome (GTPS) related to gluteal tendinopathy with partial thickness tears. The clinical results of endoscopic debridement without repair of these gluteal tears are not well known. The objectives of this study were to determine if this procedure leads to: (1) reduction of pain, (2) functional improvement, (3) patient satisfaction (on scale of 0 to 10).

HYPOTHESIS

Endoscopic treatment without tendon repair provides short-term pain relief in patients with GTPS due to partial thickness gluteal tears.

MATERIAL AND METHODS

Seventeen patients (16 women, 1 man) with GTPS due to partial thickness gluteal tears that was present for at least 6 months and was refractory to conservative treatment were included in the analysis. The average age at the time of the procedure was 53.5years (17-71). Pain was evaluated with a visual analogue scale (VAS). Functional outcomes were defined using the Harris Hip Score and the UCLA activity score. Satisfaction was evaluated using a VAS and Odom's criteria.

RESULTS

The average follow-up was 37.6months (12-48). The average preoperative and follow-up values were respectively: (1) Pain: 7.2±1.1 (5-9) versus 3.3±1.9 (1-7) (P<0.001), (2) Harris score: 53.5±8.4 (36-68) versus 79.8±14.7 (45-96) (P<0.001). Seven patients (41.2%) were able to resume sports activities. The average satisfaction score for the surgery was 6.2±2.4 (0-9) at follow-up. Five patients had a poor outcome at the review: four still had pain and one had recurrence of the lateral snapping hip.

CONCLUSION

Endoscopic treatment without repair of partial thickness gluteal tears is a treatment option with modest clinical results for GTPS patients refractory to conservative treatment.

LEVEL OF EVIDENCE

IV, retrospective study.

Greater Trochanteric Pain Syndrome

Patients who have lateral hip pain historically have been diagnosed with trochanteric bursitis and treated with nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy. Although this strategy is effective for most patients, a substantial number of patients continue to have pain and functional limitations. Over the past decade, our understanding of disorders occurring in the peritrochanteric space has increased dramatically. Greater trochanteric pain syndrome encompasses trochanteric bursitis, external coxa saltans (ie, snapping hip), and abductor tendinopathy. A thorough understanding of the anatomy, examination findings, and imaging characteristics aids the clinician in treating these patients. Open and endoscopic treatment options are available for use when nonsurgical treatment is unsuccessful.

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

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

Outcomes of Open Versus Endoscopic Repair of Abductor Muscle Tears of the Hip: A Systematic Review

PURPOSE

To compare the outcome of open versus endoscopic gluteal tendon repair.

METHODS

An extensive review of PubMed was conducted by 2 independent reviewers for articles containing at least 1 of the following search terms: gluteus medius, gluteus medius tear, gluteus medius tendinopathy, gluteus medius repair, hip abductors, hip abductor tears, hip abductor repair, hip rotator cuff, hip rotator cuff repair, trochanteric bursa, trochanteric bursitis, trochanteric bursectomy, peritrochanteric procedures, peritrochanteric repair, and peritrochanteric arthroscopy. This yielded 313 articles. Of these articles, 7 satisfied the following inclusion criteria: description of an open or endoscopic gluteal repair with outcomes consisting of patient-reported outcome scores, patient satisfaction, strength scores, pain scores, and complications.

RESULTS

Three studies on open gluteal repairs and 4 on endoscopic gluteal repairs met the inclusion criteria. In total, there were 127 patients who underwent open procedures and 40 patients who underwent endoscopic procedures. Of the 40 patients who underwent endoscopic procedures, 15 had concomitant intra-articular procedures documented, as compared with 0 in the open group. The modified Harris Hip Score was common to 1 study on open repairs and 3 studies on endoscopic repairs. The scores were similar for follow-up periods of 1 and 2 years. Visual analog pain scale scores were reported in 1 study on open gluteal repairs and 1 study on endoscopic repairs and were similar between the 2 studies. Improvement in abductor strength was also similarly reported in selected studies between the 2 groups. The only difference between the 2 groups was the reported incidence of complications, which was higher in the open group.

CONCLUSIONS

Open and endoscopic gluteal repairs have similar patient-reported outcome scores, pain scores, and improvement in abduction strength. Open techniques have a higher reported complication rate. Randomized studies of sufficient numbers of patients are required to ultimately determine if one technique produces superior patient outcomes over the other.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Outcomes of Endoscopic Gluteus Medius Repair: Study of Thirty-four Patients with Minimum Two-Year Follow-up

BACKGROUND

Surgical intervention for partial and full-thickness gluteus medius tears is often recommended for patients who have persistent pain despite nonoperative treatment. Traditionally, the surgical intervention has been carried out through open techniques with good results; however, advantages of endoscopic techniques include less tissue dissection, improved tendon mobilization, and the benefit of arthroscopic correction of intra-articular pathological conditions. The purpose of this report is to provide an update on a previously published study of patients with a gluteus medius tear, with inclusion of additional patients followed for a minimum of two years.

METHODS

The study included thirty-four patients who had undergone an endoscopic gluteus medius repair with correction of intra-articular pathological conditions between April 2009 and April 2012 and had been followed for a minimum of two years. Patient-reported outcome measures included the modified Harris hip score, Nonarthritic Hip Score, and Hip Outcome Score-Activities of Daily Living and Sport-Specific Subscale. A visual analog scale (VAS) pain score and a patient satisfaction score were also recorded.

RESULTS

The cohort consisted of two men and thirty-two women with a mean age of fifty-seven years (range, twenty to seventy-nine years). Ten patients had a full-thickness tear, and twenty-four patients had a partial-thickness tear. Seventeen patients were treated with a suture bridge technique, after completion of the tear if it was not already complete, and seventeen patients were treated with the transtendinous technique. All patients had surgical correction of intra-articular pathological conditions. There was a significant improvement in all four patient-reported outcomes at three specified time-points. The mean VAS pain score decreased from 6.6 preoperatively to 2.4 at the time of the two-year follow-up (p < 0.001). The mean satisfaction score was 8.5 at two years postoperatively. Of twenty-six patients who had a gait deviation preoperatively, fifteen (58%) regained a completely normal gait. There was no significant difference in patient-reported outcome measures between the two surgical techniques. Four patients required total hip replacement at eleven to sixteen months postoperatively.

CONCLUSIONS

After a minimum of two years of follow-up, endoscopic surgical repair with correction of intra-articular pathological conditions was found to be an effective treatment for patients with a gluteus medius tear.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Clinical Features That Predict the Need for Operative Intervention in Gluteus Medius Tears

Background:

Gluteus medius tears are a common cause of lateral hip pain. Operative intervention is usually prescribed for patients with pain despite physical therapy and/or peritrochanteric injections.

Purpose:

To identify clinical features that predict operative intervention in gluteus medius tears.

Study Design:

Case control study; Level of evidence, 3.

Methods:

A matched-pair controlled study was conducted on patients who underwent endoscopic gluteus medius repairs from June 2008 to August 2014 for full-thickness tears. The exclusion criterion was previous hip disorders (eg, Legg-Calve-Perthes disease, avascular necrosis). The control group contained patients with full-thickness gluteus medius tears on magnetic resonance imaging (MRI) who did not require operative intervention. Both groups had a minimum trial of 3 months of nonoperative management. Matching criteria included age within 5 years, sex, and body mass index (BMI) class. The following clinical parameters were analyzed: presence of lateral-sided hip pain, duration of symptoms, power of resisted hip abduction, gait deviation (antalgic or Trendelenburg), greater trochanter tenderness, and hip passive range of abduction.

Results:

Twenty-four patients who underwent isolated endoscopic gluteus medius repairs were identified; all patients were females, with a mean age of 65 years (range, 52-82 years) and mean BMI of 29.2 kg/m² (range, 21.55-44.398 kg/m²). The matched control cohort contained 12 females treated nonoperatively for gluteus medius tears with mean age of 66 years (range, 52-81 years) and mean BMI of 29.9 kg/m² (range, 20.20-43.59 kg/m²). There were significant differences between the groups in power of resisted abduction and presence of gait deviation. The operative cohort had a mean power grading of 3.63 (95% CI, 3.28-3.98) compared with 4.58 (95% CI, 4.29-4.87) for the matched cohort (P < .05). Abnormal gait was found in 75% of the operative cohort, compared with 33% of the matched cohort (P < .05). Specifically, 83.3% of the surgical cohort had a Trendelenburg gait, compared with 25% of the matched cohort (P = .002). The odds of requiring surgical intervention was 14-fold higher for patients with a gluteus medius tear and gait deviation compared with those without gait deviation. There were no significant differences in the other parameters.

Conclusion:

Reduced power of resisted abduction and the presence of gait deviation on initial evaluation of patients with gluteus medius tears increases the likelihood of surgical intervention.

Clinical and MRI results in 67 patients operated for gluteus medius and minimus tendon tears with a median follow-up of 4.6 years

INTRODUCTION

Although various techniques can be used to repair gluteal tendon tears, the long-term outcome is unclear and published studies typically involve only a small number of patients. The goals of this study were to determine (1) if functional improvement can be obtained, (2) if the repairs are continuous based on MRI, and (3) which factors determine success.

HYPOTHESIS

Gluteus medius and minimus tears can be repaired effectively with an open double-row technique.

MATERIAL AND METHODS

Seventy-three patients were operated on between 2003 and 2010. Of these patients, 67 (62 women, 5 men) were available for review consisting of functional clinical tests and MRI of the hip and pelvis. A double-row repair was performed on all tendon tears, no matter the type of injury. Age, body mass index (BMI), fatty degeneration and muscle atrophy were also evaluated to determine if these variables affected the outcome.

RESULTS

The average follow-up was 4.6 years (range 1-8). The pre-operative scores had improved at the last follow-up: (1) pain (VAS): 8.7 ± 1.1 versus 1.7 ± 2.7 at the follow-up, (P<0.001), (2) Lequesne index: 12.3 ± 2.6 versus 4.0 ± 4.0 at the follow-up, (P<0.001), (3) Harris Hip Score: 50.5 ± 8 versus 87.9 ± 15.5 at the follow-up, (P<0.001). There were 11 failures (16%) including two repeat tears that were reoperated successfully. In the other 56 patients, the MRI showed no signs of the initial tear or bursitis. Of the four factors (age, BMI, fatty degeneration, muscle atrophy) that were potential predictors of the outcome, only muscle atrophy had a negative impact on functional outcome (P<0.05).

CONCLUSION

Using an open double-row technique to repair gluteal tendon tears led to 85% of patients having good clinical results with significant improvement in symptoms and disappearance of abnormal findings on MRI. This technique can be used with all types of tendon tears, but should be performed before muscle atrophy sets in.

LEVEL OF PROOF

Level IV-retrospective study.