Endoscopic treatment of calcific tendinitis of gluteus medius and minimus

Gluteus medius calcific tendonitis as a cause of severe anterior hip pain

Calcific tendinopathy in the gluteus medius is uncommon and sporadically reported. It may be asymptomatic or present with acute or chronic pain. Pain is usually isolated to the lateral hip overlying the gluteal muscles or greater trochanter. We present a rare case of gluteus medius calcific tendonitis as a cause of severe anterior hip pain. Given the atypical local and clinical presentation these can be often misdiagnosed as septic arthritis or fracture which may lead to overtreatment and even unnecessary surgery. This article will detail the clinical presentation, imaging findings, and clinical course following treatment. This will facilitate the clinician in making a timely diagnosis and establishing an effective treatment course.

Calcific Tendinopathy Atypically Located Outside the Rotator Cuff: A Systematic Review

BACKGROUND AND PURPOSE

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited. The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

METHODS

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

RESULTS

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

CONCLUSION

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

Endoscopic treatment for calcific tendinitis of the gluteus medius: A case report and review

Tendon calcification is a common disease, with the shoulder rotator cuff being the most common site. However, calcific tendinitis of the gluteus medius has rarely been reported. This study reports the case of a 64-year-old woman diagnosed with calcific tendinitis of the gluteus medius and experiencing right lateral hip pain with no apparent trigger. After unsuccessful conservative treatment, hip endoscopy was performed on this patient, allowing for a clear view of a “toothpaste-like” lesion in the gluteus medius tendon. A shaver was used to remove the lesion. After 8 weeks and 14 months of follow-up, the patient could return to regular daily and social activities. This study shows that endoscopic surgery can lead to effective, rapid recovery and minimally invasive clinical outcomes in patients with tendon calcification near the hip joint.

Bilateral gluteus medius and minimus calcific tendonitis in a patient with previous bilateral calcific tendonitis of the shoulder: A case report

Calcific tendonitis of the gluteus medius and minimus tendons is a rare complication of hydroxyapatite deposition disease, with bilateral involvement even more so. Although patients can be asymptomatic, there is often an acute-on-chronic presentation of pain. We present a case of bilateral calcific tendonitis of the gluteus medius and minimus tendons on a background of previous bilateral rotator cuff calcific tendonitis in a middle-aged woman. This patient's long-standing history of multi-focal involvement required a multidisciplinary approach between orthopedics, rheumatology, and musculoskeletal radiology for optimal management, requiring different treatment options for different affected sites.

Multimodality imaging of greater trochanter lesions

Purpose

Greater trochanter (GT) lesions are relatively uncommon. They can be traumatic, infective including tuber-culosis, inflammatory, and neoplastic (primary and metastatic osseous lesions). Although imaging of greater trochanter lesions remains essential for differential diagnoses, an image-guided biopsy is a mainstay for diagnosis and to guide subsequent management.

Material and methods

A retrospective search for the word ‘greater trochanter’ was performed of a computerised radiology information system (CRIS) of a tertiary referral centre for orthopaedic oncology over a period of 12 years (2007-2019). This revealed 6019 reports with 101 neoplasms. The imaging, histology, and demography were reviewed by a dedicated musculoskeletal radiologist.

Results

We identified 101 GT neoplasms with a mean age of 51.5 years (range 6 to 85 years) and a slight female predominance of 1.2 : 1 (46 males and 55 females). Using 30 years of age as a cut-off, we further segregated the patient cohort into 2 groups: 26 (25.74%) lesions in patients less than 30 years age and the remaining 75 (74.26%) lesions in patients over 30 years old. Chondroblastoma was the most common neoplasm in patients below 30 years of age, and metastases were the most common neoplasms in patients over 30 years of age.

Conclusions

Greater trochanter pathologies show a broad spectrum of aetiologies. Imaging including radiographs, computed tomography, magnetic resonance imaging, and nuclear medicine scans help to narrow down the differen-tials diagnosis.

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

CASE

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

CONCLUSION

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

Clinical Outcomes After Endoscopic Repair of Gluteus Medius Tendon Tear Using a Knotless Technique With a 2-Year Minimum Follow-Up

PURPOSE

To evaluate clinical outcomes in patients who underwent endoscopic gluteus medius repair with at least 2-year follow-up.

METHODS

This was a single-center, single-surgeon retrospective study of 19 patients (20 hips) who underwent endoscopic knotless gluteus medius repair between August 2010 and August 2016 with ≥2 years of follow-up. Preoperative magnetic resonance imaging (MRI) was reviewed and graded according to the Goutallier/Fuchs classification; preoperative X-rays were reviewed and graded according to the Tonnis classification. Baseline and 2-year postoperative modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were prospectively collected. The numbers of patients reaching the minimal clinically important difference (MCID) and patient acceptable symptomatic rate (PASS) were determined.

RESULTS

Twenty hips from 19 patients met the inclusion criteria and were separated based on tear type. The study population comprised 15 (79%) females and 4 (21%) males presenting with a mean age of 51.3 ± 11.9 years and an average body mass index of 25.3 ± 3.9 kg/m². Patients with partial tears reported average preoperative mHHS and NAHS of 33.6 ± 11.3 and 40.4 ± 14.9, respectively; at 2-year follow-up, average mHHS and NAHS of 72.9 ± 22.9 and 77.2 ± 19.7 were reported. Patients with full-thickness tears reported average preoperative mHHS and NAHS of 43.8 ± 14.7 and 46.4 ± 8.3, respectively; at 2-year follow-up, average mHHS and NAHS of 80.1 ± 8.5 and 79.5 ± 10.1 were reported. There was significant clinical improvement at 2-year follow-up, relating to both outcome measures in each subject group (P < .001). At 2 years, 90% of hips surpassed MCID, and 63% of hips achieved PASS.

CONCLUSION

Endoscopic repair for gluteus medius tears results in improved mHHS and NAHS at 2 years of follow-up compared with baseline. Most patients reach critical thresholds of minimal and satisfactory clinical improvement.

LEVEL OF EVIDENCE

Level IV, case series with subgroup analysis.

Non-rotator cuff calcific tendinopathy: ultrasonographic diagnosis and treatment

Calcific tendinopathy is a condition that is related to the deposition of calcium, mostly hydroxyapatite crystals, within the tendons. The shoulder and the hip are commonly affected joints, but calcific tendinopathy may occur in any tendon of the body. While there is an extensive literature on the ultrasound diagnosis of calcific tendinopathy of the shoulder, there are only sporadic reports on other sites. This review combines the experience of our centers and a thorough analysis of the literature from the last 45 years (1972-2017) in order to highlight the localizations beyond the rotator cuff, their ultrasound characteristics and therapeutic possibilities.

[Tendonitis calcarea of the piriformis muscle in a young amateur athlete]

Distinct calcific tendonitis associated with chronic pain refractory to conservative treatment can require operative treatment. Symptomatic calcific tendonitis of the piriform muscle, despite calcific tendonitis of other regions, is an extremely rare diagnosis. We report about a young athlete with persistent gluteal pain despite long-term conservative treatment. MRI scans revealed tendonitis calcarea with surrounding soft tissue inflammation. On open surgical removal of the calcification, pain symptoms were relieved and the patient was able to return to sports.

The effects of therapeutic exercise using PNF on the size of calcium deposits, pain self-awareness, and shoulder joint function in a calcific tendinitis patient: a case study

[Purpose] The purpose of this case study was to identify the effects of independent and intensive therapeutic exercise using Proprioceptive neuromuscular facilitation on the size of calcium deposits, pain self-awareness, and shoulder joint function in a patient with calcific tendonitis. [Subject and Methods] The subject was a 42-year-old female patient with calcific tendonitis and acute pain who had difficulty with active movement and problems with general function. The independent and intensive Proprioceptive neuromuscular facilitation exercise was applied for 40 min twice a day five times a week for two weeks for a total of 20 times. An X-ray, the visual analog scale, a simple shoulder test, the Constant-Murley Scale, and passive range of motion was used to evaluate the patient’s change. [Results] The size of the calcium deposit, the visual analog scale score, and the simple shoulder test score decreased. The Constant-Murley Scale score and the passive range of motion were increased. [Conclusion] The results of this study suggested that intensive and independent therapeutic short-term exercise without any other exercise reduced pain and produced positive effects in shoulder function in a patient with the calcific tendonitis, which could confirm the importance of therapeutic exercise in the treatment of calcific tendonitis.

Calcium Apatite Deposition Disease: Diagnosis and Treatment

Calcium apatite deposition disease (CADD) is a common entity characterized by deposition of calcium apatite crystals within and around connective tissues, usually in a periarticular location. CADD most frequently involves the rotator cuff. However, it can theoretically occur in almost any location in the musculoskeletal system, and many different locations of CADD have been described. When CADD presents in an unexpected location it can pose a diagnostic challenge, particularly when associated with pain or swelling, and can be confused with other pathologic processes, such as infection or malignancy. However, CADD has typical imaging characteristics that usually allows for a correct diagnosis to be made without additional imaging or laboratory workup, even when presenting in unusual locations. This is a review of the common and uncommon presentations of CADD in the appendicular and axial skeleton as well as an updated review of pathophysiology of CADD and current treatments.

Endoscopic Extra-articular Surgical Removal of Heterotopic Ossification of the Rectus Femoris Tendon in a Series of Athletes

BACKGROUND

Calcific deposits in tendon, muscles, and periarticular areas are very common. Heterotopic ossification of the rectus femoris (HORF) is a rare condition, and several theories exist regarding the etiopathogenesis, which appears to be multifactorial with traumatic, genetic, and local metabolic factors involved. Although HORF typically responds to nonoperative treatment, when this approach fails, endoscopic treatment is a minimally invasive technique to address the pathology.

PURPOSE

To report the clinical and radiological outcomes of 9 athletes with HORF who underwent endoscopic resection.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Nine male athletes were treated with endoscopic extra-articular resection of HORF after failure of a 6-month course of nonoperative treatment. All patients were studied with radiographs, computed tomography, and magnetic resonance imaging. Outcomes were assessed clinically using the modified Harris Hip Score (mHHS), a visual analog scale for sport activity-related pain (VAS-SRP), patient satisfaction, and ability and time to return to the preoperative sport level. Radiographic assessment was performed to determine recurrence.

RESULTS

The mean age of the patients was 32 years (range, 23-47 years). Mean follow-up was 44 months (range, 14-73 months). All patients had improved mHHS scores from a mean preoperative of 65.6 (SD, 8.2) to 93.9 (SD, 3.6). Pain decreased from a mean 8.2 preoperatively (SD, 0.9) to 0.4 (SD, 0.7) at last follow-up. There were no complications, and all patients were able to return to their previous sports at the same level except for 1 recreational athlete. There was only 1 radiological recurrence at last follow-up in an asymptomatic patient.

CONCLUSION

To our knowledge, this is the largest case series of athletes with HORF treated with endoscopic resection. We found this extra-articular endoscopic technique to be safe and effective, showing clinical outcome improvement and 90% chance of return to full activity. We also found 10% recurrence rate of asymptomatic heterotopic ossification.

Calcific Tendinitis of the Gluteus Maximus in a Golfer

Calcific tendinitis is a relatively rare condition in which calcium is inappropriately deposited in tendons, resulting in a local inflammatory reaction that can cause severe symptoms in certain cases. The cause of this disease process is not completely understood, although repetitive microtrauma likely plays a role in its development. Although the disorder most often involves the rotator cuff, it can affect other structures throughout the body, such as the tendons about the ankle and hip-including the rectus femoris and gluteus maximus. Nonoperative management typically involves using an anti-inflammatory medication and activity modification and can be augmented with formal physical therapy and modalities. Although nonoperative management provides adequate relief for many patients, sometimes operative debridement of the calcific deposit with or without repair of the involved tendon is required. The authors report an unusual case of calcific tendinitis of the gluteus maximus insertion in a golfer. The patient had tried nonoperative treatment for approximately 2 years with no real relief, and a recent exacerbation of the pain was significantly delaying his return to sport. Although plain radiographs did not show abnormalities, magnetic resonance imaging showed a calcific deposit in the insertion of the gluteus maximus tendon. After discussing further treatment options with the patient, the decision was made to remove the deposit and repair the insertion. He recovered completely and was able to return to play. The frequency, pathogenesis, and treatment of this condition are discussed in this case report, as well as the possible link to golf in this patient. [Orthopedics.2016; 39(5):e997-e1000.].

Acute Calcific Tendinitis of the Rectus Femoris: A Case Series

Introduction:

Periarticular calcific tendinitis is a common cause of Orthopedic outpatient referral. Calcific tendinitis of the rectus femoris, however, is very rare and not well known. Due to its rarity, correct diagnosis and prompt treatment are not fully understood.

Case Report:

Two females (38 and 40 years old) of acute calcific tendinitis of the rectus femoris with the good clinical course without any operative treatment were presented. The pain was managed with oral non-steroidal antiinflammatory drugs and/or local steroid injection. Interval radiographic assessment showed complete resorption of the calcification.

Conclusion:

Establishing the correct diagnosis and initiating prompt treatment are shown to be important in achieving resolution of symptoms and in avoiding unnecessary investigations.

Calcific Tendinopathy of the Gluteus Medius Mimicking Lumbar Radicular Pain Successfully Treated With Barbotage: A Case Report

We report a case of calcific tendinopathy of the gluteus medius initially misdiagnosed as a lumbar herniated intervertebral disc. It was successfully treated with barbotage under ultrasonographic guidance finally. A 56-year-old woman was referred to interventional pain clinic for right hip pain due to an L5-S1 disc herniation. Serial L5 and S1 spinal nerve root blocks and epidural steroid injections were administered. However, pain relief was sustained only for a very short period. Plain radiography of the right hip revealed a solid calcific nodule at adjacent to the insertion site of the gluteus medius tendon. Physical modalities and extracorporeal shock wave therapy failed to improve the pain. Therefore, we attempted ultrasound-guided barbotage of the calcification. Barbotage was performed twice serially and her pain was considerably improved. At 6-month follow-up, the calcification was completely resolved.

A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications

PURPOSE

This systematic review examines outcomes and risk profiles of the hip arthroscopy in the supine versus lateral decubitus positions to elucidate any superiority of one approach over the other.

METHODS

Three databases (Embase, PubMed, and Medline) were searched for studies that addressed hip arthroscopy performed in either position, and were subsequently screened by two reviewers with data abstracted in duplicate.

RESULTS

Similar outcomes were observed. Supine studies showed a greater mean postoperative improvement for modified Harris hip score (33.74), visual analog scale (-3.99), nonarthritic hip score (29.61), Harris hip score (35.73), and hip outcome score (31.4). Lateral decubitus studies showed greater improvement using the Western Ontario and McMaster University Osteoarthritis (14.76) score. Supine studies reported more neuropraxic injuries (2.06% v 0.47%), labral penetration (0.65% v 0%), and heterotopic ossification (0.21% v 0%). Lateral decubitus studies reported more fluid extravasation (0.21% v 0.05%) and missed loose bodies (0.08% v 0.01%). Similar rates of revision (1.8% lateral, 1.4% supine) and conversion to open procedures (2.6% in lateral, 2.0% in supine) were also identified.

CONCLUSIONS

Because of quality of evidence, direct comparisons are currently limited; however, the supine position is associated with more neuropraxic injuries, labral penetration, and heterotopic ossification, whereas lateral decubitus has increased risk of fluid extravasation and missed loose bodies. At this time, no evidence exists to establish superiority of one position.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Endoscopic Surgical Removal of Calcific Tendinitis of the Rectus Femoris: Surgical Technique

Calcific tendinitis of the rectus femoris (CTRF) is an under-recognized condition and, because of its self-limiting nature, is usually managed conservatively. Nevertheless, when nonsurgical therapy fails, further invasive alternatives are required. At this point, arthroscopic resection provides a minimally invasive and interesting alternative to open surgery. The aim of this work is to report the surgical technique of endoscopic surgical removal in patients with CTRF at the periarticular region of the hip joint. Endoscopic surgical removal of CTRF was performed without traction following anatomic landmarks for hip arthroscopy portal placement. We used the anterolateral portal and the proximal accessory portal to obtain access to the lesion. A shaver and radiofrequency device are useful tools to depict the calcific lesion while the whole resection is performed with a 5-mm round burr. Intraoperative fluoroscopy control during the entire procedure is essential. Endoscopic treatment of calcific tendinitis of the hip is a valuable technique in the treatment of patients who do not respond to conservative treatment.

Management of acute calcific tendinitis around the hip joint

BACKGROUND

Although the natural history of calcific tendinitis within the rotator cuff of the shoulder is established, the natural history of calcific tendinitis around the hip joint remains unknown.

PURPOSE

To examine the duration of symptoms including pain, the location of calcific tendinitis around the hip joint, the radiologic course of calcium phosphate crystals, and the proportion of patients who required surgical treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty hips (29 patients) with acute calcific tendinitis were treated between January 2010 and December 2012. Level of subjective hip pain using the visual analog scale pain score, radiologic type, and the location and size of calcium deposits were measured during a follow-up period of 12 to 32 months.

RESULTS

The 29 patients included 7 men (24%) and 22 women (76%) with a mean age of 51.5 years (range, 28-78 years). All visual analog scale pain scores significantly improved from a mean of 7.1 to 0.8 at the latest follow-up (P < .001). The most common site of calcium deposition was the tendon of the gluteus medius. During follow-up, calcium deposition completely resolved in 5 of 20 hips. Symptoms in 23 patients (24 hips) responded to nonoperative treatment. Two patients (2 hips) were treated with ultrasound-guided local anesthetic and steroid injection. Four patients (4 hips) with long duration (>3 months) of severe pain, solid type, and large size (range, 96-416 mm(2)) were treated with arthroscopic excision.

CONCLUSION

Nonoperative treatment in patients with acute calcific tendinitis of the hip joint might be successful in most patients. Surgical treatment is of value for patients experiencing prolonged severe pain, solid type, and large size.

The Acute and Chronic Presentation of Gluteus Medius Calcific Tendinitis- A Case Report of Two

Introduction:

The calcific tendinitis is a common to happen around the shoulder, calcific tendinitis of tendons adjacent to the hip is not common like the shoulder. It can present either as acute hip pain and limitation of movement or chronic hip pain. We present two patients one with acute presentation and the other one chronic.

Case Report:

We present a case series of two patients with calcific tendinitis of the gluteus medius muscle. One patient a 37-year-old male presented with acute severe hip pain associated with a raised temperature, prompting concern about septic arthritis. The second patient presented with chronic hip pain. Calcification of the soft tissues adjacent to the greater trochanter was evident on plain radiographs in both patients. CT and MRI scans excluded septic or inflammatory arthritis in the patient with an acute presentation, the patient’s condition settled with analgesia and NSAIDs.

Conclusion:

An unusual combination of symptoms and finding mimicking septic arthritis should be considered in patients presenting with acute calcific tendinitis of the hip gluteus medius muscle.

Acute calcific tendinitis of the gluteus medius: an uncommon source for back, buttock, and thigh pain

OBJECTIVE

This study was conducted to describe the imaging features and clinical manifestations in acute calcific tendinitis (CaT) of the gluteus medius muscle (GMe).

METHODS

A retrospective analysis was conducted, aimed at six patients with acute calcific tendinitis of the gluteus medius muscle (CaT-GMe), who were seen between January 2011 and December 2012. Clinical presentations, radiologic data (radiography, CT, and MRI), and laboratory reports were all subject to review.

RESULTS

All patients presented with pain and decreased range of motion (ROM) at the hip. Two of the six patients experienced pain in the anterolateral thigh and groin, with antalgic gait (anterior group). The other four complained of low back, buttock, and posterolateral thigh pain, accompanied by difficulty in standing and antalgic gait (posterior group). Edema within the GMe or effusion surrounding the muscle was regularly identified on MRIs. Calcific deposits were conspicuous in the gluteus medius tendon attachments to the lateral (anterior group) and superoposterior (posterior group) facets of the greater trochanter on radiography, CT, or MRI. Complete resolution of symptoms was uniformly achieved in 5-10 days with conservative management.

CONCLUSIONS

Acute CaT-GMe should be considered in any patient suffering lateral hip pain (with either groin or low back pain) and ROM limitation. Images of the hip characteristically show edema of the gluteus medius and calcifications lateral or superior to the greater trochanter.

Arthroscopic treatment of chronically painful calcific tendinitis of the rectus femoris

Background

Relatively large calcific tendinitis with persistent symptoms after extended periods of conservative treatment is an indication for operative therapy. Arthroscopy, as a treatment for calcific tendinitis of the hip abductors and calcinosis circumscripta, has been described previously; however, to our knowledge, the clinical and radiological response to arthroscopic removal of calcific tendinitis of the rectus femoris tendon has not.

Methods

We present arthroscopic treatment of unusual calcific tendonitis of the origin of the rectus femoris and associated intra-articular lesions in 3 patients with chronic coxa pain.

Results

Our cases show that hip arthroscopy is an effective therapeutic modality for calcific tendinitis of the hip joint with satisfactory short-term outcomes.

Conclusions

Calcific tendinitis, although an uncommon clinical entity, should be a part of the differential diagnosis of acute or chronic hip pain.

Hip arthroscopy for extra-articular hip disease

The increasing popularity and success of hip arthroscopy has led to the development of related techniques for treating hip pathologies external to the joint proper. These minimally invasive endoscopic procedures serve in a diagnostic role to complement clinical evaluations and offer a therapeutic alternative to traditional open techniques. The indications for extra-articular hip endoscopy continue to expand. Recent literature describes applications for treating greater trochanteric pain syndrome, internal snapping hip, deep gluteal syndrome, and subspine impingement and for diagnosing and treating extra-articular sources of hip pain in patients who have undergone hip arthroplasty.

Peri-articular diseases of the hip: emerging frontiers in arthroscopic and endoscopic treatments

The precise diagnosis of both intra and extra-capsular disease of the hip is now possible because of commonly available advanced diagnostic imaging techniques. An increasing number of reports in the orthopedic literature describe new endoscopic and arthroscopic techniques to address peri-articular pathology of the hip. The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.

Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up

BACKGROUND

Gluteus medius tears may be present in as many as 25% of late middle-aged women and 10% of middle-aged men, and they are often misdiagnosed. Outcomes of endoscopic repair of gluteus medius tears have seldom been reported.

PURPOSE

To report the early outcomes of endoscopic repair of partial- and full-thickness gluteus medius tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2009 and January 2010, data were prospectively collected for all patients undergoing endoscopic gluteus medius repair by one of the authors. Inclusion criteria for the study were patients undergoing repair for either high-grade, partial-, or full-thickness tears. Only patients with endoscopic evidence of a gluteus medius tear were treated surgically. In the case of an articular-side tear, a transtendinous repair technique was used, whereas in the presence of a full-thickness tear, the tendon was refixated to the bone directly.

RESULTS

A total of 15 patients met the inclusion criteria. The cohort included 14 women and 1 man, with an average age of 58 years (range, 44-74 years). Endoscopically, 6 cases were found to be partial-thickness tears. Nine were either full-thickness tears or near-full-thickness tears, which were completed for the repair. Follow-up was obtained on all patients at an average of 27.9 months postoperatively (range, 24-37 months). Fourteen of the 15 patients showed postoperative improvement in all 4 hip-specific scores used to assess outcome, with an average improvement of more than 30 points for all scores. Satisfaction with the surgery results was reported to be from good to excellent (scores of 7-10 out of 10) in 14 of 15 patients.

CONCLUSION

This study demonstrates that endoscopic surgical repair, whether performed through a transtendinous or full-thickness technique, can be an effective treatment of gluteus medius tears at a minimum follow-up of 2 years. Longer term follow-up studies are necessary to determine whether these therapeutic and functional gains are maintained.

Endoscopic repair of proximal hamstring avulsion

Hamstring muscle injuries are common in athletes and mostly consist of sprains at the myotendinous junction, which often respond well to conservative treatment. Proximal hamstring avulsion injuries, though less common, can be severely debilitating. This injury is often seen in water skiers but has been described in many other sports and in middle-aged patients. Complete avulsions in young and active individuals do not respond well to conservative treatment and may require surgical repair. In contrast, many partial tears may be treated nonoperatively. However, when symptoms continue despite a trial of extensive therapy, surgery may be warranted. Traditional surgery for proximal hamstring repair is performed with the patient in the prone position with an incision made longitudinally or along the gluteal fold, followed by identification of the torn tendons and fixation to the ischial tuberosity. We describe a novel surgical technique for endoscopic repair of proximal hamstring avulsion injuries.

Extra-articular hip endoscopy: A review of the literature

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

Accessibility of extra-articular pathologies of iliopsoas tendon and bursitis of greater trochanter in hip arthroscopy

PURPOSE

Different pathologies leading to psoas tendon pain and chronic bursitis of the greater trochanter are well known. The purpose of the study was to underline the accessibility of the psoas tendon at lesser trochanter, reproduce the results and measure the distances to anatomical landmarks.

METHODS

Twelve hips of six human cadavers underwent hip arthroscopy. The accessibility of the iliopsoas tendon at the lesser trochanter and the bursa at the greater trochanter was documented with the camera. In addition to the usual access portals, alternative ventral ports were analysed concerning accessibility of the lesser trochanter. Afterwards, arthroscopy needles were placed along the extra-articular portals followed by dissection. The distances of the portals in relation to important anatomical landmarks were analysed.

RESULTS

The accessibility to the iliopsoas tendon at the lesser trochanter and to the bursa at the greater trochanter throughout the conventional portals was reproducible. Sufficient distances to the important anatomical landmarks could be shown. The mean distance of the distal ventro-lateral and the wide distal ventro-lateral portal to the nervous cutaneous femoris lateralis was 26.8 ± 5.4 mm and 32.2 ± 3.9 mm. The mean distance from the more ventral located portals to the nervous arteria and vena femoralis was 28.3 ± 2.1 mm.

CONCLUSION

This is the first study known to us that describes in detail the accessibility of the extra-articular structures underlined by anatomical preparation. In addition, it was demonstrated that a more ventrally located portal had sufficient distance to the important neurovascular structures of the ventral femur and can also be used in addendum if necessary.

Posterior hip pain in an athletic population: differential diagnosis and treatment options

Context:

Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population.

Evidence Acquisition:

Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010.

Results:

Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases.

Conclusions:

Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Lateral hip pain in an athletic population: differential diagnosis and treatment options

CONTEXT

Historically, the term greater trochanteric pain syndrome has been used to describe a spectrum of conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, snapping iliotibial band, and/or strains or tendinopathy of the abductor mechanism. Diagnosis of these conditions may be difficult because clinical presentations are variable and sometimes inconclusive. Especially difficult is differentiating intrinsic pain from pain referred to the greater trochanteric region. The purposes of this article are to review the relevant anatomy and pathophysiology of the lateral hip.

EVIDENCE ACQUISITION

Data were collected through a thorough review of the literature conducted through a MEDLINE search of all relevant papers between 1980 and January 2010.

RESULTS

Recent advances in imaging and an improved understanding of pathomechanics have helped to guide the evaluation, diagnosis, and appropriate treatment for patients presenting with lateral hip pain.

CONCLUSION

Various diagnostic tools and treatment modalities can be used to effectively manage the athletic patient presenting with lateral hip pain.

Partial-thickness tears of the gluteus medius: rationale and technique for trans-tendinous endoscopic repair

Tears in the gluteus medius and minimus tendons, often misdiagnosed as trochanteric bursitis, have recently emerged as an important cause of recalcitrant greater trochanter pain syndrome. Advances in endoscopic surgery of the hip have created opportunities to better evaluate and treat pathology in the peritrochanteric compartment. We reviewed the literature on trochanteric pain syndrome and gluteus medius tendon injuries. Existing techniques for endoscopic and open gluteus tendon repair and potential challenges in restoration of abductor function were analyzed. Partial-thickness undersurface tears of the gluteus medius were identified as a common pathologic entity. Although these tears are otherwise analogous to partial-thickness tears of the rotator cuff, the lack of arthroscopic access to the deep side of the gluteus medius tendon represents a unique technical challenge. To address the difficulty in visualizing and thus repairing undersurface tears of the gluteus medius, a novel endoscopic trans-tendinous repair technique was developed. The purposes of this article are to review the anatomy, pathology, and existing repair techniques of gluteus medius tendon tears and to describe the rationale and surgical steps for endoscopic trans-tendinous repair.

Endoscopic treatment of calcinosis circumscripta of the hip joint: a report of 2 cases of arthroscopic removal of a calcific deposition between the labrum and capsule

We present 2 cases of arthroscopic removal of a calcific deposition in the form of calcinosis circumscripta between the labrum and capsule of the hip joint. Case 1 was a 42-year-old woman who presented with complaints of a 2-year history of right hip pain. Radiographs showed a calcific deposition in the area of the acetabular roof. Arthroscopy showed a calcific deposition between the labrum and capsule in the form of calcinosis circumscripta. At the 4-month follow up, she was symptom free with painless full range of motion. Case 2 was a 48-year-old slim woman who presented with complaints of right hip pain over the last 6 months. Preoperative radiographs showed a hip with a calcific deposition lateral to the pronounced acetabular roof. At the 4-month follow up after removal, she was also symptom free. To our knowledge, these are the first patients with calcinosis circumscripta treated by hip arthroscopy. We recommend the endoscopic approach, which is effective and minimally invasive, for treatment of calcinosis circumscripta and other calcifications in the hip joint. Especially in young patients, with a high activity level and without any symptoms of hip osteoarthritis, hip arthroscopy is the ideal treatment.

Calcific tendinitis of the rectus femoris

This article describes calcific tendinitis of the rectus femoris treated with a local injection of a mixture of steroid and local anesthetic under C-arm control. From March 2004 to May 2005, 6 patients were treated for calcific tendinitis of the rectus femoris at our institution and followed for at least 2 years. The male:female ratio was 1:5, and mean patient age was 41 years (range, 33-49 years). Calcifications were located in the direct head in 1 patient and in the reflected head of the rectus femoris in 5. One patient underwent open surgical removal and 5 were treated with a local steroid and anesthetic injection. The patient undergoing surgical removal obtained immediate pain relief but reported discomfort in the wound area for 10 days postoperatively. The 5 patients receiving injections achieved dramatic pain relief within 2 days; follow-up radiographs revealed complete calcification disappearance within 16 weeks of treatment in all 5. No patient had experienced recurrence or complications at >2-year follow-up. Prompt diagnosis and early treatment with a local injection of a mixture of steroid and local anesthetic under C-arm control successfully relieved symptoms and facilitated a return to normality.

Endoscopic repair of gluteus medius tendon tears of the hip

BACKGROUND

Tears of the gluteus medius tendon at the greater trochanter have been termed "rotator cuff tears of the hip." Previous reports have described the open repair of these lesions.

HYPOTHESIS

Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys.

RESULTS

At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal.

CONCLUSION

With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement

PURPOSE

This study evaluated 11 arthroscopic portals (4 central, 4 peripheral, and 3 peritrochanteric) with regard to their proximity to neurovascular structures and the extra-articular path taken before entering their intended compartments.

METHODS

We established 11 standard portals in 10 cadaveric hips, under arthroscopic and fluoroscopic visualization, using 3/16-inch Steinmann pins. Each hip was dissected, and the relation of the pins to the pertinent anatomy was recorded to the nearest 1 mm.

RESULTS

Only 2 of the 11 portals, the anterior and midanterior portals, came within 2 cm of a neurovascular structure before entering their respective compartments. The anterior portal placed the lateral femoral cutaneous nerve at risk, lying at a mean of 15.4 mm (range, 1 to 28 mm) away. The midanterior portal lies a mean of 19.2 mm (range, 5 to 42 mm) from the ascending branch of the lateral circumflex femoral artery. In addition, a small terminal branch of this artery courses a mean of 14.7 mm (range, 2 to 33 mm) and 10.1 mm (range, 1 to 23 mm) from the anterior portal and midanterior portal, respectively.

CONCLUSIONS

This study showed that 11 arthroscopic portals can be safely inserted into the central, peripheral, and peritrochanteric compartments of the hip. The midanterior and anterior portals pass in close proximity to a small terminal branch of the ascending lateral circumflex femoral artery. The greatest risk still comes from the proximity of the anterior portal to the lateral femoral cutaneous nerve. However, a slightly more lateral location seems to provide substantial benefits.

CLINICAL RELEVANCE

This study investigated 11 arthroscopic hip portals inserted in a standardized fashion. This knowledge should help surgeons place the necessary portals both safely and accurately.

Lateral hip pain: findings from magnetic resonance imaging and clinical examination

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVES

To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology.

BACKGROUND

LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem.

METHODS AND MEASURES

Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance imaging (MRI) studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined.

RESULTS

Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large.

CONCLUSIONS

The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MRI as a diagnostic reference standard. This factor, together with the imprecise point estimates of the likelihood ratios, means that no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology.

Fibular collateral ligament-biceps femoris calcific bursitis causing flexion contracture in the knee, external rotation in the leg, and equinus deformity in the ankle

OBJECTIVE

The fibular collateral ligament (FCL)-biceps femoris (BF) bursa is not a commonly known location for calcific bursitis. A case of FCL-BF calcific bursitis is presented.

CLINICAL FEATURES

An 18-year-old man had a blunt trauma on the lateral side of his right knee approximately 1 year before his examination. The pain and physical distortion developed in the trauma region over time. Physical examination revealed a 30 degrees flexion contracture and slight valgus deformity in the right knee. There was 30 degrees of external rotation in the leg and a 15 degrees equinus deformity in the ankle. The patient had toe-toe gait. There was a tender swelling 3 x 4 cm in size on the posterolateral aspect of the right knee.

INTERVENTION AND OUTCOME

Plain radiography and computed tomography revealed a calcific mass, approximately 1.5 x 4 cm in size, between soft tissues adjacent to the posterolateral side of the right lateral femoral condyle. There were articular cartilage thinning and joint space narrowing at the lateral site of the knee joint, and magnetic resonance imaging showed bone marrow edema at the lateral condyles of the tibia and femur. The enlarged calcified bursa was excised. A segment of the contracted iliotibial tract was excised, and a fractional lengthening was performed on the BF tendon.

CONCLUSION

This case report revealed that calcific bursitis can occur in the FCL-BF bursa, which may lead to complications when neglected.

Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

Arthroscopic bursectomy for recalcitrant trochanteric bursitis

PURPOSE

The purpose of this prospective study was to evaluate the arthroscopic treatment of trochanteric bursitis in patients who have not responded to nonoperative treatment.

METHODS

Thirty patients were enrolled in this study to evaluate the results of arthroscopic bursectomy. Outcomes were assessed by use of a visual analog pain scale, Harris Hip Score, Short Form 36 Health Survey, and additional specific hip function questions. Patients were given the self-administered outcome questionnaires before surgery and at subsequent follow-up visits. Of the patients, 25 were available for a mean follow-up of 26.1 months (range, 13.8 to 41 months).

RESULTS

Pain scores on the visual analog scale improved from a preoperative mean of 7.2 (0, no pain; 10, worst pain) to a postoperative mean of 3.1 at final follow-up (P = .0001). Mean Harris Hip Scores improved from a mean of 51 preoperatively to 77 at follow-up (P = .0001). Improvements were also noted in the physical component summary scores of the Short Form 36. The mean physical function score improved from 33.6 preoperatively to 54 at follow-up (P = .022), and in the pain category, the mean score improved from 28.7 to 51.5 (P = .001). One postoperative complication occurred, a seroma that required repeat surgery. One patient had a failed arthroscopic bursectomy and subsequently underwent open bursectomy with resolution of symptoms.

CONCLUSIONS

Arthroscopic bursectomy appears to be an effective option for recalcitrant trochanteric bursitis and is a viable alternative to open bursectomy. In this prospective study patients had good pain relief and improved function compared with their preoperative status. Improvements in a patient's status are usually evident by 1 to 3 months after surgery and appear to be lasting.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Labral tears, extra-articular injuries, and hip arthroscopy in the athlete

Labral tears in athletes can lead to disabling hip pain and affect their athletic performance. Other intra-articular lesions, including chondral injuries, capsular abnormalities, and ligamentum teres tears, commonly coexist with acetabular labral tears. Isolated athletic injury or repetitive traumatic activity can lead to labral tears; however, underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing athletes to labral pathology must be addressed. Recent studies have demonstrated lesions associated with acetabular labral tears, and that labral tears rarely occur as isolated injuries. Return to sport is favorable in athletes who have labral tears if they are properly treated with arthroscopic intervention.

MR Imaging of the Hip Abductors: Normal Anatomy and Commonly Encountered Pathology at the Greater Trochanter

Lateral hip pain, also referred to as the greater trochanteric pain syndrome, is a commonly encountered clinical problem with a broad set of differential considerations. A detailed understanding of the osseous anatomy of the greater trochanter, the correspond-ing attachment sites of the abductors of the hip, and the spatial and anatomic relations of their corresponding bursae is crucial to the accurate characterization and localization of pathologic findings in these structures. This article reviews the anatomy and pathologic findings of the osseous and soft tissue anatomy of the greater trochanter.

Acute calcific tendinitis of the gluteus medius: a case report with serial magnetic resonance imaging findings

A case of calcific tendinitis of the gluteus medius is presented. Calcification was evident in the soft tissue adjacent to the greater trochanter on plain radiographs. On the initial magnetic resonance images (MRI), inflammatory edematous change was detected not only in the gluteus medius but also in the bone marrow of the greater trochanter, corresponding to the painful area. Three months later, calcification disappeared on plain radiographs and the femur showed normal signal intensity on MRI. Initial MRI excluded other diseases' including infection and bone tumor, and serial MRI confirmed that the change in extraosseous and intraosseous findings were in accordance with self-limiting clinical symptoms.

Basic calcium phosphate deposition in the joint: a potential therapeutic target in osteoarthritis

PURPOSE OF REVIEW

Basic calcium phosphate crystals are responsible for a number of clinical syndromes. The study of basic calcium phosphate crystal deposition diseases has been hindered by a lack of readily available, accurate, diagnostic tests. Recent data have provided further understanding of the mechanisms by which basic calcium phosphate crystals induce inflammation and degeneration within the joint, as well as their potential role in other conditions such as cancer and atherosclerosis.

RECENT FINDINGS

New information on the effects of basic calcium phosphate crystals on matrix metalloproteinases and mitogenesis further supports a role for basic calcium phosphate crystals in the pathogenesis of osteoarthritis. Phosphocitrate remains the most promising of the potential therapeutic agents, which could antagonize the effects of basic calcium phosphate crystals, although other therapies have also been examined.

SUMMARY

Further work is needed to clarify the exact role basic calcium phosphate crystals play in the development of osteoarthritis.