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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

Article

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

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Abstract

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.

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... Patient satisfaction was reported in 12 studies a and was commonly determined using a Likert scale. Common functional outcome assessments were resisted hip abduction in 7 studies, 14,21,22,29,31,40,42 a 30-second single-leg stance test (3 studies 14,21,31 ), a 6-minute walk test (2 studies 21,22 ), or an evaluation of range of motion or gait abnormalities (Trendelenburg sign, limping; 6 studies 18,23,29,38,40,41 ). The follow-up period ranged from 1.5 weeks to 100 months. ...
... Patient outcomes measured using the mHHS peaked at 6 weeks after a single CSI according to data published by Fitzpatrick et al 25,26 (LoE 1b) and thereafter declined. However, the mHHS scores obtained from this References 8,9,17,18,21,22,29,31,38,[40][41][42]50,51,53,55. {{ References 4,8,9,14,17,22,23,29,31,33,36,38,39,42,50,53. ...
... However, the mHHS scores obtained from this References 8,9,17,18,21,22,29,31,38,[40][41][42]50,51,53,55. {{ References 4,8,9,14,17,22,23,29,31,33,36,38,39,42,50,53. ## population at 52 and 104 weeks from baseline were at the same level as those at the 6-week mark and were significantly higher than were baseline values. ...
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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.
... While several clinical HAT studies have been published over the past 3 years [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], detail provided on post-operative rehabilitation within these studies remains limited. This provides little direction to the therapist working with these patients in their post-operative management. ...
... This manuscript reviews the more recent published literature [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] and associated content provided pertaining to rehabilitation following surgical HAT repair and, combined with the authors' published clinical experience working with these patients, a rehabilitation protocol is presented providing therapists a more structured resource. While the proposed protocol should be modified as required based on individual patient characteristics, together with the nature (i.e. ...
... Now, both open and endoscopic techniques are commonly described, with systematic reviews reporting no difference in post-operative clinical scores albeit a higher complication rate with open repair techniques that may include infection/hematoma, deep vein thrombosis (DVT) an re-tear [31,42]. However, the repair technique employed is generally dependent on the nature and size of the tear [12,16,17,23,26,31,43,44], with studies over the past few years increasingly reporting the use of augmentation devices to assist the surgical repair [11,13,14,18,24,[45][46][47][48]. ...
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Introduction Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is hip abductor tendon (HAT) tears. Traditionally, these patients have been managed non-operatively, often with temporary pain relief. More recently, there has been an increase in published work presenting the results of surgical intervention. A variety of open and endoscopic transtendinous, transosseous and/or bone anchored suture surgical techniques have been reported, with and without the use of tendon augmentation for repair reinforcement. While patient outcomes have demonstrated improvements in pain, symptoms and function, post-operative rehabilitation guidelines are often vague and underreported, providing no guidance to therapists. Materials and methods A systematic search of the literature was initially undertaken to identify published clinical studies on patients undergoing HAT repair, over a 3-year period up until May 2020. Following the application of strict inclusion and exclusion criteria, studies were identified and the detail relevant to rehabilitation was synthesized and presented. Published detail was combined with the authors clinical experience, with a detailed overview of rehabilitation proposed for this patient cohort. Results A total of 17 studies were included, reporting varied detail on components of rehabilitation including post-operative weight bearing (WB) restrictions, the initiation of passive/active hip range of motion (ROM) and resistance exercises. A detailed rehabilitation guide is proposed. Conclusion In combining the current published literature on rehabilitation after HAT repair and our own clinical experience in the surgical management and post-operative rehabilitation of these patients, we present an evidence-based, structured rehabilitation protocol to better assist surgeons and therapists in treating these patients. This rehabilitation protocol has been implemented for several years through our institutions with encouraging published clinical outcomes.
... We placed reflective markers on the manubrium of the sternum (Dingenen et al., 2014), anterior superior iliac spine (ASIS) bilaterally (Dingenen et al., 2014;Scholtes & Salsich, 2017;Stickler et al., 2015), center of the patella (Huxtable et al., 2017), and center of the talocrural joint (Stickler et al., 2015;Willson et al., 2006) for 2D kinematic analysis in the frontal plane. We placed reflective markers on the dominant side greater trochanter, lateral femoral epicondyle, and lateral malleolus (Dingenen et al., 2015a) for sagittal plane analysis. ...
Article
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... Total knee and hip replacement arthroplasty are commonly used procedures in which the knee or hip joint is replaced by an artificial joint [3]. The success of the engineered artificial joint depends on the biomechanical and material properties [4][5][6]. A total hip replacement is shown in Fig. 1 and is composed of an acetabular component, which usually is made of metal (titanium alloys etc), a Plastic Liner (made of polymers), a femoral head and a femoral stem that are usually made of the same material as the acetabular cup [7]. ...
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The article presents a case study that was realized at the Technical University of Cluj-Napoca (TUC-N) in the field of customized medical implants made by using different additive manufacturing (AM) technologies, such as the Selective Laser Sintering (SLS) and the Selective Laser Melting (SLM). Finite element analysis was successfully used to determine the mechanical behavior of an acetabular liner that was made from PA 2200 powder material by SLS and to determine the optimum technological parameters required to be used in the manufacturing process of the acetabular liner by SLS, so as the contact pressure between the acetabular liner made from PA 2200 material by SLS and the femoral head made from TiAl6V4 material by SLM will be optimum at the end and the displacement between the components will remain in the admissible limits.
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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.
Article
Purpose: Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm. Methods: Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips. Results: A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%. Conclusion: The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments. Level of evidence: IV.
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Abstract BACKGROUND: Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome (GTPS), though limited information exists on the disability associated with this condition and specific presentation of these patients. PURPOSE: To describe the clinical, functional and biomechanical presentation of patients with symptomatic HAT tears. Secondary purposes were to investigate the association between these clinical and functional measures, and to compare the pain and disability reported by HAT tear patients to those with end-stage hip osteoarthritis (OA). STUDY DESIGN: Prospective case series. METHODS: One hundred forty-nine consecutive patients with symptomatic HAT tears were evaluated using the Harris (HHS) and Oxford (OHS) Hip Scores, SF-12, an additional series of 10 questions more pertinent to those with lateral hip pain, active hip range of motion (ROM), maximal isometric hip abduction strength, six-minute walk capacity and 30-second single limb stance (SLS) test. The presence of a Trendelenburg sign and pelvis-on-femur (POF) angle were determined via 2D video analysis. An age matched comparative sample of patients with end-stage hip OA was recruited for comparison of all patient-reported outcome scores. Independent t-tests investigated group and limb differences, while analysis of variance evaluated pain changes during the functional tests. Pearson's correlation coefficients investigated the correlation between clinical measures in the HAT tear group. RESULTS: No differences existed in patient demographics and patient-reported outcome scores between HAT tear and hip OA cohorts, apart from significantly worse SF-12 mental subscale scores (p = 0.032) in the HAT tear group. Patients with HAT tears demonstrated significantly lower (p < 0.05) hip abduction strength and active ROM in all planes of motion on their affected limb. Pain significantly increased throughout the 30-second SLS test for the HAT tear group, with 57% of HAT tear patients demonstrating a positive Trendelenburg sign. POF angle during the test was not significantly associated with pain. CONCLUSION: Patients with symptomatic HAT tears demonstrate poor function, and report pain and disability similar to or worse than those with end-stage hip OA. This information better defines and differentiates the presentation of these patients. LEVEL OF EVIDENCE: Level 3 case-controlled study, with matched comparison. KEYWORDS: Assessment; clinical outcomes; hip abductor tears; patient presentation
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Background: Lateral hip pain during single leg loading, and hip abductor muscle weakness, are associated with gluteal tendinopathy, but it has not been shown how or whether kinematics in single leg stance differ in those with gluteal tendinopathy. Purpose: To compare kinematics in preparation for, and during, single leg stance between individuals with and without gluteal tendinopathy, and the effect of hip abductor muscle strength on kinematics. Methods: Twenty individuals with gluteal tendinopathy and 20 age-matched pain-free controls underwent three-dimensional kinematic analysis of single leg stance and maximum isometric hip abductor strength testing. Maximum values of hip adduction, pelvic obliquity (contralateral pelvis rise/drop), lateral pelvic translation (ipsilateral/contralateral shift) and ipsilateral trunk lean during preparation for leg lift and average values in steady single leg stance, were compared between groups using an analysis of covariance, with and without anthropometric characteristics and strength as covariates. Results: Individuals with gluteal tendinopathy demonstrated greater hip adduction (standardized mean difference (SMD)=0.70, P=0.04) and ipsilateral pelvic shift (SMD=1.1, P=0.002) in preparation for leg lift, and greater hip adduction (SMD=1.2, P=0.002) and less contralateral pelvic rise (SMD=0.86, P=0.02) in steady single leg stance than controls. When including strength as a covariate, only between-group differences in lateral pelvic shift persisted (SMD=1.7, P=0.01). Conclusion: Individuals with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg stance than pain-free controls. This finding is not influenced by pelvic dimension or the potentially modifiable factor of body mass index, but is by hip abductor muscle weakness.
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Purpose: To compare hip abductor muscle strength between individuals with symptomatic, unilateral gluteal tendinopathy (GT) and asymptomatic controls. Methods: Fifty individuals with GT aged between 35 and 70 years, and 50 sex- and age-comparable controls were recruited from the community. Maximal isometric strength (torque normalized to body mass) of the hip abductors was recorded in supine using an instrumented manual muscle tester. A two-way mixed analysis of covariance (ANCOVA), with covariates of self-reported pain during testing and pain limiting maximum effort, was used to compare hip abductor strength of the symptomatic and asymptomatic hip between GT and control individuals. Data were expressed as mean and standard deviation, with the pairwise comparisons expressed as mean differences and 95% confidence intervals. Results: Individuals with GT demonstrated significantly lower hip abductor torque of both their symptomatic and asymptomatic hip than healthy controls (both p<0.05) with mean strength deficits of 0.35 Nm/kg (32%) on the symptomatic hip and 0.25 Nm/kg (23%) on the asymptomatic hip. In individuals with GT, the symptomatic hip was significantly weaker than the asymptomatic hip with a mean strength deficit of 0.09 Nm/kg (11%) (p<0.05). Conclusion: People with unilateral GT demonstrate significant weakness of the hip abductor muscles bilaterally when compared with healthy controls. Although it is not clear whether hip weakness precedes GT or is a consequence of the condition, the findings provide a basis to consider hip abductor muscle weakness in the treatment plan for management of GT.
Article
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. Gluteus medius and minimus tears can be repaired effectively with an open double-row technique. 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. 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). 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 IV-retrospective study. Copyright © 2014. Published by Elsevier Masson SAS.
Article
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.
Article
The purpose of this study was to assess the surgical outcomes of endoscopically repaired full-thickness abductor tendon tears using validated outcome measures. After institutional review board approval was obtained, clinical outcome data were retrospectively collected from patients who underwent endoscopic gluteus medius and/or minimus repair by a single surgeon between August 2009 and September 2011. With a minimum follow-up of 1 year, patients were evaluated using the modified Harris Hip Score and the validated Hip Outcome Score (HOS). The HOS questionnaire included 2 subsections: HOS-Activities of Daily Living and HOS-Sports. Physical examination data were gathered during routine clinic visits, 1 year postoperatively. Statistical analysis was descriptive. The change in strength testing postoperatively was assessed with the Wilcoxon signed rank test, with significance set at P ≤ .05. Twelve patients were identified, 1 of whom was excluded; 10 of 11 patients (91%) completed the study requirements. The mean patient age was 65.9 years (range, 60 to 74 years), 70% were women, and the mean follow-up period was 23 months (range, 13 to 38 months). The mean postoperative scores were 84.7 (SD, 14.5) for the modified Harris Hip Score and 89.1 (SD, 11.3) for the HOS-Activities of Daily Living, with 90% patient satisfaction. All patients had clinically and statistically improved abductor tendon strength (P = .004). Patients with good to excellent outcomes were younger (P < .001). There were no complications identified. In our small series, endoscopic abductor tendon repair was an effective surgical intervention after failed conservative management at short-term follow-up. Patients had reliably good to excellent outcomes with improved strength during hip abduction, were at low risk of complications, and were satisfied with the outcome. In addition, younger patients achieved better outcomes. Level IV, therapeutic case series.
Article
Disorders of the peritrochanteric space include 3 well-described entities: external coxa saltans, greater trochanteric bursitis, and gluteus medius and/or minimus tears. These disorders have been previously grouped into the “greater trochanteric pain syndrome.” In most cases, conservative treatment consisting of local corticosteroid and anesthetic injections combined with a structured physical therapy program, provides a successful outcome. When conservative treatment fails, endoscopic trochanteric bursectomy, iliotibial band lengthening, and/or gluteus medius tendon repair can be performed.
Article
Partial-thickness tear of the gluteus medius and minimus muscles has recently been recognized as a cause of chronic trochanteric pain resistant to medical treatment. The present article reports an original endoscopic technique of identification and repair. It uses a standard arthroscope at 30°, with the patient in lateral decubitus, without fluoroscopy. In case of partial-thickness undersurface tear, careful hook palpation followed by bursa exploration enables the pathological tendon to be diagnosed. A trans-tendinous approach then allows debridement, with systematic resection of the bone structures implicated in the impingement, followed by side-to-side tendon suture. Level IV (case series).
Article
Greater trochanteric pain syndrome is a common orthopaedic condition related to underlying bursitis, but it may reflect gluteal tendinopathy with tendon disruption from the greater trochanter. Our goal was to evaluate our clinical experience with surgical repair of these tears. We retrospectively evaluated a consecutive series of twenty-two patients (twenty-three hips) with a tear of the hip abductor tendons who underwent surgical reconstruction and were followed for a minimum of five years. The preoperative evaluation revealed chronic lateral hip pain, a positive Trendelenburg sign, and a tear documented by magnetic resonance imaging (MRI). The tears were defined intraoperatively with a four-tiered scheme that accounted for the dimension of the tear ranging from partial-thickness undersurface tears to complete tears of the gluteus muscle tendon insertion. The mean Harris hip score improved from 53 points preoperatively to 87 points at one year and 88 points at five years. The mean Lower-Extremity Activity Scale score improved from 6.7 points preoperatively to 8.9 points at one year and 8.8 points at five years. With the numbers available, no significant difference in the degree of clinical improvement was found on the basis of the severity of the tear. However, the three patients with poor results were in the group with the largest tears. Overall, sixteen of nineteen patients were satisfied with their surgical result and were willing to undergo the procedure again if necessary. Surgical repair of torn abductor tendons of the hip is a viable option when MRI and clinical findings are consistent with tendon disruption and weakness. There was substantial and durable improvement in strength and clinical performance in most cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
An end-result analysis is presented of thirty-nine mold arthroplasties performed at the Massachusetts General Hospital between 1945 and 1965 in thirty-eight consecutive private patients for arthritis of the hip following fractures of the acetabulum or dislocations of the hip. Of the nineteen unilateral cases in the second half of the series, sixteen were rated good or excellent. Results in the second half of the series were significantly better statistically than those in the first half of the series. Possible reasons for this improvement are discussed. No significant deterioration occurred with the passage of time. Among the thirty-nine hips, three revisions were required. One patient had postoperative sepsis after arthroplasty. Four patients who had had intra-articular sepsis prior to arthroplasty showed no evidence of sepsis postoperatively. Factors influencing the choice between hip fusion and hip arthroplasty in these cases are presented. A new system for rating hip function is proposed and is compared with the systems of Larson and Shepherd.
Article
Recent decisions of the Supreme Court of Canada have established firm legal principles concerning the compelled production of therapeutic records to the defence in criminal proceedings. These principles may act as a model for legal developments in Australia and New Zealand. This article describes the leading Canadian cases, identifies the legal issues presented for decision and summarises the principles established. It concludes with discussion of arguments for and against disclosure of therapeutic records to the defence in sexual assault cases. The emerging Canadian doctrines are endorsed as sensible lines of compromise in a difficult field.
Article
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.
Article
Single leg loading tests are used clinically to examine balance and loading strategies in individuals with lower limb pain. Interpretation of these tests is through pain responses and comparisons with the asymptomatic leg. The purpose of this study was to examine normal differences in trunk and pelvic movement between legs during the single leg stand, single leg squat, hip hitch and hip drop tests, and to compare observational and quantitative assessments of trunk movement during the single leg squat test. Thirty-one asymptomatic females (age = 21.7 ± 3.1 years) performed each test in a random sequence and quantitative analysis of coronal plane trunk lean (magnitude and direction), and femoro-pelvic angle was conducted using photographic image analysis. Within- and between-side minimal significant differences (MD) for femoro-pelvic angle were defined for each test. All tests had excellent within-side reliability (intra-class correlation coefficients (ICC) = 0.87-0.97, standard error of measurement (SEM) = 0.6-1.2°). The between-side MD for femoro-pelvic angle was 6.3, 6.5, 9.7, and 6.7° for the single leg stand, single leg squat, hip hitch and hip drop tests respectively. The magnitude of trunk lean was small, increased with test complexity and was not consistent in relation to the stance leg. Excellent agreement (87-93%) for the direction of trunk movement between observers, and between observational and quantitative analysis (80-96%) was established for the single leg squat test. The patterns of trunk motion, and thresholds for significant difference in femoro-pelvic angle established in this study, will assist the interpretation of single leg loading tests in individuals with lower limb pain disorders.
Article
Avulsion of the abductors from the hip can be an infrequent but debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. This can result in intractable pain, limp, Trendelenberg lurch and instability of the hip. There have been various methods described for repairing or reconstruction of this abductor muscle complex including direct trans-osseous repair, muscle transfers, muscle and tendon sling, bone tendon allograft reconstruction and endoscopic repair techniques. In a prospective study at our institution we evaluated the results of a surgical technique in 12 patients using a trans-osseous repair of gluteus medius and minimus insertions augmented by a Graft Jacket® allograft acellular human dermal matrix (Graft Jacket®; Wright Medical Technology, Arlington, TN) over the anterior and anterolateral aspects of the greater trochanter. Diagnosis of hip abductor avulsions was made by evaluation of the history of presenting complaint, clinical examination and confirmed by ultrasound or MRI scans. Evaluation of results included pain scoring, gait evaluation, Trendelenberg test, and the Harris hip score. There was a significant improvement in pain (VAS mean values 8.25 to 2.33; p value < 0.0001), limp and gait along with abductor strength. The Trendelenberg test became negative in all but one. At the mean follow up of 22 months Harris hip scores improved from 34.05 to 81.26 (p value <0.0001). Overall this procedure appears to be safe and associated with high patient satisfaction, without the morbidity of any tendon or muscle transfers.
Repair of a chronic rupture with a defect of the gluteus medius muscle with or without a total hip replacement. Improvement of gait and limping by functional stabilization of the pelvis. Reduction of pain in the region of the greater trochanter. Chronic rupture with a defect of the gluteus medius. Complete bony defect and absence of the greater trochanter and hip infection. Lateral positioning of the patient. Longitudinal incision of 12-15 cm over the greater trochanter. Preparation to the fascia and longitudinal incision slightly dorsal to the greater trochanter. Preparation and mobilization of the ruptured parts of the gluteal muscles. Smoothening of the insertion of the gluteal muscle. Transosseus fixation of the ventral part of the ruptured gluteal muscles using fiber wires (Arthrex, Munich, Germany) with a Mason-Allen technique. Suturing of the mobilized posterior part of the ruptured gluteal muscle on the resutured ventral gluteal part. Securing of the readaptation by suturing a nonresorbable collagen patch (Zimmer, Winterthur, Switzerland) in a rhomboid direction with nonresorbable sutures (Ethibond, Ethicon, Norderstedt, Germany). Wound closure. POSTOPERATIVE TREATMENT: Prophylaxis of deep venous thrombosis. Early functional mobilization. Continuous increase of weight bearing over a period of 6 weeks and 6 weeks no adduction or active abduction. Ten patients (9 women, 1 man; age 73.4 ± 12.3 years) showed significant improvement of their symptoms after 1 year. All were pain free and did not need crutches anymore. Four could walk without any limping and in 6 slight limping was observed. The Harris Hip Score increased from 47.5 ± 9.5 points preoperative to 85.2 ± 7.6 points 1 year postoperative. Complications were not observed.
Article
13 patients with tears in the gluteus medius tendon following total hip arthroplasty were studied. The diagnosis of a gluteal tear was made on the basis of clinical signs and a positive arthrogram of the hip in all cases. 11 patients underwent gluteus medius repair and two patients declined surgery. 10 patients attended a review clinic (eight gluteal repair patients and two conservatively managed patients) and three were reviewed by telephone and medical notes. The mean follow up was 61 months (range 12–116 months). The mean age at follow up was 71.42 years (69–79 years) and the male to female ratio was 5:8. The mean duration of symptoms prior to repair was 16 months. An anterolateral transgluteal approach had been used for primary surgery in nine cases and in four cases the original surgical approach was unknown. The mean Harris Hip score prior to repair was 77.4 (range 55–87), which improved to a mean post operative Harris hip score of 86.97 (range 79–96) following repair. The Oxford hip score prior to repair was 20 (range 16–25) which improved to a mean of 14.2 after repair (range 4–29). 9 out of 11 patients who had the repair were satisfied and would recommend the procedure. We believe an accurate and timely diagnosis together with repair can reduce the morbidity associated with this post-operative complication following THA.
Article
Adequate function of the hip abductor mechanism has been shown to be integral to ideal lower limb function and musculoskeletal health. Clinical assessment of hip abductor muscle function may include observational assessment of postural habits, muscle bulk, and of the ability to control optimal frontal plane femoropelvic alignment during a variety of single leg tasks. Strength testing using a hand held dynamometer is perhaps our most robust clinical assessment tool but should not be considered a 'gold standard' in the assessment of abductor muscle function. Evidence from magnetic resonance imaging (MRI), and electromyography (EMG) studies provides a deeper understanding of specific deficits that occur within the abductor synergy. The assessment of abductor function should not be based on a single test, but a battery of tests. The findings should be interpreted together rather than independently, and in the context of a thorough understanding of function of the lateral stability mechanism. Manner and comprehensiveness of abductor assessment will have important implications for management and particularly therapeutic exercise.
Article
Originally defined as "tenderness to palpation over the greater trochanter with the patient in the side-lying position," greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans.
Article
Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.
Article
The abductor release sometimes does not heal after a transgluteal approach for hip arthroplasty. Factors influencing the success of subsequent repair are unclear. We used magnetic resonance imaging (MRI) to compare the condition of the gluteus medius with clinical outcome after late repair of abductor dehiscence in 12 total hip patients. Evaluation included a pain rating, gait evaluation, Trendelenburg test, strength grading, and Harris Hip Score. Most had both prerepair and postrepair MRI studies to assess the repair and to grade abductor muscle fatty degeneration. Two repairs without MRI were explored surgically. Although average pain, limp, and strength scores improved significantly, rerupture occurred in 4 subjects and fatty degeneration in the gluteus medius did not improve, even with intact repair. Nine patients were satisfied; 7 of these had an intact repair. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair.
Article
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. Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term. Case series; Level of evidence, 4. 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. 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. 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.
Article
The purpose of this study was to develop a clinically useful method of assessing the strength of the hip musculature and to develop a normal data base with this technique. The strength of 72 subjects aged 20-81 years (37 women and 35 men) was measured through the use of a modified Cybex II with an upright stabilization frame for testing sagittal and frontal plane motions; transverse plane motions of internal and external rotation were tested in the seated position. The subjects were tested at multiple isokinetic speeds and isometric angles. Regardless of age or gender, hip extensors were the strongest muscle group, following by flexors, adductors, abductors, and rotators. As the velocity of exercise increased, the magnitude of the torques produced decreased. Demographically, younger men produced the greatest torques and older women the lowest. The strength values of older men and younger women were similar. The results have clinical implications for objective assessment of strength in pathologic patient populations.
Article
In a prospective study, 10 patients with well-documented osteoarthritis (O.A.) of the hips were imaged using spin-echo pulse sequences (TR = 0.5 to 1.5 s and TE = 28 to 60 ms). After analyzing the changes observed, an MR grading system for assessing severity of O.A. in the hips was developed. Using this grading system and an established grading system for osteoarthritis using roentgenograms (both systems use grades 0-4), two radiologists independently graded the MR studies and plain films separately, twice. The roentgenogram grading system was more accurate in predicting symptoms in the more severe cases, whereas the MR grading system was slightly more useful in the less severe cases. Our results show that MR can demonstrate a spectrum of changes of O.A. in the hips. Its ability to directly image articular cartilage makes it a powerful research and clinical tool.
Article
Trendelenburg's test of function of the hip joint was first reported before radiology was available. At least four methods of performing it have since been described in the literature. We examined 50 normal subjects and 103 people with disorders affecting either the spine or the hip, in order to determine the different responses that occurred when they were asked to stand on one leg. This has enabled us to define a standard method of performing the Trendelenburg test, and to interpret the test as a method of assessing hip abductor function. The major pitfalls that result in misinterpretation, or false-positive responses, are pain, lack of cooperation from the patient, and impingement between the rib cage and the iliac crest. False-negative responses result from the patient using muscles above and below the pelvis, and from leaning beyond the hip on the standing side.
Article
The effects of lateral approaches to total hip arthroplasty on abductor weakness and limp were studied in 264 patients with primary osteoarthritis. The Hardinge approach was used in 82 patients, the transtrochanteric approach in 94, and the Liverpool approach in 88. There was no difference in functional level, range of movement, and limp among three lateral approaches. There was no increase in Trendelenburg gait after the Hardinge or Liverpool approach compared with the transtrochanteric approach. It is evident that the Trendelenburg test is a useful part of clinical examination if performed and interpreted correctly.
Article
The results of reoperation and repair of abductor musculature avulsion that occurred as a complication of a primary total hip arthroplasty performed through an anterolateral approach were reviewed in nine patients 2 to 13.5 years (mean, 4.8) after repair. Limp was markedly decreased in five of nine patients, and need for ambulatory aids also was reduced in five of the nine. Improvement continued for 1 to 3 years after the repair. Objectively, three of the four patients (75%) without significant preoperative pain had a good or excellent result, whereas only one of five patients (20%) with significant preoperative pain had a good or excellent result. In all three cases where hip instability was a presenting symptom, it was successfully treated. Four patients felt they were much better, three felt somewhat better, and two felt they gained no improvement by repair. This information suggests that the best indications for repair are symptoms of marked abductor weakness or hip instability; significant preoperative pain is less likely to be decreased.
Article
The American Thoracic Society has issued guidelines for the 6-minute walk test (6MWT). The 6MWT is safer, easier to administer, better tolerated, and better reflects activities of daily living than other walk tests (such as the shuttle walk test). The primary measurement is 6-min walk distance (6MWD), but during the 6MWT data can also be collected about the patient's blood oxygen saturation and perception of dyspnea during exertion. When conducting the 6MWT do not walk with the patient and do not assist the patient in carrying or pulling his or her supplemental oxygen. The patient should walk alone, not with other patients. Do not use a treadmill on which the patient adjusts the speed and/or the slope. Do not use an oval or circular track. Use standardized phrases while speaking to the patient, because your encouragement and enthusiasm can make a difference of up to 30% in the 6MWD. Count the laps with a lap counter. If the 6MWD is low, thoroughly search for the cause(s) of the impairment. Better 6MWD reference equations will be published in the future, so be sure you are using the best available reference equations.
Article
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.
Article
To evaluate the value (sensitivity and specificity) of 2 modified physical tests for the diagnosis of gluteal tendinopathy in patients with refractory greater trochanter pain syndrome (GTPS). The 2 tests were prospectively evaluated by a single physician in all consecutive patients with persistent (> or =4 months) GTPS and no hip joint arthropathy seen on radiography between 2002 and 2006. The 2 tests evaluated the occurrence of pain similar to spontaneous pain during a single-leg stance held for 30 seconds and resisted external derotation in a supine position (hip flexed 90 degrees ) then prone position (hip extended). A matched control population without hip pain was examined similarly. Tendinitis, tendon tear, and associated bursitis in the target group were documented by magnetic resonance imaging (MRI) in transverse, coronal, and sagittal planes, with MRI serving as the gold standard. Seventeen patients completed the study (mean +/- SD age 68.1 +/- 10.8 years, mean duration of symptoms 13 months). MRI revealed tendinopathy and/or bursitis of the gluteus medius and/or minimus tendons in all patients, with evidence of tearing in 15. Sensitivity and specificity were 100% and 97.3%, respectively, for the single-leg stance test and 88% and 97.3%, respectively, for the resisted external derotation test in the supine position. The 30-second single-leg stance and resisted external derotation tests had very good sensitivity and specificity for the diagnosis of tendinous lesion and bursitis in patients with MRI-documented refractory GTPS.
Article
Hip abductor muscle weakness is related to many lower extremity injuries. A simple procedure, the Trendelenburg test, may be used to assess hip abductor performance in patient populations. To describe the minimal detectable change (MDC) in pelvic-on-femoral (P-O-F) position of the stance limb during the Trendelenburg test. Laboratory. 45 healthy women (28 +/- 8 years) and 45 healthy men (33 +/- 11 years). P-O-F position in degrees in single-leg stance. Baseline P-O-F position (hip adduction) was 83 degrees +/- 3 degrees with a range from 76 degrees to 94 degrees. The intratester reliability (ICC3,1) for measurement of P-O-F position using a universal goniometer was 0.58 with a standard error of measurement (SEM) of 2 degrees. The minimal detectable change (MDC) was calculated to be 4 degrees. If a person's P-O-F position changes less than 4 degrees between measurements, then the P-O-F position is within measurement error and it can be determined that there has been no change in the performance of the hip abductor muscles when examined by the Trendelenburg test.
Article
Abductor avulsion after primary total hip arthroplasty (THA) is an uncommon event and is associated with the lateral approach. Results of surgical repair have only been reported in one previous study. In a retrospective review of 2657 primary THAs, we identified 19 (0.7%) patients operated upon for repair of abductor avulsion on average 19 months after primary THA. The study's aim was to assess improvement in pain and limp, patient satisfaction, and functional outcome (Harris Hip Score) after surgical repair. Eighteen patients were evaluated at a mean follow-up of 38 months. Overall, only half of the patients had substantial improvement of both limp and pain. Limping and functional outcome markedly improved with early repair (<15 months), whereas obesity was associated with worse functional results.
  • E Huxtable
E. Huxtable et al. Clinical Biomechanics 46 (2017) 57-63