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Surgical Repair of Chronic Tears of the Hip Abductor Mechanism

Authors:
  • Karolinska Institutet, Danderyd Hospital

Abstract and Figures

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn't settle and warrants further investigation and treatment. We present a series of 28 patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors. There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D'Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores. Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10 (p=0.0024) The mean change of oxford hip score was 20.5 (p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery. We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.
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Original article
Hip International / Vol. 19 no. 4, 2009 / pp. 00-00
INTRODUCTION
Lateral sided hip pain is a common problem encountered
in the orthopaedic clinic. However trying to elucidate and
treat its cause can be difficult. Potential causes include;
tumours, infection, osteoarthritis of the hip, osteonecrosis
of the femoral head, spinal disease and entrapment neu-
ropathies. Trochanteric bursitis however is the most fre-
quent cause of lateral sided hip pain. This entity usually
presents with dull aching lateral sided pain over the greater
trochanter that is exacerbated by lateral pressure over the
area, weight bearing and resisted abduction. This diagno-
sis can usually be confirmed if symptomatic relief is gained
with a local anaesthetic injection into the area.
Surgical repair of chronic tears of the hip abductor
mechanism
HYWEL DAVIES1, SOHELIA ZHAEENTAN2, ADEL TAVAKKOLIZADEH3, GREGORY JANES4
1 Avon Orthopaedic Centre, Bristol - UK
2 Kings College Hospital, London - UK
3 Täby Närsjukhus and Danderyd University Hospital, Stockholm - Sweden
4 Perth Orthopaedics and Sports Medicine, Perth - Australia
ABSTRACT. Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common
cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few
cases it doesn’t settle and warrants further investigation and treatment. We present a series of 28
patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors.
All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter
of the hip to reattach the abductors.
There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-
operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain,
Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score
of Trendelenburg and SF36 scores.
Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re
ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remain-
ing 11 patients there were statistically significant improvements in hip symptoms. The mean change
in visual analogue score was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5
(p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6
patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.
We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain
that should be further investigated with MRI scanning. Surgical repair is a successful operation for
reduction of pain and improvement of function. However there is a relatively high failure rate. (Hip
International 2009; 19: 00-000)
KEY WORDS. Avulsion, Hip Abductor, Tear, Trochanteric pain
Accepted: 00/00/0000
Repair of hip abductor tears
2
Patients and Methods
From July 2006 to February 2008, 28 patients with lateral
hip pain who had had little or no response to non-surgical
treatment were further investigated with MRI scanning of
their affected hip. Usually the patients had been treated
elsewhere initially but all reported having received at least
1 steroid injection to the trochanteric region. 22 of the 28
patients who were investigated with MRI had had 2 or
more injections. 26 of 28 patients had received a course of
physiotherapy aimed at rehabilitating their abductors. Pa-
tients with previous arthroplasty or surgery to the affected
hip were excluded from the study. All patients who were
identified as having a tear on MRI were offered surgery to
repair the tendon, or tendons. Figure 1 demonstrates the
typical radiographic findings on MRI scanning.
16 patients were identified as having a tear of the hip ab-
ductors and all of these underwent surgery following con-
sultation with the senior author. Of the 16 patients who
underwent surgery there were 15 females and 1 male. The
mean age of the patients was 63 (range 47 to 82). There
was no history of significant trauma to the hip in any of the
patients. The mean duration of symptoms prior to surgery
was 23 months (range 6 to 48 months).
Surgical Technique
Under general anaesthesia the patient was positioned in
the lateral decubitus position. A lateral incision was made
Treatment of this entity is non-surgical in the first instance.
This entails the use of Non-steroidal anti-inflammatory,
physical therapy and steroid injection into the area of the
bursa. A number of cases however remain recalcitrant and
may require surgical treatment. Tearing of the common in-
sertion of the tendons of gluteus medius and minimus on to
the greater trochanter of the proximal femur have relatively
recently been described as a potential cause of this pain.
This clinical entity has been described as a rotator cuff tear
of the hip (1, 2) as it appears to show some similarities with
tears of the rotator cuff musculature in the shoulder. It has
been postulated that pelvic morphology, leg-length discrep-
ancy and a high valgus angle of the knee may produce a
biomechanical environment that predispose patients to in-
jury as the greater trochanter impinges on a tight iliotibial
band. Tension within the iliotibial band may result in frictional
trauma to the gluteal tendons, just as the acromial process
causes trauma to the rotator cuff in the shoulder (3-7).
Tears of the hip abductors have been detected in 22% of
patients undergoing fixation of fractures of the neck of fe-
mur1 and in 20% of patients undergoing total hip replace-
ment (8). Undoubtedly therefore there are large numbers of
such tears which remain asymptomatic.
We present a series of patients who were investigated for
recalcitrant trochanteric pain syndrome with MRI. All pa-
tients who were shown to have torn abductors underwent
surgical repair and have been prospectively followed up.
To our knowledge this is the first prospective study review-
ing the results of treatment of such lesions.
Fig. 1 - T2 weighted MRI image demonstrating tear of hip abductor
complex at insertion onto the greater trochanter.
Fig. 2 - Intra-operative findings post debridement demonstrating
complete detachment of gluteus minimus and maximus.
Davies et al
3
weeks. They commence active range of movement exer-
cises at 6 weeks and resisted exercises at 12 weeks.
Functional outcome analysis
All patients completed a self-administered questionnaire
pre-operatively and at 1 year post-operatively. Data collect-
ed included: A visual analogue score for hip pain, the Merle
D’Aubigne and Postel hip score9, Oxford hip score (10),
Kuhfuss score of Trendelenburg (11) and SF36 (12) scores.
Statistics
All information was gathered onto a Microsoft excel
spreadsheet (Microsoft, Richmond, Washington) for analy-
sis. Comparison between pre- and post-operative scores
was performed with a paired t-test. Significance was ac-
cepted with a p value of less than 0.05.
RESULTS
At surgery 4 of the tears were deemed to involve both the
gluteus medius and minimus tendons with at least 2/3 de-
tachment of the medius tendon. We called this a severe
tear. In 2 of these, part of the gluteus medius muscle was
retracted significantly. 8 of the tears involved gluteus me-
dius only and had between 1/3 and 2/3 detachments of
the medius tendon. We called this a moderate tear. 4 tears
involved less than 1/3 of the gluteus medius tendon. We
called this a mild tear.
Of the 16 patients who underwent surgery 11 completed
full follow up. Of the 5 remaining patients, 4 had re-tears
of the repair during the follow up period. These re-tears
were all proven on MRI scanning. The indication for repeat
scanning was poor function and return of Trendelenburg at
follow up. 3 of these have been revised with repeat repair.
1 of these patients with a partial re-tear has decided not to
undergo further surgery but remains under review. 1 Pa-
tient sustained a deep wound infection and had to undergo
debridement. These 5 patients have not been included in
the follow up group. 2 of these failures had large tears, 1
had a moderate tear and 1 had a small tear as found at
the initial operation. 1 of the failures with a large initial tear
was an insulin dependant diabetic otherwise there were
no discernable co morbidities that may have contributed
to failure. Length of symptoms prior to presentation didn’t
appear to have any affect on the likelihood of repair fail-
centred over the trochanter of the hip. The incision was
deepened through the fascia lata exposing the greater
trochanter and hip abductors. The trochanteric bursa was
excised and any defect in the insertion of the hip abduc-
tors was identified. An attempt was made to document
the extent of the defect. Figure 2 demonstrates the intra-
operative appearance of the torn abductors. Frequently
the Abductors had reattached to the trochanter with poor
quality scar tissue in an elongated position. This scar tis-
sue was excised. Both Gluteus Medius and Minimus were
identified as separate layers. The insertion points of the
abductors on the trochanter were identified and debrided.
A high-speed burr was then used to produce a roughened
surface on the trochanteric attachment area to improve the
healing potential. In some cases osteophytes were found
on the femoral neck that would have prevented firm reat-
tachment of the abductors, these were removed. Suture
anchors were inserted into the abductor footprint and the
sutures used to suture the free edge of the avulsed abduc-
tors back onto the anchors. A double row configuration of
sutures was used to produce a ‘watertight’ seal akin to a
rotator cuff repair in the shoulder (Fig. 3). The free edge of
the abductors was then over sewn with a heavy absorb-
able suture. The hip is finally put through a range of move-
ment to test the quality of the repair. The surgical wound
was closed in standard fashion.
Postoperatively patients are allowed to mobilise touch
weight bearing with the aid of crutches for a period of 6
Fig. 3 - same hip as figure 2 demonstrating positioning of sutures
leading from suture anchors with double row configuration
Repair of hip abductor tears
4
failure post total hip replacement (16). In 9 patients followed
up at a mean of 4.5 years 4 were deemed to be significantly
better, 3 slightly better and 2 had no improvement.
Tendinitis, tears, and ruptures of the gluteal tendons are
most accurately diagnosed by magnetic resonance im-
aging, with coronal T1-weighted images with fat satura-
tion and axial fast-spin-echo T2-weighted images. These
techniques may reveal calcification within the tendons and
oedema within the muscle and adjacent compartments3.
The number of patients presenting with intractable greater
trochanteric pain who were found to have an abductor
tear on MRI scanning in our series is similar to a previous
study performed by Bird (17) In their series of 24 patients
presenting with intractable trochanteric pain 11 patients
(45.8%) were found to have a tear on MRI scanning. In our
study 16 0f 28 patients (57%) were found to have a tear
on scanning. This suggests that MRI scanning should be
advocated in all patients in whom Trochanteric pain fails to
resolve with conservative measures, as hip abductor avul-
sion is probably an under-diagnosed entity.
We feel that tears of the hip abductor mechanism represent
one end of a spectrum of the pathological process with
bursitis being at the other end, this probably progresses
in some patients to a tendonitis that may finally result in
partial or complete tearing of the hip abductors.
In our series there is a relatively high rate of repair failure.
3 of 16 patients having a complete re-tear requiring revi-
sion surgery and 1 sustaining a partial re-tear, which was
managed conservatively. On further analysis of the clinical
notes of the patients that failed we were unable to estab-
lish any differences between them and the patients that had
successful surgery. The failure rate may reflect poor qual-
ity tissues that are frequently found in these patients. The
numbers involved in our study were not sufficient to draw
any significant conclusions with regard to initial size of tear
and likelihood of recurrence following repair however 2 of
the failures did occur in the severe tear group. It would seem
likely that a similar phenomenon would occur in the hip ab-
ure and the failures were not in any particular age range.
2 of the failures had received 2 steroid injection at various
points prior to surgery 1 had received 1 injection and 1,
3 injections. Numbers were not sufficient to demonstrate
any correlation between number of injections of steroid
and failure of repair.
Table I demonstrates the outcome scores pre and post-
surgery. There was significant improvement in all measure-
ments post surgery apart from the Sf-36 MCS score, which
showed a trend towards improvement but was not statisti-
cally significant.
Evaluation of Trendelenburg according to Kuhfuss pre-oper-
atively demonstrated 4 patients with mild Trendelenburg, 4
patients with moderate and 3 patients with severe Trendelen-
burg. Post surgery all patients improved. There were 6 patients
rated as no Trendelenburg, 4 with mild and 1 moderate.
The 4 re-tears had a mean oxford hip scores of 26.2 at the
time of detection as opposed to the mean hip score of 38.4
at follow up of the successful repairs. The revision proce-
dures have not been included in this review.
DISCUSSION
We have presented a prospectively followed series of pa-
tients undergoing hip abductor repair for recalcitrant tro-
chanteric pain. This procedure provides for good relief of
pain and improvement in hip function. However there is a
relatively high failure rate.
There have been a number of previous isolated case reports
(7, 13) and a small case series (14) reporting on operative
repair of primary hip abductor avulsion. Kagan (14) reported
on 7 repairs with a mean follow up of 45 months. All re-
ported good relief of pain, all bar 1 patient returned to nor-
mal function. There has also been a report of the surgical
technique of arthroscopic repair of the hip abductors (15)
although this didn’t present any follow up. Surgical repair
of the hip abductors has also been reported on following
TABLE I - OUTCOME SCORES (MEAN VALUES)
ScorePre-operative Post-operative Improvement p-value
VAS 7250.0024
MDP 10.5 15 4.5 0.0003
Oxford Hip 21.4 38.9 17. 5 0.0008
Sf-36 PCS 28.4 40.2 11. 8 0.0020
Sf-36 MCS 54.9 59.4 4.5 0.134
VAS, Visual analogue scale; MDP, Merle D’Aubigne Postel,: PCS, Physical component score; MCS, Mental component score.
Davies et al
5
Work carried out at Perth Orthopaedics and Sports Medicine,
Perth - Australia.
Institutional Review Board (IRB)/Ethics Committee approval was
obtained.
Conflict of interest statement: No Authors have proprietry
interest.
Address for correspondence:
Hywel Davies
10 Ormerod Road
Bristol, BS9 1BB, UK
hyweldavies1@hotmail.co.uk
ductors as in the shoulder rotator cuff where it has been
proven that there is a reduced potential for repair as tear
size increases (18). There may be underlying biomechanical
factors that needs to be addressed or our surgical technique
may need to be refined to improve the results of repair.
We are aware of the main limitation of this study, which is
the relatively small sample size. We hope to follow up fur-
ther patients in the future.
In conclusion tears of the abductor mechanism of the hip are
an underdiagnosed cause of recalcitrant greater trochanteric
pain. The use of MRI scanning can help in the diagnosis. Op-
erative repair is very successful for decreasing pain and im-
proving function however there is a relatively high failure rate.
REFERENCES
1. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip.
J Bone Joint Surg Br 1997; 79: 618-20.
2. Kagan A, 2nd. Rotator-cuff tear of the hip. J Bone Joint Surg
Br 1998; 80: 182-3.
3. Kingzett-Taylor A, Tirman PF, Feller J, et al. Tendinosis and
tears of gluteus medius and minimus muscles as a cause of
hip pain: MR imaging findings. AJR Am J Roentgenol 1999;
173: 1123-6.
4. LaBan MM, Weir SK, Taylor RS. ‘Bald trochanter’ sponta-
neous rupture of the conjoined tendons of the gluteus me-
dius and minimus presenting as a trochanteric bursitis. Am
J Phys Med Rehabil 2004; 83: 806-9.
5. Lonner JH, Van Kleunen JP. Spontaneous rupture of the glu-
teus medius and minimus tendons. Am J Orthop 2002; 31:
579-81.
6. Traycoff RB. “Pseudotrochanteric bursitis”: the differen-
tial diagnosis of lateral hip pain. J Rheumatol 1991; 18:
1810-2.
7. Fisher DA, Almand JD, Watts MR. Operative repair of bilateral
spontaneous gluteus medius and minimus tendon ruptures. A
case report. J Bone Joint Surg Am 2007; 89: 1103-7.
8. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor
mechanism tears of the hips in patients with osteoarthritis.
J Arthroplasty 2001; 16: 121-3.
9. D’Aubigne RM, Postel M. Function al results of hip arthro-
plasty with acrylic prosthesis. J Bone Joint Surg Am 1954;
36: 451-75.
10. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire
on the perceptions of patients about total hip replacement.
J Bone Joint Surg Br 1996; 78: 185-90.
11. Kuhfuss W, Schildhauer M, Tonnis D. [The influence of surgi-
cally introduced muscle tension on the function of total hip
prostheses (author’s transl)]. Z Orthop Ihre Grenzgeb 1975;
113: 316-22.
12. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form
health survey (SF-36). I. Conceptual framework and item se-
lection. Med Care 1992; 30: 473-83.
13. Chebil M, Mezghani M, Kooli M, Zlitni M. [From diagnosis to
treatment of gluteus medius tendon tear of the hip: a case
report]. Ann Readapt Med Phys 2007; 50: 48-54.
14. Kagan A, 2nd. Rotator cuff tears of the hip. Clin Orthop Relat
Res 1999; 368: 135-40.
15. Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.
Arthroscopic anatomy and surgical techniques for peritro-
chanteric space disorders in the hip. Arthroscopy 2007; 23:
1246 e1-5.
16. Web er M, Berry DJ. Abductor avulsion after primary total hip
arthroplasty. Results of repair. J Arthroplasty 1997;12-2:202-6.
17. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective
evaluation of magnetic resonance imaging and physical ex-
amination findings in patients with greater trochanteric pain
syndrome. Arthritis Rheum 2001; 44: 2138-45.
18. Matthews TJ, Hand GC, Rees JL, Athanasou NA, Carr AJ.
Pathology of the torn rotator cuff tendon. Reduction in po-
tential for repair as tear size increases. J Bone Join Surg Br
2006; 88: 489-95.
... Several studies of both open and endoscopic hip abductor repair have demonstrated postoperative improvement in pain levels and patient-reported outcome (PRO) scores for most patients [8][9][10][11][12][13][14]. Despite these encouraging clinical results, there remains an estimated 5-25% of tears that do not heal [8][9][10], leaving room for potential improvement or augmentation of surgical techniques. ...
... Several studies of both open and endoscopic hip abductor repair have demonstrated postoperative improvement in pain levels and patient-reported outcome (PRO) scores for most patients [8][9][10][11][12][13][14]. Despite these encouraging clinical results, there remains an estimated 5-25% of tears that do not heal [8][9][10], leaving room for potential improvement or augmentation of surgical techniques. In an effort to address the analogous clinical problem of healing limitations of the rotator cuff of the shoulder, Thon et al. described their case series of patients undergoing arthroscopic repair of large or massive rotator cuff tendon tears augmented with a bioinductive collagen patch [15]. ...
... At 6 months postoperative, 7/9 (77.8%) of tendons were qualitatively classified as completely healed by a fellowship-trained musculoskeletal radiologist. These findings are not surprising, as there have been imperfect healing rates noted in multiple prior clinical studies of gluteus medius repairs [8][9][10]19]. The patch serves to improve the biology surrounding the repair and healing environment with enhanced vascularity. ...
Article
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The purpose of this study was to perform an initial, prospective evaluation of imaging findings and outcomes after open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation. A prospective study was performed of patients with clinical and magnetic resonance imaging (MRI) evidence of symptomatic gluteus medius tears who underwent open, double-row suture anchor repair with bioinductive bovine collagen patch augmentation. Preoperative and 6-month postoperative MRIs were reviewed by a fellowship-trained musculoskeletal radiologist, and outcome scores were recorded preoperatively and 6 months postoperatively [Hip Outcome Score (HOS) Sport; HOS Activities of Daily Living (HOS ADL); Modified Harris Hip Score (mHHS) and International Hip Outcomes Tool (iHOT-33)]. Nine patients, four high-grade tears (≥50% tendon thickness) and five low-grade tears (<50% thickness) underwent surgical repair. At 6 months, 7/9 (77.8%) of tendons were qualitatively classified as completely healed on MRI, with no complications. Mean tendon thickness increased significantly: mediolateral dimension by 5.8 mm (P < 0.001), anteroposterior dimension by 4.1 mm (P = 0.02) and cross-sectional area (CSA) by 48.4 mm2 (P = 0.001). Gluteus medius and minimus CSA did not change significantly (P > 0.05). Patients demonstrated improvements in mean scores for HOS ADL, mHHS and iHOT that met defined minimum clinically important differences (P < 0.05). Open surgical repair of gluteus medius tendon tears with bioinductive collagen patch augmentation is safe and associated with increased tendon thickness on postoperative MRI. Early outcome scores are encouraging and should be evaluated after patients have completed postoperative rehabilitation to measure the whole effect of treatment.
... 4,14 Outcome Measures A variety of outcome measures was used across the included studies to assess treatment success. Pain was most commonly assessed using a visual analog scale (VAS; 16 studies {{ ) or numeric rating scale (NRS; 2 studies 10,42,51 8,9,17 ), and Patient Acceptable Symptom State (3 studies 4,25,26 ). Rarely used measures for the determination of outcomes were the Lower Extremity Functional Scale, 10,18 Nonarthritic Hip Score, 29,53 and Merle D'Aubigné-Postel score 17,55 in 2 studies each. ...
... Pain was most commonly assessed using a visual analog scale (VAS; 16 studies {{ ) or numeric rating scale (NRS; 2 studies 10,42,51 8,9,17 ), and Patient Acceptable Symptom State (3 studies 4,25,26 ). Rarely used measures for the determination of outcomes were the Lower Extremity Functional Scale, 10,18 Nonarthritic Hip Score, 29,53 and Merle D'Aubigné-Postel score 17,55 in 2 studies each. The Oswestry Disability Index, 23 EuroQol-5 Dimensions, 42 Victorian Institute of Sport Assessment-Gluteal Tendon, 42 International Hip Outcome Tool (iHOT-33 37 /iHOT-12 50 ), lateral hip pain questionnaire, 42 Lequesne index, 38 University of California Los Angeles activity scale, 14 or Western Ontario and McMaster Universities Arthritis Index 4 was used in 1 study each. ...
... 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. ...
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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.
... management, the need for surgical intervention, and what type of surgical intervention to undertake [1e5]. The injury presents as a continuum of symptoms, with pain and gait abnormalities ranging from mild to severe [1,2]. Lateral nonspecific hip pain can result from a variety of conditions, making it difficult to diagnose [3,4]. ...
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Background Hip abductor complex tears remain an injury without clear consensus on management. Surgical treatment has been recommended after unsuccessful non-operative management. This study evaluates both tenodesis and bone trough techniques, with treatment choices guided by previously described tear classification. Methods This is a retrospective cohort study of 45 hips in 44 patients who underwent surgical treatment for symptomatic, chronic hip abductor tear unresponsive to non-operative treatment. Demographics and pre- and post-operative values (including visual analog pain scores, gait assessment and muscle strength) were evaluated. Type I tears were treated using tendon tenodesis. Type II tears were treated through a bone trough repair. Results Forty-five hips (44 patients) were operated on with minimum of 6 months follow-up. There were 27 Type I and 18 Type II tears. Eighty-seven percent of patients were female. Twenty-eight percent of Type II patients (5/18) had a pre-existing arthroplasty in place. Significant improvements in pain (p<0.001), gait (p<0.001) and muscle strength (p<0.001) were achieved in both tear types. Type I repairs showed superior results to Type II. However, both showed significant improvement. Post-operative MRI at 6 months showed healed tenodesis in 81% (17/21) of Type I tears, and 50% (5/10) in Type II. Conclusion Our study shows improvement in pain and function after surgical repair of hip abductor tendon injuries in both simple and complex tears. This improvement is seen even during ongoing surgical site healing. MRI findings may remain abnormal for upwards of 1 year after surgery and do not clearly denote repair failure.
... Massive gluteus medius lesions (with tendon retraction and/or severe muscle atrophy) cause chronic pain and limping known as Trendelenburg gait [1,2]. The literature shows good results for endoscopic and open repair of small-sized gluteus medius tendon tear [3][4][5]. ...
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We report preliminary results for a novel technique of endoscopic Whiteside transfer for massive gluteus medius tear: i.e., tendon reinsertion not or only partly feasible and/or severe fatty atrophy of the muscle. Endoscopic transfer of gluteus maximus and/or tensor fasciae latae is associated to double-row gluteus medius tendon reinsertion. In a continuous series of 6 patients at a minimum 2 years’ follow-up, there was 1 early failure; 2 patients showed no improvement in pain and limping; 3 had satisfactory results, including 2 with complete resolution of limping and pain. Endoscopic Whiteside transfer associated to gluteus medius tendon repair provided only moderate results in terms of recovery of abduction power and resolution of Trendelenburg gait.
... deficient muscle or tendon [4][5][6][7][8] . Moreover, even successful repairs may show fatty degeneration on magnetic resonance imaging (MRI), a predisposing factor for retears 7,9 . ...
Article
Introduction Gluteus medius tendon tears may not be feasible for direct repair when significant retraction or fatty degeneration is present. Several augmentation techniques have been reported for challenging cases. We describe a novel technique using a transfer of the anterior portion of the gluteus maximus combined with synthetic mesh to reinforce the direct suture of the gluteus medius. The goal of this study was to assess the functional and pain outcomes in three patients treated with this reconstruction technique. Case presentation A retrospective study was performed including 3 patients with complete and retracted ruptures of the abductor mechanism. When conservative management failed, surgical treatment was attempted. After a minimum follow-up of 12 months (mean follow-up of 18 months), all of the patients showed clinical improvement. The mean Harris Hip Score improved from 31.8 to 75.6, with an average postoperative abduction strength of 3 in the Medical Research Council muscle strength grading system, and no residual limp was noticed. The mean Visual Analogue Scale pain score decreased from 8.3 preoperatively to 1.6 postoperatively. No complications were reported. Conclusion In conclusion, this technique demonstrates efficacy in terms of improving clinical symptoms and functional status and is a reproducible way to augment irreparable gluteus medius tears.
Chapter
Greater trochanteric pain syndrome has recently gained traction in the literature, with gluteus medius and minimus tears being a prevalent source of lateral hip and thigh pain. Typically, patients present with chronic tears and are treated conservatively with rest, oral nonsteroidal anti-inflammatory drugs (NSAID’s), physical therapy, and injections. Gluteus medius and minimus tears can also be associated with femoral neck fractures, osteoarthritis, or avulsion after total hip arthroplasty. Magnetic resonance imaging (MRI) is beneficial in determining the extent of the tear size and retraction, as well as amount of greater trochanteric bursitis. The focus in this chapter is on an open repair technique for large, retracted gluteus medius and minimus tears utilizing suture anchors.
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Background With a hip abductor tendon tear, widening of the intergluteal space, or “fat stripe,” is a characteristic change seen in and around the gluteus medius and minimus. Purpose To determine the relationship of the intergluteal fat stripe in hips with pathologic abductor tears compared with the contralateral side and to evaluate the association of fat stripe size with hip-specific patient-reported outcome measures. Study Design Case series; Level of evidence, 4. Methods Of the 43 patients (42 female, 1 male; mean age, 56.6 years; range, 38-85 years) who underwent endoscopic gluteus medius repair, 19 met inclusion criteria of preoperative bilateral hip magnetic resonance imaging (MRI) scans and 2-year follow up. A single board-certified fellowship-trained orthopaedic surgeon (J.F.), who was blinded to outcomes, evaluated the MRI scans to measure the intergluteal fat stripe on the operative and nonoperative sides. The 2-year postoperative International Hip Outcome Tool (iHOT-12) and modified Harris Hip Score (mHHS) values were analyzed to determine their relationship to the size of the fat stripe. Statistical analysis was performed using a paired t test, and associations were determined using Pearson product correlation as well as nonparametric measurements. Results The size of the intergluteal fat stripe differed significantly between the operative and nonoperative sides. The area of the fat stripe on the operative side was 645.73 ± 513.09 mm ² , and on the nonoperative side it was 313.47 ± 360.71 mm ² , an average of 332.36 mm ² greater than the nonoperative side ( P = .02). The width of the fat stripe was 9.10 ± 4.60 mm on the operative side and 5.15 ± 3.87 mm on the nonoperative side, 3.95 mm greater than the nonoperative side ( P < .01). There was no correlation between the width or area of the fat stripe on the operative side and iHOT-12 or mHHS values at 2-year follow-up. Conclusion The study findings indicated that the intergluteal fat stripe is significantly wider and has a significantly larger area in hips with abductor tears compared with unaffected hips. This did not correlate with 2-year patient-reported outcomes.
Article
Résumé Nous avons mis au point et rapportons les résultats préliminaires d’une nouvelle technique endoscopique de transfert de Whiteside dans les lésions chroniques dépassées du moyen glutéal (tendon non ou partiellement réinsérable et/ou involution graisseuse musculaire sévère). Un transfert endoscopique du grand glutéal et/ou du tenseur du fascia lata est réalisé en complément de la réinsertion double rang du tendon moyen glutéal. Nous rapportons les résultats préliminaires d’une série continue de 6 patients revus avec un recul minimum de 2 ans. Une patiente a eu un échec précoce. Deux patients n’ont pas été améliorés sur les douleurs et la boiterie. Trois patients ont eu des résultats satisfaisants dont 2 avec disparition complète de la boiterie et des douleurs. Le transfert endoscopique de Whiteside combiné à la réparation du tendon moyen glutéal donne des résultats mitigés sur la récupération de la force d’abduction et la disparition de la boiterie de Trendelenburg.
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We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description. We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.
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A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Article
Full-text available
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Article
Late results in 243 arthroplasties with an acrylic prosthesis for traumatic or osteoarthritic conditions are reported. Early results (after one year) show the importance of the restoration of the normal mechanics of the hip joint by the preservation or the restoration of normal length of the femoral neck, the exact correction of anteversion, and the precise fit of the prosthetic head to the acetabulum. A good exposure of the joint through the posterolateral approach appears necessary in order to fulfill these conditions. Late results (from two to five years) show deterioration of the functional results in 20 per cent. These deteriorations appear to be caused by bone absorption around the Judet prosthesis and the consequent loosening of the prosthesis. A new type of cervico-capital prosthesis is proposed which makes possible: 1. Restoration of the normal length of the femoral neck when it is congenitally or pathologically short; 2. Correction of anteversion, even when very marked; 3. A weight-bearing surface on a more vascularised part of the femur; 4. The distribution of pressure on bone so as to lessen bone absorption, to prevent its ill effects, and, particularly, to decrease mobility of the prosthesis.
Article
Objective To report a case of spontaneous gluteus medius tear repaired surgically in a 42-year-old woman patient without any other antecedent other than diabetes.Patient and methods–resultsTrochanteric pain evolving for 7 months led to scintigraphy objectifying a hyperfixation of the trochanter and ultrasonography showing an inflammatory gluteus medius tendon. These examinations were supplemented by magnetic resonance imaging and tomodensitometry visualising the tendon rupture but no marked fat degeneration of the muscle despite atrophy of this one. Surgical exploration confirmed the presence of a major rupture of the gluteus medius tendon, which was reinserted through an osseous trench. Rehabilitation involved protecting the tendon, by an installation of the member in abduction and passive mobilization from the third postoperative day, with a move to partial support on day 45. The result after 16 months was excellent, the patient returning to work 8 months after the surgery without any residual pain.Conclusion The spontaneous rupture of the gluteus medius, often ignored, can occur in young subjects and induce limited function, often well corrected by reinsertion surgery.
Article
Pain over the lateral aspect of the hip commonly is attributed to trochanteric bursitis. Typical findings include local tenderness and weakness of hip abduction. When conservative measures fail to relieve symptoms, surgical release of the iliotibial band over the greater trochanter has been recommended. In the management of seven such patients, an unusual finding was encountered: partial tear of the gluteus medius tendon at its attachment to the greater trochanter. Each patient presented with increasing hip pain of duration of months to years. There were no diagnostic findings on physical examination. Magnetic resonance imaging showed an abnormal signal within the tendon of gluteus medius and fluid within the trochanteric bursa. The disrupted tendons were reattached to bone with heavy nonabsorbable suture. At a median followup of 45 months (range, 21-60 months), all patients were free of pain.
Article
The functional results of total hip prosthesis are influenced significantly by the tension given to the glutaeus medium muscle at operation. Low tension may result in a limp (positive Trendelenburg sign), high tension may decrease movement. In 206 cases of total hip replacement the Trendelenburg sign (grades from 0-3), the movement (in grades 0-4) and a grade of extension (distance or prosthetic femoral head and plastic acetabulum in cm at maximal extension after resection of the capsule) have been evaluated. In 191 hip joints not operated before the Trendelenburg sign was negativ before operation in only 31%, after operation it was negativ in 73%. The evaluation of the partial correlation coefficient showed a definite relation between Trendelenburg sign and the grade of extension. The higher the extensibility of the hip joint the more pronounced the Trendelenburg sign. In 71% of 191 cases the movement was increased after total hip replacement. With increased extensibility, the movement becomes better. However it is also related to the movement before operation. The optimal muscular tension and movement of the hip joint can be expected at an extension grade of 1.5-2.0 cm (distance between the prosthetic femoral head and the plastic acetabulum at maximal extension during operation).
Article
Eighteen patients who were initially diagnosed as having trochanteric bursitis refractory to conventional therapy are reported. The most common causes of pseudotrochanteric bursitis were lumbar radiculopathy (L2, L3), lumbar facet syndrome with pain referred to the lateral thigh, and entrapment neuropathies involving the subcostal, and the lateral cutaneous branches of the iliohypogastric nerves. Less common causes were undisplaced femoral neck fracture, adiposa dolorosa, and hip abductor muscle strain. Diagnosis was facilitated by selective neuroblockade.