Endoscopic Gluteus Medius Repair Augmented With Bioinductive Implant.
ABSTRACT: Patients with gluteus minimus and medius tears that fail nonoperative management may be indicated for surgical repair; however, structural failure after gluteal tendon repair remains unacceptably high. This is likely related to the limited healing potential of tendinous tissue, which is poorly vascular and heals by formation of fibrocartilaginous scar tissue rather than histologically normal tendon. An emerging option to augment tendon healing is the use of a bioinductive implant that is designed to amplify the host healing response and induce the formation of healthy tendon tissue. Though it is rapidly being adopted for partial- and full-thickness rotator cuff tears, this implant has not yet been used in the hip. A detailed technical description and a discussion of the advantages and disadvantages of the technique are provided.
Project description:Lateral hip pain in patients without significant osteoarthritis may be due to a number of different etiologies. Recent attention has been placed on the role of abductor tendon (gluteus medius and minimus) deficiency in these patients. These tears, analogous to rotator cuff tears in the shoulder, may cause pain, weakness, limp, and dysfunction. Mainstays of treatment include nonoperative treatment and, in select patients, operative fixation. This article presents an overview of management of patients with symptomatic, large, retracted, chronic tears of the abductor tendons. The highlighted repair is a "double-row" repair with biological patch augmentation.
Project description:Abductor tendon tears are an increasingly recognized clinical entity in patients with lateral thigh pain and weakness. These "rotator cuff tears of the hip" typically result from chronic, nontraumatic rupture of the anterior fibers of the gluteus medius. Although the abductor tendon typically tears from the osseous insertion, the case discussed here ruptured at the musculotendinous junction. This is the first report of this abductor tear subtype and its endoscopic repair.
Project description:Greater trochanteric pain syndrome can be caused by gluteus medius and minimus tendinopathy/tears and chronic trochanteric bursitis. Specifically, moderate-to-severe abductor tendon tears can cause severe lateral hip pain, limp, and abnormal gait. A variety of open and endoscopic techniques to treat glut abductors hip tears have been described. The use of scaffolds, such as acellular human dermal allograft, to augment tendon repair, already has been successfully reported in rotator cuff repairs of the shoulder. Still, the use of acellular human dermal allograft in the hip has been limited. However, there are some clinical scenarios in which augmentation of abductors hip tendon repair with scaffold is indicated. Chronic or massive gluteus tears or revision cases may benefit from augmentation with a scaffold. The purpose of this technical note and accompanying video is to describe our indications, pearls, and pitfalls of repair of moderate to severe gluteus tears via a minimally invasive technique augmented with acellular human dermal allograft.
Project description:Symptomatic partial-thickness rotator cuff tears and full-thickness tears with poor tissue quality often pose a dilemma for orthopaedic surgeons. Despite advances in repair techniques and fixation devices, retear rates remain high. Progression of partial-thickness tears has been noted to be over 50%, with remaining fibers seeing increased strain. Patch augmentation that induces a healing response while decreasing peak strain of adjacent tissue is becoming more popular among orthopaedic surgeons. Therefore, we present an all-arthroscopic technique guide for application of a Food and Drug Administration-approved bovine bioinductive patch (Rotation Medical, Plymouth, MN).
Project description:Proximal hamstring tendon avulsions are a relatively rare type of hamstring injury associated with persistent morbidity, including pain, weakness, and functional limitations. Open or endoscopic surgical repair is the standard treatment for complete tendon avulsions or partial tears that remain symptomatic despite conservative management in relatively young, healthy, and active patients. However, complications known to occur include retearing of the hamstring, infection, nerve injury, inability to return to work or sport, subjective persistent weakness, and subjective persistent pain. In the case of persistent pain where the repair is partially retorn, a careful history, physical examination, and scrutiny of radiologic studies can help guide management. We describe a technique for using revision endoscopy and augmentation with a bovine bioinductive patch in a case of chronic persistently painful partial retear after a proximal hamstring repair.
Project description:The management of rotator cuff defects after arthroscopic debridement for calcific tendinitis can be a challenge for physicians. To date, treatment options have included debridement alone, in situ repairs of the tendon, or full-thickness takedown and repair. Each option, however, has been fraught with its own pitfalls and limitations. We propose a technique for the management of rotator cuff defects through the application of a bioinductive collagen implant that may allow for rapid tissue incorporation and regeneration.
Project description:The merits of double-row tendon fixation have been well defined in the shoulder and may have greater applicability for gluteus medius tears in the hip, in which protection of the repair site can be even more of a challenge because the hip is a weight-bearing extremity. A detailed technique for double-row fixation with a reliable method and implants is highlighted in the accompanying stepwise-approach video. Standard laterally based peritrochanteric portals are used, including a viewing portal posterior to the vastus lateralis ridge and a working portal distal to the ridge, with anchors placed proximally, perpendicular to the cortex of the trochanter. Proximal fixation is accomplished with double-loaded Healicoil anchors (Smith & Nephew, Andover, MA) by use of sutures placed in a mattress fashion. Distal fixation is accomplished with a Footprint anchor (Smith & Nephew) paired to each Healicoil.
Project description:Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.
Project description:Tendon inserts into bone via a fibrocartilaginous interface (enthesis) that reduces mechanical strain and tissue failure. Despite this toughening mechanism, tears occur because of acute (overload) or degradative (aging) processes. Surgically fixating torn tendon into bone results in the formation of a scar tissue interface with inferior biomechanical properties. Progress toward enthesis regeneration requires biomaterial approaches to protect cells from high levels of interfacial strain. We report an innovative tissue reinforcement strategy: a stratified scaffold containing osseous and tendinous tissue compartments attached through a continuous polyethylene glycol (PEG) hydrogel interface. Tuning the gelation kinetics of the hydrogel modulates integration with the flanking compartments and yields biomechanical performance advantages. Notably, the hydrogel interface reduces formation of strain concentrations between tissue compartments in conventional stratified biomaterials that can have deleterious biological effects. This design of mechanically robust stratified composite biomaterials may be appropriate for a broad range of tendon and ligament-to-bone insertions.
Project description:Lateral hip pain along with tenderness of the greater trochanter has been associated with greater trochanteric pain syndrome. Radiographically, this has been associated with gluteus medius pathology on magnetic resonance imaging. This has led some surgeons to conclude that abductor pathology is a primary cause of lateral hip pain. Failure of conservative treatment in the setting of gluteus medius pathology may lead to surgical intervention. In some patients a focal tear of the gluteus medius cannot be visualized and likely represents more diffuse tendinopathy. In these patients we propose micropuncture of the greater trochanter. Similar procedures have shown effectiveness in the elbow and shoulder by eliciting a healing response. Our experience suggests that trochanteric micropuncture at the insertion of the gluteus medius tendon can be effectively performed endoscopically for gluteus medius tendinopathy.