Open Gluteus Medius and Minimus Repair With Double-Row Technique and Bioinductive Implant Augmentation.
ABSTRACT: 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: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: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:Recently, attention has been given to recalcitrant lateral hip pain, also known as greater trochanteric pain syndrome. Although, historically, this has been attributed to greater trochanteric bursitis, the literature has shown that many patients will have a lesion of the gluteus medius and minimus tendons. Endoscopic hip abductor tendon repair has been shown to provide good outcomes with decreasing overall morbidity and is becoming more popular. However, failure rates have been reported to be as high as 35%, likely due to the poor tissue quality in this older population. Acellular human dermal allograft has been used to augment rotator cuff repairs in an attempt to improve tendon healing. The technique described in this Technical Note shows endoscopic gluteus medius and minimus repair with acellular human dermal allograft augmentation focusing on graft preparation, implantation, and fixation in a safe and reproducible manner.
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: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:Tears in the gluteus medius and minimus tendons recently have emerged as an important cause of chronic greater trochanteric pain syndrome. Increasing recognition of the gluteal insertion as a cause of chronic pain and weakness, as well as technologic advances in endoscopic hip surgery, has made gluteal insertional repair a rapidly emerging technique in minimally invasive surgery of the hip. We present an endoscopic double-row technique for gluteal insertional repair that allows for visualization, debridement, and repair, re-creating the normal footprint.
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.
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:In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.
Project description:Post-stroke gait is often accompanied by muscle impairments that result in adaptations such as hip circumduction to compensate for lack of knee flexion. Our previous work robotically enhanced knee flexion in individuals post-stroke with Stiff-Knee Gait (SKG), however, this resulted in greater circumduction, suggesting the existence of abnormal coordination in SKG. The purpose of this work is to investigate two possible mechanisms of the abnormal coordination: (1) a reflex coupling between stretched quadriceps and abductors, and (2) a coupling between volitionally activated knee flexors and abductors. We used previously collected kinematic, kinetic and EMG measures from nine participants with chronic stroke and five healthy controls during walking with and without the applied knee flexion torque perturbations in the pre-swing phase of gait in the neuromusculoskeletal simulation. The measured muscle activity was supplemented by simulated muscle activations to estimate the muscle states of the quadriceps, hamstrings and hip abductors. We used linear mixed models to investigate two hypotheses: (H1) association between quadriceps and abductor activation during an involuntary period (reflex latency) following the perturbation and (H2) association between hamstrings and abductor activation after the perturbation was removed. We observed significantly higher rectus femoris (RF) activation in stroke participants compared to healthy controls within the involuntary response period following the perturbation based on both measured (H1, p < 0.001) and simulated (H1, p = 0.022) activity. Simulated RF and gluteus medius (GMed) activations were correlated only in those with SKG, which was significantly higher compared to healthy controls (H1, p = 0.030). There was no evidence of synergistic coupling between any combination of hamstrings and hip abductors (H2, p > 0.05) when the perturbation was removed. The RF-GMed coupling suggests an underlying abnormal coordination pattern in post-stroke SKG, likely reflexive in origin. These results challenge earlier assumptions that hip circumduction in stroke is simply a kinematic adaptation due to reduced toe clearance. Instead, abnormal coordination may underlie circumduction, illustrating the deleterious role of abnormal coordination in post-stroke gait.