Endoscopic treatment of gluteus medius tears: a review.
Tears of the abductor mechanism are thought to be a gradual degenerative process. (7) They occur most commonly in middle-aged women. Abductor tears were first described by Bunker and Kagan in the late 1990s. (8, 9) Bunker and coworkers used the rotator cuff as an analogous structure to describe the pathological process associated with gluteus medius tears. In 1923, Schein and Lehmann were the first to call attention to the similarity between calcific bursitis of the shoulder and hip. (10) They speculated that injury or degeneration in the gluteus medius tendon was responsible for the calcifications. In 1961, Gordon stated that trochanteric bursitis started in the gluteus tendons at their attachment to the greater trochanter. (11) Gordon thought adjacent bursae were involved secondarily, analogous to bursitis and tendinitis of the shoulder. (11) Bunker prospectively looked at 50 hips undergoing surgery for femoral neck fractures and found the incidence of gluteus medius tears to be 22%. (9) Howell and associates looked at the prevalence of abductor tears in patients with hip osteoarthritis (OA). They identified a 20% prevalence of capsule and abductor mechanism tears of the hip in association with OA. (8) This review will focus on the diagnosis, management, and outcomes of gluteus medius tears of the hip.
The gluteus medius serves as a strong abductor and external rotator of the hip. It also serves as an important stabilizer of the contralateral hemi-pelvis, preventing it from dropping distally during ipsilateral stance phase. Proximally, the gluteus medius originates on the inferior edge of the iliac crest, extending from the anterior superior iliac spine to the posterior superior iliac spine. (12) The gluteus medius muscle is innervated by the superior gluteal nerve, which arises from the L4, L5, and S1 nerve roots. (13) The superior gluteal artery provides the primary bloody supply to the muscle belly. (13) The gluteus medius muscle is tripennate, with three distinct muscle bellies. (14) The posterior fibers have a more horizontal orientation. (14) Progressing anteriorly, the fibers take a more vertical orientation. (14) The anterior fibers are important in maintaining pelvic stability along with the middle fibers across the stance phase of the gait cycle. (15) The posterior fibers are oriented parallel to the femoral neck and function as a dynamic stabilizer of the femoral head in the acetabulum. The gluteus medius muscle converges and attaches on the superoposterior facet and lateral facet on the greater trochanter. The posterior muscle belly of the gluteus medius predominately attaches on the superoposterior facet. The anterior and central muscle bellies predominantly attach on the lateral facet. Using cadaveric specimens, Robertson and colleagues characterized the dimensions of the gluteus medius footprint and found the mean areas of the lateral and superoposterior facet to be 438.0 [mm.sup.2] and 196.5 [mm.sup.2], respectively. (16)
Gluteus medius tears have received little attention in the orthopaedic literature, resulting in a paucity of information available on the diagnosis and management. (17) Patients may endure extensive workups and delays in treatment due to the lack of surgeon awareness and clinical notoriety. In 2005, Cormier and coworkers surveyed French orthopaedic surgeons and found that 13% of surgeons had never suspected a diagnosis of gluteus medius tears in their patients while 42% were unaware that they could occur. (18) Tears of the gluteus medius tendon can often be difficult to recognize. Two separate studies found the average time interval from the onset of symptoms to clinical diagnosis to be 15 months. (17, 19) The clinical presentation is often attributed to trochanteric bursal inflammation, without any further workup. Although trochanteric bursitis is regarded as a clinical diagnosis, several investigators have reported a limited role for imaging in confirming the diagnosis. However, Kingzett-Taylor and associates evaluated 250 MRI examinations of the hip and concluded that trochanteric bursitis was likely associated with a tendinopathy involving the gluteus medius and minimus tendons. (20)
There are several scenarios in which gluteus medius tears can present. Gluteus medius tears commonly present as non-traumatic chronic tears, symptomatic from 1 month to 10 years. (8) However, they less commonly present as an acute onset of lateral hip pain and abductor weakness following a traumatic event. Twenty-two percent of patients being treated for femoral neck fractures (9) and 20% of patients undergoing a Hardinge approach to total hip arthroplasty (7) can present with tears of the GM tendon. Patients with gluteus medius tears often describe an insidious onset lateral thigh pain, which may radiate to the buttock or groin. In rare instances, the patient may report an acute traumatic event, preceding symptoms. Howell and coworkers postulated that an underlying pathologic process of ischemia at the vascular watershed of the anterior intertrochanteric line resulted in degenerative changes within the capsule and tendinous insertion of the abductors, leading to an eventual tear. (7) Patients with abductor tendon tears typically present with pain that lasts for months and occurs during walking and rising from a chair. Patients often experience fatigue when ambulating and describe difficulty with stair climbing, walking up slopes, and particularly when re-extending the hip. Patient may also report tenderness over the lateral thigh, particularly when lying on the affected side.
Provocative hip physical examination findings are an important key to proper diagnosis of abductor injuries. Depending on the size of the tear, patients with abductor tendon pathology may present with a Trendelenburg gait and reduced resisted abduction strength accompanied by pain. In 1895, Freidrich Trendelenburg described a clinical sign useful for determining the integrity of the function of hip abductor muscles, with specific reference to congenital dislocation of the hip and progressive muscular atrophy. (21) During a one-legged stance, the pelvis should remain parallel to the floor. If the pelvis tilts opposite the side of the planted extremity during a one-legged stance, the test indicates weakness in the hip abductor musculature on the standing side. The Trendelenburg sign refers to a static observation in a one legged stance; in contrast, the Trendelenburg gait corresponds to the pathologic gait seen in patients with abductor insufficiency. The Trendelenburg or abductor lurch refers to the compensatory adaptation seen in patients with abductor insufficiency. The trunk is observed as it lurches to the side of abductor insufficiency in an attempt to maintain a level pelvis throughout the gait cycle.
Imaging of gluteus medius tears typically begins with an anterior-posterior (AP) pelvis radiograph as well as orthogonal views of the affected hip. Although plain radiographs are usually unremarkable, findings such as osteophytes at the anterior edge of the greater trochanter with an associated irregular border or sclerotic rim may be indicative of an underlying abductor tear. Magnetic resonance imaging (MRI) is the imaging modality of choice when evaluating abductor tendon tears. Recalcitrant hip pain and lack of response to conservative management with a presumed diagnosis of trochanteric bursitis constitute a relative indication for an MRI. (2)
The imaging evaluation of the gluteus medius tendon is based on tendon continuity, tendon morphology, tendon integrity, and signal intensity. Cvitanic and colleagues evaluated the abductor tendons of the hip using five major criteria: tendon discontinuity, tendon elongation, atrophy of the gluteus medius and gluteus minimus muscles, presence of an area of high signal intensity superior to the greater trochanter on T2-weighted images, and presence of an area of high signal lateral to the greater trochanter on T2-weighted images. (22) The abnormal morphology seen in tendinosis of the GM tendon is characterized by thickening or attenuation of the tendon, which may manifest as abnormal signal intensity. Partial tears demonstrate an abnormal high signal intensity within the tendon on fluid-sensitive sequences. The tendon can appear normal in morphology, attenuated, or thickened. (23) Full-thickness tendon tears exhibit complete disruption of the tendon from the footprint with discontinuity of the tendon fibers (Fig. 1). In the setting of a full-thickness tear, it is important to note the location of the tear, degree of retraction, and presence or absence of atrophy to determine the acuity and its potential response to therapy. (23) Chung and associates evaluated gluteus medius tendon tears using MRI and found that a thickened appearance of the tendon, as indicated by increased signal intensity on T2-weighted images, was found to be diagnostic of partial-thickness tears. The appearance of full-thickness tears consisted of discontinuity of tendon fibers with or without muscle retraction or atrophy.
Initial noninvasive management of greater trochanteric pain syndrome includes oral or topical anti-inflammatory medication and activity modification. Physical therapy or other treatment modalities can be considered, with a focus on core strengthening, truncal alignment, and iliotibial band stretching. Mani-Babu and coworkers recently found extracorporeal shockwave therapy to be more effective than home training and corticosteroid injection in the short (< 12 months) and long (> 12 months) term for GTPS. (24) Although the patients in this series had long standing symptoms, a confirmatory diagnosis of a gluteus medius tear was not made. Foot orthotics can also be considered to address any flexible and correctable malalignment disorders. A non-fluorinated glucocorticoid at the site of greatest pain on palpation can be both diagnostic as well as therapeutic. When this treatment fails to induce a long-lasting improvement, imaging studies of the soft tissues should be obtained.
There are currently no evidence-based clinical guidelines on when operative repair of a gluteus medius tear is indicated. There are, however, recommendations to consider when conservative management fails. These recommendations are extrapolated from the inclusion criteria in the limited number of case series that discuss surgical management of abductor tendon tears. The decision to perform surgery rests on several criteria. First and foremost, the patient should have clinical signs of a symptomatic gluteus medius tear, which includes a chronic or relapsing course of peritrochanteric pain with tenderness over the greater trochanter. In addition, it is important to objectively identify abductor weakness on manual muscle strength testing that has not improved with physical therapy over the course of more than 3 months of non-operative treatment. Patients must have also have had at least temporary subjective relief from a trochanteric bursal injection. High-grade partial- or full-thickness tearing on MRI should be confirmed. It is important to note the absence of significant retraction or fatty degeneration that would preclude a successful arthroscopic repair.
Gluteus medius tears have historically been repaired in an open fashion; however, the advent of new endoscopic surgery techniques has allowed for a less invasive approach. The periarticular area of the hip is accessible by means of an arthroscope without necessarily requiring capsular breach. Access to the peritrochanteric space affords the surgeon with access to pathology associated with the greater trochanter, iliotibial band, trochanteric bursa, sciatic nerve, short external-rotators, iliopsoas tendon, and the gluteus medius and minimus tendon attachments. (25) (Fig. 2)
Voos and associates first introduced an endoscopic approach to gluteus medius repairs in 2007. (6) In their series, 10 patients underwent endoscopic repair of a partial or full-thickness gluteus medius tear using an anterior, lateral, and distal portal. (2) (26) At 2-year follow-up, all 10 patients reported a complete resolution of pain and a complete return of abduction strength. Although they had very good early subjective outcomes, Voos' study was limited by a small sample size, with no objective strength testing, and no preoperative baseline outcome measures. Regardless of the study flaws, it provided a novel approach to addressing gluteus medius tears.
Partial thickness tearing of the gluteus medius tendon occurs in a pathologically similar manner to extensor carpi radialis brevis (ECRB) tears in lateral epicondylitis. (27) Degenerative partial-thickness tearing occurs on the deep side of the tendon, near its bony insertion. Partial-thickness under-surface tears present a particular problem as they are not readily visible by arthroscopic or open examination from the peritrochanteric space. In addition, partial-tears are commonly misdiagnosed and treated as chronic bursitis. It is important to have a high index of suspicion in any patient with debilitating GTPS refractory to conservative management and near normal abduction strength. Domb and colleagues devised a trans-tendinous technique for the endoscopic treatment of partial-thickness GM tears lesions. (27) They were are able to visualize and treat intra-substance and undersurface tears by utilizing an arthroscopic longitudinal split of the GM tendon. The partial tear was than debrided and repaired, incorporating the longitudinal split, without affecting the integrity and strength of the tendon itself. (28)
Unfortunately, scientific evidence on hip endoscopy for GTPS remains poor. Retrospective, single-surgeon case series and "expert opinions" based on empirical impressions currently make up the majority of reports available. However, given the small number of patients being diagnosed with GM tears, it may be difficult to conduct sound qualitative prospective, randomized controlled trials. The paucity of patients presenting with GM tears could be related to the overall lack of clinical awareness of the disease entity. Hip endoscopy provides a minimally invasive alternative to open surgical procedures. Over the last decade, we have seen rapid technological advances in hip arthroscopy, improved diagnostic imaging and interpretation, and an improved understanding of intra-articular and peritrochanteric hip pathology. As the emphasis on hip arthroscopy in residency and fellowship training programs continues to increase, the learning curve for endoscopic management of peritrochanteric disorders will continue to improve.
Frantz R. Lerebours, M.D., Randy Cohn, M.D., and Thomas Youm, M.D.
Frantz R. Lerebours, M.D., Randy Cohn, M.D., and Thomas Youm, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.
Correspondence: Frantz R. Lerebours, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003; email@example.com.
None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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Caption: Figure 1 MRI proton density-weighted T2 coronal of the left hip shows a full-thickness tear of the gluteus medius tendon.
Caption: Figure 2 Right hip following an endoscopic gluteus medius repair. The torn tendon is repaired back to its native footprint (right side of the image corresponds to the distal aspect of the gluteus medius footprint). To view this fgure in color, see www.hjdbulletin.org.
Please note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Lerebours, Frantz R.; Cohn, Randy; Youm, Thomas|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jan 1, 2016|
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