We describe a repair technique utilizing a longitudinal bone trough in the greater trochanter, which allows for reconstitution of the abductor tendon and improved outcomes compared with the traditional repair with suture anchors or transosseous bone tunnels.
Indications & Contraindications
- Absolute indications
- ○ Magnetic resonance imaging (MRI) evidence of gluteus medius and/or complete abductor complex avulsion
- Relative indications
- ○ Pain and disability for >6 months despite conservative therapy (including nonsteroidal anti-inflammatory drugs [NSAIDs] and physical therapy)
- ○ MRI evidence of gluteus medius or gluteus minimus tendinitis and/or a partial tear
- In an attempt to describe abductor tendon tear entities with more anatomic accuracy and to guide the appropriate surgical technique, we designed a new classification system (Table I):
- ○ Type I: No evidence of gluteus medius avulsion from the bone
- ▪ A: Partial tear of the gluteus minimus or gluteus medius tendon
- ▪ B: Complete tear of the gluteus minimus tendon
- ▪ C: Longitudinal tear of the gluteus medius tendon
- ○ Type II: Evidence of gluteus medius avulsion
- ▪ A: Avulsion of <50% of the insertion into the greater trochanter
- ▪ B: Avulsion of ≥50% of the insertion into the greater trochanter
- We require at least 6 weeks of nonoperative therapy for patients with a Type-I tear.
- In our experience, patients with a Type-II tear demonstrate little benefit from physical therapy or guided home exercise.
- ○ While pain relief and gait improvement may be seen in these patients, long-term results may worsen as a result of chronic muscle atrophy and fatty infiltration, which can be seen on MRI scans.
TABLE I -
Hip Abductor Muscle Tear Classification System
|Abductor Tear Type
||No evidence of gluteus medius avulsion from the bone
|| Partial tear of the gluteus minimus or gluteus medius tendon
|| Complete tear of the gluteus minimus tendon
|| Longitudinal tear of the gluteus medius tendon
||Evidence of gluteus medius avulsion from the bone
|| Avulsion of <50% of the greater trochanter insertion
|| Avulsion of ≥50% of the greater trochanter insertion
- ○ Nonambulatory patients
- ○ Poor surgical candidates
Step-by-Step Description of Procedure
Step 1: Positioning and Incision
After placing the patient in the lateral position, make an incision in line with the midline of the femur, dissect down to the iliotibial fascia, and incise the fascia in line with the center of the greater trochanter.
- Place the patient in the lateral position.
- Use a straight, or slightly curved, skin incision, in line with the midline of the femur, beginning approximately 2 cm proximal to the greater trochanter tip and extending 7 cm distally (Fig. 1).
- ○ The incision is similar to that used for a posterolateral approach to the hip.
- Dissect down to the iliotibial fascia, dissecting off a clean edge for closure at the end of the procedure (Fig. 2).
- Incise the fascia in line with the center of the greater trochanter, taking care to not damage the abductors as the incision is made through the gluteus maximus (Fig. 3).
Step 2: Determine the Extent of the Tear
Carefully examine the gluteus medius insertion, use tenodesis of the gluteus medius to the gluteus minimus tendon for Type-IA or IB tears, and use repair into a bone trough for all avulsion tears of the gluteus medius (Type-IIA or IIB tears).
- Carefully examine the gluteus medius insertion.
- ○ Check to see if the patient may have a tear that has scarred into bursal tissue.
- ○ Resect bursal tissue to ensure adequate exposure of the tendon edge.
- ○ Determine if a Cobb elevator needs to be passed along the tendon edge to free up any scarring.
- Repair the gluteus medius to the gluteus minimus tendon when there are partial-thickness tears of the gluteus medius or minimus (Type IA) or complete tears of the gluteus minimus (Type IB).
- Use repair into a bone trough for all avulsion tears of the gluteus medius (Type IIA or B).
Step 3: Tenodesis Repair of Type-I Tears
Using 2 heavy sutures, perform tenodesis of the gluteus medius to the gluteus minimus with 2 running, looped sutures spanning the width of the gluteal tendons.
- Perform tenodesis of the gluteus medius to the gluteus minimus with 2 running, looped sutures spanning the width of the gluteal tendons (Fig. 4).
- Perform the tenodesis with 2 heavy sutures (e.g., number-5 nonabsorbable suture).
- Place the first suture approximately 1 cm medial to the gluteus medius insertion and pass it deep enough to capture both the gluteus medius and gluteus minimus tendons to pull them together (Fig. 5).
- Begin the stitch distally and advance it proximally, just proximal to the tip of the greater trochanter, in a locked, running fashion, and then return the stitch distally and tie it to itself (Fig. 6).
- Place the second suture approximately 2 cm medial to the first suture and run it in the same described fashion (Fig. 7).
- If the gluteus medius tear is longitudinal (Type IC) in nature, utilize a side-to-side suture to close the tear interval for the full length of the tear.
Step 4: Bone Trough Repair: Mobilizing the Tendon (Video 1)
To begin bone trough repair, mobilize the gluteus medius tendon by performing substantial soft-tissue dissection.
- Note that the avulsed tendon demonstrates exposed (bare) greater trochanter bone (Fig. 8).
- Place surgical clamps on the free edge of the tendon to aid in mobilizing the gluteus medius tendon and reestablishing the tissue planes (Fig. 9).
- To mobilize the tendon, perform substantial soft-tissue dissection, as the retracted abductor tendon will be scarred to overlying iliotibial fascia (Fig. 10).
- In chronic tears, after freeing all soft-tissue adhesions from the overlying fascia, it is occasionally necessary to perform additional dissection off the distal part of the ilium to obtain tendon reduction at the midpoint of the greater trochanter.
Step 5: Bone Trough Repair: Tendon Preparation
Continue bone trough repair by resecting any degenerative tissue and placing 2 Krackow stitches, running medially toward the musculotendinous junction of the gluteus medius, and then repeat with the second Krackow stitch, leaving 4 evenly spaced suture limbs.
- Resect any degenerative or frayed tendon edges to healthy tissue edges.
- ○ Keep resection to a minimum to ensure adequate tissue for repair.
- Place 2 Krackow stitches, running medially approximately 5 cm (or as medial as possible) toward the musculotendinous junction of the gluteus medius.
- ○ Place the first suture at the most distal portion of the tear (Fig. 11).
- ○ Run the suture proximally and return it to exit from the midportion of the tear (Fig. 12).
- ○ Remove the clamps and use the first 2 suture limbs for control of the tendon edge (Fig. 13).
- ○ Repeat with the second Krackow stitch such that there are 4 suture limbs evenly spaced, for transosseous fixation into the bone trough (Fig. 14).
Step 6: Bone Trough Repair: Formation of the Trough
Using an osteotome or a burr, create the bone trough, which is placed along the longitudinal center of the greater trochanter; then make 3 drill holes, pass the suture limbs through the holes and tie the limbs over the outer cortex of the posterolateral aspect of the trochanter, pulling the tendon edge into the trough.
- Use an osteotome, or preferably a burr (Fig. 15), to create the bone trough, which is approximately 5 to 8 mm deep to expose cancellous bone and is placed along the longitudinal center of the greater trochanter (Fig. 16).
- Make 3 drill holes in the posterior cortex of the greater trochanter, aimed toward the posterior cancellous bone trough (Fig. 17).
- Make an intraosseous tract from the trough to the posterior drill hole with a penetrating towel clamp (Fig. 18).
- Pass the suture limbs with 2 sutures through the middle drill hole and 1 suture through each outer drill hole (Fig. 19).
- Tie these respective limbs over the outer cortex of the posterolateral aspect of the trochanter, pulling the tendon edge evenly down into the trough (Figs. 20 and 21).
- Ensure that the leg remains in neutral abduction and rotation when the tendon attachment is secured.
- Then place a running suture along the tendon edge, pulling it down to remaining periosteum and muscle fascia to reinforce the repair and remove any rough tendon edges (Fig. 22).
- Perform gentle internal and external rotation of the hip in neutral abduction to confirm that the tendon has been adequately mobilized and repaired (Fig. 23).
Step 7: Postoperative Care
Instruct patients with a Type-I or Type-II tear to bear full weight with use of a walker for 2 or 6 weeks, respectively, and then transition to a cane; to avoid all hip abduction and adduction for 6 or 12 weeks; and to begin exercises to strengthen the hip abductor complex at 12 or 16 weeks.
- Type-I tears (tenodesis)
- ○ Instruct the patient to bear full weight with the use of a walker at all times.
- ○ At 2 weeks postoperatively, discontinue the use of the walker and have the patient transition to the use of a cane.
- ○ Advise the patient that it is important to avoid all hip abduction or adduction for 6 weeks.
- ○ Allow gentle, patient-directed hip abduction and adduction at 6 weeks postoperatively.
- ○ Advise the patient to begin exercises to strengthen the hip abductor complex at 12 weeks postoperatively.
- Type-II tears (bone trough repair)
- ○ Instruct the patient to bear full weight with the use of a walker for 6 weeks.
- ○ At 6 weeks postoperatively, advise the patient to discontinue the walker as tolerated and transition to the use of a cane for an additional 6 weeks.
- ○ Instruct the patient that it is mandatory to avoid all hip abduction or adduction for 12 weeks.
- ○ Allow gentle, patient-directed hip abduction and adduction at 12 weeks postoperatively.
- ○ Advise the patient to begin exercises to strengthen the hip abductor complex at 16 weeks postoperatively.
This article is based on the surgical repair first described, to our knowledge, by Smith et al., who demonstrated superior outcomes using a bone trough in the setting of abductor tear repair at the time of total hip arthroplasty1. Because of discouraging results experienced by us and others2-4, a new technique (the greater trochanter longitudinal bone trough) was developed in an effort to improve surgical results. Published outcomes for open abductor tendon repair have been limited to small case series5. Although this procedure has consistently been reported to provide significant improvement with respect to pain and functional capacity, high rates of retear (6% to 50%) with traditional repair, consisting of decortication and suture fixation, have been reported2,6,7. For our technique, we defined failure as no improvement with respect to pain or gait, or the need for repeat surgery, and we found a similar failure rate (40%; 6 of 15 patients) when repairs utilized the traditional decortication and suture fixation techniques. Our experience with the bone trough technique was similar to the outcomes in the original study that described a more transverse bone trough, in which 79% (15) of 19 patients had complete resolution of pain, symptoms, and gait abnormalities1.
There are many variables that affect the outcomes of abductor tendon repair, including tear size, chronicity, scarring and/or retraction, degenerative muscle fatty infiltration, and the repair technique. The only modifiable factors in these variables would be to diagnose abductor tears earlier in the pathogenesis, avoiding irreversible degeneration prior to repair, and to modify the technique utilized to repair the tendon tear. In evaluating the literature on endoscopic abductor repairs, we found that the majority of outcomes were based on small case series that included a substantial number of small and partial-thickness tears of the gluteus medius or minimus (presumably our Type-I tears)8-12. Therefore, when comparing the results of our Type-I tear repairs with those of endoscopic small tear repairs, the reported outcomes mirror our findings in this case series. It should be noted that endoscopic evaluation and repair could address tearing on the undersurface of the tendon insertions10, in contrast to open repair, which evaluates the lateral surface of the tendon insertion footprint. Therefore, the location of the tear and surgeon preference should be considered when deciding which approach to use. To address avulsion of the gluteus medius and abductor tendon complex, complex salvage operations have been proposed, including the use of mesh, the Ligament Augment and Reconstruction System (LARS; Corin Group), biologic patch augmentation, Achilles allograft reconstruction, gluteus maximus and tensor fascia lata tendon transfers, vastus lateralis transfer, and other variants of these techniques13-18. Our experience has included complete or nearly complete avulsions (n = 6) of the abductor tendon insertion (Type IIB), which were repaired into a bone trough. While these patients had some residual lurch following repair, there was a noticeable improvement in the lurch for each of these patients. We believe that repair into a bone trough is an alternative to these large salvage procedures, provided that the tendon can be mobilized and reduced to the bone.
While others have described the utility of MRI scans to define the type and extent of the tear19,20, terms like “partial tear” can be imprecise. In Figure 24, a preoperative MRI scan, which was reported as a “partial tear of the gluteus minimus insertion,” had evidence of intratendinous edema and disruption of tendon fibers. On intraoperative assessment, however, it was found to be an 80% avulsion of the insertion of both the gluteus medius and gluteus minimus tendons, and the patient underwent a bone trough repair. A postoperative MRI scan, acquired 6 months postoperatively, showed complete healing with a small amount of residual trochanteric bursitis (Fig. 25). This is just 1 example of the difficulties with MRI interpretation and the need to heavily weigh clinical correlation with MRI findings.
We believe that gluteus medius avulsions and postoperative tears require open, rather than arthroscopic, treatment. It is our opinion that the best surgical treatment for nonavulsed gluteus medius tears has not been determined. Therefore, we treat both the described Type-I and Type-II tears with open surgical repair. This allows the appropriate treatment to be applied after intraoperative assessment of the tear without a large deviance in surgical plan. A preoperative MRI scan (Fig. 26) and video (Video 2) of an operatively treated patient show a common preoperative dysfunction. A postoperative MRI scan (Fig. 27) and postoperative video (Video 3) show that even with a partial retear of the repair, clinical improvement in function and pain can still be achieved.
Pitfalls & Challenges
- When determining which repair treatment to use, it is important to carefully examine the gluteus medius insertion to eliminate confusion between Type-I tears and Type-II tears, which are more serious.
- The gluteus minimus is not generally visualized with the tenodesis technique, as it is deep to the gluteus medius.
- ○ The surgeon must ensure that sutures are passed trans-tendinously through the gluteus medius and gluteus minimus with each pass.
- Mobilization of the scarred abductor tendon is a critical portion of Type-II repairs, and therefore care should be taken at this step to ensure adequate mobilization while minimizing damage to the overlying fascial layer.
- ○ Tendon mobilization is important because our bone trough technique requires some lateral advancement of the tendon into the trough.
- ○ A substantial portion of the length of the procedure should be dedicated to this step, as adequate mobilization will allow for easy completion of the following steps.
- Ensure that the bone trough is centralized in the greater trochanter and is longitudinal to avoid greater trochanter fracture.
- ○ Although this placement does not mimic the natural anatomic footprint, we think that this is necessary to avoid weakening the trochanteric bone.
- Patients with a Type-I tear often have rapid, complete pain resolution by 2 weeks.
- ○ Despite this result, we recommend adherence to the postoperative protocol to ensure complete healing of the repair.
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