How To Repair Torn Hip Tendons

JBJS Essent Surg Tech. 2022 Jun; 4(2): e11.

Surgical Technique for the Repair of Tears to the Gluteus Medius and Minimus Tendons of the Hip

Joseph F. Davies

¹Aurora Avant-garde Orthopedics, 13328 Hawthorne Court, Milwaukee, WI 53097. Electronic mail address: moc.loa@deojcod

Dana Thou. Davies

²2231 East Pratt Street, Apartment iii, Baltimore, Dr. 21231

Overview

Introduction

We depict the surgical treatment of tears to the abductor tendons of the hip, which are typically progressive and tin lead to recalcitrant hurting and progressive weakness, leading to considerable difficulties with walking.

Footstep i: Perform the Exposure and Identify the Tear

Place the patient in the lateral decubitus position, expose the lateral peritrochanteric infinite, and and so place the extent of the tear.

Step two: Mobilize the Tendon(southward)

Mobilize the typically scarred-in tendons from the surrounding tissue to let the tendon to exist brought dorsum downwardly to the trochanter.

Step three: Prepare the Tendon and Greater Trochanter

Debride the tendon, and lightly burr the greater trochanter to maximize the healing of the tendon to the bone.

Footstep four: Locate the Insertional Site of the Tendons and Place the Suture Anchors or Drill Holes Into This Site

Identify the area of the footprint for each of the tendons; all suture anchors should be placed in the footprint, and the transosseous drill holes should straddle the near and far edges of the footprint.

Stride 5: Reattach the Tendons

After all of the sutures are placed, necktie them downwardly, starting with the pull sutures first, to bring the tendon back to os; then secure the tendon down with the simple sutures.

Pace six: Reinforce Larger Tears

Reinforce larger tears to protect them and assistance in their healing.

Step 7: Postoperative Protocol

The postoperative protocol period consists of fractional weight-bearing for specific periods of time, followed by vigorous physical therapy for strengthening and gait retraining.

Results

Surgical repair can meliorate role and reliably decreases pain in patients with a hip abductor tear.

Indications

Contraindications

Pitfalls & Challenges

Introduction

We describe the surgical treatment of tears to the abductor tendons of the hip, which are typically progressive and tin can lead to recalcitrant pain and progressive weakness, leading to considerable difficulties with walking.

Awareness of tears of the gluteus medius and minimus of the hip has been increasingly recognized as a cause of lateral hip pain and substantial disability^1-12. This awareness has been aided by improvement in the imaging of the peritrochanteric space with magnetic resonance imaging (MRI)^13-16. The prevalence of such tears in patients with a hip fracture or full hip replacement has been shown to range from 20% to 25%^5,11,17. Surgical management has been recommended and has been resulted in consistent pain relief and functional improvement^18-20.

The surgical treatment is similar to that of repair of the rotator cuff tear of the shoulder. The extent of the tear must get-go exist evaluated on the basis of both preoperative MRI and intraoperative findings. We volition nowadays our nomenclature that both directs our technique and allows us to counsel our patients.

The retracted tendons are mobilized to allow for placement back to their insertion site on the greater trochanter. The trochanteric bed is prepared by removing any inapplicable soft tissue and is lightly burred to obtain some bleeding to assistance in healing of the tendon to the bone.

With the tendon mobilized and the bed prepared, the tendon must be securely fastened to the bone. This can be accomplished with suture anchors for smaller tears with minimal retraction. However, for larger tears, we prefer transosseous fixation through paired tunnels to allow for the usage of both pull and simple sutures. This combination allows us to bring the tendon dorsum down to the bone with the pull sutures and then further secure it with the elementary sutures. A number of adjuvants may exist added on the basis of the complexity of the tear and the quality of the tissue to reinforce the repair and maximize information technology take a chance of healing.

The process is performed with the post-obit steps.

Step ane: Perform the Exposure and Identify the Tear

Identify the patient in the lateral decubitus position, expose the lateral peritrochanteric space, and and then identify the extent of the tear (Video ane).

Brand a standard lateral or posterior approach to the hip. Place the leg on a padded Mayo stand, which helps command adduction/abduction. Incise the iliotibial band, and split the gluteus maximus muscle in line with its fibers.
Remove the trochanteric bursae when nowadays in patients with smaller tears to uncover the gluteal tendons. The gluteus medius is fan-shaped, originating from the aponeurosis and the ilium between the inferior and posterior gluteal lines, inserting on the lateral surface of the greater trochanter (Fig. 1). The gluteus minimus, which is deep to the gluteus medius, originates from the ilium betwixt the inferior and anterior gluteal lines. Information technology inserts onto both the inductive aspect of the capsule and via its long head onto the anterior surface of the greater trochanter (Fig. two).

A cadaveric dissection demonstrating the anatomy of the gluteus medius.

A cadaveric dissection demonstrating the anatomy of the gluteus minimus, as viewed looking caudally from a cephalad position. The gluteus minimus originates from the ilium betwixt the inferior and inductive gluteal lines. Information technology inserts onto both the anterior function of the sheathing and via the long head onto its discrete facet (*) onto the inductive surface of the greater trochanter.
Identify and grade the tear on basis of its size (see Milwaukee classification, Fig. three). The specific surgical technique is based on its relative size.

The classification organization for tears of the hip abductors for the correct and left hips. It is based on the hours of the clock. In a right hip, the gluteus medius inserts between the 11 o'clock and 3 o'clock positions; in a left hip, it inserts between nine o'clock and 1 o'clock. Each grade of the tear is equal to ane 60 minutes of the clock. A Class-I tear involves one hour; Class Ii, two hours, and so on.
The tears typically start in the central fibers of the gluteus medius and then progress inferiorly and posteriorly from that spot (Fig. iv).

A drawing demonstrating the appearances of the various grades of tears in a right hip, showing their progression. Tears typically begin in the fundamental fibers of the gluteus medius at about i o'clock (right hip) and and then extend inferiorly and posteriorly, increasing the course as the tear progresses (blue arrows).
Try to identify and split up the long head of the gluteus minimus from the overlying gluteus medius to let for its separate repair.

Video one

Identification of the tear.

Footstep 2: Mobilize the Tendon(south)

Mobilize the typically scarred-in tendons from the surrounding tissue to allow the tendon to be brought back down to the trochanter (Video 2).

When the gluteus medius is retracted, mobilize it from the overlying gluteus maximus and tensor muscles above and the gluteus minimus beneath by edgeless autopsy.
Mobilize the gluteus minimus from the overlying gluteus medius and from the ilium and capsule beneath. Take intendance when elevating the gluteus minimus off of the ilium as you lot can encounter bleeding from the multiple perforating vessels. Mobilization in primary repairs rarely requires all-encompassing dissection either proximally or anteriorly as it is only the tendon that becomes adherent to the adjacent structures. In revisions, which crave a more extensive dissection, widespread muscle-musculus scarring tin can occur. The long caput of the gluteus minimus, which inserts into its own facet on the anterior aspect of the trochanter, is the most robust and of import portion of this tendon to repair.
The superior gluteal neurovascular parcel must be identified and protected with cephalad dissection >iii cm superior to the greater trochanter (Fig. 5).

A cadaveric autopsy demonstrating the anatomy of the superior gluteal neurovascular (NV) bundle.
With inductive dissection, you may meet bleeding from the ascending lateral femoral circumflex vessels.
Be aware of the terminal branches of the superior gluteal neurovascular parcel that supply the tensor fasciae latae muscle that lies between information technology and the gluteus medius muscle. Fortunately, it is ordinarily well medial and superior to the autopsy.

Video 2

Mobilizing the tendons.

Pace iii: Prepare the Tendon and Greater Trochanter

Debride the tendon, and lightly burr the greater trochanter to maximize the healing of the tendon to the bone (Video 3).

Debride the frayed, fibrillated, and poorly vascularized tissues from the ends of the tendons. However, make every endeavor to preserve the bulk of the tendon as it is relatively short and the anterior and central fibers of the gluteus medius are rather thin.
Release the torn portions of the tendon that are withal attached to the bone. This assists in mobilization of the tendon and allows for an adequate osseous surface for placement of either the suture anchors or the transosseous drill holes.
After removing any inapplicable tissue, lightly burr the lateral cortical surface of the greater trochanter to elicit subchondral bleeding to aid in healing. Minimize the burring to avoid decorticating the very thin cortex overlying the trochanter. Remove all osteophytes.

Video 3

Preparing the greater trochanter.

Footstep 4: Locate the Insertional Site of the Tendons and Place the Suture Anchors or Drill Holes Into This Site

Place the surface area of the footprint for each of the tendons; all suture anchors should be placed in the footprint, and the transosseous drill holes should straddle the most and far edges of the footprint.

Repair of Form-I and Most Course-2 Tears

Some smaller tears are undersurface tears and cannot exist seen from the trochanteric bursal side. Most tears start in the central fibers of the gluteus medius and then progress inferiorly, eventually involving the long head of the gluteus minimus, and then posteriorly toward the superior fibers of the gluteus medius (Fig. 4). The MRI tin can act as a road map for the position of the tear. Conversely, with abduction and internal rotation, a waviness or laxity can be seen overlying the undersurface tear. Incise the tendon longitudinally in the direction of its fibers to discover the tear.
Whenever possible, perform a separate repair of the long head of the gluteus minimus. It is uncommon for smaller tears to exist isolated tears of the gluteus minimus. However, Class-III and Grade-IV tears normally involve the gluteus minimus. As the gluteus medius is rarely retracted in Grade-I and 2 tears, they are typically repaired with a suture-anchor-only technique.
Nosotros have changed from using the 6.5-mm metal or PEEK (polyether ether ketone) suture anchor with three number-2 sutures to using a 2.iii-mm all-suture ballast with two number-5 Force Fibers (ICONIX All Suture Ballast; Stryker, Mahwah, New Jersey) to solve a number of bug:
- » Most importantly, our experience with a express number of failures demonstrated cutting through of the number-2 sutures equally one of the main modes of failure.
- » Oftentimes these repairs are washed in the presence of a femoral component that does not allow full seating or optimal placement of a screw-in anchor.
- » The modest hole size is of import, specially when used in concert with multiple transosseous drill holes and in a compromised trochanter to prevent its fracture.
- » The all-suture implant aids in minimizing artifacts that can be seen, even with the PEEK anchors, when MRI is required to evaluate the integrity of the tendon repair postoperatively.
Place all sutures and position the lower limb in approximately xx° of abduction and 20° of internal rotation prior to tying the sutures down.

Repair of Form-III and 4 Tears (Figs. 6 and vii)

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Two illustrations of the insertion sites of the gluteus medius. (Reproduced, with permission from Elsevier, from: Robertson WJ, Gardner MJ, Barker JU, Boraiah Southward, Lorich DG, Kelly BT. Anatomy and dimensions of the gluteus medius tendon insertion. Arthroscopy. 2008 February;24[2]:130-vi.)

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Repair of a Grade-Iv tear in a right hip. Fig. vii-A Two rows of transosseous holes placed parallel to the inductive and posterior margins of the lateral and superior-posterior facets as described by Robertson et al.²¹ create tunnels. Krackow stitches with number-5 FiberWire are woven into the tendon to create pull sutures that exit 7 to 10 mm from the underside of the tendon edge. These pull sutures are routed through tunnels, cartoon the tendon over the footprint site. Additional simple stitches are placed through each tunnel to secure the tendon margin to the abductor footprint. The sutures from a 6.5-mm suture ballast are placed in the tendon of the long caput of the gluteus minimus (G Minimus). Fig. 7-B The sutures from the suture ballast secure the gluteus minimus downwardly to its anterior facet, and and so pull sutures are tied down under maximum tension, drawing the gluteus medius (Chiliad Medius) tendon back down to its footprint on the greater trochanter. Fig. 7-C The tendon, having been reduced into its position, is further secured with the unproblematic sutures.

For larger tears, and for those of the stouter fibers of the gluteus medius, employ transosseous drill holes with alternating number-five sutures of Forcefulness Cobweb and FiberWire (Arthrex, Naples, Florida), which have different coloration, once more to assistance with suture management.
When possible, perform an isolated repair of the long head of the gluteus minimus with a suture anchor (Video 4). The anterior facet for the long head is just anterior to the lateral facet of the gluteus medius. Its facet has a thick cortex, and its insertion site is rather focal, which is ideal for repair with a suture anchor.
For higher-form tears with a compromised tendon, weave a bankroll suture of number-v Mersilene (Ethicon) through the musculus just deep to the musculotendinous junction. Identify the leading limb of the simple sutures and the deep locking stitch of the leading pull sutures just proximal to this to foreclose their pullout (Video 5).
Identify the anatomic footprint as described past Robertson et al.²¹ (Fig. 6) for the gluteus medius. The gluteus medius attaches via two distinct attachment sites. The stout posterior fibers insert into the posterior-superior facet, whereas the anterior and cardinal fibers insert into the lateral facet (Video vi).
Place transosseous tunnels side by side perpendicular to the axis of the footprint and in line with the direction of the fibers of the gluteus medius. This volition assume a curvilinear shape similar to the outline of the footprint from the posterior-superior tip, to the junior-most point of the inductive fibers of the gluteus medius. A general rule of thumb is that the number of transosseous tunnels equals the grade of the tear—i.e., two tunnels for a Class-II tear (if it is not repairable with simple suture anchors), three tunnels for a Grade-III tear, and four tunnels for a Form-4 tear (Video vii).
Place the medial holes in the near border of the footprint, and the lateral holes in the far edge. This allows for the proximal portion of the tendon to be secured to the medial border of the footprint while leaving the distal flap to be secured over the footprint itself. To accomplish this, nosotros utilise the Tornier tunneling device. Information technology provides an excellent osseous bridge, allows for variable depth of the tunnel (especially important in the presence of an implant), is straightforward, and facilitates the passage of multiple number-5 sutures. Straight tunnels oftentimes need to be drilled too deep (difficult with an implant present) and typically cannot be kept within the anatomic footprint.
Then place a combination of multiple simple and pull sutures (Fig. 7-A).
- » Route the pull suture through the bone tunnel distal to proximal, weave it through the tendon with the apply of a Krackow-blazon cantankerous-stitch, and and so route information technology back out through the adjacent drill hole. The stitch enters 7 to 10 mm proximal to the torn edge of the tendon and goes proximal toward, and sometimes includes, the musculotendinous junction. When traction is applied, this draws that portion of the tendon to the medial edge of the footprint.
- » Simple sutures, which were passed simultaneously through each tunnel with the pull sutures, enter and go out each tunnel at the medial and lateral holes, respectively. Pass the leading limb through the tendon to the musculotendinous juncture and pass the distal limb with a free needle but proximal to the torn tendon edge. When tied, this secures the flap onto the entirety of the osseous footprint. This simulates a double-row repair and allows for a very broad area for healing of the tendon.
- » Suture management is paramount. After each suture is placed, secure information technology in the suture stadium, which is numbered and subdivided further every bit A or B. Place all pull sutures in the more than distal stadium in the A dividers and the uncomplicated sutures in the more proximal stadiums in the B dividers.

Video iv

Isolated repair of the gluteus minimus.

Video 5

Placement of the backing suture.

Video 6

Insertion sites of the gluteus medius.

Video seven

Transosseous drill holes and sutures.

Footstep 5: Reattach the Tendons

After all of the sutures are placed, tie them downwardly, starting with the pull sutures first, to bring the tendon back to bone; and then secure the tendon down with the simple sutures (Video eight).

Tie the pull sutures with the lower limb in 20° of internal rotation and 20° of abduction. Placement of the lower limb on a Mayo stand aids in positioning.
With tension applied, sequentially and deeply tie the pull sutures. As they exit next tunnels, at that place is little take a chance of them cut through the osseous span fifty-fifty with maximum tension applied (Fig. vii-B).
And so tie the simple sutures sequentially with only enough force to judge the tendon downwards to the osseous bed to avoid either strangulating the tendon or cutting through the roof of the tunnel (Fig. 7-C).

Video 8

Tying down the sutures and reattaching the tendon.

Step vi: Reinforce Larger Tears

Reinforce larger tears to protect them and aid in their healing (Video nine).

When a patient has a larger tear, it is important to reinforce the repair. We utilise a human dermal fascial supplement that is approximately 5 × 7 cm and 1.8 to ii.ii mm thick. This adds both structural support and scaffolding for cellular repopulation and vascularization, which are presumed to improve healing. Rao et al.²² used a similar suture technique and a dermal graft and reported good results in twelve patients at an average of twenty-ii months.
Lay the graft obliquely over the repair with the edge slightly overhanging the most distal and lateral portions of the repair.
Secure the corners and midpoint of the longer sides with a number-i nonabsorbable suture. Tie it down under some stretch. Next run a number-ii absorbable suture around the entire border.
Tears of the abductor tendons of the hip, like all other diseases, are highly variable. They encompass the unabridged spectrum from modest undersurface Grade-I tears with minimum muscular atrophy to massive retracted tears (a bald trochanter) with profound muscle atrophy. Each is addressed with guiding principles of secure fixation back downwards to its anatomical insertion site and maximization of the potential for healing. The various adjuvants (instruments and implants) are utilized in a graduated stepwise mode, with the augments added as the situation demands, to satisfy these principles. While 1 must always be cognizant of the costs, the adjuvants let for an efficient operative procedure (minimizing the operating-room fourth dimension-related costs) and have hopefully decreased the incidence of retears and reoperations, both of which have associated societal and economic costs.

Video 9

Placement of the dermal graft.

Pace 7: Postoperative Protocol

The postoperative protocol period consists of partial weight-begetting for specific periods of time, followed by vigorous concrete therapy for strengthening and gait retraining.

We treat all patients with the same deep venous thrombosis prophylaxis as we use for our patients after total hip arthroplasty.
All of our patients, regardless of the size of the tear, begin with 25% weight-bearing, just they maintain it for variable periods of time: six weeks for Grade-I tears, eight weeks for Grade-II, ten weeks for Grade-Three, and twelve weeks for Grade-4. They are enrolled in a prehabilitation program to help them in partial weight-begetting.
All patients are instructed to avoid adduction. A hip orthosis is oftentimes utilized when a noncompliant patient has a larger (Grade-4) tear.
A physical therapy protocol for strengthening of the abductors and gait retraining, specific to the size of the tear, is begun at the higher up time intervals.

Results

Xx-two patients (20-three hips) were included in our original study²³. They were evaluated both preoperatively and postoperatively with utilize of the Trendelenburg test and Medical Research Council (MRC) muscle force grading system. Their outcomes were measured with apply of the Harris hip score²⁴ (HHS) and the Lower-Extremity Activity Scale (LEAS)²⁵ in addition to a satisfaction survey. The tears were graded with utilize of the Milwaukee nomenclature (Fig. 3).

Ninety-1 percent of the patients were women, and the hateful historic period in the series was 67.seven years. 70-eight percent of the hips had a larger (Grade-Three or IV) tear. All of the hips were evaluated at ane yr, and 83% were evaluated at five years.

The mean HHS improved from 53 points preoperatively to 87 points at one year. The mean LEAS score as well improved, from half-dozen.7 to 8.nine points, in this time interval. In that location was no statistically detectable divergence between the groups. However, as expected, there was an obvious tendency for amend results the smaller the tear. These results were maintained over the five-twelvemonth time interval, with a mean HHS of 88 points and a hateful LEAS score of viii.viii points. Muscle strength improved past one.half-dozen grades on boilerplate. Seventy-nine percentage of the patients had a negative Trendelenburg sign, and 84% used no ambulatory aids. Hurting relief was reliable obtained (xc% improvement co-ordinate to patient report), equally was improvement in part (80% comeback). At five years, sixteen of the 19 patients were satisfied with their result and stated that they would undergo the procedure again if required. No major orthopaedic or medical complications occurred.

Surgical repair can amend function and reliably decreases hurting in patients with a hip abductor tear. The clinical part was maintained over the five-year time frame.

What to Watch For

Indications

Clinical symptoms of peritrochanteric pain and weakness.
An MRI-documented tear of the gluteus medius or minimus tendon of the hip. Ultrasound may be used if the patient is unable to undergo MRI and you have the technical ability at your facility.

Contraindications

These tears typically occur in elderly patients, some of whom might not be suitable medical candidates for an orthopaedic hip procedure.
Insufficient quality of the tendon and substantial muscle cloudburst and fatty infiltration. The MRI must be scrutinized for these factors, particularly for larger tears.

Pitfalls & Challenges

To appointment, twelve of 610 procedures take been followed by revision. At the time of revision, the typical failure has been either rupture or pull-through of the number-2 suture. The tension exerted on the abductor tendon repair during daily activities appears to require a stouter suture.

With a femoral implant in place, the technique has to be slightly modified to avert interference from the implant.
- » When using suture anchors, we take switched to using an all-suture implant and accept placed this at an angle slightly greater than the typical xc° that is recommended for well-nigh other anchors.
- » For the transosseous holes, we can modify the depth of the tunnel past modifying the bending of the tunneling device so that the implant does non deflect the loop of the shuttle suture.
The quality of this relatively short and thin (central and anterior portions of the gluteus medius) tendon tin can be moderately or severely attenuated. This can be addressed in three different means:
- » Run a reinforcing umbilical tape at the musculotendinous junction and place the proximal-most limb of the suture merely proximal to it to improve the grab of the suture.
- » Add a BioFiber scaffolding patch (Tornier), which works like a grommet, to the construct to foreclose the sutures from pulling through the compromised tendon.
- » If the musculus is non too atrophic but the tendon is severely compromised, reinforce the construct with an Achilles tendon graft as described by Fehm et al.²⁶.
With severe atrophy, particularly with considerable fatty infiltration, we supplement the repair with a tensor fasciae latae and gluteus maximus transfer²⁷. Whiteside et al. reported good results afterwards a transfer of the gluteus maximus²⁸. The Milwaukee classification organisation has recently been modified to account for muscle atrophy.
In cases of tendon destruction secondary to adverse local tissue reaction (ALTR), the remaining tendon is often seriously destroyed and devoid of any vascularity and therefore any healing potential. Consider either an Achilles tendon graft reinforcement or a musculotendinous transfer, which is our preferred technique for this situation.

Clinical Comments

What percentage of patients undergoing full hip replacement have been shown to have a tear of the abductor mechanism?
What neurovascular structures are at greatest risk with superior dissection during mobilization of the gluteus medius?
What modifications are required with this technique in patients with either poor remaining tendon or profound musculus cloudburst and fatty infiltration?

Acknowledgments

Note: The authors acknowledge Jon Haven for his artistic assistance with the figures, Mr. Thomas Kaemmerling for his editorial assistance with the video clips, and Mr. Jon Schneck for his assistance with the making of the video.

Footnotes

Based on an original commodity: J Os Articulation Surg Am. 2022 Aug seven;95(15):1420-5.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third political party in back up of whatever attribute of this piece of work. Ane or more than of the authors, or his or her establishment, has had a fiscal relationship, in the thirty-six months prior to submission of this piece of work, with an entity in the biomedical loonshit that could be perceived to influence or have the potential to influence what is written in this work. In addition, ane or more of the authors receives royalties that are broadly relevant to the work. No author has had any other relationships, or has engaged in any other activities, that could exist perceived to influence or take the potential to influence what is written in this work. The consummate Disclosures of Potential Conflicts of Interest submitted by authors are e'er provided with the online version of the article.

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