Peritrochanteric Disorders

History

Gluteus medius and minimus tears were first described in 1997 as the “rotator cuff tear of the hip.” The tears are commonly seen in aging individuals, with up to 25% of women in their 60s reporting abductor tendon tears. Similar to rotator cuff tear repairs, the abductor tendon tear repairs were initially done with open surgical techniques, which have increasingly been replaced by endoscopic techniques in recent years. The gluteus medius and minimus span from the ilium to the greater trochanter and are innervated by the superior gluteal nerve. Functionally they serve to abduct the hip and stabilize the pelvis during gait. The gluteus medius and minimus stabilize the pelvis by elevating the contralateral hemipelvis during the stance phase of gait, and if pelvic stabilization is not achieved, a Trendelenburg gait can be appreciated. Ultimately proper ambulation and stability can be severely compromised if the gluteal tendons are weak or ruptured.

Physical Examination

Abductor tendon tears are classically insidious or due to trauma, causing avulsion of the tendon from its attachment on the greater trochanter. The patient may present with symptoms of hip abductor weakness, including a Trendelenburg sign, gait, and lurch, which may mimic a leg-length discrepancy from lack of pelvic stabilization. This pelvic instability, especially during the stance phase of gait, results in difficulty ambulating properly and without pain. In addition to pain during activity, the patient can present with lateral hip tenderness over the greater trochanter, with reports of tenderness to palpation or inability to lie on the affected side. Additional physical exam maneuvers that mimic those done in patients with rotator cuff pathology can support the diagnosis of gluteal tendon tears. The hip lag sign has been described with the patient's symptomatic hip passively put into extension and internal rotation with the knee flexed at 90 degrees while lying on their unaffected side. The patient's inability to maintain the position of the leg when the examiner stops supporting the limb could yield sensitivities and specificities for abductor tendon damage as high as 89% and 96%, respectively.

Imaging

A clinical evaluation is paired with magnetic resonance imaging (MRI) findings for diagnosis of the condition ( Fig. 83.1 ), since MRI findings alone may discover incidental gluteal tendon tears in elderly populations. Radiographs are usually unremarkable, since they do not accurately visualize tendinous structures, and although ultrasound can detect inflammation and gluteal tendon tears, MRI is preferred.

Decision-Making Principles

Although trauma can elicit acute tears, gluteal tendon tears are often insidious in onset, making them difficult to diagnose. Due to their gradual progression of pain and functional limitation, abductor tendon tears are commonly mistaken for chronic processes within the hemipelvis, such as arthritis, bursitis, or radiculopathy from lumbar deterioration. Further clinical evaluation and workup of abductor tendon tears can be found in Box 83.1 .

Treatment Options

Since gluteal tendon tears can range from partial to full tears, treatment modalities span from conservative to surgical as well. Conservative management should be started in patients initially presenting with signs of abductor tendon weakness. Physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), and activity modification are preferred to limit inflammation and strengthen the remaining musculature and surrounding hemipelvis. Surgical repair is generally reserved for discrete gluteal tendon tears or tears that have failed previous conservative therapies. Of note, patients with the symptomology of abductor tendon rupture who simply suffer from chronic weakness accompanied by image-supporting muscle atrophy may not be surgical candidates.

Authors’ Preferred Technique

Prior to surgical repair, the anatomic attachments of the abductor tendons must be well understood to reestablish the native anatomy and abductor biomechanics. The complicated insertion sites are best described in relation to the following four facets of the greater trochanter: superoposterior, lateral, anterior, and posterior. The gluteus medius is composed of anterior, middle, and posterior fiber groupings, which attach to two facets on the greater trochanter. The anterior and middle fibers of the gluteus medius insert onto the lateral facet of the greater trochanter, and the posterior fibers insert onto the superoposterior facet. The gluteus minimus, which travels deep to the gluteus medius, attaches at the lateral facet of the greater trochanter and joint capsule. The natural configuration of the attachments of gluteal tendon7 on the greater trochanter forms a tendon-free “bald spot” between the insertion sites. The identification of these greater trochanteric landmarks is important in recreating the native anatomy during endoscopic repair ( Fig. 83.2 ).

The peritrochanteric space is accessible with the patient in the lateral decubitus position, utilizing a bean bag or peg board, with the pelvis orthogonal to the floor. Slight abduction of the operative extremity is maintained with a padded bump between the legs and the hip in neutral rotation to reduce tension on the iliotibial band (ITB). The peritrochanteric space is injected with epinephrine-infused saline to further enable access to the space while also maintaining hemostasis. Viewing portals are established on the lateral aspect of the thigh approximately 3 to 4 cm proximal and distal to the greater trochanter. The portals are angled toward the gluteal tendon insertion sites at approximately 45 degrees. Fluoroscopic guidance is used to assist the surgeon with triangulation of the instruments toward the greater trochanter. Anterior and posterior accessory portals can be established by direct visualization upon completion of the placement of the lateral portal ( Fig. 83.3 ).

Once the space has been visualized endoscopically with a pump pressure of approximately 40 mm Hg, further anatomic orientation is possible. The peritrochanteric space is divided into superficial and deep regions. The superficial peritrochanteric space is bordered superficially by the subcutaneous tissue and deep by the musculotendinous sheath, which is made up of the ITB, tensor fascia lata, and gluteus maximus ( Fig. 83.4 ). The deep peritrochanteric space is accessed with advancement of the scope through the ITB and musculotendinous sheath, which serves as the ceiling to the deep space ( Fig. 83.5 ). The floor of the deep peritrochanteric space is the greater trochanter of the femur. Noteworthy structures within the deep space include the proximally located gluteus medius and minimus tendons, the posteriorly located gluteus maximus muscle belly and tendon, the distally located origin of the vastus lateralis, and the trochanteric bursa.

The gluteus medius and minimus tendons, which retract posteriorly from their attachment sites in full-thickness tears, are identified within the deep peritrochanteric space ( Figs. 83.6 and 83.7 ). Partial-thickness tears are technically more challenging to repair within the deep peritrochanteric space since tendon retraction is limited and the intact tendon crowds the available footprint for anchor placement ( Fig. 83.8 ).

Once the torn structures have been identified and mobilized, the bony footprint is scarified for tendon attachment. The senior author prefers a composite 4.75-mm SwiveLock (Arthrex, Inc., Naples, FL) anchor double-loaded with no. 2 FiberWire (Arthrex, Inc.) suture and no. 2 FiberTape (Arthrex, Inc.) for the proximal row of the transosseous equivalent technique. A composite 5.5-mm anchor can be used if bone quality is poor. The sutures are shuttled through the tear with a suture shuttle relay in a horizontal mattress configuration and pulled through a waiting portal. Next, FiberWire is passed through the tendon both anteriorly and posteriorly and put through a separate composite 4.75-mm SwiveLock anchor. The sutures are then tied down using a sliding knot with a Weston knot and multiple half hitches. The second row of anchors, placed at a “dead man's” angle of 45 degrees into the region of the vastus ridge, secure the limbs of the previously tied sutures. This technique provides a tension-free tendon repair ( Figs. 83.9–83.13 ). A similar repair can be accomplished with the aid of a clever hook for passing sutures through the tendon.

Postoperative Management

For the first 6 weeks postoperatively, crutches are used with a flat-footed gait, with weight bearing as tolerated. The patient is instructed to maintain a level pelvis without a limp or Trendelenburg lurch during ambulation, avoiding unnecessary tension on the tendon repair. Activity is progressively integrated, with strengthening beginning at 3 months after surgery. Physical therapy–guided strengthening can gradually improve the patient's gait toward normal after several months of targeted exercise.

Results

Outcomes of endoscopic abductor tendon tear repairs have been investigated in relatively small samples. This is partially because of the few patients who present themselves as surgical candidates and the relatively short time period within which endoscopy has been utilized for these repairs. Overall, endoscopic gluteal tendon repairs have shown remarkable improvements in functional outcome, with the benefit of very low complication rates ( Table 83.1 ).

Complications

Although the current literature has not reported significant complications after endoscopic abductor tendon repair, potential complications include tendon retear, muscle herniation through the ITB, neurovascular injury, wound dehiscence, or infection.

Future Considerations

Like many tendinous repairs in orthopaedics, future considerations for gluteus tendon repair could benefit from the evolving field of biologics. The implementation of stem cell therapies may serve to augment the healing of these repairs, similarly to the research currently conducted on the use of biologics on rotator cuff tendon repairs.

Internal Coxa Saltans

Physical Examination

The snapping can be heard and reproduced with provocative movements but is not commonly visualized during the physical exam. The snapping often occurs when the hip is moved from a position of flexion, abduction, and external rotation to a position of extension, adduction, and internal rotation ( Fig. 83.14 ). At times the snapping can occur with just hip flexion to extension; nevertheless the patient is likely familiar with the movements that produce the snapping.

Treatment Options

Since the condition is commonly asymptomatic, only symptomatic individuals experiencing painful snapping should be treated. Conservative treatment—such as physical therapy, NSAIDs, and activity modification—should be relied on initially. Anesthetic and corticosteroid injections have also been used successfully for pain relief and the reduction of inflammation. If conservative treatment is ineffective, patients may be candidates for surgical intervention with iliopsoas tendon recession.

Authors' Preferred Technique

Iliopsoas tendon recession is performed only in symptomatic patients who have intractable snapping hip pain after failing conservative treatment modalities. The iliopsoas tendon release can be done from an intra-articular approach or directly with endoscopic techniques. Intra-articularly, the tendon can be accessed medial to the anterior portal in the peripheral compartment between the zona orbicularis and the labrum at the level of the medial synovial fold. Extra-articular release of the tendon is performed endoscopically with two portals—one anteriorly at the level of the lesser trochanter, and the other 4 cm distal to the lesser trochanter, which functions as the utility portal. Electrocautery is used in a transverse plane to cut the psoas component of the tendon, partially releasing the iliopsoas, so as to avoid compromising its function ( Fig. 83.15 ).

External Coxa Saltans