Area of Focus: Sports Medicine and Arthroscopy
Greater trochanteric hip pain is a common ailment of middle-aged adults. Epidemiologic studies estimate a prevalence of up to 15%, with an incidence of 1 in 500 persons. Women have more than a three-fold increased risk compared to men, with the typical age distribution occurring in the fifth and sixth decades. Patients typically have atraumatic presentations; they often complain of chronic pain and tenderness over the affected greater trochanter. Walking, climbing stairs, or lying on the affected side usually exacerbates symptoms. The physical exam is often notable for point tenderness over the greater trochanter and a variable amount of weakness with hip abduction. The patient is best assessed while lying on his/her unaffected side as the examiner abducts the leg against active resistance. Some patients may progress to having a lurch with ambulation.
The diagnosis of greater trochanteric pain syndrome (GTPS) is based on history and physical examination. However, MRI is indicated after conservative measure failure in order to surgically evaluate for gluteus medius tears. Plain radiographs are often unremarkable. However, they may demonstrate greater trochanteric sclerosis, osteophyte formation, and irregular cortical borders. An MRI is the preferred method of imaging. Identifying T2 signal hyperintensity at an area superior to the greater trochanter is the best diagnostic determinant. This approach has a sensitivity of 73% and a specificity of 95% for diagnosing gluteus medius tears. As in rotator cuff imaging, full-thickness tears demonstrate tendon discontinuity, whereas increased signal intensity or a thickened tendon is suggestive of tendinopathy or partial tears.
Until recently, the treatment for GTPS was limited to conservative measures. Most patients find relief with anti-inflammatories, lifestyle modifications, physical therapy, and judicious local corticosteroid injections. However, many patients can be unresponsive to conservative treatments and, until recently, they had no other options. The differential diagnosis of recalcitrant GTPS may include: trochanteric bursitis, coxa saltans externa, and chronic tears of the gluteus medius muscle. All are now amenable to endoscopic treatment.
Hip arthroscopy is gaining momentum as a reliable, minimally invasive surgical option for hip disorders. Recent advances in experience, technology, and imaging have led to an expanding role in arthroscopic, and now endoscopic, surgery of the hip. Successful techniques can now address the central compartment; peripheral compartment; and the peritrochanteric spaces, specifically, tears of the gluteus medius.
Authors first described gluteus medius tears in 1997, later calling the gluteus medius the rotator cuff of the hip. In recent years, recognition has expanded to endoscopic treatment with great promise. Voos et al report the prospective results of ten patients with endoscopic gluteus medius repair with suture anchors. At an average follow-up of 25 months and average age of 50 years, ten of ten patients had complete resolution of pain Moreover, subjects reported a mean 94 Modified Harris Hip Score and a mean of 93 Hip Outcome Score. The authors reported no complications. Understanding the anatomy of the peritrochanteric space is a surgical requisite. The greater trochanter is the centerpiece of the peritrochanteric space, bordered by the tensor fascia lata and iliotibial band laterally, abductor tendons superioromedially, vastus lateralus inferomedially, and gluteus maximus muscle superiorly and posteriorly.
The gluteus medius is a fan-shaped muscle that originates on the iliac crest from the anterosuperior iliac spine to the posterosuperior iliac spine. It has three different portions (anterior, middle, posterior), all innervated by the superior gluteal nerve and supplied by the superior gluteal artery. Importantly, it inserts at two distinct sites on the greater trochanter: the lateral facet and superoposterior facet. The posterior gluteus medius fibers insert onto the superoposterior facet; whereas, the anterior and middle portions insert onto the lateral facet. The anterior and middle gluteus medius aid in initiating hip abduction. They also aid in external and internal rotation, as well as pelvic stability. The posterior gluteus medius acts to stabilize the hip joint in early gait from heel strike to full stance.
The gluteus minimus is located deep to the medius, and it inserts on the iliacus at the middle gluteal line of the outer table, spanning from the anteroinferior iliac spine to the posteroinferior iliac spine. This muscle is also innervated by the superior gluteal nerve and supplied by the superior gluteal artery. It divides into two heads at its insertion, with one capsular insertion at the medial lateral facet, and the other at the long head distal to the bald spot on the lateral facet. The gluteus minimus also acts in leg abduction, aids in external and internal rotation, and adds to pelvic stability. It also acts to stabilize the hip joint in mid and late cycles of gait.The following is the surgical technique: Under general anesthesia, position the patient in the lateral decubitus position lying on the unaffected hip supported by a beanbag. Prep and drape the patient, exposing the hip widely. Prep a portion of the medial half of the affected leg, both front and back, including from the knee to the abdomen. Next, place the leg with the hip in the neutral position. Consider placing the knee on a mayo stand to release tension on the iliotibial band (ITB). Inject the peritrochanteric space with epinephrine-soaked saline to extend the ITB and release adhesions. Set the pump pressures at 50-70 mm Hg saline with epinephrine. Use a 70o scope for optimal visualization. Place the portals in the shape of a diamond, with a posterior peritrochanteric portal, an anterior peritrochanteric portal, a superior portal, and a distal portal. Each portal can be used as a working or viewing portal; cannulas are often unnecessary. Often the superficial bursa is exposed to direct portal placement below the ITB. Deep to the ITB, débride the trochanteric bursa with a shaver and then with a radio frequency device to address bleeding. This enhances visualization and may also be therapeutic. Finally, identify the tear at the lateral facet of the greater trochanter. Gently débride with a shaver to cortical bone to stimulate bleeding, taking care not be too aggressive because the greater trochanter cancellous bone is notoriously osteoporotic. Vigorous debridement could weaken anchor pull-out. Grasp the tendon with a grasper to ensure tendon-free insertion at the lateral facet. If necessary, employ margin convergence or tissue release. We prefer to insert one to two suture anchors inserted at 45o degrees to the bone and use trans-tendinous repair with medial row sutures backed up with lateral row anchors.
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