Hip Arthroscopy With Concomitant Endoscopic Gluteus Medius/Minimus Repair

Abstract

Background:

Gluteus medius and minimus tears can lead to significant lateral hip pain, abductor weakness, and functional impairment. These tears are more frequently seen in middle-aged and older adults. These tears typically involve the anterolateral portion of the tendon footprint on the greater trochanter and can range in degree and severity. Gluteus medius and minimus tears most commonly develop due to chronic tendinous degeneration but may also arise as a result of acute trauma. Endoscopic repair has emerged as a more minimally invasive alternative to open techniques, offering effective tendon reattachment via suture anchors with reduced surgical morbidity. Additionally, concomitant arthroscopic intervention may allow for intra-articular pathology to be addressed, which may further improve patient outcomes.

Indications:

Indications for endoscopic gluteus medius and/or minimus repair include partial-thickness tearing, leading to significant pain and functional deficits that are recalcitrant to conservative management. While full-thickness and retracted tears may also be approached endoscopically, this technique may be particularly suited for cases with smaller tears and minimal fatty infiltration.

Technique Description:

A standard anterolateral portal and a modified mid-anterior portal are established with fluoroscopic assistance. After intra-articular pathology is addressed, the greater trochanteric space is accessed. The torn tendon is identified and debrided, and the tendon footprint is exposed and prepared with a burr. The gluteal tendon is repaired to its attachment on the greater trochanter with suture anchors.

Results:

Endoscopic gluteus medius and/or minimus repair has demonstrated improvement in pain and function over short-term postoperative follow-up. An endoscopic approach may reduce the surgical morbidity relative to what is conferred by an open approach.

Discussion/Conclusion:

Gluteus medius and/or minimus tears may be effectively treated endoscopically. This approach may minimize surgical morbidity compared with an open approach and allows for concomitant treatment of intra-articular pathology.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

The following is a surgical technique video on hip arthroscopy with concomitant endoscopic gluteus medius/minimus repair.

Here are our disclosures.

Background

Gluteus medius and/or minimus tears have become an increasingly recognized cause for a spectrum of pathologies categorized by greater trochanteric pain syndrome. ⁵ Gluteus medius and/or minimus tears, which may present with lateral hip pain and abductor weakness, are more commonly seen in middle-aged and older adults as a result of chronic tendon degeneration. Gluteal tendon tears exist along a wide spectrum of severity, including tendinosis, partial- and full-thickness tearing, and retracted tears with significant muscular atrophy and fatty infiltration. ⁶ While open repair has traditionally been utilized for gluteus medius and/or minimus repair, an endoscopic approach has become increasingly utilized due to its relatively reduced surgical morbidity. ² This treatment approach has demonstrated efficacy in reducing pain and improving function for patients with this pathoanatomy.^2,6

Indications

We will utilize a case presentation to discuss the indications and surgical technique for endoscopic gluteus medius and/or minimus repair. Our patient is a 59-year-old woman who has experienced 9 months of predominantly laterally based left hip pain that has been recalcitrant to conservative treatment, including activity modification, anti-inflammatory medications, physical therapy, and trochanteric bursal corticosteroid injections. Notably, the patient had undergone left hip arthroscopy approximately 4 years prior, with acetabular labral repair and correction of femoroacetabular impingement. Her physical examination is notable for the presence of a mild Trendelenburg gait; groin pain reproduced with hip flexion, adduction, and internal rotation; tenderness to palpation over the greater trochanter of the femur; and weakness with hip abduction.

Anteroposterior and Dunn lateral radiographic views do not demonstrate any obvious acute pathology and no significant femoroacetabular joint degeneration. On magnetic resonance imaging, high-grade, partial-thickness tearing of the gluteus medius and minimus tendons is present, in addition to trochanteric bursitis. Some signal is also seen about the labrum, which is inconclusive, but could represent postsurgical changes versus recurrent labral tearing.

Given that the patient had unsuccessful extensive conservative management, surgical intervention was recommended, consisting of left hip endoscopic trochanteric bursectomy and gluteus medius and minimus repair. Other treatment considerations included an open versus endoscopic approach, whether to address concomitant intra-articular pathology, and whether augmentation of the repair would be required. An endoscopic approach was favored to reduce surgical morbidity in the setting of partial-thickness tendon tearing and to allow for concomitant treatment of intra-articular pathology. More significant tendon retraction or muscular degeneration may have prompted consideration for an open approach to allow for improved tendon mobilization and potential augmentation of the repair construct.

Technique Description

Following the initiation of general anesthesia, patients are placed supine on a standard hip arthroscopy table (Hip Positioning System; Smith & Nephew) with a post, and traction is initiated to open the joint space. A standard anterolateral (AL) portal is established under fluoroscopic guidance, followed by the creation of a modified mid-anterior portal (MMAP) under direct visualization. The MMAP is created using spinal needle localization, with fluoroscopic assistance to assess the trajectory over the greater trochanter.

A diagnostic arthroscopy is then performed to evaluate and treat sources of intra-articular pain. In this case, the previous suture labral anchors were grossly intact with no evidence of recurrent labral tearing. Thus, a gentle labral debridement was performed with an arthroscopic shaver to eliminate capsulolabral adhesions and inflamed tissue. Once the intra-articular portion of the case is completed, traction is released, and attention is turned to the peritrochanteric space.

The hip is abducted 15° to 20° to relieve gluteal tension. A 5.0-mm metal cannula with an obturator is then inserted through the MMAP, passing between the iliotibial band and the lateral aspect of the greater trochanter. The cannula is swept from proximal to distal to open the potential space, and the arthroscope is introduced for visualization of the peritrochanteric space. Using a switching stick through the AL portal, another 5.0-mm metal cannula is positioned between the tip of the greater trochanter and the iliotibial band. A 4.5-mm shaver (Formula 180; Stryker) is then inserted and used to debride the bursal tissue, allowing for visualization of the gluteus medius, gluteus minimus, vastus lateralis, and gluteus maximus tendon insertions. The gluteus medius tendon tear is identified on the AL aspect of the greater trochanter. Nonviable tendinous tissue is debrided with the arthroscopic shaver and radiofrequency (RF) ablation device to prepare the tendon and its footprint, respectively. The tendon footprint on the greater trochanter is then decorticated with an arthroscopic burr (Formula; Stryker) to create a bleeding surface of bone that will facilitate tendon healing. Next, a 5.5-mm, triple-loaded suture anchor with tape (AlphaVent; Stryker) is inserted into the gluteus medius footprint on the lateral aspect of the greater trochanter. Fluoroscopy can be used to confirm the location of suture anchor placement if desired. A standard posterolateral (PL) portal is then established 1 cm proximal and posterior to the PL corner of the greater trochanter under spinal needle localization. A penetrator-retriever (Penetrator Suture Retriever–Wishbone; Arthrex) is then used to pass like-colored pairs of tape suture through the anterior and posterior leaflets of the tendon split, respectively, in a simple fashion. The like-colored pairs of tape sutures are then sequentially tied through the PL portal under arthroscopic visualization to complete the proximal row repair in a horizontal mattress fashion.

Next, the RF device is used to remove soft tissue from the distal insertion site for the distal, posterior gluteus medius tendon insertion. One limb of each pair of suture tape is then withdrawn and loaded into a knotless suture anchor that is placed at the distal tendon attachment site (AlphaVent Knotless; Stryker). The process is subsequently repeated at the insertion site for the distal anterior gluteus medius tendon insertion to complete the distal row fixation. The final repair construct is seen here. Postoperatively, the wounds are closed in a standard fashion, and patients are transitioned to a rehabilitation protocol focused on gradual restoration of strength and function.

To improve surgical technique, several pearls are highlighted here. During the procedure, slight abduction of the hip should be performed to help open the peritrochanteric space. ¹ Furthermore, fluoroscopic guidance may be used to help obtain the appropriate access trajectory and confirm the appropriate location of instrumentation throughout the case. Finally, bleeding in the peritrochanteric space can be controlled with cautery. This step is important to maintain a clear operative field and reduce surgical morbidity.

Results

After surgery, patients undergo a 4-phase rehabilitation protocol, each lasting 6 weeks. During phase 1, patients are instructed to use crutches, bearing approximately 20% of their body weight, and to restrict hip abduction and internal rotation. Phase 2 is initiated at postoperative week 6. At this time, range of motion and weightbearing restrictions are lifted, and patients initiate strength and gait training. Phase 3 begins at postoperative week 12, at which time patients are allowed to return to some prior activities, with a focus on functional training during guided rehabilitation. During phase 4, beginning at postoperative week 18, patients are encouraged to increase their activity level. By 6 months postoperatively, patients are allowed to return to prior sports activity, provided they have completed a sport-specific, return-to-play progression.

Discussion/Conclusion

Prior studies have demonstrated the efficacy of endoscopic repair of gluteus medius and/or minimus tendons. Nazal et al ⁴ reported outcomes of a prospective study including 15 hips that underwent endoscopic repair of full-thickness gluteus medius and minimus tears. At 2 years postoperatively, significant improvement was seen in all patient-reported outcomes assessed. The authors cited the potential advantages of less tissue violation, ambulatory same-day surgery, and fewer complications in comparison with an open approach to repair. Another study by Byrd et al ¹ involving 63 patients similarly examined the outcomes of endoscopic gluteus medius and minimus repair at long-term follow-up. In this study, endoscopic repair led to a 34.9-point mean improvement in modified Harris Hip Score, with 92.2% of patients surpassing the minimal clinically important difference threshold. Finally, a systematic review by Longstaffe et al ³ examined the literature surrounding open and endoscopic gluteal tendon repairs and found that in 22 studies, patients had similar improvements in reported outcomes and function for both endoscopic and open repair. In addition, endoscopic repair demonstrated lower complication rates and similar retear rates compared to an open approach. These studies suggest that the endoscopic repair of gluteus medius and minimus tears remains a viable option and has been shown to minimize complications while producing favorable patient-reported outcomes up to 10 years after surgery.

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