Gluteus Medius Tears After Hip Arthroplasty. John Urse, DO, FAOAO Jason Spangler, DO Dzi-Viet Nguyen, DO Grandview Medical Center Dayton, OH

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1 Gluteus Medius Tears After Hip Arthroplasty John Urse, DO, FAOAO Jason Spangler, DO Dzi-Viet Nguyen, DO Grandview Medical Center Dayton, OH

2 Disclosures AANA (Arthroscopy Association of North America) Lodging and meals received for services as a Hip Arthroscopy Master Instructor Arthrex Laboratory use and cadaveric supplies for research

GLUTEUS MEDIUS AND MINIMUS TEARS Lachiewicz JAAOS 2011 4 Types Degenerative tears Traumatic tears

6 GLUTEUS MEDIUS AND MINIMUS TEARS Lachiewicz JAAOS Types Degenerative tears Traumatic tears Asymptomatic tears W/ Femoral Neck Fxs/THA Avulsion/failure of repair following THA Anterolateral approach

7 Gluteus Medius Tears in OA Bourne et al, 176 pts underwent THA for OA 20 % degenerative pathology of abductor mechanism More common in elderly women 16% with isolated gluteus medius or minimus tears

$al 50 pts with femoral neck fractures 22 % had tear at insertion$

8 Rotator Cuff Tear of the Hip Bunker et. al 50 pts with femoral neck fractures 22 % had tear at insertion of gluteus medius/minimus

438 mm 2 Superoposterior facet Circular 8 mm Total

9 Anatomy Gluteus Medius 2 distinct insertions Lateral facet Rectangular 34 mm +/- 4mm Total surface area 438 mm 2 Superoposterior facet Circular 8 mm Total surface area mm 2 Gluteus minimus Anterior facet

10 Anatomy Robertson et. al, Vol 24, No 2 (February), 2008: pp

11 Gluteal Triad Single-leg squat test Unilateral Bridge test Positive Trendelenburg sign

12 Single-Leg Squat Test Crossley et. al Reliable tool to identify patients with hip muscle dysfunction AJSM Vol. 39, No. 4, 2011

in patient with hip implants Need MSK radiologist

13 Plain x-ray often normal Imaging Implant alignment and stability Dynamic ultrasound Imaging of choice in patient with hip implants Need MSK radiologist MRI Significant artifact/scatter if prosthesis in place

15 Ultrasound GM Tear GT Cortex Euro Radiol (2003) 13:

16 Endoscopic Repair Technique Lateral decubitus Bean bag Pillow/bump placed between the legs

17 Portals Anterior and posterior portals 2 cm distal to the tip of GT 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

18 Anchor Placement Lateral facet Largest surface area (35 mm) Most tendon to bone contact

19 Insert the loaded anchor(s) into the prepared proximal bone sockets through your percutaneous lateral portals 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

20 Pass each suture tape individually through the tendon and out the anterior portal Sutures may be managed separately by bringing each suture out through the percutaneous portal after being passed through the tendon 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

21 Through the anterior portal, grasp one suture from each of the two anchors, pulling it out of this portal 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

22 Load these two sutures through one anchor 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

23 Create pilot holes for the distal second row using the punch at a dead man s angle 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

24 Place the preloaded anchor down into the first distal hole 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

25 Grasp the other two sutures and load these two sutures through the final anchor 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

26 Place the preloaded anchor down into the second distal hole 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

27 Pull on the sutures to cinch the tendon down to the footprint on the GT and lock the anchor down to bone 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

28 Cut ends of the suture IR and ER to hip and visualize the tendon Dr. John Urse Dr. Dzi-Viet Nguyen

29 Case Study

31 4.7mm Swivel lock with Fibertape

37 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

38 Post Op Care Hip Abduction Brace California Type brace Use when ambulatory Hip abduction pillow in bed/chair 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

39 Post Op Care Protection Phase (Week 0-6) Abduction brace immediately postop until week 6 Partial weight-bearing with walker/crutches No forced adduction/external rotation with hip flexed at Dr. John Urse Dr. Dzi-Viet Nguyen

40 Post Op Care Motion Phase (Week 6-8) No abduction brace Advance protected weight bearing while monitoring Trendelenberg All motions allowed, gradual increase in strength 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

41 Post Op Care Strength Phase (Week 8-12) Full weight bearing, full active ROM Proprioception exercises Return to Sport Phase (Week 12-18) Full hip and LE strength, on all terrain Begin sport specific activity 2011 Dr. John Urse Dr. Dzi-Viet Nguyen

42 Other Factors Double row vs. single row Bone Density Anchor placement

43 Double Row vs Single Row Barber et. al; Arthroscopy Sept Shoulder data Suture-tape DR rotator cuff repair Greater footprint coverage Less footprint displacement during rotation Greater mean failure load than triple-loaded single row repair with mechanical testing

44 Bone Density Dishkin-Paset et al; Arthroscopy 2012 Compared 2 different doublerow techniques for GM repairs Biomechanical stability similar Failure load of DR knotless lateral anchors strongly correlated to BMD Thus, bone quality may be important

45 Literature Review Only one study (France) Rajkumar et al; Hip Int patients with GM tears after THA 11 underwent open repair of GM Preop HHS 77.4, Postop HHS /11 patients satisfied and would recommend the procedure

46 Our Research 95 cases of endoscopic repair of GM Treated between patients with previous hip arthroplasty All treated with double row repair using knotless suture bridge technique 4.7 mm bioabsorbable anchors with suture tape

47 Surgical Treatment All patients underwent endoscopic repairs

48 Methods Ten patients with previous hip arthroplasty Failed conservative treatment NSAIDS Corticosteroid injections X-rays negative All prostheses in appropriate position and alignment No signs of loosening Ultrasound confirmed gluteus medius tears in all patients Confirmed by MSK radiologist

49 Table 1 Results

50 Results Table 2 All patients Significant pain relief Improvement in modified Harris Hip Scores Average mhhs 43 preop (range 13-84) 79 postop (range 34-92) 70 percent of patients with mhhs 80 or greater postop

51 Conclusion Gluteus medius tears can be significant cause of lateral hip pain after THA Gluteal triad on physical exam US most useful imaging in patients with THA Recommend double row endoscopic repair

53 Thank You

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