Gluteus Medius Tears After Hip Arthroplasty

John Urse, DO, FAOAO Jason Spangler, DO Dzi-Viet Nguyen, DO Grandview Medical Center Dayton, OH 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 • Asymptomatic tears • W/ Femoral Neck Fxs/THA • Avulsion/failure of repair following THA • Anterolateral approach 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 Rotator Cuff Tear of the Hip

• Bunker et. al – 50 pts with femoral neck fractures – 22 % had tear at insertion of gluteus medius/minimus Anatomy

• Gluteus Medius – 2 distinct insertions • Lateral facet – Rectangular – 34 mm +/- 4mm – Total surface area 438 mm2 • Superoposterior facet – Circular – 8 mm – Total surface area 196.5 mm2 • Gluteus minimus – Anterior facet Anatomy

Robertson et. al, Vol 24, No 2 (February), 2008: pp 130-136 Gluteal Triad

• Single-leg squat test

• Unilateral Bridge test

• Positive Trendelenburg sign Single-Leg Squat Test

• Crossley et. al

• Reliable tool to identify patients with hip muscle dysfunction

AJSM Vol. 39, No. 4, 2011 Imaging • Plain x-ray often normal – 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

Ultrasound

Tear GM Cortex

GT Euro Radiol (2003) 13:1339-1347 Endoscopic Repair Technique

• Lateral decubitus

• Bean bag

• Pillow/bump placed between the legs Portals

• Anterior and posterior portals

• 2 cm distal to the tip of GT

• Lateral facet – Largest surface area (35 mm) – Most tendon to bone contact • Insert the loaded anchor(s) into the prepared proximal bone sockets through your percutaneous lateral portals

©2011 Dr. John Urse Dr. Dzi-Viet Nguyen • 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

• IR and ER to hip and visualize the tendon.

4.7mm Swivel lock with Fibertape

• Hip Abduction Brace – California Type brace – Use when ambulatory – Hip abduction pillow in bed/chair

 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 90°

 Motion Phase (Week 6-8) • No abduction brace • Advance protected weight bearing while monitoring Trendelenberg • All motions allowed, gradual increase in strength

 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

• Double row vs. single row

• Bone Density

• Anchor placement Double Row vs Single Row

• Barber et. al; Arthroscopy Sept. 2012 – 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 Bone Density

• Dishkin-Paset et al; Arthroscopy 2012 – Compared 2 different double- row techniques for GM repairs – Biomechanical stability similar – Failure load of DR knotless lateral anchors strongly correlated to BMD – Thus, bone quality may be important Literature Review

• Only one study (France) • Rajkumar et al; Hip Int. 2011 – 13 patients with GM tears after THA – 11 underwent open repair of GM – Preop HHS 77.4, Postop HHS 86.97 – 9/11 patients satisfied and would recommend the procedure Our Research

• 95 cases of endoscopic repair of GM – Treated between 2010-12

• 10 patients with previous hip arthroplasty

• All treated with double row repair using knotless suture bridge technique – 4.7 mm bioabsorbable anchors with suture tape Surgical Treatment

• All patients underwent endoscopic repairs 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 Results Table 1 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 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

Thank You

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