Abductor Tendon Tears of the Hip: Evaluation and Management

Review Article Abductor Tendon Tears of the Hip: Evaluation and Management

Abstract Paul F. Lachiewicz, MD The gluteus medius and minimus muscle-tendon complex is crucial for gait and stability in the hip joint. There are three clinical presentations of abductor tendon tears. Degenerative or traumatic tears of the hip abductor tendons, so-called rotator cuff tears of the hip, are seen in older patients with intractable lateral hip pain and weakness but without arthritis of the hip joint. The second type of tear may be relatively asymptomatic. It is often seen in patients undergoing arthroplasty for femoral neck fracture or elective total hip arthroplasty (THA) for osteoarthritis. The third type of abductor tendon dysfunction occurs with avulsion or failure of repair following THA performed through the anterolateral approach. Abductor tendon tear should be conﬁrmed on MRI. When nonsurgical management is unsuccessful, open repair of the tendons with transosseous sutures is recommended. Good pain relief has been reported following endoscopic repair. Abductor tendon repair has had inconsistent results in persons with avulsion following THA. Reconstruction with a gluteus maximus muscle ﬂap or Achilles tendon allograft has provided promising short-term results in small series.

From the Department of Orthopaedic Surgery, Duke ateral hip pain, or greater tro- short-term use of a nonsteroidal anti- University School of Medicine, and Lchanteric pain syndrome, is a inflammatory drug, physical therapy the Durham VA Medical Center, common clinical complaint that is for stretching and strengthening, and Durham, NC, and Chapel Hill Orthopedics Surgery & Sports often referred to as “greater trochan- judicious use of corticosteroid plus Medicine, Chapel Hill, NC. teric bursitis.” This finding is more local anesthetic injection into the 2 Dr. Lachiewicz or an immediate prevalent in women than men, with tender trochanteric bursa. In the family member serves as a board peak incidence between the fourth past several years, surgical explora- member, owner, officer, or and sixth decades of life.1 Typical tion and MRI studies have elucidated committee member of The Hip clinical findings are chronic pain and the condition of chronic tears of the Society, the Orthopaedic Surgery & anterior tendons of the gluteus me- Trauma Society, and the Southern tenderness over the proximal lateral Orthopaedic Association; is a aspect of the hip, usually directly on dius and minimus (ie, rotator cuff member of a speakers’ bureau or or anterior to the greater trochanter. tear of the hip). has made paid presentations on behalf of Cadence and Zimmer; Pain may be worsened by lying on serves as a paid consultant to or is the affected hip, walking, or climb- Anatomy an employee of GlaxoSmithKline; ing stairs. The patient may have a and has received research or slight or moderate limp. Usually, The gluteus medius muscle is a large institutional support from Zimmer. passive hip range of motion is not re- curved fan-shaped muscle that origi- J Am Acad Orthop Surg 2011;19: stricted, but there may be a variable nates from the anterior superior iliac 385-391 degree of weakness in side-lying ab- spine and the outer edge of the iliac Copyright 2011 by the American duction. crest back to the posterior superior Academy of Orthopaedic Surgeons. Typically, management begins with iliac spine. The origin is approxi-

July 2011, Vol 19, No 7 385 Abductor Tendon Tears of the Hip: Evaluation and Management

Figure 1 Figure 2

Illustration of a superolateral view of the right proximal femur in a cadaveric specimen demonstrating the attachment sites of the gluteus medius tendon, the two Illustration of the lateral hip musculature demonstrating heads of the gluteus minimus muscle, and the piriformis the three parts of the gluteus medius muscle (ie, muscle, as well as the bald spot of the greater anterior, middle, posterior) in relation to the hip joint. trochanter. (Adapted with permission from Robertson (Adapted with permission from Gottschalk F, Kourosh S, WJ, Gardner MJ, Barker JU, Boraiah S, Lorich DG, Leveau B: The functional anatomy of tensor fasciae Kelly BT: Anatomy and dimensions of the gluteus latae and gluteus medius and minimus. J Anat medius tendon insertion. Arthroscopy 2008;24[2]: 1989;166:179-189.) 130-136.)

mately 1 cm broad and is limited to mus are also horizontally oriented in The superoposterior facet has an ap- the iliac crest. The muscle fibers are relation to the femoral neck, and proximately circular shape, with a separated from the iliac periosteum they run parallel to it. The gluteus radius of 8.5 mm and a total surface by loose fibrous tissue. The muscle minimus also stabilizes the hip joint area of 196.5 mm2. The lateral facet has three distinct portions of equal during the mid and late stages of the has an approximately rectangular volume—anterior, middle, and poste- gait cycle.3 shape, with a larger surface area rior—which are innervated by the The anatomy of the attachment (438 mm2). The gluteus minimus superior gluteal nerve (Figure 1). The sites of the gluteus medius tendon at tendon inserts into both the hip cap- fibers of the anterior and middle the greater trochanter is much more sule (ie, capsular head) and the lat- parts are vertically oriented and have complex than previously realized. A eral facet beneath the gluteus medius a vertical pull, and they aid in initiat- recent anatomic study indicated that tendon (ie, long head). There is a ing hip abduction.3 The anterior part bald area on the greater trochanter is also a primary pelvic rotator. The the gluteus medius tendon inserts between the capsular head of the glu- posterior part of the gluteus medius onto the greater trochanter by two teus minimus and the lateral facet in- is horizontal, running parallel to the distinct attachment sites—the supero- 4 sertion of the gluteus medius. femoral neck. It stabilizes the hip posterior facet and the lateral facet joint in gait from heel strike to full (Figure 2). The posterior gluteus me- stance. The gluteus minimus muscle dius fibers insert onto the superopos- Differential Diagnosis originates from the anterior inferior terior facet of the greater trochanter. iliac spine to the posterior inferior il- Most of the central portion and all The differential diagnosis of lateral iac spine along the middle gluteal of the anterior portion of the gluteus hip pain caused by chronic abductor line. The fibers of the gluteus mini- medius insert into the lateral facet. tendon tear includes hip osteoarthri-

386 Journal of the American Academy of Orthopaedic Surgeons Paul F. Lachiewicz, MD tis (OA), occult fracture of the proxi- terior edge of the greater trochanter.5 transgluteal approach.10 Symptom- mal femur, neuropathy or iatrogenic Large osteophytes of the greater tro- atic patients had significantly more injury of the superior gluteal nerve, chanter may be associated with the defects in the gluteus minimus and lower lumbar spondylosis, and lum- presence of small cysts. These find- medius tendons (P < 0.001). Fatty at- bar spinal stenosis. Hip OA is usu- ings are sometimes seen in patients rophy was seen in the anterior two ally accompanied by limited range of with primary OA of the hip. thirds of the gluteus minimus muscle motion. With occult fracture of the Diagnosis of gluteus medius ten- in both groups, but fatty atrophy of proximal femur, the patient is unable don tears using MRI was described the gluteus medius muscle was pres- to perform a resisted straight-leg in a group of six women with no his- ent only in the symptomatic patients. raise while lying supine. Radio- tory of trauma or underlying medical problems (mean age, 70 years).6 graphs are helpful in the diagnosis of Thickened appearance of the tendon hip OA and hip fracture. Clinical Scenarios and (ie, increased signal intensity on T2- With lumbar spondylosis and spi- Management weighted images) was found to be di- nal stenosis, the pain pattern is more agnostic of partial-thickness tear. There are three clinical scenarios of radicular, rather than localized to the Full-thickness tear consisted of dis- abductor tendon tear of the hip: greater trochanter. However, the pa- continuity of tendon fibers with or chronic, nontraumatic tear of the an- tient may present with a limp and without muscle retraction or atro- terior fibers of the gluteus medius hip abductor weakness. Neuropathy phy. In a study of 250 patients with tendon; abductor tendon tears found of the superior gluteal nerve is rare pain of the lateral hip, buttock, or coincidentally at the time of open and may be associated with diabetes groin, MRI demonstrated tendinosis surgical management of femoral mellitus or rheumatoid arthritis. The or tears of the gluteus medius and neck fracture or elective THA for patient with a history of prior hip minimus tendons in 35 (14%).7 A OA; and abductor tendon avulsion surgery performed through the an- thickened tendon and increased sig- following THA performed through terolateral or another approach or a nal intensity on T2-weighted images an anterolateral or transgluteal ap- revision arthroplasty may present without discontinuity was indicative proach. with iatrogenic injury of the superior of tendinosis. Focal discontinuity in- The first type, chronic, nontrau- gluteal nerve. dicated partial tear, and complete matic tear of the anterior fibers of Suggested treatment for the patient tear was diagnosed only with retrac- the gluteus medius tendon, was first with lateral hip pain and tenderness tion of the torn tendon. A study of described by Kagan11 in seven pa- over the anterolateral greater tro- 74 hips in 45 patients indicated 91% tients with so-called trochanteric chanter includes initial use of non- accuracy of MRI in diagnosing ab- bursitis that was unresponsive to steroidal anti-inflammatory medica- ductor tendon tears.8 Identification nonsurgical management. Kagan11 tions and physical therapy for the of an area of hyperintensity on the referred to this disorder as “rotator abductor muscles. If this is not help- T2-weighted image superior to the cuff tear of the hip.” The mean age ful, management with one or two greater trochanter had the highest of the five women and two men in corticosteroid injections into the sensitivity and specificity (73% and the study was 69 years (range, 52 to greater trochanteric bursa should be 95%, respectively) (Figure 3). 81 years). Symptoms included lateral attempted. MRI may be considered MRI has also been used to assess hip pain, local tenderness, and weak- for patients with severe pain and hip the abductor tendons and muscles af- ness of hip abduction lasting 1 abductor weakness that is not re- ter total hip arthroplasty (THA). In month to 10 years. Hip radiographs sponsive to these nonsurgical mea- one study of eight patients with clini- were normal in all patients. MRI il- sures. This treatment algorithm is cal prosthesis failure after THA per- lustrated fluid in the trochanteric not evidence-based. formed through the anterolateral ap- bursa as well as tears of the gluteus proach, abductor muscle avulsion medius tendon, either from the bone Imaging was noted on MRI and confirmed at or within the substance of the ten- surgical exploration in two women.9 don. These tears were repaired with In patients with chronic tears of the Another prospective study used MRI heavy sutures drilled through bone. abductor tendon, plain radiographs to evaluate 25 patients with and 39 In most cases, the fascia lata was left are usually unremarkable. However, patients without trochanteric pain open to prevent impingement of the they may illustrate sclerosis, an irreg- and abductor weakness following fascia over the suture line. At an av- ular border, or osteophytes at the an- THA performed through the lateral erage follow-up of 41.6 months

July 2011, Vol 19, No 7 387 Abductor Tendon Tears of the Hip: Evaluation and Management

Figure 3 medius tendon tear with metal suture anchors has been reported in 10 patients with a mean age of 50.4 years (range, 33 to 66 years).15 At a mean follow-up of 25 months (range, 19 to 38 months), all 10 patients had complete pain relief and excellent abductor muscle strength. The second clinical scenario involves abductor tendon tear found coincidentally at the time of either open surgical management of femoral neck fracture or elective THA to manage OA. Bunker et al5 studied 50 consecutive patients undergoing arthroplasty for a femoral neck fracture (mean age, 83.5 years; range, 56 to 98 years). Eleven patients were found to have a tear of the anterior one third of the gluteus medius and minimus tendons (22%). The tear was large (2 to 3 cm) in six patients, small (0.5 to 1 cm) in two, and inter- A, Illustration of a hip coronal section at the level of the mid greater stitial in three. The tear presented as trochanter demonstrating normal abductor muscles and tendons. B, T2- a circular or oval defect in the com- weighted coronal magnetic resonance image of the left hip in a 72-year-old mon insertional tendon of the glu- woman with a surgically proven full-thickness tear of the abductor tendon. There is a 2-cm area of high signal intensity superior to the greater teus medius and minimus (Figure 4). trochanter (D). The tendon tear is not directly visualized. A = gluteus minimus The trochanteric bursa was filled muscle, B = gluteus medius muscle, C = subgluteus minimus bursa, with fluid, and the surface of the D = subgluteus medius bursa, E = subgluteus maximus bursa, f = intermus- bare greater trochanter was often cular fat, F = hip joint capsule, G = superior neck recess of hip joint, H = inferior neck recess of hip joint, I = vastus lateralis muscle, J = fascia eburnated and sclerotic, with some lata. (Adapted with permission from Cvitanic O, Henzie G, Skezas N, Lyons osteophytes present. Bunker et al5 J, Minter J: MRI diagnosis of tears of the hip abductor tendons [gluteus recommended excision of trochan- medius and gluteus minimus]. AJR Am J Roentgenol 2004;182[1]:137-143.) teric osteophytes and decortication of sclerotic bone prior to repair with (range, 21 to 60 months), all patients The most frequent complication was three intraosseous sutures. They did had pain relief, and only one had deep vein thrombosis (6%). Abduc- not state whether the fascia lata was persistent weakness. tor tendon tears may also occur in repaired, nor did they report the re- Recently, the results of two larger younger patients. Fisher et al14 results of repair. series of abductor tendon tears were ported sequential spontaneous rup- In a prospective study of 176 con- reported. Davies et al12 described 24 tures of the gluteus medius and mini- secutive patients who underwent patients (22 women, 2 men) with a mus tendons in a 42-year-old woman elective THA using the direct lateral mean age of 67 years who under- with no history of trauma or any approach for OA, Howell et al16 re- went repair with transosseous su- predisposing condition. ported that 34 patients had degener- tures or suture anchors. All but one Rotator cuff tear of the hip should ative pathology of the abductor patient had improvement in hip pain be suspected in patients with lateral mechanism (20%). This finding was and muscle strength at a minimum hip pain and weakness that is unre- seen in 22 of 99 women and 12 of 2-year follow-up. Walsh et al13 re- sponsive to nonsurgical care. When a 77 men (mean age, 68 and 70 years, ported the results of surgical repair tear is visible on MRI, surgical repair respectively). All persons with an ab- in 89 patients treated from 2000 should be considered early, before ductor tendon tear were significantly through 2008. At 6-month follow- the onset of serious fatty muscle at- older than those without a tear. up, 88% had minimal or no pain. rophy. Endoscopic repair of a gluteus There was no significant difference

388 Journal of the American Academy of Orthopaedic Surgeons Paul F. Lachiewicz, MD

Figure 4 ated, but they used a walker for 6 marked with several metal marker weeks to protect the repair. At sutures, and the distances between follow-up of 1 to 5 years, four of the the metal sutures were measured on five women had complete pain relief sequential radiographs. At 2 weeks and no limp or a slight limp. One pa- postoperatively, a separation >1 cm tient had chronic lateral hip pain. between the markers was seen in 23 Surgeons should consider identifi- of 97 hips. At 2 months, the separa- cation by direct inspection and pal- tion was >1 cm in 41 hips, >2 cm in pation of the tendon, and probably 21, and >3 cm in 2. At 1-year repair abductor tendon tear in all follow-up, separation of >1 cm was patients undergoing elective THA, seen in 54 hips, >2 cm in 21, and >3 especially in older women with a re- cm in 6. However, the only statistical cent exacerbation of pain preopera- correlation was between separation tively. >2.5 cm and limp, and there was no The third clinical scenario involves correlation between separation and abductor tendon avulsion after THA pain or function. performed through an anterolateral In a review of the Mayo Clinic Illustration demonstrating the or transgluteal approach. The antero- Joint Replacement Database, Weber typical site of a tear of the gluteus lateral (ie, direct lateral, transgluteal) and Berry21 reported the results of re- medius tendon. A = tendon of the approach popularized by Hardinge is pair of abductor avulsion in nine pa- anterior one third of the gluteus medius and gluteus minimus. favored by many surgeons in North tients at a mean follow-up of 4.8 (Adapted with permission from America and Europe because it offers years. Prior to reoperation, all pa- Bunker TD, Esler CN, Leach WJ: extensive exposure, and the reported tients had a severe limp, eight used a Rotator-cuff tear of the hip. J Bone rate of dislocation is low.17,18 The walking support full time, and five Joint Surg Br 1997;79[4]:618-620.) two potential complications with had moderate or severe pain. Repair this approach are injury to the supe- consisted of freshening the bony bed in mean body mass index in women rior gluteal nerve or vessels and ab- on the trochanter followed by repair and men with or without a tear. Tear ductor insufficiency, with persistent with heavy nonabsorbable braided size ranged from <1 to 12 cm2, and pain, limp, and, in some cases, ante- sutures through drill holes. Postoper- 21 of 34 patients had a tear of <1 rior dislocation as the result of dehis- atively, there was modest improve- cm2 involving the hip capsule and cence of the abductor repair.18 In one ment in limp (five of nine improved) abductor tendon. Only five patients study, 24 of 543 patients had persis- and use of walking support (six used had a tear >3 cm2. Twenty-five pa- tent lateral trochanteric pain that be- no support). However, only one of tients with tears of the abductor ten- gan at a mean of 19 months after five patients with moderate or severe don retrospectively recalled an acute primary THA (range, 6 to 43 pain was improved. The authors sug- exacerbation of pain before arthro- months).19 This pain was signifi- gested that the best indications for plasty (74%). These authors theo- cantly more common in females than abductor repair are severe abductor rized that the pathologic process was in males and in patients who under- weakness and hip instability and that ischemia with resultant degenerative went a direct lateral approach rather significant preoperative pain is less changes within the capsule and ab- than a posterior approach (P < 0.04 likely to be decreased. ductor tendons, eventually resulting and P < 0.01, respectively). In another study, MRI was used to in a tear. The method of repair and In one prospective study of 97 con- evaluate the results of late repair of the results of arthroplasty were not secutive THAs performed through abductor avulsion in 12 patients who reported. the direct lateral approach, the ab- underwent THA via the transgluteal In five women with tears >1 cm2, ductors were repaired with inter- approach.22 The diagnosis of avul- this author used a posterior ap- rupted No. 0 PDS (polydioxanone; sion was made on the basis of persis- proach to the hip combined with ab- Johnson & Johnson, New Bruns- tent trochanteric pain, tenderness, a ductor tendon repair using transosse- wick, NJ) sutures and reinforced limp despite physical therapy, and ous sutures after decortication of the with an osteosuture using a Mersi- weak hip abduction in the lateral po- greater trochanter. The fascia lata lene band (B. Braun, Melsungen AG, sition. The repair was performed by was routinely repaired. The patients Melsungen, Germany).20 During clo- débriding the greater trochanter to a were allowed to bear weight as toler- sure, each side of the suture line was bleeding surface and affixing the

July 2011, Vol 19, No 7 389 Abductor Tendon Tears of the Hip: Evaluation and Management

Figure 5 Figure 6

Illustration demonstrating posterior gluteus maximus flap transfer to reconstruct the abductor muscle deficiency resulting from nonunion of the greater trochanter. A 6- to A, Illustration demonstrating a defect caused by dehiscence of the common 10-cm posterior gluteus maximus aponeurosis closure after an anterolateral (ie, transgluteal) approach to the flap is transferred into an abductor hip. To close the defect, the anterior gluteus medius muscle is advanced defect and sutured to the anterior (arrow). When necessary, adhesions are released from the ilium (oval area). capsule of the hip joint, the The exposed greater trochanter is decorticated to obtain a bleeding surface. remains of the quadratus femoris, B, Illustration demonstrating nonabsorbable transosseous sutures holding the and the posterior edge of the tendinous tissue to the greater trochanter. The vastus lateralis fascia and the gluteus medius. (Redrawn with edges of the repaired aponeurosis have been repaired, as well. (Redrawn permission from Whiteside LA, with permission from Miozzari HH, Dora C, Clark JM, Nötzli HP: Late repair Nayfeh T, Katerberg BJ: Gluteus of abductor avulsion after the transgluteal approach for hip arthroplasty. J maximus flap transfer for greater Arthroplasty 2010;25[3]:450-457, e1.) trochanter reconstruction in revision THA. Clin Orthop Relat Res 2006;453:203-210.) conjoint insertion to the trochanter on MRI did not reverse in any pa- with three to five nonabsorbable No. tient; this finding may explain the tient is kept partial weight bearing 3 transosseous sutures (Ethibond; lack of improvement in abductor with two supports, and abduction Ethicon, Somerville, NJ) (Figure 5). muscle strength. exercises are prohibited for 8 weeks. Partial weight bearing on two Two reconstruction techniques In this study, the patients treated crutches was maintained for 8 have been described. Whiteside with a gluteus maximus flap had less weeks. All 12 patients were evalu- et al23 reported the results of a new pain, reduced limp, and reduced use ated preoperatively with MRI, and technique using a posterior gluteus of walking supports than did pa- 10 had a postoperative MRI. The re- maximus muscle flap transfer to tients who did not undergo this pro- maining two patients underwent manage osteolytic destruction of the cedure.23 The results of this tech- subsequent revision surgery. At greater trochanter with abductor in- nique are promising, but they require 1-year follow-up, 9 of the 12 pa- sertion deficiency. They used this confirmation by other studies. tients were satisfied with the result technique in five patients and left the Fehm et al24 reported on the use of and had improved pain scores. How- trochanter unrepaired in five other Achilles tendon allograft to repair ever, four patients experienced a per- patients. A 6- to 10-cm posterior flap massive abductor tear after THA in sistent limp. MRI examination post- of gluteus maximus muscle is cre- seven patients with lateral hip pain operatively demonstrated an intact ated, which is transferred into the and abductor weakness (mean Har- repair in six patients and failure in abductor–greater trochanteric defect ris hip score, 34.7). The calcaneal four. The fatty degeneration seen in and sutured into the anterior capsule bone block was fastened to the the anterior gluteus medius muscle of the hip joint (Figure 6). The pa- greater trochanter, and the allograft

390 Journal of the American Academy of Orthopaedic Surgeons Paul F. Lachiewicz, MD tendon was woven into the abductor 12. Davies JF, Geiger PB, Davies JA, Yahr D, muscle-tendon complex. At a mini- References Kroner JM: Results of open surgical treatment of abductor tendon tears of mum 2-year follow-up, all patients the hip. 76th Annual Meeting Evidence-based Medicine: Reference demonstrated improvement in pain Proceedings. Rosemont, IL, American 2 is level V expert opinion. All other Academy of Orthopaedic Surgeons, score and function (mean Harris hip references are level IV studies. 2009, p 463. score, 85.9). Additional studies with References printed in bold type are 13. Walsh M, Walsh NA, Walton J, Millar longer follow-up are required to con- N: Surgical repair of the abductor those published in the past 5 years. firm the utility of and success with mechanism of the hip. 76th Annual Meeting Proceedings. Rosemont, IL, this technique. 1. Bird PA, Oakley SP, Shnier R, Kirkham American Academy of Orthopaedic BW: Prospective evaluation of magnetic Surgeons, 2009, p 463. resonance imaging and physical examination findings in patients with 14. Fisher DA, Almand JD, Watts MR: Summary greater trochanteric pain syndrome. Operative repair of bilateral spontaneous Arthritis Rheum 2001;44(9):2138-2145. gluteus medius and minimus tendon ruptures: A case report. J Bone Joint Tear of the abductor tendon complex 2. Dougherty C, Dougherty JJ: Managing Surg Am 2007;89(5):1103-1107. (ie, rotator cuff tear of the hip) is a and preventing hip pathology in trochanteric pain syndrome. The 15. Voos JE, Shindle MK, Pruett A, Asnis relatively infrequent cause of lateral Journal of Musculoskeletal Medicine PD, Kelly BT: Endoscopic repair of trochanteric hip pain. However, it 2008;25:521-523. gluteus medius tendon tears of the hip. Am J Sports Med 2009;37(4):743-747. should be considered in all patients, 3. Gottschalk F, Kourosh S, Leveau B: The functional anatomy of tensor fasciae 16. Howell GE, Biggs RE, Bourne RB: particularly older women, with lat- latae and gluteus medius and minimus. Prevalence of abductor mechanism tears eral hip pain and abductor weakness J Anat 1989;166:179-189. of the hips in patients with osteoarthritis. J Arthroplasty 2001;16(1):121-123. that are unresponsive to nonsurgical 4. Robertson WJ, Gardner MJ, Barker JU, management. MRI has great diag- Boraiah S, Lorich DG, Kelly BT: 17. Hardinge K: The direct lateral approach Anatomy and dimensions of the gluteus to the hip. J Bone Joint Surg Br 1982; nostic sensitivity and specificity, with medius tendon insertion. Arthroscopy 64(1):17-19. 2008;24(2):130-136. increased T2-weighted signal inten- 18. Mulliken BD, Rorabeck CH, Bourne RB, sity at the greater trochanter. Repair 5. Bunker TD, Esler CN, Leach WJ: Nayak N: A modified direct lateral of the torn abductor tendons to a Rotator-cuff tear of the hip. J Bone Joint approach in total hip arthroplasty: A Surg Br 1997;79(4):618-620. comprehensive review. J Arthroplasty bleeding trochanteric bed with trans- 1998;13(7):737-747. 6. Chung CB, Robertson JE, Cho GJ, osseous sutures typically provides Vaughan LM, Copp SN, Resnick D: 19. Iorio R, Healy WL, Warren PD, Appleby good pain relief as well as improved Gluteus medius tendon tears and D: Lateral trochanteric pain following avulsive injuries in elderly women: primary total hip arthroplasty. strength and function. Coincidental Imaging findings in six patients. AJR Am J Arthroplasty 2006;21(2):233-236. abductor tendon tears are found J Roentgenol 1999;173(2):351-353. 20. Svensson O, Sköld S, Blomgren G: with relative frequency in older pa- 7. Kingzett-Taylor A, Tirman PF, Feller J, Integrity of the gluteus medius after the tients, usually women with femoral et al: Tendinosis and tears of gluteus transgluteal approach in total hip medius and minimus muscles as a cause arthroplasty. J Arthroplasty 1990;5(1): neck fractures or OA. These patients of hip pain: MR imaging findings. AJR 57-60. do well after arthroplasty and con- Am J Roentgenol 1999;173(4):1123- 1126. 21. Weber M, Berry DJ: Abductor avulsion comitant repair. Late avulsion of the after primary total hip arthroplasty: abductor tendons after THA per- 8. Cvitanic O, Henzie G, Skezas N, Lyons Results of repair. J Arthroplasty 1997; J, Minter J: MRI diagnosis of tears of the 12(2):202-206. formed through the anterolateral or hip abductor tendons (gluteus medius transgluteal approach is relatively and gluteus minimus). AJR Am J 22. Miozzari HH, Dora C, Clark JM, Nötzli Roentgenol 2004;182(1):137-143. HP: Late repair of abductor avulsion uncommon; however, it is a cause of after the transgluteal approach for hip lateral trochanteric pain, weakness, 9. Twair A, Ryan M, O’Connell M, Powell arthroplasty. J Arthroplasty 2010;25(3): T, O’Byrne J, Eustace S: MRI of failed 450-457, e1. and limp requiring walking supports. total hip replacement caused by abductor Repair is successful in approximately muscle avulsion. AJR Am J Roentgenol 23. Whiteside LA, Nayfeh T, Katerberg BJ: 2003;181(6):1547-1550. Gluteus maximus flap transfer for three quarters of patients, with dem- greater trochanter reconstruction in onstrated pain relief but variable im- 10. Pfirrmann CW, Notzli HP, Dora C, revision THA. Clin Orthop Relat Res Hodler J, Zanetti M: Abductor tendons 2006;453:203-210. provement in strength. Small series and muscles assessed at MR imaging have reported promising results fol- after total hip arthroplasty in 24. Fehm MN, Huddleston JI, Burke DW, Geller JA, Malchau H: Repair of a lowing reconstruction of the abduc- asymptomatic and symptomatic patients. Radiology 2005;235(3):969-976. deficient abductor mechanism with tor tendon complex with either a Achilles tendon allograft after total hip 11. Kagan A II: Rotator cuff tears of the hip. replacement. J Bone Joint Surg Am 2010; gluteus maximus muscle flap or an Clin Orthop Relat Res 1999;(368):135- 92(13):2305-2311. Achilles tendon allograft. 140.

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