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Editorial Commentary: Pioneering the Gluteal Interval: Understanding and Treating Undersurface and Full-Thickness Gluteus Medius Tears of the Hip
Editorial Commentary: Pioneering the Gluteal Interval: Understanding and Treating Undersurface and Full-Thickness Gluteus Medius Tears of the Hip Hal David Martin, D.O., Editorial Board
Abstract: Lateral-based hip disease is severely impairing for many patients. Treatment decision making requires a thorough understanding of the biomechanical and clinical interpretation of the physical examination. The outcomes of these under-recognized pathologies are explained with success. A recent study has described the diagnostic and surgical treatment outcomes of this impairing condition of partial and full-thickness gluteus medius tears.
See related article on page 2159
T
he article “Endoscopic Gluteus Medius Repair With Concomitant Arthroscopy for Labral Tears: A Case Series With Minimum Five Year Outcomes,” by Perets, Mansor, Yuen, Chen, Chaharbakhshi, and Domb1 is a well-done 5-year minimum outcome on gluteus medius repair in both partial and complete subtypes presenting with treatment to intra-articular and extraarticular pathology. Domb et al.2 were the first to recognize and publish on the importance of partial thickness tears providing a historic insight into the diagnosis and treatment of this condition. Their contribution has been valuable in the recognition of patients presenting with lateral-based hip pain. The physical examination is critical to the diagnosis of gluteus pathology. The article directs the reader to the recognition of lateral facet pain for the gluteus medius and the tenderness to anterior facet with gluteus minimus tears. This physical examination finding combined with the strength loss in isolated testing of these muscles is helpful in the identification of both partial and complete gluteus medius and minimus tendinopathy. The gluteus medius strength test is best performed with the knee in flexion with the patient in the lateral decubitus position, to release the gluteus maximus and iliotibial band
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/17937/$36.00 https://doi.org/10.1016/j.arthro.2017.08.238
2168
contribution, whereas the overall abductor strength is evaluated with the knee in extension.3 The article highlights the important consideration of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol. The article identifies the need for randomized controlled trials to develop a nonoperative strategy. An assessment of the data from the nonoperative success and failure group would be helpful to provide further recommendations in treatment. The thickness of the iliotibial band has recently been analyzed finding increased thickness in those who failed nonoperative treatment and feel this factor worthy of consideration in both nonoperative and operative RCT considerations. As platelet rich plasma, stem cell, and biologic membranes advance, the RCT would provide a valuable insight for making this next leap in treatment options including cost effectiveness and efficacy.4,5 The techniques described in this article and the original publication are significant advancements in the understanding of partial gluteus medius tears. The article describes a “longitudinal incision made in line with the tendon fibers over the lateral facet” allowing the undersurface inspection of the tendinous pathology. The courage to open the interval to address this pathology for me in the early stages took faith in the described technique and results. Their contribution has translated well to those surgeons working commonly with endoscopic techniques in the peritrochanteric space. The prior publication and this update do indeed build on the prior work as clearly outlined in Table 5 of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 12 (December), 2017: pp 2168-2169
EDITORIAL COMMENTARY
the article.6-12 The outstanding reported results can also be attributed to case selection bringing to mind the importance of good magnetic resonance imaging. Tears of the gluteus medius demonstrating any T2 fatty infiltration do best with open techniques for grafts or transfers.13 The endoscopic technique does allow the opportunity to address the intra-articular pathology at the same surgical intervention and is a clear advantage over the open technique.9 Congratulations to the entire team at American Hip Institute for advancing our understanding of outcomes and endoscopic techniques of the peritrochanteric space. The contribution of this article helps identify and direct treatment of patients impaired with partial and full thickness gluteus tendinopathy. Thanks for sharing your insight.
5.
6. 7.
8.
9.
10.
References 1. Perets I, Mansor Y, Yuen LC, Chen AW, Chaharbakhshi EO, Domb BG. Endoscopic gluteus medius repair with concomitant arthroscopy for labral tears: A case series with minimum five year outcomes. Arthroscopy 2017;33:2159-2167. 2. Domb BG, Nasser RM, Botser IB. Partial-thickness tears of the gluteus medius: Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy 2010;26:1697-1705. 3. Martin HD, Palmer IJ, Hatem MA. Physical examination of the hip. In: Nho SJ, Leunig M, Larson CM, Bedi A, Kelly BT, eds. Hip arthroscopy and hip joint preservation surgery. New York: Springer, 2015. 4. Lee JJ, Harrison JR, Boachie-Adjei K, Vargas E, Moley PJ. Platelet-rich plasma injection with needle tenotomy for gluteus medius tendinopathy: A registry study with pro-
11.
12.
13.
2169
spective follow-up. Orthop J Sports Med 2016;4: 2325967116671692. Kaplan DJ, Dold AP, Fralinger DJ, Meislin RJ. Endoscopic gluteus medius repair augmented with bioinductive implant. Arthrosc Tech 2016;5:e821-e825. Kagan A II. Rotator cuff tears of the hip. Clin Orthop Relat Res 1999;(368):135-140. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: A report of 72 cases. J Arthroplasty 2011;26:1514-1519. Davies JF, Stiehl JB, Davies JA, Geiger PB. Surgical treatment of hip abductor tendon tears. J Bone Joint Surg Am 2013;95:1421-1425. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of the gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747. McCormick F, Alpaugh K, Nwachukwu BU, Yanke AB, Martin SD. Endoscopic repair of full-thickness abductor tendon tears: Surgical technique and outcome at minimum of 1-year follow-up. Arthroscopy 2013;29: 1941-1947. Thaunat M, Chatellard R, Noël E, Sonnery-Cottet B, Nové-Josserand L. Endoscopic repair of partial-thickness undersurface tears of the gluteus medius tendon. Orthop Traumatol Surg Res 2013;99: 853-857. Chandrasekaran S, Gui C, Hutchinson MR, Lodhia P, Suarez-Ahedo C, Domb BG. Outcomes of endoscopic gluteus medius repair: Study of thirty-four patients with minimum two-year follow-up. J Bone Joint Surg Am 2015;97:1340-1347. Whiteside LA. Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res 2014;472:645-653.
Abstract: Lateral-based hip disease is severely impairing for many patients. Treatment decision making requires a thorough understanding of the biomechanical and clinical interpretation of the physical examination. The outcomes of these under-recognized pathologies are explained with success. A recent study has described the diagnostic and surgical treatment outcomes of this impairing condition of partial and full-thickness gluteus medius tears.
See related article on page 2159
T
he article “Endoscopic Gluteus Medius Repair With Concomitant Arthroscopy for Labral Tears: A Case Series With Minimum Five Year Outcomes,” by Perets, Mansor, Yuen, Chen, Chaharbakhshi, and Domb1 is a well-done 5-year minimum outcome on gluteus medius repair in both partial and complete subtypes presenting with treatment to intra-articular and extraarticular pathology. Domb et al.2 were the first to recognize and publish on the importance of partial thickness tears providing a historic insight into the diagnosis and treatment of this condition. Their contribution has been valuable in the recognition of patients presenting with lateral-based hip pain. The physical examination is critical to the diagnosis of gluteus pathology. The article directs the reader to the recognition of lateral facet pain for the gluteus medius and the tenderness to anterior facet with gluteus minimus tears. This physical examination finding combined with the strength loss in isolated testing of these muscles is helpful in the identification of both partial and complete gluteus medius and minimus tendinopathy. The gluteus medius strength test is best performed with the knee in flexion with the patient in the lateral decubitus position, to release the gluteus maximus and iliotibial band
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/17937/$36.00 https://doi.org/10.1016/j.arthro.2017.08.238
2168
contribution, whereas the overall abductor strength is evaluated with the knee in extension.3 The article highlights the important consideration of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol. The article identifies the need for randomized controlled trials to develop a nonoperative strategy. An assessment of the data from the nonoperative success and failure group would be helpful to provide further recommendations in treatment. The thickness of the iliotibial band has recently been analyzed finding increased thickness in those who failed nonoperative treatment and feel this factor worthy of consideration in both nonoperative and operative RCT considerations. As platelet rich plasma, stem cell, and biologic membranes advance, the RCT would provide a valuable insight for making this next leap in treatment options including cost effectiveness and efficacy.4,5 The techniques described in this article and the original publication are significant advancements in the understanding of partial gluteus medius tears. The article describes a “longitudinal incision made in line with the tendon fibers over the lateral facet” allowing the undersurface inspection of the tendinous pathology. The courage to open the interval to address this pathology for me in the early stages took faith in the described technique and results. Their contribution has translated well to those surgeons working commonly with endoscopic techniques in the peritrochanteric space. The prior publication and this update do indeed build on the prior work as clearly outlined in Table 5 of
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 12 (December), 2017: pp 2168-2169
EDITORIAL COMMENTARY
the article.6-12 The outstanding reported results can also be attributed to case selection bringing to mind the importance of good magnetic resonance imaging. Tears of the gluteus medius demonstrating any T2 fatty infiltration do best with open techniques for grafts or transfers.13 The endoscopic technique does allow the opportunity to address the intra-articular pathology at the same surgical intervention and is a clear advantage over the open technique.9 Congratulations to the entire team at American Hip Institute for advancing our understanding of outcomes and endoscopic techniques of the peritrochanteric space. The contribution of this article helps identify and direct treatment of patients impaired with partial and full thickness gluteus tendinopathy. Thanks for sharing your insight.
5.
6. 7.
8.
9.
10.
References 1. Perets I, Mansor Y, Yuen LC, Chen AW, Chaharbakhshi EO, Domb BG. Endoscopic gluteus medius repair with concomitant arthroscopy for labral tears: A case series with minimum five year outcomes. Arthroscopy 2017;33:2159-2167. 2. Domb BG, Nasser RM, Botser IB. Partial-thickness tears of the gluteus medius: Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy 2010;26:1697-1705. 3. Martin HD, Palmer IJ, Hatem MA. Physical examination of the hip. In: Nho SJ, Leunig M, Larson CM, Bedi A, Kelly BT, eds. Hip arthroscopy and hip joint preservation surgery. New York: Springer, 2015. 4. Lee JJ, Harrison JR, Boachie-Adjei K, Vargas E, Moley PJ. Platelet-rich plasma injection with needle tenotomy for gluteus medius tendinopathy: A registry study with pro-
11.
12.
13.
2169
spective follow-up. Orthop J Sports Med 2016;4: 2325967116671692. Kaplan DJ, Dold AP, Fralinger DJ, Meislin RJ. Endoscopic gluteus medius repair augmented with bioinductive implant. Arthrosc Tech 2016;5:e821-e825. Kagan A II. Rotator cuff tears of the hip. Clin Orthop Relat Res 1999;(368):135-140. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: A report of 72 cases. J Arthroplasty 2011;26:1514-1519. Davies JF, Stiehl JB, Davies JA, Geiger PB. Surgical treatment of hip abductor tendon tears. J Bone Joint Surg Am 2013;95:1421-1425. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of the gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747. McCormick F, Alpaugh K, Nwachukwu BU, Yanke AB, Martin SD. Endoscopic repair of full-thickness abductor tendon tears: Surgical technique and outcome at minimum of 1-year follow-up. Arthroscopy 2013;29: 1941-1947. Thaunat M, Chatellard R, Noël E, Sonnery-Cottet B, Nové-Josserand L. Endoscopic repair of partial-thickness undersurface tears of the gluteus medius tendon. Orthop Traumatol Surg Res 2013;99: 853-857. Chandrasekaran S, Gui C, Hutchinson MR, Lodhia P, Suarez-Ahedo C, Domb BG. Outcomes of endoscopic gluteus medius repair: Study of thirty-four patients with minimum two-year follow-up. J Bone Joint Surg Am 2015;97:1340-1347. Whiteside LA. Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res 2014;472:645-653.