Surgical Technique

Acellular allograft used to augment endoscopic gluteus medius, minimus repair

Endoscopic hip abductor tendon repair, once a rare procedure, has become more common because the surgical techniques and instrumentation have improved. As our understanding of the arthroscopic anatomy and pathology of the hip has advanced, so has the ability to effectively treat these lesions of the gluteus medius and minimus. Despite these advancements, hip abductor tendon repair failure rates have been reported to be as great as 35%.

As outcome data with respect to patient characteristics and surgical technique are still sparse in the hip abductor tendon literature, techniques and patient selection have been borrowed from shoulder procedures that are similar. In fact, hip abductor tendons have been called the “rotator cuff of the hip.” The failure rates may be attributable to poor tissue quality, especially in older patients where this pathology is common. To increase healing rates and structural strength, allograft tissue such as nonirradiated acellular human dermis may be used to help augment repairs in the shoulder and hip.

Acellular human dermis provides a graft with superior tensile strength and excellent biocompatibility that can provide immediate structural support compared to other tissue augmentation grafts that have been described, such as xenograft. Arthroscopic or endoscopic techniques that include allograft augmentation can be complex. Therefore, this Surgical Technique article presents a technique that is reproducible and straightforward, which focuses on graft preparation, delivery and fixation.

Patient positioning

The patient is brought to the OR and placed under general anesthesia, and then placed supine on the hip arthroscopy table and positioned in the boots with the foot internally rotated 20° and adducted to neutral. Care is taken to ensure no traction is applied as this will close the peritrochanteric space and make access more difficult. The patient is prepped and draped in the standard orthopedic fashion and a time-out is performed. We use fluoroscopy to plan our proximal anterolateral portal (PALA) and distal anterolateral portal (DALA) using a 17-gauge spinal needle to localize the portals to the proximal femur (Figure 1). The PALA portal is placed proximal to the greater trochanter and in line with the femur, so the needle is perpendicular to the footprint of the greater trochanter. This will allow for both ideal visualization and anchor placement for both the primary repair and allograft augmentation. The DALA portal is also placed in line with the femur, at an angle parallel to the footprint of the gluteal tendons. Once both portals are established, the approach to the peritrochanteric space can begin.

endocopic gluteus medius tear repair
Figure 1. Under fluoroscopic guidance, needle localization of the DALA and PALA portals is shown with the patient in the supine position.
Figure 2. A probe is used to palpate a soft spot to localize the partial gluteus medius and minimus tear. The labels shown are oriented for a patient in the supine position.
Figure 3. After completion of the partial gluteus medius tear repair, multiple 2.8-mm anchors are placed, and sutures are passed in a horizontal mattress fashion and tied after all sutures are passed, as necessary.
Figure 4. After repair of the tendon, fluoroscopic guidance and a calibrated probe with 5-mm markings are used to measure the length and width of the footprint to help size the graft required.
Figure 5. Placement of a 1.3-mm percutaneous anchor, single-loaded, is carried out under fluoroscopic guidance.

Source: Jovan R. Laskovski, MD

Approach, tendon repair

The arthroscope is placed in the PALA portal and a radiofrequency ablation wand is placed in the DALA portal. The iliotibial band (ITB) is exposed and hemostasis is achieved. Next, a longitudinal incision in line with the long axis of the femur is made in the ITB to expose the peritrochanteric space. At this point, 20° to 30° abduction is placed on the operative limb to provide better access and more volume to the peritrochanteric space. The trochanteric bursa is encountered, and the ablation wand and a reciprocating shaver are used to remove the trochanteric bursa in its entirety. The tendons of the gluteus medius, gluteus minimus, vastus lateralis and gluteus maximus are then identified and examined. Once the partial or full-thickness tear has been identified (Figure 2), the footprint is debrided using the reciprocating shaver to expose cancellous bone and provide a biologic milieu for tendon to bone healing.

A 17-gauge needle is then placed anteriorly, parallel to the greater trochanter to allow for suture passing and management. An accessory percutaneous proximal anterolateral portal (APALA) is established for anchor placement. Depending on the size of the repair, one to five triple-loaded Y-Knot RC 2.8-mm all-suture anchors (Conmed Linvatec) are placed through the APALA portal. Retrograde and antegrade suture passers are used to primarily repair the gluteus medius and minimus tendons back down to the footprint (Figure 3). Once all sutures are tied and cut, allograft can be placed.

Allograft delivery, initial fixation

The footprint of the tendons are measured using a calibrated right-angle probe with 5-mm markings (Figure 4). Superior-to-inferior and anterior-to-posterior measurements are made, and the graft is prepared on a separate Mayo stand. The graft should be fashioned into a rectangle based on intraoperative measurements. Care should be taken to mark the epidermal surface of the graft using a surgical marker to ensure proper graft orientation. When implanted, the epidermal side of the graft should be superficial, and the dermal side should be deep and in contact with the tendon.

Place two percutaneous anchors from the Y-Knot Flex 1.3-mm Disposable Percutaneous Pack with T-Guide (Conmed Linvatec) transtendinously at the anterosuperior and posterosuperior portions of the footprint (Figure 5). One limb from each suture is then shuttled through the DALA portal taking care to ensure there is no entanglement of the suture limbs. The anterosuperior suture is shuttled through the anterosuperior portion of the allograft with a free needle or antegrade suture passer and a mulberry knot is tied (Figure 6). The posterosuperior suture limb is then passed through the posterosuperior portion of the graft and another mulberry knot is tied (Figure 7). The graft is then placed at the aperture of the DALA cannula and folded in half along the longitudinal axis of the graft (Figure 8). Opposite limbs of the suture anchors are then pulled simultaneously, and an arthroscopic knot pusher is used to help the allograft traverse the cannula. The allograft is then unfurled onto the footprint and the sutures are individually tied, securing the superior aspect of the allograft to the tendon.

graft placement
Figure 6. The graft is marked to help with its orientation during placement. Its epidermal side should face superficial during fixation. An antegrade suture passer device is used to pass the suture from deep to superficial and a grasper is used to retrieve the suture. A mulberry knot is then tied so it lies on the graft’s superficial (epidermal) surface.
Figure 7. With the anterosuperior and posterosuperior mulberry knots placed, the graft is then oriented appropriately to the cannula.
Figure 8. The graft is folded longitudinally to ease its delivery and the opposite limbs of the previously placed anchors are used to shuttle the graft to the footprint.
Figure 9. Fluoroscopic-guided placement of the anteroinferior and posteroinferior 1.3-mm percutaneous anchors is shown.
Figure 10. Final graft fixation is shown with six knots tied that compress the graft to the tendon footprint.

Final allograft fixation

A looped suture grasper is used to hold the inferior portion of the allograft to the tendon and estimate the anteroinferior and posteroinferior placement of the following two anchors (Figure 9). Additional anteroinferior and posteroinferior anchors are placed using the percutaneous guide through the DALA portal site at the level of the vastus lateralis tubercle. One limb of each suture anchor is then passed through the anteroinferior and posteroinferior aspects of the graft using an antegrade suture passer and tied. The graft is then stably attached to the footprint. Two additional suture anchors can be placed in the midportion of the graft for additional fixation, one anterior and one posterior, to provide rigid fixation of the allograft (Figure 10). Alternatively, if tissue quality is good, two free sutures can be passed through the allograft and native tendon if desired. Once the allograft is secured, the native repair and allograft can be checked by internally and externally rotating the limb, abducting and adducting, and flexing and extending while observing the graft and repair.

ITB repair

The leg is then placed into internal rotation and neutral adduction. The anterior and posterior portions of the ITB are identified and a self-retrieving suture passer is used to pass #2 Vicryl (Ethicon) through the edges of the ITB. Three to five sutures are used to close the ITB anatomically.

Click here to watch video of this technique.

Disclosures: Laskovski reports he is a consultant for Smith & Nephew and Conmed Linvatec, is a minority shareholder in Crystal Clinic Orthopedic Center and is a member of the OLC and compliance committees of Arthroscopy Association of North America. Urchek reports no relevant financial disclosures.

Endoscopic hip abductor tendon repair, once a rare procedure, has become more common because the surgical techniques and instrumentation have improved. As our understanding of the arthroscopic anatomy and pathology of the hip has advanced, so has the ability to effectively treat these lesions of the gluteus medius and minimus. Despite these advancements, hip abductor tendon repair failure rates have been reported to be as great as 35%.

As outcome data with respect to patient characteristics and surgical technique are still sparse in the hip abductor tendon literature, techniques and patient selection have been borrowed from shoulder procedures that are similar. In fact, hip abductor tendons have been called the “rotator cuff of the hip.” The failure rates may be attributable to poor tissue quality, especially in older patients where this pathology is common. To increase healing rates and structural strength, allograft tissue such as nonirradiated acellular human dermis may be used to help augment repairs in the shoulder and hip.

Acellular human dermis provides a graft with superior tensile strength and excellent biocompatibility that can provide immediate structural support compared to other tissue augmentation grafts that have been described, such as xenograft. Arthroscopic or endoscopic techniques that include allograft augmentation can be complex. Therefore, this Surgical Technique article presents a technique that is reproducible and straightforward, which focuses on graft preparation, delivery and fixation.

Patient positioning

The patient is brought to the OR and placed under general anesthesia, and then placed supine on the hip arthroscopy table and positioned in the boots with the foot internally rotated 20° and adducted to neutral. Care is taken to ensure no traction is applied as this will close the peritrochanteric space and make access more difficult. The patient is prepped and draped in the standard orthopedic fashion and a time-out is performed. We use fluoroscopy to plan our proximal anterolateral portal (PALA) and distal anterolateral portal (DALA) using a 17-gauge spinal needle to localize the portals to the proximal femur (Figure 1). The PALA portal is placed proximal to the greater trochanter and in line with the femur, so the needle is perpendicular to the footprint of the greater trochanter. This will allow for both ideal visualization and anchor placement for both the primary repair and allograft augmentation. The DALA portal is also placed in line with the femur, at an angle parallel to the footprint of the gluteal tendons. Once both portals are established, the approach to the peritrochanteric space can begin.

PAGE BREAK
endocopic gluteus medius tear repair
Figure 1. Under fluoroscopic guidance, needle localization of the DALA and PALA portals is shown with the patient in the supine position.
Figure 2. A probe is used to palpate a soft spot to localize the partial gluteus medius and minimus tear. The labels shown are oriented for a patient in the supine position.
Figure 3. After completion of the partial gluteus medius tear repair, multiple 2.8-mm anchors are placed, and sutures are passed in a horizontal mattress fashion and tied after all sutures are passed, as necessary.
Figure 4. After repair of the tendon, fluoroscopic guidance and a calibrated probe with 5-mm markings are used to measure the length and width of the footprint to help size the graft required.
Figure 5. Placement of a 1.3-mm percutaneous anchor, single-loaded, is carried out under fluoroscopic guidance.

Source: Jovan R. Laskovski, MD

Approach, tendon repair

The arthroscope is placed in the PALA portal and a radiofrequency ablation wand is placed in the DALA portal. The iliotibial band (ITB) is exposed and hemostasis is achieved. Next, a longitudinal incision in line with the long axis of the femur is made in the ITB to expose the peritrochanteric space. At this point, 20° to 30° abduction is placed on the operative limb to provide better access and more volume to the peritrochanteric space. The trochanteric bursa is encountered, and the ablation wand and a reciprocating shaver are used to remove the trochanteric bursa in its entirety. The tendons of the gluteus medius, gluteus minimus, vastus lateralis and gluteus maximus are then identified and examined. Once the partial or full-thickness tear has been identified (Figure 2), the footprint is debrided using the reciprocating shaver to expose cancellous bone and provide a biologic milieu for tendon to bone healing.

A 17-gauge needle is then placed anteriorly, parallel to the greater trochanter to allow for suture passing and management. An accessory percutaneous proximal anterolateral portal (APALA) is established for anchor placement. Depending on the size of the repair, one to five triple-loaded Y-Knot RC 2.8-mm all-suture anchors (Conmed Linvatec) are placed through the APALA portal. Retrograde and antegrade suture passers are used to primarily repair the gluteus medius and minimus tendons back down to the footprint (Figure 3). Once all sutures are tied and cut, allograft can be placed.

Allograft delivery, initial fixation

The footprint of the tendons are measured using a calibrated right-angle probe with 5-mm markings (Figure 4). Superior-to-inferior and anterior-to-posterior measurements are made, and the graft is prepared on a separate Mayo stand. The graft should be fashioned into a rectangle based on intraoperative measurements. Care should be taken to mark the epidermal surface of the graft using a surgical marker to ensure proper graft orientation. When implanted, the epidermal side of the graft should be superficial, and the dermal side should be deep and in contact with the tendon.

PAGE BREAK

Place two percutaneous anchors from the Y-Knot Flex 1.3-mm Disposable Percutaneous Pack with T-Guide (Conmed Linvatec) transtendinously at the anterosuperior and posterosuperior portions of the footprint (Figure 5). One limb from each suture is then shuttled through the DALA portal taking care to ensure there is no entanglement of the suture limbs. The anterosuperior suture is shuttled through the anterosuperior portion of the allograft with a free needle or antegrade suture passer and a mulberry knot is tied (Figure 6). The posterosuperior suture limb is then passed through the posterosuperior portion of the graft and another mulberry knot is tied (Figure 7). The graft is then placed at the aperture of the DALA cannula and folded in half along the longitudinal axis of the graft (Figure 8). Opposite limbs of the suture anchors are then pulled simultaneously, and an arthroscopic knot pusher is used to help the allograft traverse the cannula. The allograft is then unfurled onto the footprint and the sutures are individually tied, securing the superior aspect of the allograft to the tendon.

graft placement
Figure 6. The graft is marked to help with its orientation during placement. Its epidermal side should face superficial during fixation. An antegrade suture passer device is used to pass the suture from deep to superficial and a grasper is used to retrieve the suture. A mulberry knot is then tied so it lies on the graft’s superficial (epidermal) surface.
Figure 7. With the anterosuperior and posterosuperior mulberry knots placed, the graft is then oriented appropriately to the cannula.
Figure 8. The graft is folded longitudinally to ease its delivery and the opposite limbs of the previously placed anchors are used to shuttle the graft to the footprint.
Figure 9. Fluoroscopic-guided placement of the anteroinferior and posteroinferior 1.3-mm percutaneous anchors is shown.
Figure 10. Final graft fixation is shown with six knots tied that compress the graft to the tendon footprint.

Final allograft fixation

A looped suture grasper is used to hold the inferior portion of the allograft to the tendon and estimate the anteroinferior and posteroinferior placement of the following two anchors (Figure 9). Additional anteroinferior and posteroinferior anchors are placed using the percutaneous guide through the DALA portal site at the level of the vastus lateralis tubercle. One limb of each suture anchor is then passed through the anteroinferior and posteroinferior aspects of the graft using an antegrade suture passer and tied. The graft is then stably attached to the footprint. Two additional suture anchors can be placed in the midportion of the graft for additional fixation, one anterior and one posterior, to provide rigid fixation of the allograft (Figure 10). Alternatively, if tissue quality is good, two free sutures can be passed through the allograft and native tendon if desired. Once the allograft is secured, the native repair and allograft can be checked by internally and externally rotating the limb, abducting and adducting, and flexing and extending while observing the graft and repair.

PAGE BREAK

ITB repair

The leg is then placed into internal rotation and neutral adduction. The anterior and posterior portions of the ITB are identified and a self-retrieving suture passer is used to pass #2 Vicryl (Ethicon) through the edges of the ITB. Three to five sutures are used to close the ITB anatomically.

Click here to watch video of this technique.

Disclosures: Laskovski reports he is a consultant for Smith & Nephew and Conmed Linvatec, is a minority shareholder in Crystal Clinic Orthopedic Center and is a member of the OLC and compliance committees of Arthroscopy Association of North America. Urchek reports no relevant financial disclosures.