Surgical Technique

Transtendinous window facilitates endoscopic repair of gluteus medius tears

Benjamin G. Domb

Benjamin G. Domb

Itay Perets

Itay Perets

Greater trochanteric pain syndrome is often a manifestation of tears in the gluteus medius tendon. This condition is most prevalent in female patients who are between 40 and 70 years old. A gluteus medius tear is diagnosed through a combination of the following: collection of patient medical history; performance of a thorough physical exam; and analysis of the imaging. MRI can reveal various degrees of damage, including tendinosis, a partial-thickness tear or a full-thickness tear with tendon discontinuity. Especially in the case of attritional tears, physicians initially employ a conservative treatment approach. Non-surgical management incorporates physical rehabilitation and activity modification; anesthetic and cortisone injections into the peri-trochanteric compartment; and administration of NSAIDs. Biologic injections of platelet-rich plasma, stem cells and amniotic fluid are new treatments under investigation. If patients have debilitating pain even after sustained conservative treatment, surgical intervention may be recommended.

Open repair procedures have demonstrated improvement in patient-reported outcome scores, reduction in levels of pain, and increases in hip strength, function and range of motion. Recent advances in surgical instrumentation and technique have led to the development of an endoscopic gluteus medius repair technique. Patients treated endoscopically have experienced fewer complications and report improvements comparable to those in patients undergoing open procedures. Partial-thickness tears were found to be a more common injury than full gluteal rupture. Despite sharing similarities with partial rotator cuff tears of the shoulder, the specific location of these tears on the deep side of the tendon may cause difficulty in diagnosis and treatment through either an open or endoscopic approach.

The surgical technique is presented here with some pearls, pitfalls, advantages and disadvantages. The procedure was developed to access and repair partial-thickness tears on the undersurface of the gluteus medius.

endoscopic repair of gluteus medius tear
Figure 1. This is the view from the peritrochanteric compartment. The undersurface tear cannot be visualized because the superficial side of the tendon remains intact. Therefore, the tendon must be palpated to appreciate the undersurface delamination.
Figure 2. The torn fibers of the partial-thickness tear are exposed after a longitudinal incision of the tendon fibers is made.
Figure 3. Following the endoscopic repair, the gluteus medius tendon is repaired in a side-to-side manner and reattached to the footprint.
Figure 4. The suture bridge construct for large tears provides compression of the tendon against the footprint on the greater trochanter.

Source: Benjamin G. Domb, MD

Surgical technique

Patients are positioned in the modified supine position with 20° abduction of the ipsilateral hip function to open the peritrochanteric compartment. A 70°-arthroscope is inserted into the peritrochanteric region under fluoroscopic visualization through the distal lateral accessory portal. By aiming just inferior to the vastus ridge, the surgeon avoids iatrogenic damage to the gluteus medius insertion. A trochanteric bursectomy is performed through the anterolateral portal and the surgeon completes a thorough diagnostic endoscopy of the peritrochanteric compartment, examining all three gluteal muscles — medius, minimus and maximus — as well as the iliotibial band and vastus lateralis muscle. The gluteus medius tendon is carefully examined for signs of subsurface destabilization from the lateral facet (Figure 1). To proceed with the repair procedure, an additional posterolateral portal is created, which will be used for anchor and suture placement. A longitudinal incision is made in line with the fibers of the tendon centered over the lateral facet using a beaver blade (Figure 2). Through this incision, the undersurface tear can be visualized.

Pearls and advantages

Address torn gluteal fibers

The surgeon uses a shaver through a transtendinous window to identify and debride torn gluteal fibers. A burr is used to decorticate the lateral facet to promote healing. To help evaluate the placement and trajectory of the anchor, the anchor is placed under fluoroscopy. The Knotless SutureTak Anchor (Arthrex) or BioComposite Corkscrew FT Suture Anchor (Arthrex) are inserted in the lateral facet. Horizontal mattress stitches are passed to close the longitudinal tendon incision over top of the decorticated footprint (Figure 3). Suture passage may be performed with a suture shuttle instrument. Suture bridge construct may be performed for additional fixation and compression of the tendon against the footprint (Figure 4).

Partial tears of the gluteus medius can be the source of chronic debilitating lateral hip pain. The endoscopic technique presented allows visualization, debridement and repair of these tears while introducing minimal surgical complications or soft tissue damage.

Disclosures: Domb reports he is a paid consultant and presenter/speaker for and receives IP royalties and research support from Arthrex. Perets reports no relevant financial disclosures.

Benjamin G. Domb

Benjamin G. Domb

Itay Perets

Itay Perets

Greater trochanteric pain syndrome is often a manifestation of tears in the gluteus medius tendon. This condition is most prevalent in female patients who are between 40 and 70 years old. A gluteus medius tear is diagnosed through a combination of the following: collection of patient medical history; performance of a thorough physical exam; and analysis of the imaging. MRI can reveal various degrees of damage, including tendinosis, a partial-thickness tear or a full-thickness tear with tendon discontinuity. Especially in the case of attritional tears, physicians initially employ a conservative treatment approach. Non-surgical management incorporates physical rehabilitation and activity modification; anesthetic and cortisone injections into the peri-trochanteric compartment; and administration of NSAIDs. Biologic injections of platelet-rich plasma, stem cells and amniotic fluid are new treatments under investigation. If patients have debilitating pain even after sustained conservative treatment, surgical intervention may be recommended.

Open repair procedures have demonstrated improvement in patient-reported outcome scores, reduction in levels of pain, and increases in hip strength, function and range of motion. Recent advances in surgical instrumentation and technique have led to the development of an endoscopic gluteus medius repair technique. Patients treated endoscopically have experienced fewer complications and report improvements comparable to those in patients undergoing open procedures. Partial-thickness tears were found to be a more common injury than full gluteal rupture. Despite sharing similarities with partial rotator cuff tears of the shoulder, the specific location of these tears on the deep side of the tendon may cause difficulty in diagnosis and treatment through either an open or endoscopic approach.

The surgical technique is presented here with some pearls, pitfalls, advantages and disadvantages. The procedure was developed to access and repair partial-thickness tears on the undersurface of the gluteus medius.

endoscopic repair of gluteus medius tear
Figure 1. This is the view from the peritrochanteric compartment. The undersurface tear cannot be visualized because the superficial side of the tendon remains intact. Therefore, the tendon must be palpated to appreciate the undersurface delamination.
Figure 2. The torn fibers of the partial-thickness tear are exposed after a longitudinal incision of the tendon fibers is made.
Figure 3. Following the endoscopic repair, the gluteus medius tendon is repaired in a side-to-side manner and reattached to the footprint.
Figure 4. The suture bridge construct for large tears provides compression of the tendon against the footprint on the greater trochanter.

Source: Benjamin G. Domb, MD

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Surgical technique

Patients are positioned in the modified supine position with 20° abduction of the ipsilateral hip function to open the peritrochanteric compartment. A 70°-arthroscope is inserted into the peritrochanteric region under fluoroscopic visualization through the distal lateral accessory portal. By aiming just inferior to the vastus ridge, the surgeon avoids iatrogenic damage to the gluteus medius insertion. A trochanteric bursectomy is performed through the anterolateral portal and the surgeon completes a thorough diagnostic endoscopy of the peritrochanteric compartment, examining all three gluteal muscles — medius, minimus and maximus — as well as the iliotibial band and vastus lateralis muscle. The gluteus medius tendon is carefully examined for signs of subsurface destabilization from the lateral facet (Figure 1). To proceed with the repair procedure, an additional posterolateral portal is created, which will be used for anchor and suture placement. A longitudinal incision is made in line with the fibers of the tendon centered over the lateral facet using a beaver blade (Figure 2). Through this incision, the undersurface tear can be visualized.

Pearls and advantages

Address torn gluteal fibers

The surgeon uses a shaver through a transtendinous window to identify and debride torn gluteal fibers. A burr is used to decorticate the lateral facet to promote healing. To help evaluate the placement and trajectory of the anchor, the anchor is placed under fluoroscopy. The Knotless SutureTak Anchor (Arthrex) or BioComposite Corkscrew FT Suture Anchor (Arthrex) are inserted in the lateral facet. Horizontal mattress stitches are passed to close the longitudinal tendon incision over top of the decorticated footprint (Figure 3). Suture passage may be performed with a suture shuttle instrument. Suture bridge construct may be performed for additional fixation and compression of the tendon against the footprint (Figure 4).

Partial tears of the gluteus medius can be the source of chronic debilitating lateral hip pain. The endoscopic technique presented allows visualization, debridement and repair of these tears while introducing minimal surgical complications or soft tissue damage.

Disclosures: Domb reports he is a paid consultant and presenter/speaker for and receives IP royalties and research support from Arthrex. Perets reports no relevant financial disclosures.