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Access to the peritrochanteric space is simple and reproducible with the technique described in this report. Two anteriorly based portals are placed between the iliotibial band and the greater trochanter. Bursal tissue and debris can be cleared, optimizing visualization of the peritrochanteric space and the anatomic structures. Lesions of the gluteus medius are a common cause of lateral hip pain unresponsive to conservative treatment and have frequently been mischaracterized as recalcitrant trochanteric bursitis. These lesions are often amenable to endoscopic repair with techniques comparable to those used for rotator cuff problems in the shoulder. Portal placement and organization and execution of a gluteus medius repair are highlighted in a video example. Repair is carried out with laterally based portals in the peritrochanteric space. A viewing portal is placed posterior to the vastus lateralis ridge, with a working portal distal to the ridge. Anchors are placed from a proximal position, entering perpendicular to the cortical surface of the trochanter.
Technique Video
See video under supplementary data.
Trochanteric bursitis is a sometimes challenging disorder to treat.
Abductor tendinopathies, including the gluteus medius and minimus, have been recognized as a source of recalcitrant lateral-sided symptoms unresponsive to conventional conservative treatment.
This has led to the term “greater trochanteric pain syndrome,” which—though less specific—is more accurate than “bursitis” for describing the constellation of disorders that can present as lateral hip pain.
The endoscopic anatomy of the peritrochanteric space has been described, and the results of endoscopic treatment of gluteus medius tears have been published.
The purpose of this report is to describe, in detail, access to the peritrochanteric space and basic principles for endoscopic repair of the gluteus medius.
Surgical Technique
The routine method usually begins with arthroscopy of the central and, possibly, peripheral compartments (Video 1).
Byrd JWT. Routine arthroscopy and access: Central and peripheral compartments, iliopsoas bursa, peritrochanteric, and subgluteal spaces. In: Byrd JWT, editor. Operative hip arthroscopy. Ed 3. New York: Springer; 2012;131-160.
This can be important because findings of advanced intra-articular disease may contraindicate gluteal repair. For peritrochanteric access, the leg is positioned in extension and slight abduction, which relaxes the overlying iliotibial band. No traction should be present on the leg.
The peritrochanteric space is initially accessed through 2 anteriorly based portals—1 proximal and 1 distal to the vastus lateralis ridge, which is identified by fluoroscopy (Fig 1). Typically, these portals are 6 to 8 cm apart, although this is variable depending on the depth of the soft tissues. The purpose is to have them converge at the vastus ridge without being too crowded together. By convention, the distal portal is placed first. It should pass deep to the iliotibial band, targeting a point just lateral to the vastus lateralis ridge. This helps to avoid inadvertently perforating the insertion of the gluteus medius above the ridge or the origin of the vastus lateralis below. Palpating the ridge with a cannula under fluoroscopy helps to determine the proper anterior-to-posterior depth of the cannula. A proximal-to-distal sweeping motion may help clear some of the bursal tissue. A 30° arthroscope is placed.
Fig 1In this right hip, 2 anteriorly based portals have been established into the peritrochanteric space, lateral to the greater trochanter, deep to the iliotibial band. Surface markings for the greater trochanter (GT) and vastus lateralis ridge (VLR) are noted, as well as routine markings that would be used for arthroscopy of the central compartment.
The proximal portal is placed under direct arthroscopic visualization. Prepositioning is performed with a spinal needle. If the view is obscured by adhesions, a cannulated system can be used with a guidewire through the spinal needle. If the view is clear, it is a simple process to just place the cannula adjacent to the prepositioned needle. The surgeon can then clear the bursal tissue and debris, identifying the normal structures within the peritrochanteric space, including the myotendinous insertion of the abductors above the vastus lateralis ridge; the ridge itself; the origin of the vastus lateralis below the ridge, covered in a glistening tendon; the deep surface of the iliotibial band; and the insertional portion of the gluteus maximus coursing diagonally to its insertion on the posterior aspect of the proximal femur. Once the space has been fully cleared and pathology identified, preparation is made for repair of the gluteus medius.
A new viewing portal is established at the posterior margin of the vastus lateralis ridge, and the anterior portals are removed (Fig 2). This is comparable to the posterior subacromial portal used in rotator cuff repair of the shoulder. A working portal is established, just distal to the ridge, for preparing the tendon and managing the repair. This is comparable to the lateral subacromial portal in the shoulder. The torn tendon edges are identified and mobilized. The exposed bony footprint, usually involving the anterior and some of the lateral trochanteric facets, is lightly freshened with a burr, creating a healthy bed for the repair site. An 8.5-mm Clear-Trac cannula (Smith & Nephew, Andover, MA) facilitates managing the repair.
Fig 2Three laterally based portals have been established for gluteal repair. A viewing portal for the 30° arthroscope is just posterior to the vastus lateralis ridge. A working portal, with an 8.5-mm Clear-Trac cannula, is just posterior to the ridge. Anchors are inserted from a proximal portal, allowing placement perpendicular to the trochanteric cortex.
The anchors are placed from a site proximal to the ridge, entering roughly perpendicular to the cortical bone surface. The exact number, size, and distribution pattern of anchors are influenced by the principal tear pattern of the tendon. In the example presented, the tendon disruption is mostly vertically oriented (Fig 3). Thus 2 vertically oriented, triple-loaded 5.5-mm Healicoil anchors (Smith & Nephew) are used. The more proximal site is selected first and initially tapped. The anchor then seats easily, with only a 2-finger touch on the inserter (Fig 4). The depth of the Healicoil anchor can be adjusted, and it can be buried beneath the bone surface without compromising its pullout strength. Because of its hollow core and fenestrations, as the Healicoil anchor is inserted, marrow products can usually be observed exuding up through its open center (Fig 5).
Fig 3A vertically oriented tear of the gluteus medius (arrows) shows the underlying bony footprint (asterisk).
Fig 5Viewing down the anchor, the open center shows a conduit from where the tendon will be approximated over the anchor to the underlying marrow products.
Once the anchor is seated, mattress sutures are created by passing 1 limb of the suture through the posterior and 1 through the anterior leaf of the tendon tear. Various suture-passing devices and shuttle techniques aid in properly placing the sutures. As sutures are passed, it is convenient to retrieve them through the previous anterior portal site, where they can be docked and out of the way during subsequent suture management. The distal anchor is then placed in an identical fashion (Fig 6).
Fig 6A more distal anchor is being seated. The 3 sutures from the proximal anchor are shown passed through the posterior and anterior leaves of the torn tendon.
Once all sutures have been passed, they are then tied, working from distal to proximal (Fig 7). The final construct of the repair is carefully inspected (Fig 8). Assessment of the security of the fixation is important in guiding the postoperative rehabilitation process.
Fig 7All 6 suture pairs have been passed and are ready to be tied, restoring the tendinous insertion site of the gluteus medius.
Access to the peritrochanteric space is simple and reproducible. It is most easily accomplished by entering from anterior. Slight abduction is important to relax the overlying iliotibial band and creates a generous potential space in which to work. The vastus lateralis ridge is an important bony landmark, identified under fluoroscopy, to prevent going too deeply.
Gluteus medius abnormalities may be an incidental finding on magnetic resonance imaging and can be a normal consequence of aging.
Clinical relevance is determined by the history and examination, correlating with laterally based pain. Gluteal lesions are probably a common cause of what seems to be recalcitrant trochanteric bursitis. Ultrasound-guided injections may have therapeutic value and great diagnostic value in determining the clinical relevance of the lesion.
Many of these can be addressed endoscopically. The techniques are comparable to those used in the shoulder for rotator cuff repair. A variety of repair methods are available, depending on the pattern of the tear; however, the portal placements and steps of the repair process are the same. In the presented example, we use Healicoil anchors, which are available in 4.5- and 5.5-mm versions with double- and triple-loaded No. 2 sutures. Food and Drug Administration–approved for gluteal repairs, they have several appealing features. The open design of the anchor with fenestrations minimizes the amount of material in the bone. Animal studies have shown bony ingrowth within the anchor.
With the use of the tap, the anchor seats quite easily with only a 2-finger touch on the screw-in inserter. Its cylindrical design allows the anchor depth to be adjusted without compromising its pullout strength. It also does not rely on cortical fixation for purchase, so it can be buried below the surface. As the anchor is seated, we routinely observe marrow products exuding through its open center, which suggests that this forms a conduit up to the tendon repair site, and logically, this would seem to create a more favorable biological healing environment.
After completion of the repair, the integrity of the repair construct is carefully assessed. This may influence the rehabilitation strategy, especially with regard to how long the patient is protected on crutches, which can range from 6 to 8 weeks. Some precautions are still necessary for at least 4 months.
Endoscopy of the peritrochanteric space can be helpful to assess and address causes of recalcitrant lateral-sided hip pain. The obvious advantage of endoscopic repair of the abductors is the less invasive nature of the procedure compared with traditional open methods. Another advantage is concomitant arthroscopy of the joint assessing for advanced degenerative disease that might contraindicate abductor repair, as well as the ability to address other accompanying intra-articular pathology. The morbidity of peritrochanteric access is minimal. Potential concerns might include inordinate fluid extravasation or injury to the soft-tissue structures of the region, although these risks should be minimal with careful technique. Some massive abductor deficits may be better served by open repair with tissue transfer.
A right gluteus medius tear is used to illustrate routine access to the peritrochanteric space, standard placement of viewing and working portals for preparing a tear, and then a method of repair. Various techniques can be used depending on the tear pattern; in this case triple-loaded Healicoil anchors are used for repair of a vertically oriented tear of the gluteus medius.
Byrd JWT. Routine arthroscopy and access: Central and peripheral compartments, iliopsoas bursa, peritrochanteric, and subgluteal spaces. In: Byrd JWT, editor. Operative hip arthroscopy. Ed 3. New York: Springer; 2012;131-160.
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