Open Hip Abductor Tendon Repair into a Bone Trough

Improved Outcomes for Hip Abductor Tendon Avulsion

Background 

Hip abductor tendon tears can cause progressive lateral hip pain, weakness, and limping in patients with native hips or those following total hip arthroplasty. However, treatment of these two distinct groups does not differ. 

Treatment options have included nonoperative and operative management. Nonoperative treatment choices include physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification with assistive walking devices. Surgical alternatives include endoscopic or open direct soft-tissue repair, suture anchor repair, bone tunnel repair, graft jacket reconstruction, or gluteus maximus muscle transfer. 

Because of discouraging outcomes, we developed a new technique to improve surgical results. This technique, utilizing an abductor tendon repair into a bone trough, improved our surgical outcomes for abductor tendon avulsions. We found that outcomes after surgical treatment of abductor tendon tears without avulsion are superior to those after repairs of abductor tendon avulsions, which is an important distinction compared with previous literature on abductor tendon repairs.

New Technique for Hip Abductor Tendon Avulsion

Our new repair technique utilizes a longitudinal bone trough in the greater trochanter. Repair into a bone trough involves (1) freeing up and mobilizing the tendon from overlying fascia, (2) placing two evenly spaced Krackow stitches in the tendon, (3) creating a bone trough using a burr in the midline of the greater trochanter, (4) creating bone tunnels out the lateral wall of the trough to pass sutures, and (5) passing sutures through the bone tunnels to allow inset of the tendon into the trough, and later tying the sutures over the lateral osseous bridge.

This new technique allows for reconstitution of the abductor tendon and improved outcomes compared with the traditional repair with suture anchors or transosseous bone tunnels.

There are many variables that affect the outcomes of abductor tendon repair, including tear size, chronicity, scarring and/or retraction, degenerative muscle fatty infiltration, and the repair technique. The only modifiable factors in these variables would be to diagnose abductor tears earlier in the pathogenesis, avoiding irreversible degeneration prior to repair, and to modify the technique utilized to repair the tendon tear.

In an attempt to describe abductor tendon tear entities with more anatomic accuracy and to guide the appropriate surgical technique, we proposed a new classification system that attempts to describe the different types of tears to guide treatment – as the existing classification system was not helpful in defining pathology or guiding treatment. 

Our proposed classification will help to better describe tear types anatomically and thereby guide appropriate surgical interventions based on these types:

  • Type I when there was no gluteus medius avulsion from bone (with subtype A indicating a partial tear of the gluteus minimus or gluteus medius; B, a complete tear of the gluteus minimus; and C, a longitudinal tear of the gluteus medius). 
  • Type II when therewas a gluteus medius avulsion (with subtype A indicating an avulsion of ,50% of the insertion into the greater trochanter, and B, an avulsion of $50% of the insertion). 

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Photo Credits: (Image: Muscolino, Joseph. Right Gluteus Medius Lateral View, “Gluteus Medius – Its true function” 29 January 2009. https://learnmuscles.wordpress.com/2009/01/29/gluteus-medius-its-true-function/ accessed)

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