Gluteus Medius Repair With Double-Row Fixation J. W. Thomas Byrd, M.D.
Abstract: The merits of double-row tendon fixation have been well defined in the shoulder and may have greater applicability for gluteus medius tears in the hip, in which protection of the repair site can be even more of a challenge because the hip is a weight-bearing extremity. A detailed technique for double-row fixation with a reliable method and implants is highlighted in the accompanying stepwise-approach video. Standard laterally based peritrochanteric portals are used, including a viewing portal posterior to the vastus lateralis ridge and a working portal distal to the ridge, with anchors placed proximally, perpendicular to the cortex of the trochanter. Proximal fixation is accomplished with double-loaded Healicoil anchors (Smith & Nephew, Andover, MA) by use of sutures placed in a mattress fashion. Distal fixation is accomplished with a Footprint anchor (Smith & Nephew) paired to each Healicoil.
M
erits of double-row fixation have been well established for rotator cuff repair in the shoulder.1,2 Abductor tears in the hip share many of the features of rotator cuff pathology in the shoulder, and techniques for endoscopic repair can be quite similar.3,4 Protection of an abductor repair during the initial postoperative rehabilitation can be more challenging because immobilization of the hip is less practical than that of the shoulder. Thus the security of soft-tissue tendon fixation to bone can be even more imperative, especially highlighting the potential advantages of double-row fixation. The purpose of this report is to describe a reliable method of endoscopic double-row gluteus medius repair for properly selected cases.
Surgical Technique Portal placement for the peritrochanteric space is performed as previously described (Video 1, Table 1).5,6 A viewing portal for the 30 arthroscope is placed at the posterior margin of the vastus lateralis ridge. A largediameter working cannula is established just distal to the ridge, and anchors are then placed from an entry site just proximal (Fig 1). Double-row fixation is best suited for large full-thickness lesions. From the Nashville Sports Medicine Foundation, Nashville, Tennessee, U.S.A. The author reports the following potential conflict of interest or source of funding in relation to this article: Smith & Nephew Endoscopy. Received January 22, 2013; accepted February 26, 2013. Address correspondence to J. W. Thomas Byrd, M.D., Nashville Sports Medicine Foundation, 2011 Church St, Ste 100, Nashville, TN 37203, U.S.A. E-mail: [email protected] Ó 2013 Elsevier Inc. All rights reserved. 2212-6287/1368/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.015
The bony footprint of the repair site, typically including the anterior trochanteric facet and part of the lateral trochanteric facet, is lightly prepared with a bur to provide a fresh surface, potentiating healing of the restored tendon. The tendon is mobilized and cleared of adhesions on its deep and superficial surfaces (Fig 2). Proximal fixation is accomplished with 2 to 3 transverse or horizontally oriented double-loaded Healicoil anchors (Smith & Nephew, Andover, MA). The most anterior anchor is placed first (Fig 3). The site is tapped and the anchor screwed into place. It advances easily with only a 2-finger touch on the inserter. Because of the anchor’s cylindrical design, its depth can be adjusted without compromising its pullout strength. The Healicoil also does not rely on cortical purchase for fixation strength and thus can be recessed as far as necessary. A tendon-penetrating device is used to pass the sutures in a mattress fashion through the proximal portion of the tendon. Once passed, the sutures can then be retrieved through an anterior portal site and docked out of the way during subsequent suture management. One or two more Healicoil anchors are then placed from anterior to posterior, as needed, to provide broad-based coverage of the damaged tendon (Fig 4). Once all sutures have been passed, each pair is tied, beginning from posterior to anterior. With each knot, 1 suture limb is retained to be incorporated into the distal fixation (Fig 5). After one ensures the structural integrity of the proximal row, attention is then turned to the distal row. Fixation is achieved with a 4.5- or 5.5-mm Footprint anchor (Smith & Nephew). One Footprint anchor is used per Healicoil anchor. The awl is used to prepare the bone. The pair of suture limbs, 1 from each knot
Arthroscopy Techniques, Vol 2, No 3 (August), 2013: pp e247-e250
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J. W. T. BYRD
Table 1. Pearls for Success Select a tear properly amenable to double-row technique: a complete tear with sufficient tendon that can be mobilized to the bony footprint. Properly prepare the peritrochanteric space, providing complete exposure and a clear view. Position portals properly for optimal access to the tear. Make sure the torn tendon is properly mobilized, and in particular, clear the superficial surface of adhesions and debris that might interfere with suture passage. Dock sutures through an anterior portal site to aid in suture management.
accompanying the doubly loaded Healicoil anchor, is withdrawn through the proximal cannula that will serve for introduction of the Footprint anchor. A lead loop through the Footprint serves to pull the suture limbs into the anchor. Slight tension is held on the suture limbs as the anchor is then passed through the cannula to the previously prepared site. The Footprint is aligned so that the sutures enter the footprint proximally in alignment with the paired Healicoil (Fig 6). The Footprint is then driven into place. At this point, the sutures still pass freely. They are individually tensioned to provide optimal approximation of the tendon to bone, avoiding excessive tension and strangulation. As the selected tension is titrated, the suture is then cleated to the inserter. Once both sutures have been satisfactorily tensioned, they are locked by tightening the knob on the Footprint anchor inserter. After 3 clicks, the knob is then loosened a few turns. The sutures are uncleated and inserter removed. The free suture ends are then cut flush with the bone. This process is repeated from anterior to posterior with 1 Footprint per Healicoil anchor.
Discussion Double-row fixation has particular appeal for repair of substantial tears of the gluteus medius because of the
Fig 1. On viewing of a left hip, the viewing portal for the 30 arthroscope is posterior to the vastus lateralis ridge (VLR). Distally is a Clear-Trac working cannula (Smith & Nephew). A Healicoil anchor is being inserted from a proximal portal. A probe has been introduced anteriorly to retract the tendon while seating the anchor. Ó J. W. Thomas Byrd.
practical challenges of protecting the repair in a weightbearing limb. The Healicoil and Footprint anchors provide a well-matched pair for accomplishing secure fixation. As mentioned, the Healicoil does not rely on cortical purchase for fixation and, with its cylindrical design, the depth can be adjusted into bone without compromising its pullout strength. The hollow core and fenestrations leave a minimal amount of material in the bone, and animal models have shown bony ingrowth.7 As the anchor is seated, we routinely observe marrow products exuding through its center, thus appearing to provide a direct conduit for these marrow products to the repair site and an enhanced biological healing environment. The footprint is a knotless device that allows the sutures from the proximal Healicoil fixation to be incorporated into a double-row repair. When the Footprint is seated in bone, the sutures can still be
Fig 2. A grasper assesses the mobility of the tendon. (A) Moving the tendon proximally exposes the bony footprint. (B) The tendon is mobilized distally over its insertion site. Ó J. W. Thomas Byrd.
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Fig 3. The anterior of 2 double-loaded Healicoil anchors is being inserted in the proximal portion of the bony footprint. Ó J. W. Thomas Byrd.
Fig 5. The 4 sutures from the 2 double-loaded anchors have been tied, leaving 1 suture limb from each knot to be incorporated into the distal fixation. Ó J. W. Thomas Byrd.
adjusted for more or less tension, allowing adjustment to the desired amount necessary for optimal tendon approximation. After completion of the repair, the integrity is carefully assessed because this influences the rehabilitation strategy for optimizing the functional outcome (Fig 7). Protected weight bearing may be necessary for 6 to 8 weeks, with some precautions for 4 months during the healing period.
The principal advantage of the described technique is optimizing the security of soft-tissue fixation to bone, which is usually the weak link in a tendon repair construct. Although we have not observed any problems with this method, 1 potential concern might be if the Footprint were overstuffed with anchors, creating a potential stress riser and introducing the possibility of a spontaneous fracture of the greater trochanter. It is also likely that there are some massive abductor deficits, not amenable to arthroscopic repair, that may require more extensive tissue transfer.
Fig 4. The more posterior of the 2 Healicoil anchors is being inserted. The colored sutures of the anterior anchor are seen emerging from the anchor hole (arrow); these have already been passed in a mattress fashion through the proximal tendon. Ó J. W. Thomas Byrd.
Fig 6. The distal Footprint anchor is driven into place, incorporating 2 suture limbs from the proximal knots. Ó J. W. Thomas Byrd.
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References
Fig 7. The final repair construct is inspected with secure double-row fixation. Ó J. W. Thomas Byrd.
1. Lapner PL, Sabri E, Rakhra K, et al. A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2012;94(14):1249-1257. 2. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of a consecutive series of subscapularis tendon tears repaired arthroscopically. Arthroscopy 2012;28:1587-1591. 3. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br 1997;79:618-620. 4. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747. 5. 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. 6. Byrd JWT. Peritrochanteric access and gluteus medius repair. Arthrosc Tech. 2013 July 8 [Epub ahead of print.] 7. Al-Beik J, Barnes G. Healicoil PK suture anchors: Evaluation of a new suture design in an ovine bone defect model [white paper]. Andover, MA: Smith & Nephew Endoscopy; 2012.
Abstract: The merits of double-row tendon fixation have been well defined in the shoulder and may have greater applicability for gluteus medius tears in the hip, in which protection of the repair site can be even more of a challenge because the hip is a weight-bearing extremity. A detailed technique for double-row fixation with a reliable method and implants is highlighted in the accompanying stepwise-approach video. Standard laterally based peritrochanteric portals are used, including a viewing portal posterior to the vastus lateralis ridge and a working portal distal to the ridge, with anchors placed proximally, perpendicular to the cortex of the trochanter. Proximal fixation is accomplished with double-loaded Healicoil anchors (Smith & Nephew, Andover, MA) by use of sutures placed in a mattress fashion. Distal fixation is accomplished with a Footprint anchor (Smith & Nephew) paired to each Healicoil.
M
erits of double-row fixation have been well established for rotator cuff repair in the shoulder.1,2 Abductor tears in the hip share many of the features of rotator cuff pathology in the shoulder, and techniques for endoscopic repair can be quite similar.3,4 Protection of an abductor repair during the initial postoperative rehabilitation can be more challenging because immobilization of the hip is less practical than that of the shoulder. Thus the security of soft-tissue tendon fixation to bone can be even more imperative, especially highlighting the potential advantages of double-row fixation. The purpose of this report is to describe a reliable method of endoscopic double-row gluteus medius repair for properly selected cases.
Surgical Technique Portal placement for the peritrochanteric space is performed as previously described (Video 1, Table 1).5,6 A viewing portal for the 30 arthroscope is placed at the posterior margin of the vastus lateralis ridge. A largediameter working cannula is established just distal to the ridge, and anchors are then placed from an entry site just proximal (Fig 1). Double-row fixation is best suited for large full-thickness lesions. From the Nashville Sports Medicine Foundation, Nashville, Tennessee, U.S.A. The author reports the following potential conflict of interest or source of funding in relation to this article: Smith & Nephew Endoscopy. Received January 22, 2013; accepted February 26, 2013. Address correspondence to J. W. Thomas Byrd, M.D., Nashville Sports Medicine Foundation, 2011 Church St, Ste 100, Nashville, TN 37203, U.S.A. E-mail: [email protected] Ó 2013 Elsevier Inc. All rights reserved. 2212-6287/1368/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.015
The bony footprint of the repair site, typically including the anterior trochanteric facet and part of the lateral trochanteric facet, is lightly prepared with a bur to provide a fresh surface, potentiating healing of the restored tendon. The tendon is mobilized and cleared of adhesions on its deep and superficial surfaces (Fig 2). Proximal fixation is accomplished with 2 to 3 transverse or horizontally oriented double-loaded Healicoil anchors (Smith & Nephew, Andover, MA). The most anterior anchor is placed first (Fig 3). The site is tapped and the anchor screwed into place. It advances easily with only a 2-finger touch on the inserter. Because of the anchor’s cylindrical design, its depth can be adjusted without compromising its pullout strength. The Healicoil also does not rely on cortical purchase for fixation strength and thus can be recessed as far as necessary. A tendon-penetrating device is used to pass the sutures in a mattress fashion through the proximal portion of the tendon. Once passed, the sutures can then be retrieved through an anterior portal site and docked out of the way during subsequent suture management. One or two more Healicoil anchors are then placed from anterior to posterior, as needed, to provide broad-based coverage of the damaged tendon (Fig 4). Once all sutures have been passed, each pair is tied, beginning from posterior to anterior. With each knot, 1 suture limb is retained to be incorporated into the distal fixation (Fig 5). After one ensures the structural integrity of the proximal row, attention is then turned to the distal row. Fixation is achieved with a 4.5- or 5.5-mm Footprint anchor (Smith & Nephew). One Footprint anchor is used per Healicoil anchor. The awl is used to prepare the bone. The pair of suture limbs, 1 from each knot
Arthroscopy Techniques, Vol 2, No 3 (August), 2013: pp e247-e250
e247
e248
J. W. T. BYRD
Table 1. Pearls for Success Select a tear properly amenable to double-row technique: a complete tear with sufficient tendon that can be mobilized to the bony footprint. Properly prepare the peritrochanteric space, providing complete exposure and a clear view. Position portals properly for optimal access to the tear. Make sure the torn tendon is properly mobilized, and in particular, clear the superficial surface of adhesions and debris that might interfere with suture passage. Dock sutures through an anterior portal site to aid in suture management.
accompanying the doubly loaded Healicoil anchor, is withdrawn through the proximal cannula that will serve for introduction of the Footprint anchor. A lead loop through the Footprint serves to pull the suture limbs into the anchor. Slight tension is held on the suture limbs as the anchor is then passed through the cannula to the previously prepared site. The Footprint is aligned so that the sutures enter the footprint proximally in alignment with the paired Healicoil (Fig 6). The Footprint is then driven into place. At this point, the sutures still pass freely. They are individually tensioned to provide optimal approximation of the tendon to bone, avoiding excessive tension and strangulation. As the selected tension is titrated, the suture is then cleated to the inserter. Once both sutures have been satisfactorily tensioned, they are locked by tightening the knob on the Footprint anchor inserter. After 3 clicks, the knob is then loosened a few turns. The sutures are uncleated and inserter removed. The free suture ends are then cut flush with the bone. This process is repeated from anterior to posterior with 1 Footprint per Healicoil anchor.
Discussion Double-row fixation has particular appeal for repair of substantial tears of the gluteus medius because of the
Fig 1. On viewing of a left hip, the viewing portal for the 30 arthroscope is posterior to the vastus lateralis ridge (VLR). Distally is a Clear-Trac working cannula (Smith & Nephew). A Healicoil anchor is being inserted from a proximal portal. A probe has been introduced anteriorly to retract the tendon while seating the anchor. Ó J. W. Thomas Byrd.
practical challenges of protecting the repair in a weightbearing limb. The Healicoil and Footprint anchors provide a well-matched pair for accomplishing secure fixation. As mentioned, the Healicoil does not rely on cortical purchase for fixation and, with its cylindrical design, the depth can be adjusted into bone without compromising its pullout strength. The hollow core and fenestrations leave a minimal amount of material in the bone, and animal models have shown bony ingrowth.7 As the anchor is seated, we routinely observe marrow products exuding through its center, thus appearing to provide a direct conduit for these marrow products to the repair site and an enhanced biological healing environment. The footprint is a knotless device that allows the sutures from the proximal Healicoil fixation to be incorporated into a double-row repair. When the Footprint is seated in bone, the sutures can still be
Fig 2. A grasper assesses the mobility of the tendon. (A) Moving the tendon proximally exposes the bony footprint. (B) The tendon is mobilized distally over its insertion site. Ó J. W. Thomas Byrd.
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Fig 3. The anterior of 2 double-loaded Healicoil anchors is being inserted in the proximal portion of the bony footprint. Ó J. W. Thomas Byrd.
Fig 5. The 4 sutures from the 2 double-loaded anchors have been tied, leaving 1 suture limb from each knot to be incorporated into the distal fixation. Ó J. W. Thomas Byrd.
adjusted for more or less tension, allowing adjustment to the desired amount necessary for optimal tendon approximation. After completion of the repair, the integrity is carefully assessed because this influences the rehabilitation strategy for optimizing the functional outcome (Fig 7). Protected weight bearing may be necessary for 6 to 8 weeks, with some precautions for 4 months during the healing period.
The principal advantage of the described technique is optimizing the security of soft-tissue fixation to bone, which is usually the weak link in a tendon repair construct. Although we have not observed any problems with this method, 1 potential concern might be if the Footprint were overstuffed with anchors, creating a potential stress riser and introducing the possibility of a spontaneous fracture of the greater trochanter. It is also likely that there are some massive abductor deficits, not amenable to arthroscopic repair, that may require more extensive tissue transfer.
Fig 4. The more posterior of the 2 Healicoil anchors is being inserted. The colored sutures of the anterior anchor are seen emerging from the anchor hole (arrow); these have already been passed in a mattress fashion through the proximal tendon. Ó J. W. Thomas Byrd.
Fig 6. The distal Footprint anchor is driven into place, incorporating 2 suture limbs from the proximal knots. Ó J. W. Thomas Byrd.
e250
J. W. T. BYRD
References
Fig 7. The final repair construct is inspected with secure double-row fixation. Ó J. W. Thomas Byrd.
1. Lapner PL, Sabri E, Rakhra K, et al. A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2012;94(14):1249-1257. 2. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of a consecutive series of subscapularis tendon tears repaired arthroscopically. Arthroscopy 2012;28:1587-1591. 3. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br 1997;79:618-620. 4. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med 2009;37:743-747. 5. 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. 6. Byrd JWT. Peritrochanteric access and gluteus medius repair. Arthrosc Tech. 2013 July 8 [Epub ahead of print.] 7. Al-Beik J, Barnes G. Healicoil PK suture anchors: Evaluation of a new suture design in an ovine bone defect model [white paper]. Andover, MA: Smith & Nephew Endoscopy; 2012.
