HIP ISSN 1120-7000
Hip Int 2015; 25 (1): 24-27 DOI: 10.5301/hipint.5000194
ORIGINAL ARTICLE
MRI and clinical analysis of hip abductor repair Lorcan McGonagle1, Samantha Haebich1, William Breidahl2, Daniel P. Fick1 1 2
The Joint Studio, Hollywood Medical Centre, Perth - Australia Perth Radiological Clinic, Perth - Australia
ABSTRACT Introduction: Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function. Methods: Patients with clinical and MRI evidence of hip abductor tears that had failed to nonoperative treatment underwent surgical repair. Pre and postoperative MRI analysis was carried out by an experienced musculoskeletal radiologist. Clinical analysis consisted of Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test. Results: This study shows no real improvement in the MRI appearances of the tendons after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the posterior gluteus medius was 83% predictive of a poor outcome. Postoperative MRI absence of posterior gluteus medius was 75% predictive of a poor outcome. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% predictive of a poor outcome respectively. Absence of posterior gluteus medius correlated with poor outcome in 75% of cases. Discussion: The MRI appearance of the tendon does not normalise after surgery and there is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome. Keywords: Hip, Abductor, Gluteal, Tendon, Repair, MRI
Introduction Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. Gluteus medius/minimus tears often form part of the greater trochanteric pain syndrome which includes abductor tendinopathy, trochanteric bursitis and iliotibial band syndrome. After total hip replacement, such problems may result from elongation/ defects in the tendon repair and/or damage to the superior gluteal nerve (1-3). However, abductor tendon tears are becoming increasingly recognised as a cause of lateral hip pain, and movement disorder, in the absence of previous hip surgery. Patients may have previously been diagnosed as having greater trochanteric pain syndrome, hip arthritis, sacro-iliac joint dysfunction or trochanteric bursitis. Hip abductor insufficiency has been noted intra-operatively amongst femoral neck fracture and arthritis patients with the reported prevalence varying between 1.6-22% (4-6). Accepted: August 12, 2014 Published online: October 22, 2014 Corresponding author: Lorcan McGonagle 6 Luscombe Lane Toronto Ontario M4Y 3B5, Canada [email protected]
The ‘personality’ of the tear has led to it being dubbed the ‘rotator cuff of the hip’. MRI studies of the rotator cuff have shown that preoperative tear size and postoperative tear size and presence of fatty degeneration are accurate predictors of postoperative outcome (7). MRI has been shown to be an accurate means of diagnosing abductor tendon tears with a sensitivity and specificity for tears at 73% and 95%, respectively (8). After excluding other potential pathology, physiotherapy is often commenced to address any co-existing trunk/pelvic movement abnormalities that could exacerbate symptoms. Surgery is performed when non-operative measures have failed and the diagnosis has been confirmed clinically and radiologically. A number of surgical techniques have been described; anchored repair, vastus lateralis shift, using LARS ligament augmented repair or gluteus maximus transfer with tensor fascia lata transfer, all with reasonable clinical results (9-11). The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function.
Materials and Methods Patients with clinical and MRI evidence of hip abductor tears that had failed to improve sufficiently after a course of physiotherapy underwent surgical repair. Surgery was © 2014 Wichtig Publishing
McGonagle et al
25
performed by a single surgeon (DPF), under general anaesthetic, in a lateral position. The greater trochanter was prepared to accept the tendon into a trough which was prepared using an osteotome. The trough measured approximately 4 cm by 2.5 cm and 1 cm deep. The torn tendon ends were fixed down in the trough using 4.5 and/ or 5.5 mm suture anchors. The iliotibial band underwent V-Y lengthening if necessary. Postoperatively patients were advised to weight bear as tolerated with crutches and avoid abduction by placing a pillow between their legs at night for 6-12 weeks. A gentle course of physiotherapy was then undertaken to strengthen postural muscles. Graduated abduction exercises were commenced after 6 weeks. Postoperative MRI analysis was carried out by an experienced musculo-skeletal radiologist using the technique described by Pfirrmann et al (3). In the cases with total hip arthroplasties, the imaging sequences were modified to reduce metal artefact. STIR images were used instead of fat suppressed T2w sequences. A shorter echo spacing, high TSE factor, high bandwidth and increased number of signal averages (NSA) were utilised to reduce metal artefact. Postoperative clinical analysis was carried out using the Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test.
MRI findings See Tables I-III. Table I shows tendon presence and thickness; Table II, tendon signal and ossification; Table III, muscle atrophy and bursal fluid. Figures 1-3 show the MRI appearances of some the pathological changes identified in the analysis. Trendelenburg sign Preoperatively, 13/15 cases were Trendelenburg positive, postoperatively 7 patients had a positive sign, 7 were negative, 1 was unable to complete the test due to recent ipsilateral foot surgery. Harris hip score Postoperative average score 66 (35-88), A fair - good score of greater than 70 was recorded by 7/15 (12). Postoperatively, 4 patients became less dependent on walking aids however 3 were reliant on more supportive aids. The main MRI predictors of a poor clinical outcome (Harris hip score under 70)
Results
Preoperatively:
Patients
• Absent gluteus minimus 3/3; • Thickening of posterior gluteus medius 4/5.
There were 14 patients and 15 repairs (including 1 revision), the average age was 63 years (range 49-82), 4 were male and 10 female. One man had bilateral surgery, 2 patients had concurrent THR. A summary of the MRI findings is present in Tables I-III.
Postoperatively: • Absent anterior gluteus medius 6/9; • Absent posterior gluteus medius 3/4;
TABLE I - Tendon presence and thickness Tendon present/absent
Tendon thickness
G min
Anterior G med
Posterior G med
G min
Anterior G med
Posterior G med
Pre-op
Present 12 Absent 3
Present 9 Absent 6
Present 14 Absent 1
Normal 2 Thick 6
Normal 4 Thick 4
Normal 8 Thick 5 Thin 2
Post-op
Present 11 Absent 4
Present 6 Absent 9
Present 11 Absent 4
Normal 1 Thick 7 Thin 7
Normal 2 Thick 7 Thin 6
Normal 6 Thick 6 Thin 3
TABLE II - Tendon signal and ossification Tendon signal
Tendon ossification
G min
Anterior G med
Posterior G med
G min
Anterior G med
Posterior G med
Pre-op
Normal 11 Abnormal 4
Normal 7 Abnormal 8
Normal 10 Abnormal 5
Yes 1 No 14
Yes 1 No 14
Yes 0 No 15
Post-op
Normal 10 Abnormal 5
Normal 8 Abnormal 7
Normal 11 Abnormal 4
Yes 1 No 14
Yes 1 No 14
Yes 1 No 14
© 2014 Wichtig Publishing
MRI and clinical analysis of hip abductor repair
26 TABLE III - Muscle atrophy and bursal fluid Muscle atrophy
Bursal fluid
G min
Anterior G med
Posterior G med
Pre-op
Yes 6 No 9
Yes 6 No 9
Yes 2 No 13
Yes 5 No 10
Post-op
Yes 8 No 7
Yes 9 No 6
Yes 7 No 8
Yes 4 No 11
Fig. 2 - Torn gluteus minimus with muscle atrophy (arrows).
Fig. 1 - Bursal fluid.
• Thickening of anterior gluteus medius 5/7; • Thickening of posterior gluteus medius 5/6; • Abnormal tendon signal signal gluteus minimus 3/5; • Abnormal tendon signal posterior gluteus medius 4/4. Satisfaction Patients were grouped as follows; dissatisfied 5, neutral 4, satisfied 2, and very satisfied 4. All but 1 of the patients who were satisfied/very satisfied had a HSS >70. Of the 5 patients who were dissatisfied 3 had a positive Trendelenburg test postoperatively.
Discussion
Fig. 3 - Torn anterior gluteus medius with muscle atrophy.
Our data shows that most measured MRI characteristics deteriorate after gluteal tendon repair. Only the appearances of tendon ossification of gluteus minimus and anterior gluteus medius remained static, whilst the tendon signal of anterior and posterior gluteus medius normalised slightly after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the poste-
rior gluteus medius was 83% predictive of a poor outcome. Other abnormal preoperative MRI findings had a weak correlation with poor postoperative outcome. Postoperative MRI absence of anterior gluteus medius and posterior gluteus medius were 67% and 75% predictive of a poor outcome respectively. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% © 2014 Wichtig Publishing
McGonagle et al
predictive of a poor outcome respectively. Abnormal tendon signal of gluteus minimus correlated with poor outcome in 60%, whilst absence of posterior gluteus medius correlated with poor outcome in 75% of cases. A smaller study similar to ours by Lequesne et al indicates a more favourable appearance of the hip abductor tendons after surgery. In the 6 patients in whom a postoperative MRI was performed, there was evidence of the sutured tendon being intact with no/moderate muscular atrophy and/or fatty atrophy present. They also reported complete remission (7/8) and partial remission (1/8) in physical examination pain amongst their cohort (13). Pfirmann et al assessed the MRI appearance of the hip abductors in symptomatic and asymptomatic patients post THR (via a transgluteal approach). Their results show defects of the abductor tendons and muscle fatty atrophy were uncommon in asymptomatic patients (3). Published reports on gluteal tendon repairs have become more prevalent over the past decade. Davies et al found that surgical reconstruction of torn hip abductor tendons resulted in an improvement in Harris Hip Score from 53-88 and lower extremity activity score 6.78.9, preoperatively and at 5 years respectively. They also report high levels (16/19 patients) of patient satisfaction after the repair (14). Davies et al report on 16 patients with MRI confirmed hip abductor tear, treated with surgical reattachment using soft tissue anchors into the greater trochanter. There were 5 failures. However there were improvements in Oxford Hip Score (20 points), visual analogue score (5 points), SF-36 PCS (8.5 points) and MCS (13.7 points) at 1-year follow-up (15). Kohl et al showed significant improvement in MRC, pain, satisfaction, Merle d’Aubigné score using the vastus lateralis shift for abductor insufficiency technique (9) in a cohort of patients who had (mostly) undergone multiple THR revision operations (16). Voos et al repaired the torn gluteus medius tendon endoscopically and reported complete resolution of pain and full abductor motor strength in all subjects. Harris Hip Score averaged 94 at 1-year follow-up (17). Walsh et al assessed 72 patients after gluteal tendon repair noting that 90% of them had minimal/no pain at 12-month follow-up. There was also improved Merle d’Aubigné and Postel scoring system scores amongst the cohort (18). This is the largest study to compare pre and postoperative MRI findings after hip abductor tendon repair. It shows no real improvement in the MRI appearances of the tendons after surgery. There is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome. In our experience, just under half recorded fair-good HHS, whilst over half of the subjects were satisfied with the outcomes of the surgical repair. Satisfaction correlated with higher HHS scores and normal Trendelenburg test. Limitations of this study include small numbers, variation in postoperative rehabilitation and lack of preoperative clinical scores. Larger studies will help further clarify if preoperative MRI appearances can guide clinical management, and help inform patients of likely outcomes. © 2014 Wichtig Publishing
27
Disclosures Financial support: None. Conflict of interest: None.
References 1. 2. 3.
4. 5. 6. 7.
8.
9. 10. 11. 12. 13.
14. 15. 16. 17. 18.
Picado CH, Garcia FL, Marques W Jr. Damage to the superior gluteal nerve after direct lateral approach to the hip. Clin Orthop Relat Res. 2007;(455):209-211. Svensson O, Sköld S, Blomgren G. Integrity of the gluteus medius after the transgluteal approach in total hip arthroplasty. J Arthroplasty. 1990;5(1):57-60. Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology. 2005;235(3):969-976. Cates HE, Schmidt MA, Person RM. Incidental “rotator cuff tear of the hip” at primary total hip arthroplasty. Am J Orthop (Belle Mead NJ). 2010;39(3):131-133. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79(4):618-620. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001;16(1):121-123. Mellado JM, Calmet J, Olona M, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. AJR Am J Roentgenol. 2005; 184(5):1456-1463. Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). AJR Am J Roentgenol. 2004; 182(1): 137-143. Beck M, Leunig M, Ellis T, Ganz R. Advancement of the vastus lateralis muscle for the treatment of hip abductor discontinuity. J Arthroplasty. 2004;19(4):476-480. Bucher TA, Darcy P, Ebert JR, Smith A, Janes G. Gluteal tendon repair augmented with a synthetic ligament: surgical technique and a case series. Hip Int. 2014;24(2):187-193. Whiteside LA. Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res. 2014;472(2):645-653. Marchetti P, Binazzi R, Vaccari V, et al. Long-term results with cementless Fitek (or Fitmore) cups. J Arthroplasty. 2005;20(6): 730-737. Lequesne M, Djian P, Vuillemin V, Mathieu P. Prospective study of refractory greater trochanter pain syndrome. MRI findings of gluteal tendon tears seen at surgery. Clinical and MRI results of tendon repair. Joint Bone Spine. 2008; 75(4):458-464. Davies JF, Stiehl JB, Davies JA, Geiger PB. Surgical treatment of hip abductor tendon tears. J Bone Joint Surg Am. 2013;95(15):1420-1425. Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G. Surgical repair of chronic tears of the hip abductor mechanism. Hip Int. 2009;19(4):372-376. Kohl S, Evangelopoulos DS, Siebenrock KA, Beck M. Hip abductor defect repair by means of a vastus lateralis muscle shift. J Arthroplasty. 2012;27(4):625-629. 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(4):743-747. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: a report of 72 cases. J Arthroplasty. 2011; 26(8):15141519.
Copyright of Hip International is the property of Wichtig International Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Hip Int 2015; 25 (1): 24-27 DOI: 10.5301/hipint.5000194
ORIGINAL ARTICLE
MRI and clinical analysis of hip abductor repair Lorcan McGonagle1, Samantha Haebich1, William Breidahl2, Daniel P. Fick1 1 2
The Joint Studio, Hollywood Medical Centre, Perth - Australia Perth Radiological Clinic, Perth - Australia
ABSTRACT Introduction: Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function. Methods: Patients with clinical and MRI evidence of hip abductor tears that had failed to nonoperative treatment underwent surgical repair. Pre and postoperative MRI analysis was carried out by an experienced musculoskeletal radiologist. Clinical analysis consisted of Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test. Results: This study shows no real improvement in the MRI appearances of the tendons after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the posterior gluteus medius was 83% predictive of a poor outcome. Postoperative MRI absence of posterior gluteus medius was 75% predictive of a poor outcome. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% predictive of a poor outcome respectively. Absence of posterior gluteus medius correlated with poor outcome in 75% of cases. Discussion: The MRI appearance of the tendon does not normalise after surgery and there is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome. Keywords: Hip, Abductor, Gluteal, Tendon, Repair, MRI
Introduction Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. Gluteus medius/minimus tears often form part of the greater trochanteric pain syndrome which includes abductor tendinopathy, trochanteric bursitis and iliotibial band syndrome. After total hip replacement, such problems may result from elongation/ defects in the tendon repair and/or damage to the superior gluteal nerve (1-3). However, abductor tendon tears are becoming increasingly recognised as a cause of lateral hip pain, and movement disorder, in the absence of previous hip surgery. Patients may have previously been diagnosed as having greater trochanteric pain syndrome, hip arthritis, sacro-iliac joint dysfunction or trochanteric bursitis. Hip abductor insufficiency has been noted intra-operatively amongst femoral neck fracture and arthritis patients with the reported prevalence varying between 1.6-22% (4-6). Accepted: August 12, 2014 Published online: October 22, 2014 Corresponding author: Lorcan McGonagle 6 Luscombe Lane Toronto Ontario M4Y 3B5, Canada [email protected]
The ‘personality’ of the tear has led to it being dubbed the ‘rotator cuff of the hip’. MRI studies of the rotator cuff have shown that preoperative tear size and postoperative tear size and presence of fatty degeneration are accurate predictors of postoperative outcome (7). MRI has been shown to be an accurate means of diagnosing abductor tendon tears with a sensitivity and specificity for tears at 73% and 95%, respectively (8). After excluding other potential pathology, physiotherapy is often commenced to address any co-existing trunk/pelvic movement abnormalities that could exacerbate symptoms. Surgery is performed when non-operative measures have failed and the diagnosis has been confirmed clinically and radiologically. A number of surgical techniques have been described; anchored repair, vastus lateralis shift, using LARS ligament augmented repair or gluteus maximus transfer with tensor fascia lata transfer, all with reasonable clinical results (9-11). The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function.
Materials and Methods Patients with clinical and MRI evidence of hip abductor tears that had failed to improve sufficiently after a course of physiotherapy underwent surgical repair. Surgery was © 2014 Wichtig Publishing
McGonagle et al
25
performed by a single surgeon (DPF), under general anaesthetic, in a lateral position. The greater trochanter was prepared to accept the tendon into a trough which was prepared using an osteotome. The trough measured approximately 4 cm by 2.5 cm and 1 cm deep. The torn tendon ends were fixed down in the trough using 4.5 and/ or 5.5 mm suture anchors. The iliotibial band underwent V-Y lengthening if necessary. Postoperatively patients were advised to weight bear as tolerated with crutches and avoid abduction by placing a pillow between their legs at night for 6-12 weeks. A gentle course of physiotherapy was then undertaken to strengthen postural muscles. Graduated abduction exercises were commenced after 6 weeks. Postoperative MRI analysis was carried out by an experienced musculo-skeletal radiologist using the technique described by Pfirrmann et al (3). In the cases with total hip arthroplasties, the imaging sequences were modified to reduce metal artefact. STIR images were used instead of fat suppressed T2w sequences. A shorter echo spacing, high TSE factor, high bandwidth and increased number of signal averages (NSA) were utilised to reduce metal artefact. Postoperative clinical analysis was carried out using the Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test.
MRI findings See Tables I-III. Table I shows tendon presence and thickness; Table II, tendon signal and ossification; Table III, muscle atrophy and bursal fluid. Figures 1-3 show the MRI appearances of some the pathological changes identified in the analysis. Trendelenburg sign Preoperatively, 13/15 cases were Trendelenburg positive, postoperatively 7 patients had a positive sign, 7 were negative, 1 was unable to complete the test due to recent ipsilateral foot surgery. Harris hip score Postoperative average score 66 (35-88), A fair - good score of greater than 70 was recorded by 7/15 (12). Postoperatively, 4 patients became less dependent on walking aids however 3 were reliant on more supportive aids. The main MRI predictors of a poor clinical outcome (Harris hip score under 70)
Results
Preoperatively:
Patients
• Absent gluteus minimus 3/3; • Thickening of posterior gluteus medius 4/5.
There were 14 patients and 15 repairs (including 1 revision), the average age was 63 years (range 49-82), 4 were male and 10 female. One man had bilateral surgery, 2 patients had concurrent THR. A summary of the MRI findings is present in Tables I-III.
Postoperatively: • Absent anterior gluteus medius 6/9; • Absent posterior gluteus medius 3/4;
TABLE I - Tendon presence and thickness Tendon present/absent
Tendon thickness
G min
Anterior G med
Posterior G med
G min
Anterior G med
Posterior G med
Pre-op
Present 12 Absent 3
Present 9 Absent 6
Present 14 Absent 1
Normal 2 Thick 6
Normal 4 Thick 4
Normal 8 Thick 5 Thin 2
Post-op
Present 11 Absent 4
Present 6 Absent 9
Present 11 Absent 4
Normal 1 Thick 7 Thin 7
Normal 2 Thick 7 Thin 6
Normal 6 Thick 6 Thin 3
TABLE II - Tendon signal and ossification Tendon signal
Tendon ossification
G min
Anterior G med
Posterior G med
G min
Anterior G med
Posterior G med
Pre-op
Normal 11 Abnormal 4
Normal 7 Abnormal 8
Normal 10 Abnormal 5
Yes 1 No 14
Yes 1 No 14
Yes 0 No 15
Post-op
Normal 10 Abnormal 5
Normal 8 Abnormal 7
Normal 11 Abnormal 4
Yes 1 No 14
Yes 1 No 14
Yes 1 No 14
© 2014 Wichtig Publishing
MRI and clinical analysis of hip abductor repair
26 TABLE III - Muscle atrophy and bursal fluid Muscle atrophy
Bursal fluid
G min
Anterior G med
Posterior G med
Pre-op
Yes 6 No 9
Yes 6 No 9
Yes 2 No 13
Yes 5 No 10
Post-op
Yes 8 No 7
Yes 9 No 6
Yes 7 No 8
Yes 4 No 11
Fig. 2 - Torn gluteus minimus with muscle atrophy (arrows).
Fig. 1 - Bursal fluid.
• Thickening of anterior gluteus medius 5/7; • Thickening of posterior gluteus medius 5/6; • Abnormal tendon signal signal gluteus minimus 3/5; • Abnormal tendon signal posterior gluteus medius 4/4. Satisfaction Patients were grouped as follows; dissatisfied 5, neutral 4, satisfied 2, and very satisfied 4. All but 1 of the patients who were satisfied/very satisfied had a HSS >70. Of the 5 patients who were dissatisfied 3 had a positive Trendelenburg test postoperatively.
Discussion
Fig. 3 - Torn anterior gluteus medius with muscle atrophy.
Our data shows that most measured MRI characteristics deteriorate after gluteal tendon repair. Only the appearances of tendon ossification of gluteus minimus and anterior gluteus medius remained static, whilst the tendon signal of anterior and posterior gluteus medius normalised slightly after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the poste-
rior gluteus medius was 83% predictive of a poor outcome. Other abnormal preoperative MRI findings had a weak correlation with poor postoperative outcome. Postoperative MRI absence of anterior gluteus medius and posterior gluteus medius were 67% and 75% predictive of a poor outcome respectively. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% © 2014 Wichtig Publishing
McGonagle et al
predictive of a poor outcome respectively. Abnormal tendon signal of gluteus minimus correlated with poor outcome in 60%, whilst absence of posterior gluteus medius correlated with poor outcome in 75% of cases. A smaller study similar to ours by Lequesne et al indicates a more favourable appearance of the hip abductor tendons after surgery. In the 6 patients in whom a postoperative MRI was performed, there was evidence of the sutured tendon being intact with no/moderate muscular atrophy and/or fatty atrophy present. They also reported complete remission (7/8) and partial remission (1/8) in physical examination pain amongst their cohort (13). Pfirmann et al assessed the MRI appearance of the hip abductors in symptomatic and asymptomatic patients post THR (via a transgluteal approach). Their results show defects of the abductor tendons and muscle fatty atrophy were uncommon in asymptomatic patients (3). Published reports on gluteal tendon repairs have become more prevalent over the past decade. Davies et al found that surgical reconstruction of torn hip abductor tendons resulted in an improvement in Harris Hip Score from 53-88 and lower extremity activity score 6.78.9, preoperatively and at 5 years respectively. They also report high levels (16/19 patients) of patient satisfaction after the repair (14). Davies et al report on 16 patients with MRI confirmed hip abductor tear, treated with surgical reattachment using soft tissue anchors into the greater trochanter. There were 5 failures. However there were improvements in Oxford Hip Score (20 points), visual analogue score (5 points), SF-36 PCS (8.5 points) and MCS (13.7 points) at 1-year follow-up (15). Kohl et al showed significant improvement in MRC, pain, satisfaction, Merle d’Aubigné score using the vastus lateralis shift for abductor insufficiency technique (9) in a cohort of patients who had (mostly) undergone multiple THR revision operations (16). Voos et al repaired the torn gluteus medius tendon endoscopically and reported complete resolution of pain and full abductor motor strength in all subjects. Harris Hip Score averaged 94 at 1-year follow-up (17). Walsh et al assessed 72 patients after gluteal tendon repair noting that 90% of them had minimal/no pain at 12-month follow-up. There was also improved Merle d’Aubigné and Postel scoring system scores amongst the cohort (18). This is the largest study to compare pre and postoperative MRI findings after hip abductor tendon repair. It shows no real improvement in the MRI appearances of the tendons after surgery. There is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome. In our experience, just under half recorded fair-good HHS, whilst over half of the subjects were satisfied with the outcomes of the surgical repair. Satisfaction correlated with higher HHS scores and normal Trendelenburg test. Limitations of this study include small numbers, variation in postoperative rehabilitation and lack of preoperative clinical scores. Larger studies will help further clarify if preoperative MRI appearances can guide clinical management, and help inform patients of likely outcomes. © 2014 Wichtig Publishing
27
Disclosures Financial support: None. Conflict of interest: None.
References 1. 2. 3.
4. 5. 6. 7.
8.
9. 10. 11. 12. 13.
14. 15. 16. 17. 18.
Picado CH, Garcia FL, Marques W Jr. Damage to the superior gluteal nerve after direct lateral approach to the hip. Clin Orthop Relat Res. 2007;(455):209-211. Svensson O, Sköld S, Blomgren G. Integrity of the gluteus medius after the transgluteal approach in total hip arthroplasty. J Arthroplasty. 1990;5(1):57-60. Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology. 2005;235(3):969-976. Cates HE, Schmidt MA, Person RM. Incidental “rotator cuff tear of the hip” at primary total hip arthroplasty. Am J Orthop (Belle Mead NJ). 2010;39(3):131-133. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79(4):618-620. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001;16(1):121-123. Mellado JM, Calmet J, Olona M, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. AJR Am J Roentgenol. 2005; 184(5):1456-1463. Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). AJR Am J Roentgenol. 2004; 182(1): 137-143. Beck M, Leunig M, Ellis T, Ganz R. Advancement of the vastus lateralis muscle for the treatment of hip abductor discontinuity. J Arthroplasty. 2004;19(4):476-480. Bucher TA, Darcy P, Ebert JR, Smith A, Janes G. Gluteal tendon repair augmented with a synthetic ligament: surgical technique and a case series. Hip Int. 2014;24(2):187-193. Whiteside LA. Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res. 2014;472(2):645-653. Marchetti P, Binazzi R, Vaccari V, et al. Long-term results with cementless Fitek (or Fitmore) cups. J Arthroplasty. 2005;20(6): 730-737. Lequesne M, Djian P, Vuillemin V, Mathieu P. Prospective study of refractory greater trochanter pain syndrome. MRI findings of gluteal tendon tears seen at surgery. Clinical and MRI results of tendon repair. Joint Bone Spine. 2008; 75(4):458-464. Davies JF, Stiehl JB, Davies JA, Geiger PB. Surgical treatment of hip abductor tendon tears. J Bone Joint Surg Am. 2013;95(15):1420-1425. Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G. Surgical repair of chronic tears of the hip abductor mechanism. Hip Int. 2009;19(4):372-376. Kohl S, Evangelopoulos DS, Siebenrock KA, Beck M. Hip abductor defect repair by means of a vastus lateralis muscle shift. J Arthroplasty. 2012;27(4):625-629. 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(4):743-747. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: a report of 72 cases. J Arthroplasty. 2011; 26(8):15141519.
Copyright of Hip International is the property of Wichtig International Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
