Various disorders of the peritrochanteric space amenable to arthroscopic treatment

Issue: June 2011

SAN DIEGO — Those skilled in extra-articular hip arthroscopy can effectively treat an array of tendon-related problems and other conditions through minimally invasive techniques, including external snapping hip, greater trochanteric pain and trochanteric bursitis, according to a recent presentation.

At the Arthroscopy Association of North America 2011 Specialty Day Meeting, Bryan T. Kelly, MD, of Hospital for Special Surgery, reviewed the anatomy of the peritrochanteric space and discussed considerations for arthroscopically managing what he described as “rotator cuff tears of the hip.”

“Endoscopic repair techniques … are an option and should be considered in cases where there is recalcitrant pain and if the short-term resolution of pain and return to activity is predictable,” said Kelly who, with colleagues, has amassed 10 years experience with peritrochanteric arthroscopy with a minimum 2-year follow-up, mostly involving abductor tendon tears.

Stopping the ‘snap’

“We define the peritrochanteric space as the location between the greater trochanter … and the iliotibial band that sits lateral and the tendinous insertions of the gluteus minimum next to the trochanteric facets that align this region,” Kelly said.

He discussed how he treats painful external snapping hip, the “constellation of symptoms” known as peritrochanteric pain syndrome, trochanteric bursitis and abductor tendon tears.

Kelly explained that although patients with symptomatic snapping hips may respond to conservative or open treatment, arthroscopy offers other key advantages.

During arthroscopic entry into the peritrochanteric space, “We can clearly visualize the location of the snap on the thickened-end aspect of the iliotibial band,” he noted. Once in that extra-articular space, correcting the snap and relieving the patient’s pain is quite readily achieved through a localized tendon release and removing the associated lesion or “bump” on the greater trochanter.

Interest in performing endoscopic bursectomy to treat recalcitrant lateral-sided hip pain, tenderness or trochanteric bursitis has recently increased, Kelly added. If patients with these conditions do not respond to conservative management, clinicians should suspect a gluteus medius or minimus tendon tear.

Tendons that cause pain

Tendinopathies in this region of the hip are by far the most frequent source of pain symptoms and usually result from an obstructed or torn tendon, according to Kelly.

“The vast majority … of trochanteric pain symptoms respond to conservative management, but in a small number of recalcitrant cases often times there are full-thickness tears of the gluteus minimus tendon,” which can be detected on MRI and other imaging, he said.

Frequently, partial thickness tears may correspond with an irregular trochanteric surface, according to a 2010 study by Steinert in Radiology. To correctly repair these, it is important to understand the footprint anatomy of the tendons and where they tend to tear most often. Be aware that the gluteus medius tendon sits on the superoposterior and lateral facets, and the gluteus minimus tendon sits on the anterior facet of the greater trochanter, Kelly said.

Return of a more normal hip

Abductor tears are common in 50- to 60-year-old patients and should be confirmed by MRI and by checking for abductor weakness. Some may result from a sudden injury, according to Kelly. “[Arthroscopy] is good for focal abductor tears with minimal retraction and a healthy tendon,” although any bone spurs should be removed, typically with a burr, before placing the tendon back down on the facet to re-establish the anatomical footprint.

“Even in the absence of the bone spur, often times we will use a burr to create a bleeding bed to promote healing,” he said.

Kelly showed a suture-anchor technique he uses in these cases involving single- and double-row and other anchor placement configurations, some of which are similar to those commonly used for treating rotator cuff tears. Among patients who underwent this type of repair, nearly all of them regained their hip strength and range of motion with average modified Harris hip scores of 92.2 points at 1 year.

“Arthroscopic treatment is possible now that you can access the peritrochanteric space with good visualization,” Kelly said. – by Susan M. Rapp

References:

Kelly BT. Peritrochanteric space: Disorders and treatment. Presented at the Arthroscopy Association of North America 2011 Specialty Day Meeting. Feb. 19. San Diego.

Steinert L, Zanetti M, Hodier J, et al. Are radiographic trochanteric surface irregularities associated with abducted tendon abnormalities? Radiology. 2010;257(3):754-763.

Strauss EJ, et al. Sports Med Arthrosc. 2010;18(2):113-119.

Voos JE, Ranawat AS, Kelly BT, et al. The peritrochanteric space of the hip. Instr Course Lect. 2009;58:193-201.

Voos JE, Shindle MK, Pruett A, et al. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med. 2009;37(4):743-747.

Bryan T. Kelly, MD, can be reached at the Center for Hip Pain and Preservation, 525 East 71st St., New York, NY 10021; 212-606-1159; kellyb@hss.edu.

Disclosure: Kelly has no relevant financial disclosures.

Dr. Kelly has truly been the pioneer in defining the arthroscopic anatomy of the peritrochanteric space and describing arthroscopic access. He has shown us this is an area that can easily be approached, and there are numerous disorders that can be treated. His own studies have revealed this, as well as his exhaustive research of the literature from open methods described in the past. He has shown us that many cases of recalcitrant trochanteric bursitis may not be bursitis at all, and we should think about deeper lesions such as tendinopathy of the hip abductors.

When necessary, snapping of the iliotibial band can be corrected with endoscopic tendinoplasty and, in properly selected cases, ruptures of the gluteus medius and minimus can be repaired in a fashion quite comparable to rotator cuff repair in the shoulder. Most data is somewhat preliminary, so there is much that remains to be proven and sorted out about this area, but Dr. Kelly is clearly showing us the way.

This endoscopic approach provides a much less invasive alternative to traditional open techniques and is helping to redefine our understanding of laterally based hip pain. He is to be congratulated on his efforts, and we will continue to observe his leadership role in this area.

— J. W. Thomas Byrd, MD
Nashville Sports Medicine Foundation
Nashville, Tenn.
Disclosure: He is a consultant to Smith & Nephew and A2 Surgical, receives research support from Smith & Nephew and holds stock in A2 Surgical.