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A 77-year-old woman with left hip pain and weakness
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A 77-year-old woman presented with severe lateral-sided left hip pain as well as difficulty with ambulation. She reported that, despite using a cane, her ability to ambulate more than a few feet was significantly limited due to fatigue. Over the years, many family members frequently commented on her worsening “lurching limp.” She also noted difficulty with stair climbing, getting in and out of a car, and getting up from a sitting position due to her lateral-sided hip pain.
AP pelvis (1a) and AP left hip (1b) views demonstrate minimal to no degenerative joint disease and mild changes at the greater trochanter.
Images: Wuerz TH and colleagues
Prior to consultation, she had seen an arthroplasty surgeon as well as a spine specialist; both physicians thought her main complaints stemmed from greater trochanteric pain syndrome after hip X-rays and a lumbar spine MRI were unremarkable. Following their advice, she tried a long course of physical therapy during the past 12 months, which did not help with her complaints.
Examination
On examination, the patient had a severe Trendelenburg gait affecting her left side. She was markedly tender over the greater trochanter laterally. Passive range of motion of the left hip was extension to 0°, flexion to 90°, external rotation to 40° and internal rotation to 20°. She had mild discomfort with active flexion, abduction and external rotation, but no pain with motion in any other direction. Strength was five out of five to hip adduction, but was limited to four out of five with hip abduction. She was able to abduct her left leg against gravity with the knee flexed, but was unable to abduct against gravity with her knee extended.
Chronic left gluteus medius and minimus tendon tear with extensive fatty atrophy (2a) and overlying trochanteric bursitis (2b) is seen.
X-ray imaging of the AP pelvis (Figure 1a) and AP left hip (Figure 1b) view demonstrated minimal to no degenerative joint disease and mild changes at the greater trochanter.
MRI showed a chronic left gluteus medius and minimus tendon tear with extensive fatty atrophy (Figure 2a) and overlying trochanteric bursitis (Figure 2b). Chronic left gluteus medius and minimus tendon tear with extensive fatty atrophy (2a) and overlying trochanteric bursitis (2b) is seen.
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Left gluteus medius and minimus massive tear with fatty infiltration and greater trochanteric pain syndrome
Abductor muscle insufficiency of the hip almost always causes a significant limp and can result in significant functional impairment. Physical exam is perhaps the most useful means for assessing the significance of abductor insufficiency, and MRI is useful to illustrate the extent of abductor and chronicity of the problem. Objective findings on exam are a Trendelenburg sign and weakness with resisted abduction in lateral decubitus position.
Discussion and management
Gluteus medius tears are increasingly being recognized as a source of lateral thigh pain and abduction weakness. Pain over the greater trochanter was previously presumed to be largely from bursitis, but gluteus medius tears have increasingly been recognized to be another etiology. Tears at the insertion of the gluteus medius can be intrasubstance, partial or complete, and can occur either spontaneously or traumatically. Described as the “rotator cuff tears of the hip” and as an underlying cause of chronic greater trochanteric pain syndrome, gluteus medius and minimus avulsions have been reported most commonly in women ranging in age from 40 years to 60 years, and cause debilitating pain and reduced mobility. The incidence of these tears has been shown to increase with history of osteoarthritis (OA) and femoral neck fracture.
Marked out fascial incisions during a gluteus maximus transfer (top of picture anterior) is shown. One transverse and one longitudinal incision is made. A transverse incision allows the gluteus maximus to be pulled onto the main aspect of trochanter, while a longitudinal incision will simultaneously allow medial transfer of the tendon. It is imperative to keep any vasculature attached to the fascia in place to promote healing.
The gluteus medius can be separated into an anterior, middle, and posterior aspect. The anterior and middle aspect consists of vertical fibers. The posterior fibers run horizontally and insert onto the superoposterior facet of the trochanter. The anterior fibers tear most commonly, particularly at the musculotendinous junction most likely from chronic microtrauma and degeneration. Local ischemia and differences in anatomy between men and women have also been implicated as risk factors, possibly causing increased breakdown of collagen fibers at the insertion sites on the greater trochanter. Tears typically occur at the dual insertion of the anterior and middle portion of the gluteus medius onto the superoposterior, anterior and lateral facets of the greater trochanter.
Gluteus medius tendon tears are typically seen in the following scenarios: chronic, non-traumatic tear of the anterior fibers of the gluteus medius tendon; abductor tendon tears found in patients with femoral neck fractures or OA; and avulsion after total hip arthroplasty performed through an anterolateral or transgluteal approach. The most common of these scenarios is chronic, non-traumatic tears.
Several repair techniques have been described including repairs using both transosseous sutures and suture anchors. Endoscopic repair techniques include gluteal debridement or repairs, bursectomy, and iliotibial band release. Gluteus maximus muscle transfers and vastus lateralis muscle transfers have been described as treatment options in the setting of irreparable tears. Furthermore, dermal matrix allograft-augmented repair techniques and Achilles tendon allograft have been reported as well.
Gluteus maximus tendon is docked into the trochanteric trough.Final repair is demonstrated after all sutures are pulled through the trough and tied over bone tunnels.
Final repair is demonstrated after all sutures are pulled through the trough and tied over bone tunnels.
As part of the description of the gluteus maximus transfer technique, Leo A. Whiteside, MD, also included a series of 11 patients with a minimum follow-up of 16 months. Preoperatively, all patients had an abductor lurch, a positive Trendelenburg sign and no abduction of the hip against gravity. Postoperatively, nine patients had strong abduction of the hip against gravity, no abductor lurch and a negative Trendelenburg sign. One patient was reported to have weak abduction against gravity, a negative Trendelenburg sign and a slight abductor lurch. One patient eventually was lost to follow-up but, at his last evaluation at 6 months after surgery, reportedly had failed to achieve strong abduction and had a severe limp. Joseph F. Davies, MD, and colleagues reported a retrospective review of a case series including 22 patients (23 hips). The mean Harris Hip Score improved from 53 points preoperatively to 87 points at 1 year and to 88 points at 5 years. The mean Lower-Extremity Activity Scale score improved from 6.7 points preoperatively to 8.9 points at 1 year and to 8.8 points at 5 years. There was no significant difference in the degree of clinical improvement in relation to the severity of the tear. However, three patients had poor results and were part of the group with the largest tears. Sixteen of 19 patients were satisfied with their outcome and willing to undergo the procedure again. In another study, H. Davies and colleagues reported on 16 patients who underwent open surgical repair. There were four re-ruptures, three of which were revised, and one deep infection requiring debridement. The remaining 11 patients had statistically significant improvements in hip symptoms. The mean change in Visual Analog Score was reported as five out of 10. The mean change in Oxford Hip Score was 20.5. The mean improvement in SF-36 physical component summary was 8.5 and mental component summary 13.7. Six patients with preoperative Trendelenburg gait had normal gait 1 year following surgery. The conclusion was that surgical repair is overall successful for reduction of pain and improvement of function, but that there is a relatively high failure rate in chronic tears. Michael J. Walsh, FRACS, FAOrthA CPL(H), and colleagues reported results of open surgical repair in 72 patients with a minimum follow-up of 1 year. Improvement in both function and pain over time was seen in 95% of their patients. James E. Voos, MD, and colleagues reported good pain relief 2 years after arthroscopic repair in 10 patients with low-grade tears.
Treatment
This patient had a massive tear of the gluteus medius and minimus with fatty infiltration and greater trochanteric pain syndrome. The defect was deemed irreparable and a reconstruction with gluteus maximus transfer was therefore chosen.
A muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons has been described by Whiteside. During this technique, a 10-cm incision is made over the greater trochanter. Once the subcutaneous tissue is cleaned off the fascia, a transverse and longitudinal fascial incision is made (Figure 3). The transverse incision is used to pull the gluteus maximus to the main aspect of the trochanter, while the longitudinal incision allows medial transfer of the gluteus maximus. A Krakow suture is run up and down the fascial flap, which is to be brought down onto the trochanter and is docked onto the trochanter using a bone trough and bone tunnels (Figure 4). Using bone bridges, the sutures are tied together to hold the transferred gluteus maximus in place (Figure 5). With this technique, the anterior portion of the gluteus maximus is transferred to the greater trochanter to substitute for abductor deficiency. In this small series of patients treated with gluteus maximus transfer, nine out of 11 patients had strong abduction of the hip against gravity, no abductor lurch and a negative Trendelenburg sign.
At 3 months postoperatively, our patient has progressed to no longer needing ambulatory aids. She has full abduction strength and no limp.
References:
Davies H. Hip Int. 2009;19(4):372–376.
Davies JF. J Bone Joint Surg. 2013;doi: 10.2106/JBJS.L.00709.
Voos JE. Am J Sports Med. 2009;doi: 10.1177/0363546508328412.
Walsh MJ. J Arthroplasty. 2011;doi: 10.1016/j.arth.2011.03.004.
Whiteside LA. Clin Orthop Relat Res. 2006;453:203-210.
Whiteside LA. Clin Orthop Relat Res. 2012; doi: 10.1007/s11999-011-1975-y.
For more information:
Thomas H. Wuerz, MD, MSc; Peter N. Chalmers, MD; and Shane J. Nho, MD, MS, can be reached at 1611 W. Harrison St., Suite 201, Chicago, IL 60612. Wuerz’s email: thomas.wuerz@gmail.com; Chalmers’ email: p.n.chalmers@gmail.com; Nho’s email: shane.nho@rushortho.com.
Sanjeev Bhatia, MD, can be reached at The Steadman Clinic and Steadman-Philippon Research Institute, 181 W. Meadow Dr., Suite 1000, Vail, CO 81657; email: sanjeevbhatia1@gmail.com.
Disclosures: Wuerz, Bhatia, Chalmers and Nho have no relevant financial disclosures.