Consider suture staple repair technique for partial-thickness abductor tendon tears

Issue: September 2017

ByDavid E. Hartigan, MD

ByBenjamin G. Domb, MD

The lateral hip is a common site for hip pain. It has been termed greater trochanteric pain syndrome and the condition can be debilitating for patients. It has been shown in MRI studies that recalcitrant greater trochanteric pain syndrome is secondary to underlying abductor tendon pathology in about 50% of cases and it may not respond to the usual treatments for greater trochanteric pain syndrome, such as therapy, NSAIDs and corticosteroid injections. Abductor tendon pathology most commonly occurs in women in their fifth and sixth decade of life and it often presents as a lateral pain, limp, Trendelenburg gait and weak abduction of the hip.

Full-thickness abductor tendon tears have traditionally responded well to surgical fixation of the torn tendon back to its anatomic insertion. It has been theorized that most full-thickness tears start as a partial-thickness tear at the anterior aspect of the gluteus medius on the lateral facet of the trochanter. We treat these conservatively as stated above, and only consider operative intervention as a last resort. Diagnosis is based on clinical evaluation and MRI results (Figure 1). An article now in press notes the operative treatment of partial-thickness tears yields significant improvement in strength and gait. In addition, the rates of patient satisfaction are high and there is significant improvement in patient-reported outcomes.

This technique article reviews the “suture staple” technique for surgical management of partial-thickness abductor tendon tears.

Preparation and draping

The patient is placed supine on an arthroscopic traction table with a well-padded peroneal post. Traction can thus be applied if central/peripheral compartment arthroscopy is warranted. The operative leg is draped proximal to the iliac crest and several inches posterior to the greater trochanter. It is helpful to ensure the leg is in neutral rotation to slight internal rotation when prepping and draping the hip, which ensures draping is sufficiently posterior. If intra-articular work is warranted, then that is performed first. To access the peritrochanteric compartment, the leg is placed in about 10° to 30° abduction to loosen the iliotibial (IT) band and to allow for more room between the IT band and the greater trochanter. Intraoperative fluoroscopy is used. The monitors are placed at the foot of the bed for easy visualization by the surgeon and the C-arm enters the surgical field from the contralateral side. The image is centered over the greater trochanter.

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Right hip arthroscopy was performed with the patient in the supine position on the OR table. Proximal is to the left and distal is to the right. The endoscope is in the DLAP and the awl is shown coming through the AL portal. The awl (black arrow) is placed perpendicular to the bone of the lateral facet of the greater trochanter at the site of the pathology (blue arrow) as judged by palpation and preoperative imaging. The abductor muscle belly (red arrow) can be seen just posterior to the awl.

The portals needed for this operation are the anterolateral portal (AL), mid-anterior portal (MAP), distal lateral accessory portal (DLAP) and a proximal posterolateral portal (PL), which is created under direct visualization. Bleeding can be an issue in these cases due to the large potential space. Therefore, using epinephrine in the bags, keeping systolic blood pressure at or below 100 mm Hg in patients who can tolerate hypotension, limiting the size of portals and using cannulas early can help minimize any bleeding problem.

Thorough trochanteric bursectomy

The DLAP is created initially. A 5.0 hip access cannula is brought into the peritrochanteric space through the DLAP portal between the fascia lata and the vastus lateralis fascia. Fluoroscopic imaging is used to place the trochar at approximately the level of the vastus tubercle. Visualization of the vastus lateralis fascia helps assure the scope is in the peritrochanteric space. The standard AL portal is created and a shaver is placed through the IT band. A thorough trochanteric bursectomy is carried out to ensure adequate visualization of the tendon and the sutures that will eventually be used. The abductor tendon is thoroughly evaluated with a probe for undersurface delamination of the abductor tendons. If it is determined there is an undersurface partial-thickness tear of the tendon, and if that tear correlates with the preoperative exam, MRI review and intraoperative findings, then the “suture staple” repair technique is initiated.

Preparation for repair

The modified PL portal is localized using a spinal needle. This is usually done 2 cm to 4 cm proximal to the trochanter along the posterior edge of the femur. This portal should be tested with a spinal needle for correct trajectory to facilitate future suture anchor placement and then checked with fluoroscopy and arthroscopic visualization prior to creation of the portal. Three disposable cannulas are then placed through the modified PL, AL and MAP.

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Micropuncture for vascularity

The trochanteric micropuncture is performed to bring vascularity to the torn or diseased tendon and to facilitate biologic healing after the repair. A microfracture awl is then inserted through the modified PL portal and the areas of gluteus medius tendinopathy are visualized. The patient’s leg can be rotated internally and externally to provide better access to the entire greater trochanter for posterior and anterior pathology, respectively. The area of gluteus medius footprint and the surrounding area are then punctured with the microfracture awl (Figure 2). It is essential to have the awl be positioned perfectly perpendicular to the bone. The rotation of the leg can be changed, if needed, to ensure the awl is positioned perpendicularly. The surgical technique facilitates biology for healing, releasing the bone marrow elements to cover the tendon footprint. This biologic enhancement was termed the “crimson duvet,” which was described by Snyder and Burns for the greater tuberosity when repairing torn rotator cuff tendons. Using a light mallet, the awl is typically driven into the bone to a depth of 3 mm to 5 mm after the tendon is pierced. Holes made with the awl are placed about 5 mm to 8 mm apart from one another.

The first two knotless anchors have been placed in a transtendinous fashion, through separate cannulas. The repair suture from each anchor has been retrieved through the opposite cannula, preparing for the “A to B and B to A” construct, which creates the “suture staple.”

Suture staple repair

The repair is carried out using Knotless SutureTaks (Arthrex). In all, four anchors are required. Transtendinous anchor placement is performed with two anchors placed in the proximal row and two anchors placed in the distal row. A 2.4 mm metal punch is used first to create a pilot hole for each anchor. The punch is advanced through the tendon to minimize tendon damage. The punch is then placed on the proximal trochanter and malleted into the bone under fluoroscopic guidance to ensure it is placed in the correct trajectory. The anchor is then placed through the tendon and into the hole that was created by the punch. Immediate placement of each anchor through the drill guide avoids losing the hole. The posteroproximal anchor is placed first, followed by the anteroproximal anchor, the posterodistal anchor and then the anterodistal anchor, working in sequence toward the endoscope. When placing posterior anchors, the leg should be internally rotated to near its maximum to make sure the punch is perpendicular to the bone. When placing anterior anchors, the position of the foot should be nearly neutral. Both anterior anchors should be placed under fluoroscopic guidance. Each pair of anchors (two proximal and two distal) are then linked together. The underlying abductor tissue is compressed between the anchors down to the bone via the suture staple construct.

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Linking anchor pairs

The Knotless SutureTak anchors contain both a FiberWire repair suture (Arthrex) and a closed-loop FiberLink (Arthrex) shuttle suture. First, the FiberWire suture from posterodistal anchor and the FiberLink suture from the anterodistal anchor are pulled through the PL cannula. Then, the repair suture from the posterodistal anchor is passed through the loop of the closed-loop shuttle suture of the anterodistal anchor and shuttled through. This process is repeated with the repair suture from the anterodistal anchor and the closed-loop shuttle suture from the posterodistal anchor. This results in a pair of sutures that link the two anchors and compress the tissue between them. The entire process is repeated for the two proximal anchors. This produces a construct that links each pair of suture anchors together and forms the suture staple construct. Arthroscopic photographs of these steps are shown in Figures 2 to 4.

Each of the repair sutures has been passed through the opposite anchor to create the “suture staple” construct. The “suture staple” is then tightened to secure the tendon to the bone.

There are several keys to a successful repair:

Run systolic blood pressure at or below 100 mg Hg and use epinephrine in inflow. Use cannulas early in the case to minimize trauma to the IT band;

Perform diagnostic arthroscopy and diligently probe the abductor insertion to look for the areas of deficiency noted on the preoperative MRI;

Use the punch under direct visualization and fluoroscopic guidance. Keep the drill guide in place when switching from the punch to the anchor so the tract through the tendon and bone remains aligned. Place the anchors immediately after the hole has been punched;

Do not try to punch all four holes and then place the anchors. With transtendinous insertion, doing this may make it difficult to exactly replicate the location and angle of the holes when placing anchors;

When placing posterior anchors, place the patient’s leg in nearly maximal internal rotation;

When placing anterior anchors, place the patient’s leg in neutral to slight external rotation; and

Proper suture management is the key to this technique. The surgeon will have 12 limbs of suture to manage at the beginning of the procedure. Therefore, an organized and consistent approach to suture fixation is critical to avoid entanglement and incomplete fixation.

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For more information:
Benjamin G. Domb, MD, can be reached at American Hip Institute, 550 W. Ogden Ave., Hinsdale, IL 60521; email: dombassistant@drdomb.com.
David E. Hartigan, MD, can be reached at Mayo Clinic Phoenix, 5777 East Mayo Blvd., Phoenix, AZ 85054; email: hartigan.david@mayo.edu.

Disclosures: Domb reports he receives research support, consulting fees and royalties from Arthrex Inc. Hartigan reports he is a paid consultant for Arthrex Inc.