Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review.

PURPOSE: The primary purpose of this study was to systematically review the literature on intraoperative findings during endoscopic treatment for greater trochanteric pain syndrome (GTPS). Secondary outcomes were preoperative imaging findings and postoperative functional outcome measures. METHODS: Medline, PubMED, and Embase databases were searched from inception (1946, 1966, and 1974, respectively), to July 15, 2021, for records reporting intraoperative findings during endoscopic surgery for GTPS. Studies of Level I-IV evidence were eligible. All studies were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) score. RESULTS: Sixteen studies met the inclusion criteria. Most patients underwent endoscopic greater trochanteric bursectomy with repair of the gluteal tendons. Intraoperative conditions reported were gluteal tendon tears usually involving the gluteus medius tendon, labral tears, and chondral lesions. Three studies reported an average of 9% of patients who subsequently underwent conversion to total hip arthroplasty. Pain was assessed using the visual analog scale, and functional outcome measures were measured using the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score Sport-Specific subscale, Hip Outcome Score Activities of Daily Living subscale, and iHOT-12. Pain and functional outcomes demonstrated significant improvement in nearly all the studies where they were reported. CONCLUSIONS: Patients who underwent endoscopic management of GTPS commonly underwent repair of gluteal tendon tears, and in many cases had concomitant labral tears and chondral lesions identified intraoperatively. There were low rates of adverse events, repair failure, and revision surgery. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively. LEVEL OF EVIDENCE: IV, systematic review of level IV or better investigations.

Editorial Commentary: It Is Imperative to Fix Symptomatic Hip Gluteus Medius Tears at Time of Femoroacetabular Impingement: Why Ignore This Pain in the Butt?

The hip can have a multitude of different pathologies leading to different symptoms. Greater trochanteric pain syndrome, historically attributed to bursitis, has been largely found to be associated with lesions of the gluteus medius and minimus tendons, and the prevalence of gluteus medius pathology in patients with femoroacetabular impingement (FAI) is as high as one-third of the FAI population. If a patient is found to have significant clinical symptoms of both FAI and a gluteus medius tear, it is imperative to fix both pathologies. The most important diagnostic predictor in hip arthroscopy is not magnetic resonance imaging but a well-executed history and physical exam. We use a quadrant approach: the medial quadrant accounts for adductor bursitis, adductor tears, pudendal neuralgia, or sports hernias. The posterior quadrant may account for a hamstring tear, lumbar radiculopathy, ischiofemoral impingement, or in rare cases piriformis syndrome. The anterior quadrant accounts for more intraarticular pathologies including FAI, Labral tears, osteoarthritis, avascular necrosis, or iliopsoas bursitis. The lateral quadrant would include greater trochanteric pain syndrome, gluteus medius and minimus tears, external snapping hip syndrome and iliotibial band syndrome. By using this systematic approach and using the magnetic resonance imaging to confirm the diagnosis, we may accurately determine patients' hip pathologies.

Calculating Intraoperative Fluid Deficit to Prevent Abdominal Compartment Syndrome in Hip Arthroscopy.

Abdominal compartment syndrome (ACS) is a rare but potentially fatal complication that can occur during hip arthroscopy. This usually occurs as a result of arthroscopic fluid passing into the retroperitoneal space through the psoas tunnel. From the retroperitoneal space, the fluid can then enter the intraperitoneal space through defects in the peritoneum. Previous studies have identified female sex, iliopsoas tenotomy, pump pressure, and operative time as potential risk factors for fluid extravasation. We present a method to measure intraoperative fluid deficit during hip arthroscopy to alert surgeons to possible ACS. Our proposed technique requires diligent intraoperative monitoring of fluid output through various suction devices, including suction canisters, puddle vacuums, and suction mats. The difference is then calculated from the fluid intake from the arthroscopic fluid bags. If the difference is greater than 1500 mL, then the anesthesiologist and circulating nurse are instructed to examine the abdomen for distension every 15 minutes. This, combined with other common symptoms such as hypotension and hypothermia, should alert the surgical team to the development of ACS. Despite limitations to this technique, this approach offers an objective method to calculate intra-abdominal fluid extravasation.

Endoscopic Gluteus Medius Repair With an ITB-Sparing Versus ITB-Splitting Approach: A Systematic Review and Meta-analysis.

BACKGROUND: During hip endoscopy, the iliotibial band (ITB) can be split or preserved to access the peritrochanteric workspace. To our knowledge, no comparative studies have been performed to analyze patient-reported outcomes (PROs) and surgical failure rates (gluteus medius retear and/or revision surgery rates) for ITB-sparing versus ITB-splitting approaches in endoscopic gluteus medius repairs. PURPOSE: To perform a systematic review and meta-analysis of the literature to evaluate PROs and failure rates of patients undergoing ITB-sparing versus ITB-splitting repairs of the gluteus medius. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed by following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines and using the PubMed, Cochrane CENTRAL, and Embase databases. The quality of evidence was evaluated using the modified Coleman Methodology Score. Level 1-4 studies were evaluated for endoscopic abductor repair techniques on all types of gluteus medius tears. Given the small number of studies and varying population sizes, all quantitative data were adjusted for study population size. RESULTS: A total of 13 studies met our inclusion criteria, while more granular data, including ITB approach, were available for 8 studies. Because of the paucity of literature on the subject, all included studies were of lower quality per the modified Coleman Methodology Score. The visual analog scale for pain, the modified Harris Hip Score (mHHS), and the surgical failure rates were compared between approaches. Patients who underwent ITB splitting had a significantly greater change in mHHS (45.5 ± 4.6 vs 27.3 ± 6.5; P < .001) and lower surgical failure rates (3.67 ± 2.33 vs 4.75 ± 2.54; P = .04). There was no significant difference in change in visual analog scale for splitting versus sparing (4.26 ± 0.41 vs 4.39 ± 0.14; P = .96). The results may have been biased by between-group differences, such as patients who undergo ITB sparing being significantly younger. CONCLUSION: Endoscopic gluteus medius repair is a reliable procedure to improve pain and function in appropriately selected patients. This study highlighted the lack of high-quality literature available regarding ITB approach. However, the evidence to date has suggested that ITB approach may influence hip-specific PROs. Splitting the ITB during abductor repair may be associated with a greater improvement in mHHS and lower surgical failure rates. Further prospective comparative studies are warranted to evaluate the effect of ITB approach.

Heterotopic Ossification in Hip Arthroscopy: an Updated Review.

PURPOSE OF REVIEW: Heterotopic ossification (HO) in hip arthroscopy is a common post-operative complication. This review was undertaken to provide an update (2014 present) on the current literature regarding HO in hip arthroscopy. RECENT FINDINGS: Risk factors for HO post-hip arthroscopy include male gender, mixed impingement, picture, and the size of CAM resection. HO prophylaxis with NSAIDs has been proven to decrease the rate of HO post-hip arthroscopy; however, there is inherent risk to long-standing NSAIDs therapy. HO post-hip arthroscopy is not uncommon as a radiological finding, but symptomatic HO post-hip arthroscopy requiring revision surgery is a rare event, at < 1%. The outcomes for revision surgery for HO excision have fair outcomes. The hip arthroscopist should stratify their patients based on known risk factors, and determine whether NSAIDs prophylaxis is warranted.

Endoscopic Proximal Hamstring Repair and Ischial Bursectomy Using Modified Portal Placement and Patient Positioning.

Endoscopic management has become an effective method to repair proximal hamstring injuries. However, due to the complexity of such a procedure, the dissemination of the technique of endoscopic hamstring repair has occurred slowly among orthopaedic surgeons. This Technical Note with a video modifies previously described techniques and provides safer and more simplified endoscopic management of proximal hamstring injuries.

Simplified Technique for Superior Capsular Reconstruction Using an Acellular Dermal Allograft.

Superior capsular reconstruction is a powerful tool for the treatment of massive irreparable rotator cuff tears. Several authors have described this evolving technique. Issues of graft sizing, graft passage, graft tensioning, and suture management make this a challenging procedure even in the hands of experienced shoulder surgeons. We describe our arthroscopic technique for superior capsular reconstruction using nonirradiated human acellular dermis. We introduce several techniques for graft passage and tensioning that may help to simplify this challenging procedure and make it more reproducible.