Surgery to Repair the Hip’s ‘Rotator Cuff’
This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
Symptoms from gluteus medius tendon tears are common in people older than 50 years, but they are hard to distinguish from referred pain due to lumbar spine conditions or hip disorders such as osteoarthritis and femoroacetabular impingement. Because conservative measures are often effective, surgical remedies are not commonly discussed in the literature.
An anatomical study of the gluteus medius tendon found that the posterior part of the tendon has a fan-like shape and converges onto the superoposterior facet of the greater trochanter. The anterolateral part runs posteroinferiorly toward the lateral facet of the greater trochanter. Both the posterior and anterolateral parts insert via fibrocartilage. Given the nonuniform structure of this tendon, the thin anterolateral part may be more prone to tears than the thick posterior part.
In another recent study, a single surgeon described his experience with 185 consecutive gluteus medius tendon tear repairs.1 Tendon changes were confirmed preoperatively on MRI. Roughening of all appropriate surfaces preceded multiple-suture repair through bone holes, with sutures in line with the tendon segment being attached. Of the 185 patients, 165 completed 5- to 10-year phone follow-ups. The average age was 69 and 92% were female. There was no histological evidence of bursitis in any case. Only 9 patients reported worse Oxford Hip Scores at the 5-year follow-up; deep vein thrombotic events occurred in 4% of patients despite prophylaxis. Other common gluteus medius tendon repair techniques include utilization of suture anchors through a mini-open2 or arthroscopic approach.
Unlike degenerative rotator cuff tears of the shoulder, both incomplete and complete acute tears of the gluteus medius respond well to repair surgery. More advanced degenerative gluteus medius tendon changes do not respond as well. It is not clear what the differences are in the mechanical and biochemical mechanisms of rotator cuff and gluteal tendon changes that make surgery to repair the former seemingly less successful than surgery to repair the latter. Nevertheless, these four studies show promise for surgical interventions that have a reasonable chance of being effective, with relatively low risk.
- Fox OJK, Wertheimer G, Walsh MJ. Primary Open Abductor Reconstruction: A 5 to 10-Year Study. J Arthroplasty. 2020 Apr;35(4):941-944. doi: 10.1016/j.arth.2019.11.012. Epub 2019 Nov 14. PMID: 31813815
- Caleb M Gulledge, Eric C Makhni. Open Gluteus Medius and Minimus Repair With Double-Row Technique and Bioinductive Implant Augmentation. Arthrosc Tech 2019 May 17;8(6):e585-e589. doi: 10.1016/j.eats.2019.01.019. eCollection 2019 Jun. PMID: 31334014 PMCID: PMC6620622