Presentation on theme: "Peritrochanteric Space: Disorders and Treatment"— Presentation transcript:
1Peritrochanteric Space: Disorders and Treatment AANA Specialty DayFriday, February 19th, 2011Bryan T. Kelly, MDCo-DirectorCenter for Hip Pain and Preservation
2Hospital for Special Surgery Bryan T. Kelly, MDHospital for Special SurgeryDisclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND DO NOT INTEND to discuss off label or investigational use of products or services.
3Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant Types of financial relationships and the companies with whom I have relationships are as follows:Pivot Medical, Inc.: ConsultantSmith & Nephew: Educational ConsultantA2 Surgical: Consultant
4The Peritrochanteric Space Greater TrochanterIliotibial BandSpace between the Greater Trochanter and Iliotibial BandAnalogous to the subacromial space in the shoulder
7External Snapping HipExternal coxa saltans results from a thickened band of the posterior iliotibial band or anterior gluteus maximus tendon sliding over the greater trochanter.Any irritation or injury to the underlying bursa results in inflammation and the addition of pain with the snapping.
8External Snapping HipAlthough conservative treatment is usually successful, small numbers of patients remain symptomatic.Open treatmentExcision of an ellipsoid-shaped portion of the iliotibial band overlying the greater trochanter and removal of the trochanteric bursa.Zoltan et al.Arthroscopic ITB release can be relatively easily accomplished via the lateral compartment.
9External Snapping HipThe thickened posterior third of the ITB can be palpated with a flexible probe.The band can be released directly across from the area of irritation on the lateral prominence of the greater trochanter.
11Greater Trochanteric Pain Syndrome (GTPS) Lateral sided hip pain and tendernessCommon clinical syndrome peaking between the 4th and 6th decades of life. 4♀:1♂Previously known as “Trochanteric Bursitis”Bursal distention is actually uncommonKingzett-Taylor et al, 1999Bird et al, 2001The initial pathology usually occurs in the tendons attached to the greater trochanter. The adjacent bursae are secondarily involved.Gordon EJ, 1961
12GTPS (cont.) Vast majority respond to conservative mgt. Recalcitrant cases are often due to gluteus medius or minimus tendon tears.Prospective MRI evaluation of 24 middle aged women with intractable GTPS45.8% had gluteus medius tendon tearsBird et al, 2001Prospective US evaluation of 75 pts with GTPS53/75 had gluteus medius tendinopathy25 of these 53 had full or partial g. medius tearsConnell et al, 2002
13Rotator Cuff Tears of the Hip Bunker et al, 199722% of patients with femoral neck fractures had gluteus medius tearsKagan A, 1999Seven pts with recalcitrant GTPS ranging from 2mos – 10yrsOpen repair through bone tunnels & or side-to–side after debrideF/u at 45 mos, all were free of painHowell et al, 200120% of women undergoing THA for OA had abductor tears
14Footprint AnatomyMost gluteus medius tears occur anteriorly, at the junction with the minimus.Gluteus MinimusGluteus Medius
154 facets, 3 have distinct insertions Dwek J. et al MR imaging of the hip abductors: normal anatomy and commonly encountered pathology at the greater trochanter. Magnetic Resonance Imaging Clinics of North America. 13(4): , vii, 2005 NovAnt- oval, med border is IT lineLat- inverted triangle, caudal portion is palpable part of troch4 facets, 3 have distinct insertions
16Anterior Facet 2 parts to Gluteus minimus Ant facet= glut min= best seen on transverseArrowhead= lat margin jt capsule, arrows= ant facet, curved arrow- glut min2 parts to Gluteus minimustendon attachment lateral to joint capsuleMuscular attachment to superior joint capsule
17Lateral FacetLat facet= lat part glut medius(muscular attachment), located at post ½ of GT on coronalsCuved arrow glut med, straight arrow= ITB, arrow heads =lat facetMiddle and Anterior portions of the medius attach to the lateral facetAlso continues anteriorly to cover insertion of minimus
18Superoposterior Facet Superopost facet= main glut med tendon attachment= best on coronalCurved whitre arrow= tendon. White Arrow=piriformisCurved black=obt ext, black arrow=obt intMain insertion point for the posterior portion of the medius.
19Posterior Facet No muscle attachments Trochanteric bursa Post facet= no muscular attachement, instead trochanteric bursa shown here on bursographyNo muscle attachmentsTrochanteric bursa
20Clinical Presentation: Recalcitrant GTPS – Abductor Tear Sometimes a history of a “pop” or sudden injury.Age group late 50’s to 60’sFemales > Males.Failure of corticosteroid injections.Refractory lateral sided hip pain.Abductor weakness.MRI confirmation.In some (many ?) cases, refractory trochanteric bursitis may be overlooked tears of the gluteus medius and minimus.
21Arthroscopic Management An arthroscopic approach through the peritrochanteric space is now possible for the repair of focal gluteus medius and minimus tendon tears.
25Abductor Repair - Preparation In some cases trochanteric spurs may be present that can be burred down to created a better surface area for tendon healing.
26Case TG: Senior Triathlete 65 y/o maleDeveloped left hip pain associated with trainingLateral BasedNo groin painTreated for trochanteric bursitis with multiple injections / PT with no improvement in symptoms over 6 month period
34Results Arthroscopic Abductor Repair Results of 10 patients with minimum of 2 year f/u:All patients had complete resolution of pain in the lateral hip.9 out of 10 (90%) had 5 out of 5 abductor muscle strength and one patient had 4 out of 5 strength.All patients maintained full hip range of motion.
35Results Arthroscopic Abductor Repair Modified Harris Hip Scores at one year averaged 92.2 points (range ) and Hip Outcomes Score 93.1 points (range ).7 out of 10 patients said their hip was normal and 3 said their hip was nearly normal.
36Conclusion Abductor Repair Endoscopic repair of the gluteus medius tendons to the greater trochanter can be performed in a predictable manner.In the short term, resolution of pain and return to activity is predictable.Long term follow-up and a larger number of patients in prospective trials will provide further insight into the treatment of abductor repairs.