1. Peritrochanteric Space: Disorders and Treatment
AANA Specialty Day
Friday, February 19th, 2011
Bryan T. Kelly, MD
Co-Director
Center for Hip Pain and Preservation

2. Hospital for Special Surgery
Bryan T. Kelly, MD
Hospital for Special Surgery
Disclosure: 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.

3. Pivot 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.: Consultant
Smith & Nephew: Educational Consultant
A2 Surgical: Consultant

4. The Peritrochanteric Space
Greater Trochanter
Iliotibial Band
Space between the Greater Trochanter and Iliotibial Band
Analogous to the subacromial space in the shoulder

6. Peritrochanteric Space Pathology
External Snapping Hip
Greater Trochanteric Pain Syndrome
Recalcitrant Trochanteric Bursitis
Gluteus Medius Tears
Gluteus Minimus Tears

7. External Snapping Hip
External 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.

8. External Snapping Hip
Although conservative treatment is usually successful, small numbers of patients remain symptomatic.
Open treatment
Excision 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.

9. External Snapping Hip
The 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.

10. Peritrochanteric Space Pathology
External Snapping Hip
Greater Trochanteric Pain Syndrome
Recalcitrant Trochanteric Bursitis
Gluteus Medius Tears
Gluteus Minimus Tears

11. Greater Trochanteric Pain Syndrome (GTPS)
Lateral sided hip pain and tenderness
Common clinical syndrome peaking between the 4th and 6th decades of life. 4♀:1♂
Previously known as “Trochanteric Bursitis”
Bursal distention is actually uncommon
Kingzett-Taylor et al, 1999
Bird et al, 2001
The initial pathology usually occurs in the tendons attached to the greater trochanter. The adjacent bursae are secondarily involved.
Gordon EJ, 1961

12. GTPS (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 GTPS
45.8% had gluteus medius tendon tears
Bird et al, 2001
Prospective US evaluation of 75 pts with GTPS
53/75 had gluteus medius tendinopathy
25 of these 53 had full or partial g. medius tears
Connell et al, 2002

13. Rotator Cuff Tears of the Hip
Bunker et al, 1997
22% of patients with femoral neck fractures had gluteus medius tears
Kagan A, 1999
Seven pts with recalcitrant GTPS ranging from 2mos – 10yrs
Open repair through bone tunnels & or side-to–side after debride
F/u at 45 mos, all were free of pain
Howell et al, 2001
20% of women undergoing THA for OA had abductor tears

14. Footprint Anatomy
Most gluteus medius tears occur anteriorly, at the junction with the minimus.
Gluteus Minimus
Gluteus Medius

15. 4 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 Nov
Ant- oval, med border is IT line
Lat- inverted triangle, caudal portion is palpable part of troch
4 facets, 3 have distinct insertions

16. Anterior Facet 2 parts to Gluteus minimus
Ant facet= glut min= best seen on transverse
Arrowhead= lat margin jt capsule, arrows= ant facet, curved arrow- glut min
2 parts to Gluteus minimus
tendon attachment lateral to joint capsule
Muscular attachment to superior joint capsule

17. Lateral Facet
Lat facet= lat part glut medius(muscular attachment), located at post ½ of GT on coronals
Cuved arrow glut med, straight arrow= ITB, arrow heads =lat facet
Middle and Anterior portions of the medius attach to the lateral facet
Also continues anteriorly to cover insertion of minimus

18. Superoposterior Facet
Superopost facet= main glut med tendon attachment= best on coronal
Curved whitre arrow= tendon. White Arrow=piriformis
Curved black=obt ext, black arrow=obt int
Main insertion point for the posterior portion of the medius.

19. Posterior Facet No muscle attachments Trochanteric bursa
Post facet= no muscular attachement, instead trochanteric bursa shown here on bursography
No muscle attachments
Trochanteric bursa

20. Clinical Presentation: Recalcitrant GTPS – Abductor Tear
Sometimes a history of a “pop” or sudden injury.
Age group late 50’s to 60’s
Females > 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.

21. Arthroscopic Management
An arthroscopic approach through the peritrochanteric space is now possible for the repair of focal gluteus medius and minimus tendon tears.

22. Gluteus Medius Tears

23. Repair

25. Abductor Repair - Preparation
In some cases trochanteric spurs may be present that can be burred down to created a better surface area for tendon healing.

26. Case TG: Senior Triathlete
65 y/o male
Developed left hip pain associated with training
Lateral Based
No groin pain
Treated for trochanteric bursitis with multiple injections / PT with no improvement in symptoms over 6 month period

34. Results 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.

35. Results 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.

36. Conclusion 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.

37. Thank You