Transcript Peritrochanteric Space: Disorders and Treatment

Peritrochanteric Space: Disorders and
Treatment
AANA Specialty Day
Friday, February 19th, 2011
Bryan T. Kelly, MD
Co-Director
Center for Hip Pain and Preservation
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.
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
The Peritrochanteric Space
Greater Trochanter
•
Space between
the Greater
Trochanter and
Iliotibial Band
•
Analogous to the
subacromial
space in the
shoulder
Iliotibial Band
Peritrochanteric Space Pathology
• External Snapping Hip
• Greater Trochanteric Pain Syndrome
– Recalcitrant Trochanteric Bursitis
– Gluteus Medius Tears
– Gluteus Minimus Tears
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.
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.
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.
Peritrochanteric Space Pathology
• External Snapping Hip
• Greater Trochanteric Pain Syndrome
– Recalcitrant Trochanteric Bursitis
– Gluteus Medius Tears
– Gluteus Minimus Tears
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
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
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
Footprint Anatomy
• Most gluteus medius tears occur anteriorly, at the
junction with the minimus.
Gluteus Medius
Gluteus Minimus
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):691-704,
vii, 2005 Nov
• 4 facets, 3 have distinct insertions
Anterior Facet
• 2 parts to Gluteus minimus
tendon attachment lateral to joint capsule
– Muscular attachment to superior joint capsule
–
Lateral Facet
• Middle and Anterior portions of the medius attach to the lateral
facet
• Also continues anteriorly to cover insertion of minimus
Superoposterior Facet
• Main insertion point for the posterior portion of the medius.
Posterior Facet
• No muscle attachments
• Trochanteric bursa
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.
Arthroscopic Management
An arthroscopic approach through the
peritrochanteric space is now possible for the repair
of focal gluteus medius and minimus tendon tears.
Gluteus Medius Tears
Repair
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.
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
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.
Results
Arthroscopic Abductor Repair
• Modified Harris Hip Scores at one year
averaged 92.2 points (range 72-100) and
Hip Outcomes Score 93.1 points (range
85-100).
• 7 out of 10 patients said their hip was
normal and 3 said their hip was nearly
normal.
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.
Thank You